Advances in Therapy

, Volume 27, Issue 6, pp 334–347 | Cite as

Management of malignant pleural effusions

  • Mateen H. Uzbeck
  • Francisco A. Almeida
  • Mona G. Sarkiss
  • Rodolfo C. Morice
  • Carlos A. Jimenez
  • Georgie A. Eapen
  • Marcus P. Kennedy


Malignant pleural effusions are a common clinical problem in patients with primary thoracic malignancy and metastatic malignancy to the thorax. Symptoms can be debilitating and can impair tolerance of anticancer therapy. This article presents a comprehensive review of pharmaceutical and nonpharmaceutical approaches to the management of malignant pleural effusion, and a novel algorithm for management based on patients’ performance status.


lung cancer management pleural effusion pleurodesis pleuroscopy thoracentesis 


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  1. 1.
    Marel M, Zrustova M, Stasny B, et al. The incidence of pleural effusion in a well-defined region. Epidemiologic study in central Bohemia. Chest. 1993;104:1486–1489.CrossRefPubMedGoogle Scholar
  2. 2.
    Antony VB, Loddenkemper R, Astoul P, et al. Management of malignant pleural effusions. Am J Respir Crit Care Med. 2000;162:1987–2001.Google Scholar
  3. 3.
    Putnam JB Jr, Walsh GL, Swisher SG, et al. Outpatient management of malignant pleural effusion by a chronic indwelling pleural catheter. Ann Thorac Surg. 2000;69:369–375.CrossRefPubMedGoogle Scholar
  4. 4.
    Rodriguez-Panadero F, Janssen JP, Astoul P. Thoracoscopy: general overview and place in the diagnosis and management of pleural effusion. Eur Respir J. 2006;28:409–422.CrossRefPubMedGoogle Scholar
  5. 5.
    Shannon VR, Eapen GA, Jimenez CA, et al. Respiratory complications. In: Kufe DW, Blast Jr RC, Hait WN, et al., eds. Cancer Medicine 7. 7th edition. Philadelphia, PA, USA: BC Decker Inc; 2006:2150–2173.Google Scholar
  6. 6.
    Sahn SA. Malignancy metastatic to the pleura. Clin Chest Med. 1998;19:351–361.CrossRefPubMedGoogle Scholar
  7. 7.
    Sahn SA. Pleural diseases related to metastatic malignancies. Eur Respir J. 1997;10:1907–1901.CrossRefPubMedGoogle Scholar
  8. 8.
    Meyer PC. Metastatic carcinoma of the pleura. Thorax. 1966;21;437–443.CrossRefPubMedGoogle Scholar
  9. 9.
    Light RW, Hamm H. Malignant pleural effusion: would the real cause please stand up? Eur Respir J. 1997;10:1701–1702.CrossRefPubMedGoogle Scholar
  10. 10.
    Chernow B, Sahn SA. Carcinomatous involvement of the pleura: an analysis of 96 patients. Am J Med. 1977;63:695–702.CrossRefPubMedGoogle Scholar
  11. 11.
    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;5:3364–3368.PubMedGoogle Scholar
  12. 12.
    Yeh HH, Lai WW, Chen HH, et al. Autocrine IL-6-induced Stat3 activation contributes to the pathogenesis of lung adenocarcinoma and malignant pleural effusion Oncogene. 2006;25:4300–4309.CrossRefPubMedGoogle Scholar
  13. 13.
    Heffner JE, Klein JS, Hampson C. Diagnostic utility and clinical application of imaging for pleural space infections. Chest. 2010;137:467–479.CrossRefPubMedGoogle Scholar
  14. 14.
    Porcel JM, Alvarez M, Salud A, Vives M. Should a cytologic study be ordered in transudative pleural effusions? Chest. 1999;116:1836–1837.CrossRefPubMedGoogle Scholar
  15. 15.
    Ashchi M, Golish J, Eng P, O’Donovan P. Transudative malignant pleural effusions: prevalence and mechanisms. South Med J. 1998;91:23–26PubMedGoogle Scholar
  16. 16.
    Abouzgheib W, Bartter T, Dagher H, Pratter M, Klump W. A prospective study of the volume of pleural fluid required for accurate diagnosis of malignant pleural effusion. Chest. 2009;135:999–1001.CrossRefPubMedGoogle Scholar
  17. 17.
    Swiderek J, Morcos S, Donthireddy V, et al. Prospective study to determine the volume of pleural fluid required to diagnose malignancy. Chest. 2010;137:68–73.CrossRefPubMedGoogle Scholar
  18. 18.
    Davies HE, Sadler RS, Bielsa S, et al. Clinical impact and reliability of pleural fluid mesothelin in undiagnosed pleural effusions. Am J Respir Crit Care Med. 2009;180:437–444.CrossRefPubMedGoogle Scholar
  19. 19.
    Menzies R, Charbonneau M. Thoracoscopy for the diagnosis of pleural disease. Ann Intern Med. 1991;114:271–277.PubMedGoogle Scholar
