Fig. 33.9  (a) Ex-vacuo hydropneumothorax on a breast cancer patient after thoracentesis with drainage of 1800 cc of pleural uid. Patient had improvement of dyspnea postprocedure. There were no clinical or radiographic evidence of tension pneumothorax. (b) Decreased

hydropneumothorax after IPC placement and drainage of 650 cc of uid and air. Drainage was stopped due to chest pressure. Catheter was placed 24 h after thoracentesis. (c) Autopleurodesis four weeks after IPC insertion with daily drainage

Especial Circumstances

Rarely, alternative modalities such as pleuroperitoneal shunts and parietal pleurectomy are used in the management of recurrent symptomatic effusions following pleurodesis failures or effusions associated with trapped lung.

Parietal pleurectomy, decortication, and pleuro-pneumonectomy are seldom feasible alternatives as these procedures are associated with more than 10% mortality rates and hardly

provide better symptom control than other palliative options. Candidates that might be consider for one of these procedures need to be in great physical condition and should have excellent disease control elsewhere and a life expectancy of more than a year [48, 82, 83].

Chylous effusions associated with malignancy are best controlled by treating the primary malignancy and implementing serial therapeutic thoracenteses while waiting on the results of the anti-cancer therapy. Prolonged loss of chyle, a

protein-rich, fat-laden, and lymphocyte-­ predominant uid, may result in lymphopenia, severe nutritional depletion, and water and electrolyte unbalances. Mortality due to chylothorax can be as high as 50%. Among those patients with recurrent symptomatic chylothorax and cancer relapse or progressive disease despite adequate treatment, using dietary modifcations, somatostatin, octreotide, midodrine, lymphatic embolization or thoracic duct ligation will be rarely successful. Case series assessing chemical pleurodesis on this population show mix results and IPCs are a reasonable palliative option. Pleuroperitoneal shunt placement appears to be an attractive alternative; however, its mechanism displaces only 1.5–2.5 mL at a time, making its use cumbersome. Additionally, the incidence of device obstruction and infection is high [84–87]. On those patients presenting with malignant chylothorax and chylous ascites, chemical pleurodesis fails frequently. A strategy combining either therapeutic thoracentesis, paracentesis, IPC, or peritoneal drainage along with anti-tumoral treatment is a sensible choice that could control symptoms using less invasive interventions.

In summary, in patients with limited life expectancies, modalities that offer the best chance for palliation of symptoms, the lowest procedure-related morbidity and mortality, and the shortest hospital stay represent a reasonable approach to the management of recurrent malignant effusions. A multidisciplinary approach, involving oncology, pulmonary medicine, interventional radiology, and thoracic surgery, offers optimal opportunities to achieve these goals.

References

1.\Chernow B, Sahn SA. Carcinomatous involvement of the pleura: an analysis of 96 patients. Am J Med. 1977;63(5):695–702.

2.\Rodriguez-Panadero F, Borderas Naranjo F, Lopez MJ. Pleural metastatic tumours and effusions. Frequency and pathogenic mechanisms in a post-­ mortem series. Eur Respir J. 1989;2(4):366–9.

3.\Meyer PC. Metastatic carcinoma of the pleura. Thorax. 1966;21(5):437–43.

4.\Rodriguez-Panadero F. Effusions from malignancy. Textbook of pleural diseases. 2nd ed. London: Hodder and Arnold; 2008. p. 323–37.

5.\Rodriguez-Panadero F, Borderas Naranjo F, Lopez MJ. Neoplastic lymphatic block as a cause of pleural effusion. Incidence in a necropsy series. Med Clin (Barc). 1987;89(17):725–7.

6.\Zebrowski BK, Yano S, Liu W, et al. Vascular endothelial growth factor levels and induction of permeability in malignant pleural effusions. Clin Cancer Res. 1999;5(11):3364–8.

7.\Yeh HH, Lai WW, Chen HHW, Liu HS, Su WC. Autocrine IL-6-induced Stat3 activation ­contributes to the pathogenesis of lung adenocarcinoma and malignant pleural effusion. Oncogene. 2006;25(31):4300–9.

