Re: [MOL] Chris and lung cancer/Chris [00047] Medicine On Line

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Re: [MOL] Chris and lung cancer/Chris

Chris the correct spelling is effusion, excuse me, my error as


Malignant pleural effusions are caused most commonly by carcinomas of the
breast, lung, gastrointestinal tract or ovary and by lymphomas. In male
patients about half of malignant effusions are caused by lung cancer, 20% by
lymphomas or leukemia, 7% from gastrointestinal primaries, 6% from
genitourinary primaries, and 11% from tumors of unknown primary site. In
female patients, about 40% of malignant effusions are caused by breast
cancer, 20% from tumors arising in the female genital tract, 15% from lung
primaries, 8% from lymphomas or leukemia, 4% from gastrointestinal tract
primaries, 3% from melanoma, and 9% from tumors of unknown primary site.[1]
Effusions may be secondary to impaired pleural lymphatic drainage from
mediastinal tumor (especially in lymphomas) and not due to direct pleural

Effusions may be the presenting sign of cancer or they may develop after the
cancer is diagnosed. Only 50% of the effusions that develop in cancer
patients during the course of their illness are malignant. Correct diagnosis
of the cause of pleural effusions is the necessary first step in their

Pleural effusions are caused principally by congestive heart failure,
malignancy, and infection. Patients present with the symptoms of cough,
dyspnea, decreased exercise tolerance, and chest pain. While larger
effusions may be detected on physical examination, effusions as small as 100
milliliters may be detected by decubitus chest radiographs, ultrasound, or
computerized tomography of the chest. A diagnostic thoracentesis should be
performed early in the course of investigation. In markedly symptomatic
patients, removal of pleural fluid can provide immediate, albeit temporary,
relief; generally 1 liter or more must be removed to improve symptoms.
Pleural fluid analysis should include protein, LDH, glucose and pH
determinations, cell counts, cell block, cytology, and smears and cultures
for bacteria, fungi, and mycobacteria. At least 250 milliliters of pleural
fluid is necessary for adequate cytologic examination.

Pleural effusions are classified as transudative or exudative. Most often,
transudative effusions are caused by congestive heart failure, cirrhosis,
nephrotic syndrome, or occasionally by lymphatic blockade produced by
cancer. Exudative effusions are caused by infection or malignancy. In the
absence of infection, an exudative pleural effusion, especially if it is
bloody, strongly suggests a malignant etiology. An exudative pleural
effusion in a patient with a current or past cancer is very likely caused by
the cancer. Effusions due to lymphoma or mediastinal involvement by any
tumor may be chylous and cytologically negative. About half of effusions
ultimately diagnosed as malignant will have a positive cytology from the
initial thoracentesis.

Two different approaches can be used to attempt to diagnose the etiology of
pleural effusions if the initial cytologic examination does not show
malignant cells. Repeat thoracenteses and pleural biopsy will confirm
malignancy in 80% to 90% of malignant effusions.[2] The pleural biopsy has a
higher complication rate but a higher yield than thoracentesis.
Determinations of pleural fluid CEA and amylase may be helpful in selected
cases. Despite thoracenteses and pleural biopsy, 10%-20% of patients with
malignant pleural effusions will still not have a diagnosis.[2,3] In such
patients, thoracoscopy will be needed for diagnosis.[2-4] Although
thoracoscopic biopsy requires local or general anesthesia, it increases the
diagnostic yield greatly compared to thoracentesis.

The alternative diagnostic approach to patients with pleural effusions whose
initial cytologic examination does not show malignant cells is to go
directly to thoracoscopy with biopsy of visually identified abnormal areas
of the pleura. The diagnostic yield of a malignancy using this approach
exceeds 90% if the effusion is caused by cancer.[2-4]

Once the diagnosis of malignant pleural effusion has been made, treatment
depends on the tumor type and prior antineoplastic therapy.[2,3,5] About 25%
of effusions do not require therapy; the effusions are small and stable.
Malignant effusions caused by lymphomas, breast cancer, small cell lung
cancer, or ovarian cancer may respond to systemic chemotherapy or hormonal
therapy. Repeated percutaneous draining of effusions may lead to tumor
growth along the needle track and through the chest wall. Patients who have
received extensive prior systemic therapy and those with
chemotherapy-resistant tumors, like non-small cell lung cancer, are not
likely to respond to systemic therapy. Palliative approaches to the
management of malignant pleural effusions are necessary in such patients.

Patients with symptomatic malignant pleural effusions whose underlying
cancer is unlikely to respond to systemic treatment should have their
pleural fluid drained. Patients with relatively large (>1,000 milliliters)
recurrent effusions whose symptoms resolve with drainage and whose lung can
fully expand are candidates for palliation. Two general approaches to the
palliative management of symptomatic pleural effusions are chest tube
drainage with installation of a sclerosing agent and thoracoscopic drainage
of the pleural effusion under local or general anesthesia with
intraoperative sclerosis of the pleural space.