  20. 20.
    Ferrer J, Roldán J, Teixidor J, Pallisa E, Gich I, Morell F. Predictors of pleural malignancy in patients with pleural effusion undergoing thoracoscopy. Chest. 2005;127:1017–1022.CrossRefPubMedGoogle Scholar
  21. 21.
    Bielsa S, Martin-Juan J, Porcel JM, Rodriguez-Panadero F. Diagnostic and prognostic implications of pleural adhesions in malignant effusions. J Thorac Oncol. 2008;3:1251–1256.CrossRefPubMedGoogle Scholar
  22. 22.
    Jones PW, Moyers JP, Rogers JT Ultrasound-guided thoracentesis: is it a safer method? Chest. 2003;123:418–423.CrossRefPubMedGoogle Scholar
  23. 23.
    Feller-Kopman D, Berkowitz D, Boiselle P, Ernst A. Large-volume thoracentesis and the risk of reexpansion pulmonary edema. Ann Thorac Surg. 2007;84:1656–1661.CrossRefPubMedGoogle Scholar
  24. 24.
    Gordon CE, Feller-Kopman D, Balk EM, Smetana GW. Pneumothorax following thoracentesis: a systematic review and meta-analysis. Arch Intern Med. 2010;170:332–339.CrossRefPubMedGoogle Scholar
  25. 25.
    Neragi-Miandoab S. Malignant pleural effusion, current and evolving approaches for its diagnosis and management. Lung Cancer. 2006;54:1–9.CrossRefPubMedGoogle Scholar
  26. 26.
    Musani A, Haas A, Seijo L, Wilby M, Sterman D. Outpatient management of malignant pleural effusions with small-bore, tunneled pleural catheters. Respiration. 2004;71:559–566.CrossRefPubMedGoogle Scholar
  27. 27.
    Putnam JB, Walsh GL, Swisher SG, et al. Outpatient management of malignant pleural effusion by a chronic indwelling pleural catheter. Ann Thorac Surg. 2000;69:369–375.CrossRefPubMedGoogle Scholar
  28. 28.
    Tremblay A, Michaud G. Single-center experience with 250 tunnelled pleural catheter insertions for malignant pleural effusion. Chest. 2006;129:362–368.CrossRefPubMedGoogle Scholar
  29. 29.
    Warren WH, Kalimi R, Khodadadian LM, Kim AW. Management of malignant pleural effusions using the Pleur(x) catheter. Ann Thorac Surg. 2008;85:1049–1055.CrossRefPubMedGoogle Scholar
  30. 30.
    Tremblay A, Mason C, Michaud G. Use of tunnelled catheters for malignant pleural effusions in patients fit for pleurodesis. Eur Respir J. 2007;30:759–762.CrossRefPubMedGoogle Scholar
  31. 31.
    Jimenez CA, Ozcakar B, Morice RC, et al. Pleurodesis after intrapleural catheter insertion is an independent factor for overall survival in patients with malignant pleural effusions. Eur Respir J. 2009;34(Suppl. 53):299.Google Scholar
  32. 32.
    Sterman DH, Recio A, Carroll RG, et al. A phase I clinical trial of single-dose intrapleural IFN-beta gene transfer for malignant pleural mesothelioma and metastatic pleural effusions: high rate of antitumor immune responses. Clin Cancer Res. 2007;13:4456–4466.CrossRefPubMedGoogle Scholar
  33. 33.
    Pien GW, Gant MJ, Washam CL, Sterman DH. Use of an implantable pleural catheter for trapped lung syndrome in patients with malignant pleural effusion. Chest. 2001;119:1641–1646.CrossRefPubMedGoogle Scholar
  34. 34.
    Jimenez CA, Mhatre AD, Martinez CH, Eapen GA, Onn A, Morice RC. Management of recurrent chylothorax in patients with cancer. Chest. 2007;132:1584–1590.CrossRefPubMedGoogle Scholar
  35. 35.
    Sartori S, Tombesi P, Tassinari D, et al. Sonographically guided small-bore chest tubes and sonographic monitoring for rapid sclerotherapy of recurrent malignant pleural effusions. J Ultrasound Med. 2004;23:1171–1176.PubMedGoogle Scholar
  36. 36.
    Spiegler PA, Hurewitz AN, Groth ML. Rapid pleurodesis for malignant pleural effusions. Chest. 2003;123:1895–1898.CrossRefPubMedGoogle Scholar
  37. 37.
    Tan C, Sedrakyan A, Browne J, et al. The evidence on the effectiveness of management for malignant pleural effusion: a systematic review. Eur J Cardio-Thorac Surg. 2006;29:829–838.CrossRefGoogle Scholar
  38. 38.
    Casal RF, Eapen GA, Morice RC, Jimenez CA. Medical thoracoscopy. Curr Opin Pulm Med. 2009;15:313–320.CrossRefPubMedGoogle Scholar
  39. 39.
    Viskum K, Enk B. Complications of thoracoscopy. Poumon Coeur. 1981;37:25–28.PubMedGoogle Scholar
  40. 40.
