Progress in diagnosis and treatment of malignant pleural effusionMalignant pleural effusion is an important complication of both internal an
Progress in diagnosis and treatment of malignant pleural effusion
Malignant pleural effusion is an important complication of both internal and external tumors. The median survival time was four months after diagnosis. It is the late manifestation of tumor. Malignant pleural effusion is a common type of cancer: lung cancer, lymphoma, ovarian cancer, breast cancer and gastrointestinal cancer. 75% of malignant pleural effusion is lung cancer, breast cancer, ovarian cancer and lymphoma. Cytological or histological diagnosis. More than 50% are benign diseases, even when they are identified. The treatment of malignant pleural effusion is still palliative, and appropriate treatment must be based on the experience of the literature and the clinical status of the patient.
Pathology: malignant pleural effusion (MPE) is defined as the presence of cancer cells in the pleural cavity. Metastatic MPEs can be spread directly from adjacent cancer (such as lung cancer, breast cancer and chest wall cancer), cancer invasion of the lung, visceral pleura, or distant tumor. Once the tumor invades the pleural cavity, the tumor deposits along the parietal pleura and blocks the lymphatic vessels, leading to obstruction of pleural effusion. At the same time, pleural tumor deposition can cause the release of cytokines, resulting in increased vascular and pleural permeability. Even if there are no cancer cells in the pleural cavity, the cancer patient has pleural effusion caused by the indirect effects of cancer. This is called paraneoplastic effusions by effusion, lymph node invasion, bronchial obstruction, chemotherapy, pulmonary embolism, superior vena cava and colloid osmotic pressure decrease.
The development of 20-30% in patients with lymphoma as pleural effusion. Most of the pleural effusion in patients with Hochkin's disease is caused by tumor invasion of the thoracic duct, the majority of pleural effusion in patients with non Hochkin's disease is directly invaded by the tumor. Non Hochkin's lymphoma is the most common cause of chylous pleural effusion.
Lymphoma usually does not show isolated pleural effusion. An exception was primary effusion lymphoma, the only or major involvement of the pleural cavity in a typical large cell lymphoma, with no lymphoma elsewhere. AIDS has been reported in patients with herpes simplex virus 8 infection. These patients can coexist Kaboshi sarcoma. Primary lymphoma of the pleural effusion appears to arise from vascular endothelial growth factor or vascular permeability factor, which appears to alter the permeability of blood vessels and pleura. Chronic pleural infection patients may develop a unique performance - a pyothorax associated lymphoma non Hochkin lymphoma.
The patient's history and physical examination of MPEs patients are nonspecific, and the pleural effusion should be analyzed by histopathology or pleural tissue. Most patients with malignant pleural effusion caused by adenocarcinoma did not have chest pain, while 60% of patients with mesothelioma had persistent or local pain. Malignant pleural effusion caused by sarcoma is pneumothorax. Patients with malignant tumors diagnosed with pleural effusions were not able to determine MPE, as 50% of such effusions were non malignant.
In some cases, it is not possible to determine the etiology of pleural effusion. If a person with a variety of comorbid conditions and without pleural effusion, can benefit from observation, rather than invasive examination. On the contrary, a person with an underlying malignancy should not take it for granted that pleural effusion is malignant.
Although standard radiographs can be found to be less than 50ml fluid from the lateral angle, they can only provide a constructive diagnosis of MPE. : pleural thickening, lobulated intercostal space narrowing, diaphragmatic elevation or atelectasis caused due to massive pleural effusion with longitudinal Moon sign, mediastinal shift, contralateral diaphragmatic flip prompt malignant pleural effusion possibility. Radiographic imaging of malignant pleural effusion including ipsilateral displacement of septum.
Ultrasound can be found as small as 5ml liquid, b-tip MPE including solid dense pleura, irregular or lobulated pleural thickening and pleural tumor invasion of adjacent structures and cell debris shock. Pleural metastasis can be annular, nodular, hemispherical or sessile flowers phyllodes invasion of pleural cavity.
Enhanced CT can provide the most valuable information. CT can improve the sensitivity of the diagnosis of massive pleural effusion because it can separate the pleura from the parietal pleura.
The following CT findings suggest that MPE: may be associated with pleural thickening, nodular pleural thickening, thickening of the parietal pleura over 1cm, mediastinal pleural thickening or primary tumor. It is suggested that the involvement of the pleura including the involvement of the leaf and the thickening of pleura is greater than 1cm. The presence of pleural plaques and diffuse pleural thickening.
MRI is better than CT for soft tissue imaging, and it can be found that the tumor invades the chest wall and diaphragm. MRI has a certain value to distinguish between exudate and transudate fluid, and a small amount of effusion easier to find. Although MRI is similar to or slightly better in the diagnosis of MPE, it should be used conservatively because it is not as good as CT in the lung parenchyma.
The sensitivity of PET-CT to MPE was 93%-100%, the negative predictive value was 94-100%, the specificity was 67-89%, and the positive predictive value was 63-94%. False positives include: Uremic pleurisy, parapneumonic effusion and other pleural inflammatory state. PET-CT can guide puncture.
