Malignant Pleural Effusion and Its Current Management: A Review

Our plain-English summary of Malignant Pleural Effusion and Its Current Management: A Review, by K. Skok, G. Hladnik, A. Grm, et al (Medicina, 2019).

The study

• Authors: K. Skok, G. Hladnik, A. Grm, A. Crnjac
• Journal: Medicina
• Published: 2019;55(8)
• Type of article: Review
• Cited by: 91 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Malignant pleural effusion (MPE) is an exudative effusion with malignant cells. MPE is a common symptom and accompanying manifestation of metastatic disease. It affects up to 15% of all patients with cancer and is the most common in lung, breast cancer, lymphoma, gynecological malignancies and malignant mesothelioma. In the last year, many studies were performed focusing on the pathophysiological mechanisms of MPE. With the advancement in molecular techniques, the importance of tumor-host cell interactions is becoming more apparent. Additionally, the process of pathogenesis is greatly affected by activating mutations of EGFR, KRAS, PIK3CA, BRAF, MET, EML4/ALK and RET, which correlate with an increased incidence of MPE. Considering all these changes, the authors aim to present a literature review of the newest findings, review of the guidelines and pathophysiological novelties in this field. Review of the just recently, after seven years published, practice guidelines, as well as analysis of more than 70 articles from the Pubmed, Medline databases that were almost exclusively published in indexed journals in the last few years, have relevance and contribute to the better understanding of the presented topic. MPE still presents a severe medical condition in patients with advanced malignancy. Recent findings in the field of pathophysiological mechanisms of MPE emphasize the role of molecular factors and mutations in the dynamics of the disease and its prognosis. Treatment guidelines offer a patient-centric approach with the use of new scoring systems, an out of hospital approach and ultrasound. The current guidelines address multiple areas of interest bring novelties in the form of validated prediction tools and can, based on evidence, improve patient outcomes. However, the role of biomarkers in a clinical setting, possible new treatment modalities and certain specific situations still present a challenge for new research.

In plain English

This narrative review, not a new study, covered recent European and American practice guidelines and more than 70 articles on malignant pleural effusion, a build-up of fluid containing cancer cells around the lungs. Citing other work, it described this as affecting up to 15% of people with cancer, most often with lung and breast cancer, lymphoma, gynecological cancers and malignant mesothelioma. For malignant mesothelioma, the review named mineral fibers such as asbestos as the most important risk factors, with onset 30–50 years after exposure, and said effusion occurs in 54–90% of malignant pleural mesothelioma cases. It summarized guideline recommendations to use ultrasound to guide procedures and not to perform therapeutic pleural intervention in people without symptoms. For breathlessness, an indwelling pleural catheter or chemical pleurodesis was first-line when the lung was known or suspected to re-expand with no prior definitive treatment; a catheter was preferred for non-expandable lung, failed pleurodesis or loculated effusion. It also described the LENT survival score. The authors concluded management has advanced but the condition remains severe and each patient still needs an individual approach.

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 literature review of recent practice guidelines and published articles on malignant pleural effusion
• Who was studied: No patients were studied directly. The authors reviewed more than 70 articles from PubMed and Medline, mostly from recent years, together with the newest guidelines on malignant pleural effusion from the European respiratory society (ERS/EACTS) and from ATS/STS/STR (American Thoracic Society, Society of Thoracic Surgeons, Society of Thoracic Radiology).
• Exposure: No exposure was studied. The review mentions asbestos only as an example of mineral fiber exposure, described as the most important risk factor for malignant mesothelioma, citing other sources.
• Main results:
  • Citing other sources, the review stated that malignant pleural effusion can occur in 15% of patients with cancer. It is most common in lung cancer, followed by breast cancer, lymphoma, gynecological cancers and malignant mesothelioma.
  • For malignant mesothelioma, the review stated that incidence is still rising because of delayed onset of the illness, 30 to 50 years after exposure.
  • The review stated that effusion occurs in 54–90% of all malignant pleural mesothelioma cases and forms at an early stage.
  • Among mesothelioma subtypes, the review described the epithelioid subtype as the most common (60–80%) with the best prognosis (overall survival of 13.1 months), and the sarcomatoid subtype as having the worst prognosis (overall survival of 4–6 months).
  • In a table taken from Clive et al., general median survival with malignant pleural effusion was 339 days (95% CI 267 to 422) for mesothelioma, compared with 74 days (95% CI 60 to 92) for lung cancer.
  • Citing the latest guidelines, the review stated that cytology of pleural fluid can be an initial screening test for mesothelioma but is not a sufficiently sensitive diagnostic test.
  • Summarized guideline recommendations: use ultrasound to guide pleural interventions, and do not perform therapeutic pleural intervention in patients with suspected or known malignant pleural effusion who have no symptoms.
  • For patients with symptoms whose lung is known or suspected to be expandable and who have had no prior definitive therapy, the guidelines recommended an indwelling pleural catheter or chemical pleurodesis as the first-line definitive intervention for breathlessness.
  • For patients with symptoms who have non-expandable lung, failed pleurodesis or loculated effusion, the guidelines named an indwelling pleural catheter as the method of choice, because it is associated with a shorter hospital stay.
  • Under the LENT prognostic score, median survival was reported as 319 days in the low-risk group, 130 days in the medium-risk group and 44 days in the high-risk group.
  • The review stated that tumors with activating mutations of EGFR, KRAS, PIK3CA, BRAF, MET, EML4/ALK and RET are connected to increased formation of malignant pleural effusion.
• The authors' conclusion: The authors concluded that management of malignant pleural effusion has advanced since the last international guidelines, but it remains a severe condition in advanced cancer. They expected the updated guidelines to help physicians, while noting that an individual approach to each patient is still required.

Topics

Medical terms in this study, explained in our Lexicon: Pleural Effusion, Mesothelioma, EGFR, Prognosis, Ultrasound, Biomarker.

Related studies

• Surgical and non-surgical management of malignant pleural effusions — D.B. Fitzgerald, C.F.N. Koegelenberg, et al. (2018)
• Current controversies in the management of malignant pleural effusions — M. Azzopardi, J.M. Porcel, et al. (2014)
• British Thoracic Society study of cryptogenic fibrosing alveolitis: current presentation and initial management. Fibrosing Alveolitis Subcommittee of the Research Committee of the British Thoracic Society — I.D. Johnston, R.J. Prescott, et al. (1997)
• Prognostic factors for survival after surgical palliation of malignant pleural effusion — J.E. Pilling, M.E. Dusmet, et al. (2010)
• Diagnostic and prognostic value of Ki67 proliferation fraction in serous effusions — A. Schönherr, M. Bayer, et al. (2004)
• Current and future options for the diagnosis of malignant pleural effusion — F. Rodriguez-Panadero, B. Romero-Romero (2013)

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