Malignant Thoracic Effusion
What is it
Malignant thoracic effusion is defined as malignant cell found in
thoracic fluid. Dyspnea is the most common symptom and is
occasionally accompanied by chest pain and cough. Dyspnea is due to
a combination of reduced compliance of the chest wall, depression of
the ipsilateral diaphragm, mediastinal shift, and reduction in lung
volume stimulating neurogenic reflexes. Chest pain is usually
related to involvement of the parietal pleura, ribs, and other
intercostal structures. Constitutional symptoms including weight
loss, malaise, and anorexia also generally accompany respiratory
symptoms.
How to treat
The goal of treatment is to eliminate or evacuate the effusion suppressing
lung to relief dyspnea and prevent recurrence. Repeat pleural
aspiration is often recommended for the palliation of breathlessness
in these patients. But because the recurrence rate at 1 month after
pleural aspiration alone is close to 100%, pleural aspiration or
intercostal tube drainage without pleurodesis is not
recommended.
The goal of chemical pleurodesis is to cause an irritation
between the two layers covering the lung. This irritation causes an
obliteration of the space between the layers where the fluid
accumulated, and prevents further fluid to be able to accumulate
there. There are a variety of agents, talc and bleomycin are often
used.
VATS management
1)Video-assisted thoracoscopy Surgery (VATS) should be considered
for the diagnosis of suspected but unproven malignant pleural
effusion.
2)Talc pleurodesis under thoracoscope should be considered for
the control of recurrent malignant pleural effusion. Advantage of
the procedure is facilitating breaking up of loculations and release
of adhesions to aid lung re-expansion and selecting apposite pleura
for talc poudrage.
Thoracoscopy is a safe procedure with low complication rates. The
VATS talc pleurodesis is appropriate for palliation of patients with
malignant pleural effusions and should be performed once the
diagnosis has been confirmed.
Thoracoscopic Procedure
It requires a general anesthetic given by an anesthesiologist.
The thoracoscope is inserted through a small incision in the
chest wall after that. Additional one or two small incisions will be
made for thoracoscopic instrument to manipulate. Then the pleural
fluid is removed. If necessary, pleural biopsies can be obtained. A
talc solution is then insufflated (blown in) over the lung and
pleural surfaces. A intercostal chest tube is then inserted and left
in place for several days.
Side effects
Complete expansion of the lung could not be achieved if tumor
implants on the visceral pleura widely or central lung cancer
obstruct bronchus. In these conditions, the result of VATS
pleurodesis will not be satisfactory because of incomplete
elimination of the dead space in chest cavity.
The other common major complications are acute respiratory
failure secondary to re-expansion pulmonary edema. This can be
avoided by slow re-expansion of the lung operated after clearance of
fluid. And can be treated by mechanical ventilation with PEEP.
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