Current controversies in the management of malignant pleural effusions

Our plain-English summary of Current controversies in the management of malignant pleural effusions, by M. Azzopardi, J.M. Porcel, C.F. Koegelenberg, et al (Seminars in Respiratory and Critical Care Medicine, 2014).

The study

• Authors: M. Azzopardi, J.M. Porcel, C.F. Koegelenberg, Y.C. Lee, E.T. Fysh
• Journal: Seminars in Respiratory and Critical Care Medicine
• Published: 2014;35(6):723-31
• Type of article: Review
• Cited by: 34 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Malignant pleural effusion (MPE) can complicate most malignancies and is a common clinical problem presenting to respiratory and cancer care physicians. Despite its frequent occurrence, current knowledge of MPE remains limited and controversy surrounds almost every aspect in its diagnosis and management. A lack of robust data has led to significant practice variations worldwide, inefficiencies in healthcare provision, and threats to patient safety. Recent studies have highlighted evolving concepts in MPE care that challenge traditional beliefs. Advancing laboratory techniques have improved the diagnostic yield from pleural fluid cytology, minimizing the need for invasive tissue biopsies, even in many cases of mesothelioma. Imaging-guided biopsy is comparable to thoracoscopy in suitable patients, if cytological examination was noncontributory. Cumulating evidence for the benefits of indwelling pleural catheters (IPCs) has led some centers to adopt this approach as first-line definitive management for MPE over conventional talc pleurodesis. The optimal technique of talc pleurodesis is still debated despite its use for many decades. Strategies combining pleurodesis and IPC are being studied. MPE consists of a heterogenous group of diseases and careful phenotyping of malignant effusion patients can provide important clinical information that will advance the field and allow better stratification of patients and planning of therapy accordingly. This review addresses the controversies in MPE diagnosis and management and exposes the deficits in knowledge of MPE that should be the focus of future research.

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In plain English

This article was a review, not an original study. The authors discussed disagreements over how malignant pleural effusion (fluid around the lung caused by cancer) is diagnosed and treated, and summarized studies by others. In one cited Western Australian study, fluid cytology with immunocytochemistry gave a correct diagnosis in 73% of 517 autopsy-confirmed mesothelioma cases. In another cited study, the first fluid sample was positive in 51% of 831 patients with malignant pleural effusion. Across four cited studies, later pleural drainage procedures were needed by 22.1% (36/163) of pleurodesis patients compared with 8.9% (21/236) of indwelling pleural catheter patients. The authors reported that tumor spread along the catheter tract occurred in up to 10% of cases, especially in mesothelioma patients. Asbestos appeared only in one figure. It showed a patient with asbestos exposure whose scan suggested malignant pleural mesothelioma, but whose biopsy showed rheumatoid pleuritis. The authors concluded that current data gave no clear conclusion on whether pleurodesis or indwelling pleural catheters were superior.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: narrative review of published evidence on the diagnosis and management of malignant pleural effusion
• Who was studied: No patients were studied directly. The review covers published studies of patients with malignant pleural effusion from various cancers, including mesothelioma
• Exposure: Not an exposure study. Asbestos is mentioned only in one figure caption describing a single patient with asbestos exposure. No fiber types are named
• Main results:
  • Cited Western Australian study: fluid cytology (with immunocytochemistry) gave a correct diagnosis of mesothelioma in 73% of 517 autopsy-confirmed mesothelioma cases, with a specificity of 99.9%
  • Cited study of patients with malignant pleural effusion (not specifically mesothelioma): the first pleural fluid specimen was positive in 51% of 831 patients. A second sample identified an additional 7%, and a third a further 2%
  • Four cited studies comparing pleurodesis and indwelling pleural catheters: subsequent pleural drainage procedures were needed in 22.1% (36/163) of pleurodesis patients and 8.9% (21/236) of catheter patients (pooled failure rate)
  • Tumor metastasis along the catheter tract complicated up to 10% of indwelling pleural catheter cases, especially in mesothelioma patients
  • Cited series of 390 mesothelioma patients: only 42% received or required pleurodesis
  • Cited randomized trial (n = 482): fluid control at 30 days was 78% with talc poudrage and 71% with talc slurry
  • Figure case: in a patient with asbestos exposure, the imaging appearances were suspicious of malignant pleural mesothelioma, but guided biopsy showed rheumatoid pleuritis
• The authors' conclusion: The authors concluded that current data provide no clear conclusion on whether pleurodesis or indwelling pleural catheters are superior

Topics

Medical terms in this study, explained in our Lexicon: Pleural Effusion, Fluid Cytology, Mesothelioma, Biopsy, Thoracoscopy, Indwelling Pleural Catheter, Talc Pleurodesis, Pleurodesis.

Related studies

• Protocol of the Australasian Malignant Pleural Effusion-2 (AMPLE-2) trial: a multicentre randomised study of aggressive versus symptom-guided drainage via indwelling pleural catheters — M. Azzopardi, R. Thomas, et al. (2016)
• Aggressive versus symptom-guided drainage of malignant pleural effusion via indwelling pleural catheters (AMPLE-2): an open-label randomised trial — S. Muruganandan, M. Azzopardi, et al. (2018)
• Interventional therapies for malignant pleural effusions: the present and the future — R. Thomas, R. Francis, et al. (2014)
• Indwelling pleural catheter versus talc pleurodesis for malignant pleural effusion: a meta-analysis — M. Yeung, E.W. Loh, et al. (2020)
• The use of indwelling pleural catheters for the management of malignant pleural effusion--direct costs in a Dutch hospital — R.C. Boshuizen, S. Onderwater, et al. (2013)
• Video-assisted management of malignant pleural effusion in breast carcinoma — R. Gasparri, F. Leo, et al. (2006)

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