8.\Yano S, Herbst RS, Shinohara H, et al. Treatment for malignant pleural effusion of human lung adenocarcinoma by inhibition of vascular endothelial growth factor receptor tyrosine kinase phosphorylation1. Clin Cancer Res. 2000;6(3):957–65.

9.\Maa H-C, Chao T-T, Wang C-Y, Pei D, Liang Y-J, Chen Y-L. VEGF-D as a marker in the aid of malignant metastatic pleural effusion diagnosis. Appl Immunohistochem Mol Morphol. 2015;23(3):209–14.

10.\Zocchi L. Physiology and pathophysiology of pleuraluid turnover. Eur Respir J. 2002;20(6):1545–58.

11.\Rodríguez-Panadero F, Borderas Naranjo F, López MJ. Benign pleural effusions in cancer patients. Frequency and etiopathogenic mechanism in a series of autopsy cases. Rev Clin Esp. 1988;183(6):311–2.

12.\Sahn S. Pleural diseases related to metastatic malignancies. Eur Respir J. 1997;10(8):1907–13.

13.\Porcel JM, Gasol A, Bielsa S, Civit C, Light RW, Salud A. Clinical features and survival of lung cancer patients with pleural effusions. Respirology. 2015;20(4):654–9.

14.\Tremblay A, Robbins S, Berthiaume L, Michaud G. Natural history of asymptomatic pleural effusions in lung cancer patients. J Bronchology Interv Pulmonol. 2007;14(2):98–100.

15.\Muruganandan S, Azzopardi M, Thomas R, et al. The pleural effusion and symptom evaluation (PLEASE) study of breathlessness in patients with a symptomatic pleural effusion. Eur Respir J. 2020;55(5):1900980.

16.\Estenne M, Yernault J-C, De Troyer A. Mechanism of relief of dyspnea after thoracocentesis in patients with large pleural effusions. Am J Med. 1983;74(5):813–9.

17.\Martínez-Moragón E, Aparicio J, Sanchis J, Menéndez R, Rogado MC, Sanchis F. Malignant pleural effusion: prognostic factors for survival and response to chemical Pleurodesis in a series of 120 cases. Respiration. 1998;65(2):108–13.

18.\Shannon VR, Eapen GA, Jimenez CA, et al. Respiratory complications. Holland-Frei Cancer Med. 2016;1–29.

19.\Sahn SA. Malignancy metastatic to the pleura. Clin Chest Med. 1998;19(2):351–61.

20.\Evans AL, Gleeson FV. Radiology in pleural disease: state of the art. Respirology. 2004;9(3):300–12.

21.\Lichtenstein D, Goldstein I, Mourgeon E, Cluzel P, Grenier P, Rouby JJ. Comparative diagnostic performances of auscultation, chest radiography, and lung ultrasonography in acute respiratory distress syndrome. Anesthesiology. 2004;100(1):9–15.

22.\Mayo PH, Doelken P. Pleural ultrasonography. Clin Chest Med. 2006;27(2):215–27.

23.\Salamonsen MR, Lo AK, Ng AC, Bashirzadeh F, Wang WY, Fielding DI. Novel use of pleural ultrasound can identify malignant entrapped lung prior to effusion drainage. Chest. 2014;146(5):1286–93.

24.\Loddenkemper R. Thoracoscopy--state of the art. Eur Respir J. 1998;11(1):213–21.

25.\Anderson CB, Philpott GW, Ferguson TB. The treatment of malignant pleural effusions. Cancer. 1974;33(4):916–22.

26.\Grosu HB, Kazzaz F, Vakil E, Molina S, Ost D. Sensitivity of initial thoracentesis for malignant pleural effusion stratifed by tumor type in patients with strong evidence of metastatic disease. Respiration. 2018;96(4):363–9.

27.\Light RW. Tumor markers in undiagnosed pleural effusions. Chest. 2004;126(6):1721–2.

28.\Porcel JM, Vives M, Esquerda A, Salud A, Pérez B, Rodríguez-Panadero F. Use of a panel of tumor markers (carcinoembryonic antigen, cancer antigen 125, carbohydrate antigen 15–3, and cytokeratin 19 fragments) in pleural uid for the differential diagnosis of benign and malignant effusions. Chest. 2004;126(6):1757–63.

