Editorial
Malignant pleural effusion management
Manejo del derrame pleural maligno
Lucía Ferreiroa,b,
Corresponding author
lucia.ferreiro.fernandez@sergas.es
Corresponding author at: Hospital Clínico Universitario de Santiago, Grupo Interdisciplinar de Investigación en Neumología, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, España.
Corresponding author at: Hospital Clínico Universitario de Santiago, Grupo Interdisciplinar de Investigación en Neumología, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, España.
a Hospital Clínico Universitario de Santiago, Grupo Interdisciplinar de Investigación en Neumología, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, España
b Hospital Clínico Universitario de Santiago, Santiago de Compostela, España
Juan Suárez-Antelo
Hospital Clínico Universitario de Santiago, Grupo Interdisciplinar de Investigación en Neumología, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, España
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"titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Manejo del derrame pleural maligno" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Malignant pleural effusion (MPE) is the second most common cause of pleural effusion, affecting 15% of cancer patients,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and its presence confirms advanced disease. Survival of cancer patients with MPE ranges from 3–12 months.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Most MPEs are symptomatic and usually present with dyspnea, chest pain, anorexia, weight loss, and significant loss of quality of life. Management of symptomatic MPE is palliative and should focus on relieving symptoms, mainly dyspnea. Management options include repeated therapeutic thoracentesis, chest drainage with chemical pleurodesis (CP), tunneled pleural catheter (TPC) placement, or surgery.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Therapeutic thoracentesis is recommended in patients with dyspnea and MPE occupying >50% of the hemithorax, followed by a definitive palliative intervention (CP or TPC). Repeated therapeutic thoracentesis should be reserved for patients with a life expectancy limited to a few days or weeks. However, the available evidence is still insufficient to determine which definitive palliative treatment is the best option for the initial management of MPEs, since studies to date confirm that both procedures are effective in controlling dyspnea.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> The choice may then depend on certain individual clinical factors (comorbidities, recurrence of effusion, presence of septa or trapped lung, tumor characteristics, type of cancer, or estimated survival)<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> that should prompt us to evaluate other factors, such as hospital stay, the need for general anesthesia or repeat procedures, side effects, and final cost.</p><p id="par0015" class="elsevierStylePara elsevierViewall">CP induces an inflammatory pleural response that binds the pleural layers, preventing fluid buildup. Results show that it improves dyspnea and survival,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and reduces hospital stay and the need for future interventions.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The chance of success increases if pH is <7.20 or effusion occupies >50% of the hemitorax.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Issues that have not yet been sufficiently clarified are the appropriate sclerosing agent, the size of the drainage tubes, and the administration of non-steroidal anti-inflammatory drugs to control pain. To date, the most widely used agent is talc, administered either via the thoracoscope using an atomizer (talc poudrage), or via an intercostal tube in the form of a suspension (talc slurry), but neither technique has shown superiority over the other. In a recent study, the failure rates of pleurodesis at 90 days were 22% (36/161) and 24% (38/159) for poudrage and slurry, respectively (OR 0.91; 95% CI: 0.54–1.55; p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.74).<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The British Thoracic Society states that both approaches have similar efficacy.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Moreover, the size of the drainage tube does not appear to influence the success rate of pleurodesis,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> although smaller tubes (10–14<span class="elsevierStyleHsp" style=""></span>F) are more comfortable for the patient.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> One of the advantages of pleurodesis is the greater likelihood of rapid resolution of pleural effusion with limited intervention over time. Nevertheless, this procedure is not recommended in the case of trapped lung<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,12</span></a> or multiple septa, as it is only effective if the talc comes into contact with both pleural layers. The procedure is invasive and additional pleural interventions may be required.