Historically, many chemical agents have been instilled into the pleural
space and shown to have some effectiveness in controlling effusions,
including tetracycline, doxycycline, minocycline, bleomycin, cisplatin,
doxorubicin, etoposide, fluorouracil, mitomycin, mitoxantrone, interferon,
Corynebacterium parvum, mepacrine, methylprednisolone, and talc.[6]

Chest tube drainage should be done by inserting the chest tube into the
pleural cavity and draining the fluid. When the drainage reaches less than
50-100 milliliters in a 24 hour period, a sclerosing agent can be
instilled.[2,5] Information on the recommended sclerosing agent is currently
inconclusive. The few randomized studies on this topic are plagued by small
numbers (all but one have fewer than 50 patients per arm), and relatively
short follow-up. The single randomized study with more than 100 patients
showed nearly twice as many patients had their pleural effusion controlled
with bleomycin at 90 days (70%) than those treated with tetracycline.[7]

Large single-arm comparative studies [8-10] and very small randomized
studies suggest advantages for talc as the sclerosing agent compared to
tetracycline and bleomycin.[11,12] In these two randomized studies,
thoracoscopy and insufflation of talc controlled the pleural effusions in
twice as many patients as tetracycline or bleomycin (>90% versus 50%,
respectively) in 63 patients with breast cancer. The comparative and
single-arm studies suggest that talc provides control of approximately 90%
of pleural effusions for 90 days or longer.[8-10] We await the results of
two different large cooperative group randomized studies to help determine
the appropriate sclerosing agent to use to treat patients with malignant
pleural effusions. One compares intrapleural bleomycin, doxycycline, and
talc as sclerosing agents.[13] Another compares the use of a talc slurry
administered via chest tube to talc insufflated during thoracoscopy.[14]
Another approach is appropriate for patients with a symptomatic malignant
pleural effusion and good performance status (ECOG performance status of
0-2) who are capable of undergoing a procedure under local, regional, or
general anesthesia. These patients can have thoracoscopy with biopsy of
suspicious pleural lesions, lysis of adhesions, evaluation to see if the
lung re-expands, and installation of the sclerosing agent during the same
procedure.[4] This potentially shortens the hospitalization because the
whole procedure can be done in the operating room in a single day.

Since tetracycline is no longer available and similar efficacy has been
shown for doxycycline, doxycycline has been substituted for tetracycline in
clinical trials.[15,16]

Pleural stripping (pleurectomy) via thoracotomy or thoracoscopy is nearly
100% effective in controlling malignant pleural effusions, but the morbidity
is so severe that this procedure is rarely used.[4]

Treatment options:

1. After histologic confirmation of diagnosis, attempt to treat the
underlying malignancy with systemic chemotherapy. Chylous effusions are not
controlled with sclerosis.

2. Pleurodesis: Where systemic therapy is not feasible or fails to control
the pleural effusion, drain the effusion with a surgical chest tube until
daily output falls to 50-100 milliliters. Small-bore chest tubes have been
used for drainage of the pleural effusion in small single-arm
studies.[16-18] The smaller chest tubes are used because they cause less
discomfort and do not limit patient mobility. Then instill either 5 grams of
talc via insufflation during thoracoscopy or as a slurry via chest tube. An
alternate agent is bleomycin 1.25 milligrams per kilogram (not to exceed 40
milligrams per square meter in elderly patients).

3. Thoracoscopic management of the pleural effusions: Patients with a
symptomatic malignant pleural effusion and good performance status (ECOG
performance status of 0-2) are candidates for this procedure. The procedure
can be performed under local, regional, or general anesthesia. After
appropriate anesthesia, the thoracoscope is introduced into the pleural
cavity. The pleural fluid is evacuated, the adhesions are lysed, and the
pleural cavity is inspected. Suspicious pleural lesions can be biopsied,
particularly if the diagnosis of a malignant pleural effusion has not been
made. An assessment is made to see if the lung re-expands. Three to 5 grams
of talc are then uniformly sprayed onto the visceral and parietal pleural
surface. After the talc is distributed, a chest tube is left in the chest
and placed to suction. The chest tube can be removed after the drainage is
less than 50 to 100 milliliters per 24-hour period.

Patients whose effusions are not controlled by talc or bleomycin
sclerosis should be considered for pleural stripping if the pleural
effusion represents the predominant active metastatic disease.

4. Insertion of a pleuroperitoneal shunt: The use of a pleuroperitoneal
shunt has also been shown to control the dyspnea associated with malignant
pleural effusions, although approximately 25% of shunts will become occluded
during the lifetime of the patient.[19,20]

We invite you to take a look at our Album.

  ( Very informational, good tips, Molers pictures, art work and much

----- Original Message -----
From: <>
To: <>
Sent: Wednesday, November 01, 2000 7:25 PM
Subject: Re: [MOL] Chris and lung cancer

> In a message dated 11/01/2000 9:30:15 PM Eastern Standard Time,
> writes:
> > plural infusion
> Heard of that, Lillian...please explain what it is - not edema?  -chris
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