Management of malignant pleural effusion: an overview

Exudative effusions in the pleural space are a significant cause of morbidity in patients with advanced cancer. Although the quantity of patients' lives is more often determined by the progress of their systemic cancer, the quality of their lives can be improved significantly by successful management of their effusions. The differential diagnosis of a malignant effusion often can be difficult in a newly diagnosed, asymptomatic patient. However, the diagnosis is rarely difficult in the patient with advanced cancer. In the symptomatic patient, a trial of thoracentesis only is rarely warranted. Tube thoracostomy with subsequent introduction of a sclerosing agent is the treatment of choice, but it initially requires almost complete removal of the fluid (less than 100 mL drainage in 24 hours) and reexpansion of the lung. When systemic therapy is not likely to cause prompt resolution of the effusion, the two most commonly employed intrapleural agents are bleomycin and tetracycline. Although there are a number of reports describing the relative merits of each of these agents, the data are inconclusive, primarily due to difficulty in the design and interpretation of the studies. A current pleural effusion study is being conducted in 13 American centers. It compares intrapleural tetracycline (1,000 mg) with intrapleural bleomycin (60 U). Full drainage and reexpansion are required, as is the lack of a change in therapy just before thoracostomy. Effusions that cannot be drained effectively may require pleurectomy, although recently intrapleural cytarabine and cisplatin have been proposed as a nonsclerosing alternative. When all of the elements required for successful management are attended to, the majority of patients with malignant pleural effusions can be palliated successfully.