29.\Faiz SA, Bashoura L, Lei X, et al. Pleural effusions in patients with acute leukemia and myelodysplastic syndrome. Leuk Lymphoma. 2013;54(2):329–35.

30.\Faiz SA, Sahay S, Jimenez CA. Pleural effusions in acute and chronic leukemia and myelodysplastic syndrome. Curr Opin Pulm Med. 2014;20(4):340–6.

31.\Nguyen A, Bashoura L, Jimenez CA, et al. Characteristics of pleural effusions in patients after hematopoietic stem cell transplantation. Chest. 2010;138(4):812A.

32.\Vakil E, Jimenez CA, Faiz SA. Pleural effusions in hematologic malignancies and their management with indwelling pleural catheters. Curr Opin Pulm Med. 2018;24(4):384.

33.\Styskel BA, Lopez-Mattei J, Jimenez CA, Stewart J, Hagemeister FB, Faiz SA. Ibrutinib-associated serositis in mantle cell lymphoma. Am J Respir Crit Care Med. 2019;199(12):e43–4.

34.\O'hara MF, Cousar JB, Glick AD, Collins RD. Multiparameter approach to the diagnosis of hematopoietic-lymphoid neoplasms in body uids. Diagn Cytopathol. 1985;1(1):33–8.

35.\Maskell N, Gleeson F, Davies R. Standard pleural biopsy versus CT-guided cutting-needle biopsy for diagnosis of malignant disease in pleural effusions: a randomised controlled trial. Lancet. 2003;361(9366):1326–30.

36.\Clive AO, Kahan BC, Hooper CE, et al. Predicting survival in malignant pleural effusion: development and validation of the LENT prognostic score. Thorax. 2014;69(12):1098–104.

37.\Psallidas I, Kanellakis NI, Gerry S, et al. Development and validation of response markers to predict survival and pleurodesis success in patients with malignant pleural effusion (PROMISE): a multicohort analysis. Lancet Oncol. 2018;19(7):930–9.

38.\Burrows CM, Mathews WC, Colt HG. Predicting survival in patients with recurrent symptomatic malignant pleural effusions: an assessment of the prognostic values of physiologic, morphologic, and quality of life measures of extent of disease. Chest. 2000;117(1):73–8.

39.\The University of Texas MD Anderson Cancer Center. Management of malignant pleural effusion - Adult. 2021.; https://www.mdanderson.org/content/dam/ mdanderson/documents/for-physicians/algorithms/ clinical-management/clin-management-pleural- effusion-diag-web-algorithm.pdf. Accessed 18 Mar 2022.

40.\Sagar AES, Landaeta MF, Adrianza AM, et al. Complications following symptom-limited thoracentesis using suction. Eur Respir J. 2020;56(5):1902356.

41.\Lentz RJ, Shojaee S, Grosu HB, et al. The impact of gravity vs suction-driven therapeutic thoracentesis on pressure-related complications: the GRAVITAS multicenter randomized controlled trial. Chest. 2020;157(3):702–11.

42.\Sundaralingam A, Bedawi EO, Harriss EK, Munnavar M, Rahman NM. The frequency, risk factors and management of complications from pleural procedures. Chest. 2022;161(5):1407–25.

43.\Fong C, Tan CWC, Tan DKY, See KC. Safety of thoracentesis and tube thoracostomy in patients with uncorrected coagulopathy: a systematic review and meta-analysis. Chest. 2021;160(5):1875–89.

44.\Grosu HB, Molina S, Casal R, et al. Risk factors for pleural effusion recurrence in patients with malignancy. Respirology. 2019;24(1):76–82.

45.\Massarelli E, Onn A, Marom EM, et al. Vandetanib and indwelling pleural catheter for non–small-cell lung cancer with recurrent malignant pleural effusion. Clin Lung Cancer. 2014;15(5):379–86.

46.\Verma A, Chopra A, Lee YW, et al. Can EGFR-­ tyrosine kinase inhibitors (TKI) alone without talc pleurodesis prevent recurrence of malignant pleural effusion (MPE) in lung adenocarcinoma. Curr Drug Discov Technol. 2016;13(2):68–76.

