Management of Pleural Burden in Metastatic Lung Cancer and Malignant Pleural Mesothelioma

  • Maria ParsonageEmail author
Part of the Principles of Specialty Nursing book series (PSN)


The burden of malignant pleural disease continues to rise, and the discovery of a malignant pleural effusion is a common problem in patients with lung cancer and malignant pleural mesothelioma. Symptomatic pleural involvement can present clinicians with a number of diagnostic and therapeutic challenges. Radiologically apparent pleural involvement requires thorough investigation and its discovery commonly represents metastatic disease across many tumour types. Histopathological pleural molecular subtyping has dramatically increased the availability of novel targeted therapies in advanced thoracic malignancy, and modern pleural intervention strategies can offer patients timely evidence-based fluid management. The impact of modern pleural research has reshaped the way in which patients are managed, shifting from what was historically a more surgical and radiological domain to the more medically focused approach. Developing pleural teams are in an excellent position to influence change in the current economically challenging environment by providing this group of patients with advanced disease, rapid management in an ambulatory setting. The use of validated prognostication tools and image-guided symptom control strategies help us to offer our patients more individualised pleural management. The chapter aims to summarise the available data around the pathophysiological mechanisms of pleural fluid production whilst considering methods of investigation, tumour staging and prognostication through to patient focused, therapeutic intervention strategies.


Pleural disease Malignant pleural effusion Tumour staging Lung cancer Malignant pleural mesothelioma Prognostication Pleural aspiration Intercostal chest drain Thoracoscopy Indwelling pleural catheter 