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">TPC consists of a fenestrated tube that is introduced into the pleural cavity and tunneled through the subcutaneous cell tissue; it terminates in a one-way valve that permits drainage when connected to a vacuum recipient, helping achieve control of the patient's symptoms. It has shown similar efficacy to talc pleurodesis,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> but requires fewer days of hospitalization, offers more advantages in patients with trapped lung, and is better tolerated by patients with a poor functional status. Pleurodesis is also achieved spontaneously in 46%–70% of patients with complete pulmonary reexpansion (the effect is greater if drainage is performed on a daily basis than only when symptoms appear).<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> However, long-term drainage is required and the complication rate (mainly cellulitis) is high, but tolerance is generally good and significant morbidity is rare. TPCs appear to be more cost-effective in patients with limited survival (<3 months), while talc pleurodesis may be more cost-effective in patients with a longer life expectancy, although this observation has not yet been confirmed in clinical trials.</p><p id="par0025" class="elsevierStylePara elsevierViewall">A recent study examined a combination of both techniques: CP via TPC. A TPC was placed in 154 patients with MPE and the fluid was drained on an outpatient basis. If there was no substantial trapped lung, patients were randomly assigned to receive talc or placebo via the TPC. The results showed that pleurodesis was achieved in 43% (30/69) of those receiving talc and in 23% (16/70) of those in the placebo group (HR 2.20; 95% CI: 1.23–3.92; p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.008), with no adverse effects in either group.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Using this combination, the tube could be removed earlier, with the corresponding reduction in drainage discomfort, possible mechanical failure, infection risks, and cost.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Finally, another novel alternative to managing recurrent MPE is to move pleural fluid into the urinary bladder using a pump system.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Surgical pleurectomy has a limited role in the management of MPE and the potential benefits might not warrant the perioperative mortality and loss of quality of life.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In short, current evidence suggests that both talc pleurodesis (in poudrage or slurry) and TPCs are effective in the management of symptomatic MPEs, so the choice will depend on factors such as the experience of the medical team, the patient's decision and their functional status and life expectancy, the tumor type, and the existence of a trapped lung. In our view, the combination of both procedures (pleurodesis by TPC) is the most effective alternative, and one that takes advantage of the benefits of both methods (outpatient management and faster resolution of the effusion), while minimizing both the discomfort and the cost of this disease. New clinical trials are needed to respond to current controversies and provide more evidence on the effective and standardized management of this disease.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Authors contribution</span><p id="par0040" class="elsevierStylePara elsevierViewall">All authors contributed in the same way to the conception, design, writing and final approval of the manuscript.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interests</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors state that they have no conflict of interests.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Authors contribution" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflict of interests" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-04-19" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Ferreiro L. Manejo del derrame pleural maligno. Arch Bronconeumol. 2020;57:7–8.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Interventions for the management of malignant pleural effusions: a network meta-analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A.O. Clive" 1 => "H.E. Jones" 2 => "R. Bhatnagar" 3 => "N.J. Preston" 4 => "N. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 2 | 5 |
| 2024 October | 49 | 17 | 66 |
| 2024 September | 52 | 14 | 66 |
| 2024 August | 93 | 32 | 125 |
| 2024 July | 56 | 18 | 74 |
| 2024 June | 55 | 29 | 84 |
| 2024 May | 77 | 42 | 119 |
| 2024 April | 44 | 30 | 74 |
| 2024 March | 46 | 13 | 59 |
| 2024 February | 44 | 26 | 70 |
| 2024 January | 40 | 26 | 66 |
| 2023 December | 39 | 26 | 65 |
| 2023 November | 63 | 27 | 90 |
| 2023 October | 38 | 30 | 68 |
| 2023 September | 46 | 35 | 81 |
| 2023 August | 51 | 31 | 82 |
| 2023 July | 54 | 22 | 76 |
| 2023 June | 39 | 20 | 59 |
| 2023 May | 65 | 17 | 82 |
| 2023 April | 51 | 26 | 77 |
| 2023 March | 66 | 15 | 81 |
| 2023 February | 57 | 21 | 78 |
| 2023 January | 77 | 25 | 102 |
| 2022 December | 65 | 32 | 97 |
| 2022 November | 75 | 31 | 106 |
| 2022 October | 67 | 40 | 107 |
| 2022 September | 49 | 24 | 73 |
| 2022 August | 47 | 52 | 99 |
| 2022 July | 53 | 59 | 112 |
| 2022 June | 50 | 34 | 84 |
| 2022 May | 61 | 37 | 98 |
| 2022 April | 50 | 32 | 82 |
| 2022 March | 50 | 35 | 85 |
| 2022 February | 31 | 23 | 54 |
| 2021 December | 16 | 2 | 18 |
| 2021 June | 1 | 2 | 3 |
| 2021 May | 1 | 0 | 1 |
| 2021 March | 1 | 2 | 3 |
| 2021 February | 1 | 1 | 2 |
| 2021 January | 6 | 6 | 12 |
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