47.\Jänne PA, Yang JC-H, Kim D-W, et al. AZD9291 in EGFR inhibitor–resistant non–small-cell lung cancer. N Engl J Med. 2015;372(18):1689–99.

48.\Heffner JE. Management of malignant pleural effusions. Up to Date. 2008;1–7.

49.\Ost DE, Niu J, Zhao H, Grosu HB, Giordano SH. Quality gaps and comparative effectiveness of management strategies for recurrent malignant pleural effusions. Chest. 2018;153(2):438–52.

50.\Mitchell MA, Dhaliwal I, Mulpuru S, Amjadi K, Chee A. Early readmission to hospital in patients with cancer with malignant pleural effusions: analysis of the nationwide readmissions database. Chest. 2020;157(2):435–45.

51.\Chung C-L, Chen Y-C, Chang S-C. Effect of repeated thoracenteses on uid characteristics, cytokines, and fbrinolytic activity in malignant pleural effusion. Chest. 2003;123(4):1188–95.

52.\Uzbeck MH, Almeida FA, Sarkiss MG, et al. Management of malignant pleural effusions. Adv Ther. 2010;27(6):334–47.

53.\Wahidi MM, Reddy C, Yarmus L, et al. Randomized trial of pleural uid drainage frequency in patients with malignant pleural effusions. The ASAP trial. Am J Respir Crit Care Med. 2017;195(8):1050–7.

54.\Muruganandan S, Azzopardi M, Fitzgerald DB, et al. Aggressive versus symptom-guided drainage of malignant pleural effusion via indwelling pleural catheters (AMPLE-2): an open-label randomised trial. Lancet Respir Med. 2018;6(9):671–80.

55.\Kapp CM, Lee HJ. Malignant pleural effusions. Clin Chest Med. 2021;42(4):687–96.

56.\Davies HE, Mishra EK, Kahan BC, et al. Effect of an indwelling pleural catheter vs chest tube and talc pleurodesis for relieving dyspnea in patients with malignant pleural effusion: the TIME2 randomized controlled trial. JAMA. 2012;307(22):2383–9.

57.\Thomas R, Fysh ET, Smith NA, et al. Effect of an indwelling pleural catheter vs talc pleurodesis on hospitalization days in patients with malignant pleural effusion: the AMPLE randomized clinical trial.

2013;20(4):299–303.

59.\Chan Wah Hak C, Sivakumar P, Ahmed L. Safety of indwelling pleural catheter use in patients undergoing chemotherapy: a fve-year retrospective evaluation. BMC Pulm Med. 2016;16(1):1–6.

60.\Ost DE, Jimenez CA, Lei X, et al. Quality-adjusted survival following treatment of malignant pleural effusions with indwelling pleural catheters. Chest. 2014;145(6):1347–56.

61.\Casal RF, Bashoura L, Ost D, et al. Detecting medical device complications: lessons from an indwelling pleural catheter clinic. Am J Med Qual. 2013;28(1):69–75.

62.\Tremblay A, Michaud G. Single-center experience with 250 tunnelled pleural catheter insertions for malignant pleural effusion. Chest. 2006;129(2):362–8.

63.\Van Meter ME, McKee KY, Kohlwes RJ. Effcacy and safety of tunneled pleural catheters in adults with malignant pleural effusions: a systematic review. J Gen Intern Med. 2011;26(1):70–6.

64.\Iyer NP, Reddy CB, Wahidi MM, et al. Indwelling pleural catheter versus pleurodesis for malignant pleural effusions. A systematic review and meta-­analysis. Ann Am Thorac Soc. 2019;16(1):124–31.

65.\Gilbert CR, Lee HJ, Akulian JA, et al. A quality improvement intervention to reduce indwelling tunneled pleural catheter infection rates. Ann Am Thorac Soc. 2015;12(6):847–53.

66.\Faiz SA, Pathania P, Song J, et al. Indwelling pleural catheters for patients with hematologic malignancies. A 14-year, single-center experience. Ann Am Thorac Soc. 2017;14(6):976–85.