    Wilson WC, Benumof JL. Anesthesia for thoracic surgery. In: Miller RD, Eriksson LI et al., eds. Miller’s Anesthesia. 7th edition. Morristown, NJ, USA: Churchill Livingstone; 2009:chapter 49.Google Scholar
  41. 41.
    Hill SE, Keller RA, Stafford-Smith M, et al. Efficacy of single-dose, multilevel paravertebral nerve blockade for analgesia after thoracoscopic procedures. Anesthesiology. 2006;104:1047–1053.CrossRefPubMedGoogle Scholar
  42. 42.
    Pompeo E. Awake operative videothoracoscopic pulmonary resections. Thorac Surg Clin. 2008;18:311–320.CrossRefPubMedGoogle Scholar
  43. 43.
    Shaw P, Agarwal R. Pleurodesis for malignant pleural effusions. Cochrane Database Syst Rev. 2004;(1):CD002916.Google Scholar
  44. 44.
    Yim AP, Chan AT, Lee TW, Wan IY, Ho JK. Thoracoscopic talc insufflation versus talc slurry for symptomatic malignant pleural effusion. Ann Thorac Surg. 1996;62:1655–1658.CrossRefPubMedGoogle Scholar
  45. 45.
    Manes N, Rodriguez-Panadero F, Bravo JL, Hernandez H, Alix A. Talc pleurodesis. Prospective and randomised study. Clinical follow-up. Chest. 2000;118:131.Google Scholar
  46. 46.
    Dresler CM, Olak J, Herndon JE 2nd, et al. Phase III intergroup study of talc poudrage vs. talc slurry sclerosis for malignant pleural effusion. Chest. 2005;127:909–915.CrossRefPubMedGoogle Scholar
  47. 47.
    Campos JR, Werebe EC, Vargas FS, Jatene FB, Light RW. Respiratory failure due to insufflated talc. Lancet. 1997;349:251–252.CrossRefPubMedGoogle Scholar
  48. 48.
    Rehse DH, Aye RW, Florence MG. Respiratory failure following talc pleurodesis. Am J Surg. 1999;177:437–440.CrossRefPubMedGoogle Scholar
  49. 49.
    Maskell NA, Lee YCG, Gleeson FV, et al. Randomized trials describing lung inflammation after pleurodesis with talc of varying particle size. Am J Respir Crit Care Med. 2004;170:377–382.CrossRefPubMedGoogle Scholar
  50. 50.
    Julius PJ, Gareth C, Phillippe A, et al. Safety of pleurodesis with talc poudarage in malignant pleural effusion: a prospective cohort study. Lancet. 2007;369:1535–1539.CrossRefGoogle Scholar
  51. 51.
    Light RW, Cheng D-S, Lee YC, et al. A single intrapleural injection of transforming growth factor-2 produces excellent pleurodesis in rabbits. Am J Respir Crit Care Med. 2000;162:98–104.PubMedGoogle Scholar
  52. 52.
    Lee YCG, Teixeira LR, Devin CJ, et al. Transforming growth factor-beta(2) induces pleurodesis significantly faster than talc. Am J Respir Crit Care Med. 2001;163:640–644.Google Scholar
  53. 53.
    Dong M, Li X, Hong LJ, et al. Advanced malignant pleural or peritoneal effusion in patients treated with recombinant adenovirus p53 injection plus cisplatin. J Int Med Res. 2008;36:1273–1278.PubMedGoogle Scholar
  54. 54.
    Rahman NM, Davies HE, Salzberg M, et al. Use of lipoteichoic acid-T for pleurodesis in malignant pleural effusion: a phase I toxicity and doseescalation study. Lancet Oncol. 2008;9:946–952.CrossRefPubMedGoogle Scholar
  55. 55.
    Crnjac A, Sok M, Kamenik M. Impact of pleural effusion pH on the efficacy of thoracoscopic mechanical pleurodesis in patients with breast carcinoma Eur J Cardiothorac Surg. 2004;26:432–436.CrossRefPubMedGoogle Scholar
  56. 56.
    Reich H, Beattie EJ, Harvey JC. Pleuroperitoneal shunt for malignant pleural effusions: a one-year experience. Semin Surg Oncol. 1993;9:160–162.CrossRefPubMedGoogle Scholar
  57. 57.
    Lee KA, Harvey JC, Reich H, et al. Management of malignant pleural effusions with pleuroperitoneal shunting. J Am Coll Surg. 1994;178:586–588.PubMedGoogle Scholar
  58. 58.
    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;117:73–78.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Healthcare 2010

Authors and Affiliations

  • Mateen H. Uzbeck
    • 1
  • Francisco A. Almeida
    • 1
  • Mona G. Sarkiss
    • 2
  • Rodolfo C. Morice
    • 1
  • Carlos A. Jimenez
    • 1
  • Georgie A. Eapen
    • 1
  • Marcus P. Kennedy
    • 3
  1. 1.Department of Pulmonary MedicineMD Anderson Cancer CenterHoustonUSA
  2. 2.Department of AnesthesiaMD Anderson Cancer CenterHoustonUSA
  3. 3.Cork University HospitalWilton, Cork, County CorkRepublic of Ireland

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