Clinical implications of pleural effusions in ovarian cancer

The pleural cavity constitutes the most frequent extra-abdominal metastatic site in ovarian carcinoma (OC). In patients with OC and pleural effusions, a positive fluid cytology is required for a stage IV diagnosis. Unfortunately, about 30% of malignant pleural effusions exhibit false-negative cytological pleural fluid results. In those circumstances, exploratory video-assisted thoracoscopic surgery (VATS) serves as a diagnostic, staging and even therapeutic modality. Maximal (no visible disease) or, at least, optimal (no residual implant greater than 1 cm) cytoreduction should be the primary surgical goal in stage IV OC patients. This is due to residual tumour after cytoreductive surgery being one of the most important factors impacting on survival. Although malignant pleural effusions do not preclude abdominal surgical debulking, excision of gross pleural nodules may be necessary to achieve optimal cytoreduction. VATS quantifies pleural tumour burden and allows for intrathoracic cytoreduction or, if the latter is not feasible, ensures that abdominal surgery is not unnecessarily performed on women in whom gross tumour would still remain in the pleural space afterwards. Taxane-platinum neoadjuvant chemotherapy should be offered to this group. Patients with tumour extension into the pleural space have a median overall survival of 2 years.