Pleural Management Pathways and Outcomes in Haematological Malignancy-Associated Malignant Pleural Effusion

Background: Malignant pleural effusion (MPE) is a common complication of advanced malignancy associated with significant symptom burden. Current British Thoracic Society guidance supports early definitive pleural intervention for recurrent MPE; however, these recommendations are largely derived from solid tumour populations, and their applicability to haematological malignancy remains uncertain. Methods: We performed a retrospective cohort study of adult patients with cytology-confirmed haematological malignancy-associated MPE managed by the Oxford Pleural Unit between 2015 and 2025. Consecutive patients undergoing at least one pleural procedure were included. Definitive pleural intervention was defined as indwelling pleural catheter (IPC) insertion, talc pleurodesis, or surgical pleural intervention. The primary outcome was time from first pleural procedure to definitive pleural intervention. Cox proportional hazards regression was used to explore factors associated with progression to definitive intervention. Results: Among 910 patients with cytology-positive MPE, 116 (12.7%) had underlying haematological malignancy. Initial pleural management was therapeutic aspiration in 90 patients (78%), chest drain insertion in 24 (21%), and direct IPC insertion in 2 (2%). Among patients managed with an aspiration-first strategy, 63/90 (70%) avoided definitive pleural intervention entirely. Thirty-six patients (40%) required only a single aspiration before systemic therapy controlled the effusion, while 27 (30%) were managed with repeat aspirations alone. Overall, only 35/116 (30%) patients required definitive pleural intervention during follow-up. Non-chemo-responsive disease was associated with earlier progression to definitive pleural intervention (adjusted HR 1.85, 95% CI 1.10-3.10; p = 0.02). Conclusions: In contrast to solid tumour-associated MPE, many patients with haematological malignancy-associated MPE can be successfully managed without early definitive pleural intervention. An aspiration-first strategy may therefore be appropriate in selected patients with anticipated chemo-responsive disease.