  1. 1.
    Bhatnagar R, Maskell N. Developing a ‘pleural team’ to run a reactive pleural service. Clin Med. 2013;13(5):452–6.CrossRefGoogle Scholar
  2. 2.
    Bhatnagar R, Maskell N. The modern diagnosis and management of pleural effusions. Br Med J. 2015;351:h4520:1–8.Google Scholar
  3. 3.
    Bhatnagar R, Cocoran JP, Maldonado F, Feller-Kopam D, Janssen J, Astoul P, Rahman NM. Advanced medical interventions in pleural disease. Eur Respir Rev. 2016;25(140):199–213.CrossRefGoogle Scholar
  4. 4.
    Clive AO, Kahan BC, Hooper CE, Bhatnagar R, Morley AJ, Zahan-Evans N, et al. Predicting survival in malignant pleural effusion: development and validation of the LENT prognostic score. Thorax. 2014;69(12):1098–104.CrossRefGoogle Scholar
  5. 5.
    Clive AO, Jones HE, Bhatnagar R, Preston NJ, Maskell N. Interventions for the management of malignant pleural effusions: a network meta-analysis. Cochrane Database Syst Rev. 2016;5:CD010529.Google Scholar
  6. 6.
    Davies HE, Mishra EK, Brennen CK, Wrightson JM, Stanton AE, Guhan A, et al. Effect of an indwelling pleural catheter vs chest tube and talc pleurodesis for relieving dyspnoea in patients with malignant pleural effusion: Davies HE, Mishra EK, Kahan BC, et al. Effect of an indwelling pleural catheter vs chest tube and talc pleurodesis for relieving dyspnoea in patients with malignant pleural effusion. The TIME2 randomised control trial. J Am Med Assoc. 2012;307(22):2383–9.CrossRefGoogle Scholar
  7. 7.
    Delgermaa V, Takahashi K, Park E, Le GV, Hara T, Sorahan T. Global mesothelioma deaths reported to the World Health Organization between 1994 and 2008. Bull World Health Organ. 2011;89(10):701–76.CrossRefGoogle Scholar
  8. 8.
    Glisson BS, Byers LA. Pathobiology and staging of small cell carcinoma of the lung. 2017. Accessed 12 Feb 2018.
  9. 9.
    Goldstraw P, Chansky K, Crowley J, Rami-Porta R, Asamura H, Eberhard WEE, et al. The IASLC Lung Cancer Staging Project: proposals for revision of the TNM stage groupings in the forthcoming (eighth) edition of the TNM Classification for lung cancer. J Thorac Oncol. 2015;11(1):39–51.CrossRefGoogle Scholar
  10. 10.
    Hooper C, Lee YGC, Maskell N. Investigation of a unilateral pleural effusion in adults: British Thoracic Society guideline. Thorax. 2010;65:ii4–17.CrossRefGoogle Scholar
  11. 11.
    Lamont T, Ml S-P, Scarpello J, Durand M, Hooper C, Maskell N, et al. Insertion of chest drains: summary of a safety report from the National Patient Safety Agency. Br Med J. 2009;339:b4923.CrossRefGoogle Scholar
  12. 12.
    Light RW, Macgregor MI, Luchsinger PC, Wilmot C, Ball JR. Pleural effusions: the diagnostic separation of transudates and exudates. Ann Intern Med. 1972;77(44):507–13.CrossRefGoogle Scholar
  13. 13.
    Lim RBL. End of life care in patients with advanced lung cancer. Ther Adv Respir Dis. 2016;10(5):455–67.CrossRefGoogle Scholar
  14. 14.
    Maldonado F, Lentz RJ, Light RW. Diagnostic approach to pleural diseases: new tricks for an old trade. F1000Res. 2017;1135:1–6.Google Scholar
  15. 15.
    Maskell N. Treatment options for malignant pleural effusion: patient preference does matter. J Am Med Assoc. 2012;307(22):2432–3.Google Scholar
  16. 16.
    Mishra A, Davies HE, Lee YCG. Malignant pleural disease in primary lung cancer. Eur Respir Mon. 2009;44:318–35.Google Scholar
  17. 17.
    Mordant P, Arame A, Legras A, Le Pimpec A, Barthes F, Riquet M. Pleural lymphatics and effusions. Rev Pneumol Clin. 2013;69(3):175–80.CrossRefGoogle Scholar
  18. 18.
    Mountain CF, Hermes KE. The role of imaging in lung cancer. Cancer Imaging. 2008;1:163–70.CrossRefGoogle Scholar
  19. 19.
    National Institute for Clinical Excellence. Quality standard for lung cancer in adults. 2012. Accessed 4 Feb 2018.
  20. 20.
    National Institute for Clinical Excellence. Suspected cancer; recognition and referral. 2015. Accessed 12 Feb 2018.
  21. 21.
    National Institute for Clinical Excellence CG 121. Lung cancer: diagnosis and management. 2011. Accessed 12 Feb 2018.
  22. 22.
    National Lung Cancer Audit annual report 2017. Royal College of Physicians. Healthcare Quality Improvement Partnership (HQIP). 2018. Accessed 4 Feb 2018.Google Scholar
  23. 23.
    Negrini D. Physiology and pathophysiology of the pleural space. In: Astoul P, Tassi G, Tschopp JM, editors. Thoracoscopy for pulmonologists. Berlin, Heidelberg: Springer; 2014.Google Scholar
  24. 24.
    Ost DE, Niu J, Zhao H, Grosu HB, Giordano SH. Quality gaps and comparative effectiveness of management for recurrent malignant pleural effusions. Chest. 2018;153(2):438–52.CrossRefGoogle Scholar
  25. 25.
    Porcel JM, Esquerda A, Vives M, Bielsa S. Aetiology of pleural effusions: analysis of more than 3000 consecutives thoracentesis. Archivos de Bronconeumología. 2014;50(5):161–5.CrossRefGoogle Scholar
  26. 26.
    Psallidas I, Kalomenidis I, Porcel JM, Robinson BW, Stathopoulos T. Malignant pleural effusion: from bench to bedside. Eur Respir Rev. 2016;25:189–98.CrossRefGoogle Scholar
  27. 27.
    Roberts ME, Neville E, Berrisford RG, Antunes G, Ali NJ on behalf of the BTS Pleural Disease Guideline Group. Management of a malignant pleural effusion: British Thoracic Society pleural disease guideline. Thorax. 2010;65(Suppl 2):ii32–40.CrossRefGoogle Scholar
  28. 28.
    Rushton L. The global burden of occupational disease. Curr Environ Health Rep. 2017;4:340–8.CrossRefGoogle Scholar
  29. 29.
  30. 30.
    Thomas KW, Gould MK. Overview of the initial evaluation, diagnosis and staging of patients with lung cancer. 2018. Accessed 12 Feb 2018.
  31. 31.
    Torre LA, Bray F, Siegel RL, Ferlay J, Lortet-Tieulent J, Jemal A. Global cancer statistics 2012. CA Cancer J Clin. 2015;65(2):87.CrossRefGoogle Scholar
  32. 32.
    Travis WD, Brambilla MD, Nicolson AG, Yasushi Y, Austin JHM, Beasley MB, et al. The 2015 World Health Organisation classification of lung tumours. Impact of genetic, clinical and radiographic advances since the 2004 classification. J Thorac Radiol. 2015;10(9):1243–60.Google Scholar
  33. 33.
    Walker S, Bibby A, Maskell N. Current best practice in the evaluation and management of malignant pleural effusions. Therapeutic Advances in Respiratory Disease. 2017:105–14. Scholar
  34. 34.
    Wilczynska MM, Davies HE. Management of a refractory malignant pleural effusion in a patient with small cell lung cancer: a case report. Int J Respir Pulm Med. 2015;2:2–3.CrossRefGoogle Scholar
  35. 35.
    Woolhouse I, Bishop L, Darlison L, De Foneska D, Edey A, Edwards J, et al. British Thoracic Society guideline for the investigation and management of malignant pleural mesothelioma. Thorax. 2018;73(i):1–130.CrossRefGoogle Scholar
  36. 36.
    World Health Organisation. Key cancer facts. 2018. Accessed 12 Feb 2018.
  37. 37.
    Yim APC, Ng CSH. Lung cancer staging. In: Schwab M, editor. Encyclopedia of cancer. Berlin, Heidelberg: Springer; 2011.Google Scholar
  38. 38.
    Zamboni MM, Teixeria da Silva C, Baretta R, Cunha ET, Cardosa GP. Important prognostic factors for survival in patients with malignant pleural effusion. BMC Pulm Med. 2015;15:29.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Respiratory MedicineWirral University NHS Hospital TrustWirralUK

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