67.\The University of Texas MD Anderson Cancer Center. Intrapleural catheters (IPC) related infections. 2021. https://www.mdanderson.org/content/dam/ mdanderson/documents/for-physicians/algorithms/ clinical-management/clin-management-intrapleural- catheters-web-algorithm.pdf. Accessed 18 Mar 2022.

68.\Vial MR, Ost DE, Eapen GA, et al. Intrapleural fbrinolytic therapy in patients with nondraining indwelling pleural catheters. J Bronchology Interv Pulmonol. 2016;23(2):98–105.

69.\Janssen JP, Collier G, Astoul P, et al. Safety of pleurodesis with talc poudrage in malignant pleural effusion: a prospective cohort study. Lancet.

71.\Shaw PH, Agarwal R. Pleurodesis for malignant pleural effusions. Cochrane Database Syst Rev. 2004(1):CD002916.

72.\Walker-Renard PB, Vaughan LM, Sahn SA. Chemical pleurodesis for malignant pleural effusions. Ann Intern Med. 1994;120(1):56–64.

73.\Bhatnagar R, Piotrowska HE, Laskawiec-Szkonter M, et al. Effect of thoracoscopic talc poudrage vs talc slurry via chest tube on pleurodesis failure rate among patients with malignant pleural effusions: a randomized clinical trial. JAMA. 2020;323(1):60–9.

74.\Dresler CM, Olak J, Herndon JE, et al. Phase III intergroup study of talc poudrage vs talc slurry sclerosis for malignant pleural effusion. Chest. 2005;127(3):909–15.

75.\Rahman NM, Pepperell J, Rehal S, et al. Effect of opioids vs NSAIDs and larger vs smaller chest tube size on pain control and pleurodesis effcacy among patients with malignant pleural effusion: the TIME1 randomized clinical trial. JAMA. 2015;314(24):2641–53.

76.\Cujiño IF, Velásquez M, Ariza F, Loaiza JH. Awake epidural anesthesia for thoracoscopic pleurodesis: a prospective cohort study. Colomb J Anesthesiol. 2013;41(1):10–5.

77.\Reddy C, Ernst A, Lamb C, Feller-Kopman D. Rapid pleurodesis for malignant pleural effusions: a pilot study. Chest. 2011;139(6):1419–23.

78.\Boujaoude Z, Bartter T, Abboud M, Pratter M, Abouzgheib W. Pleuroscopic Pleurodesis combined with tunneled pleural catheter for management of malignant pleural effusion. J Bronchology Interv Pulmonol. 2015;22(3):237–43.

79.\Krochmal R, Reddy C, Yarmus L, Desai NR, Feller-­ Kopman D, Lee HJ. Patient evaluation for rapid pleurodesis of malignant pleural effusions. J Thorac Dis. 2016;8(9):2538.

80.\Bhatnagar R, Keenan EK, Morley AJ, et al. Outpatient talc administration by indwelling pleural catheter for malignant effusion. N Engl J Med. 2018;378(14):1313–22.

81.\Chopra A, Judson MA, Doelken P, Maldonado F, Rahman NM, Huggins JT. The relationship of pleural manometry with postthoracentesis chest radiographic fndings in malignant pleural effusion. Chest. 2020;157(2):421–6.

82.\Antony VB, Loddenkemper R, Astoul P, et al. Management of malignant pleural effusions. Eur Respir J. 2001;18(2):402–19.

83.\Fry WA, Khandekar JD. Parietal pleurectomy for malignant pleural effusion. Ann Surg Oncol. 1995;2(2):160–4.

84.\Maldonado F, Cartin-Ceba R, Hawkins FJ, Ryu JH. Medical and surgical management of chylothorax and associated outcomes. Am J Med Sci. 2010;339(4):314–8.

85.\Mares DC, Mathur PN. Medical thoracoscopic talc pleurodesis for chylothorax due to lymphoma: a case series. Chest. 1998;114(3):731–5.

86.\Heffner JE. Management of chylothorax. In: Post GF, BVC, editors. UpToDate. Waltham: UpToDate; 2016. Accessed 2014.

87.\Jimenez CA, Mhatre AD, Martinez CH, Eapen GA, Onn A, Morice RC. Use of an indwelling pleural catheter for the management of recurrent chylothorax in patients with cancer. Chest. 2007;132(5):1584–90.