Pleural effusion analysis
In spite of the new chest imaging methods, the diagnosis must rely on cytology and pathology. 3-10% of malignant pleural effusion is transudate, which is associated with the diagnostic criteria, coexisting diseases such as hypoproteinemia, cirrhosis, heart failure.
To determine the standard of exudative pleural effusion
LDH 67% serum normal value
Omitted Light standard
2 standards do not require blood tests
3 standards do not require blood tests
MPE pleural effusion examination
1 cell count
Lymphocytes: MPEs greater than 50% of the lymphocytes in the possession of nuclear 50-70%; lymphocytes greater than 85% of tuberculosis, lymphoma, chronic rheumatoid pleural effusion, yellow nail syndrome or cholesterol chest.
Red blood cell: MPE common, but also found in benign asbestos pleurisy, trauma and pulmonary infarction.
Eosinophils: greater than 10% eosinophils known as eosinophilic pleural effusion, eosinophils pleural effusion in 12-24% is malignant.
2 biochemical examination:
Most of the protein and LDH: is exudate, but 3-10% is transudate; LDH > 1000IU/L narrowing the differential diagnosis: MPE, empyema, rheumatoid pleurisy and lung fluke disease.
Amylase: unless suspected pancreatic disease or rupture of the esophagus, MPEs amylase increased short term survival.
Sugar: < 60mg/dL MPE, rheumatoid pleural effusion, complicated parapneumonic effusion, tuberculous pleurisy, pleural effusion and esophageal rupture of lupus.
The treatment of MPEs pleural effusion is palliative and does not improve survival, and most physicians wait until the pleural effusion is associated with symptoms of respiratory function before interventions. However, some experts suggest that interventions to prevent the formation of pleural lobes at the beginning of the diagnosis of MPEs, making the treatment complicated. Interventions included pleural effusion, pleural fixation, or long-term drainage to prevent fluid accumulation.
Therapeutic thoracic puncture
The treatment of symptomatic MPEs should begin treatment of thoracic puncture, and dyspnea on Evaluation of liquid reaction. When a large amount of fluid is removed, the patient's breathing difficulties may not be relieved, and other causes of dyspnea are considered, including: micro - tumor thrombosis, lymphatic cancer, or side effects of chemotherapy and radiotherapy. A large amount of fluid may lead to pulmonary edema.
Although the patient's symptoms improved after thoracic surgery, the majority of patients in 30 days. Repeated drainage shall be carried out in the following conditions: 1 each pumping liquid slowly after 2 savings; with the tumor treatment of pleural effusion can be relieved; 3 survival period is less than 1-3 months; 4 cannot be carried out such as pleural cavity fixation of other interventions. In addition, long-term thoracic drainage or pleural cavity fixation should be performed.
Problems to be paid attention to in pleural fixation
1 the response of the tumor and the malignant pleural effusion to the treatment? (small cell lung cancer)
2 is the patient's symptoms caused by fluid?
Have the symptoms improved after treatment?
Is there any other cause of difficulty in breathing and no response to pleural cavity fixation?
3 the patient's life expectancy is greater than 2-3 months?
4 can pleural immobilization eliminate fluid and improve the patient's symptoms?
Can the lung after chest take out liquid?
Imaging revealed a leafy visceral pleural effusion or pleural thickening of pulmonary tips?
5 thoracic tumor block the effect of pleural fixation?
Is there a large tumor mass on the pleural surface?
Successful pleurodesis need the visceral pleura and parietal pleura docking, tracheal tumor cause airway obstruction, extensive pleural cavity tumor mass, multiple pleural mass leads to the collapse of the lung may not butt. When wearing chest X-ray after prompt pneumothorax often prompts the collapsed lung, often the reason is not pneumothorax of pulmonary reexpansion, drainage after the formation of very large negative intrathoracic pressure, air from the pinhole pumping fluid into the pleural cavity.
Most experts recommend using 9F-14F tubes without using 20-32F tubes. The daily dose of sclerosing agent is less than 150ml, which can be injected into the pleural cavity, and the drainage tube can be pulled out less than 150ml after injection.
Pleural sclerosing agent for use in pleural fixation
Reported success rate
Bacterial products and components
Bi Jia You
Staphylococcus aureus superantigen
Interferon -alpha-2 beta
Long tube drainage
Can be placed closed thoracic drainage tube, drainage pleural effusion 2-3 times a week, each time 1000ml. But must pay close attention to complications of catheter infection, cellulitis, catheter obstruction, empyema and tumor spread along the pipeline.
A number of studies have found that patients with 2-6 catheter drainage in the 40-58% of patients with spontaneous pleural immobilization. Because there is a high degree of spontaneous pleural fixation in long-term catheter drainage, some experts suggest that MPE should be treated with long-term catheter drainage.
MPEs can be diagnosed by cytology and imaging. Although MPEs can be treated with pleural or long-term drainage, all methods are palliative. All of these must be based on the method of evidence-based medicine, combined with their own experience, the establishment of a suitable for the actual situation of the Department of diagnosis and treatment methods, and in practice, constantly sum up, and constantly improve.