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Pleural and pericardial effusions
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Pleural and pericardial effusions Ani Balmanoukian and Julie R. Brahmer
Malignant pleural effusions 354 Pathophysiology 354 Clinical manifestations 354
with choosing from a menu of various therapeutic options and need to take into consideration the patient’s underlying medical condition, the tolerability of the procedure, and life expectancy. Management of pleural and pericardial effusions and ascites will be discussed in this chapter.
Diagnosis and evaluation 355 Management 355 Thoracentesis 355 Pleurodesis 356 Indwelling catheter 356 Pleurectomy 357 Shunt 357 Pericardial effusion 357 Pathophysiology 357 Clinical manifestations 357 Diagnosis and evaluation 358 Management 358 Pericardiocentesis 358 Evaluation of pericardial fluid 358 Surgical approaches 358 Sclerosing therapy and chemotherapy 359 Percutaneous balloon pericardiotomy 359 Conclusion 359
Common complications of advanced malignancy are pleural effusions and pericardial effusions. Under most circumstances, these fluid accumulations occur secondary to advanced disease and may be refractory to multiple therapeutic regimens. Oftentimes, they are the initial presentation of a malignancy. Clinically, patients present with various symptoms and severity, ranging from asymptomatic to significant degrees of discomfort and end-organ damage. Physicians are often faced 354
MALIGNANT PLEURAL EFFUSIONS One of the most common complications of advanced malignancy is the development of pleural effusion. The estimated annual incidence is 150,000 patients.1,2 In most instances, the presence of a pleural effusion is indicative of advanced disease and of unresponsiveness to systemic therapy; however, pleural effusions are caused by a variety of diseases and complications, including pneumonia, congestive heart failure, pulmonary embolus, and atelectasis (Table 32-1). Careful workup of the underlying cause is necessary before any decisions regarding therapy are made. The development of malignant pleural effusion for most malignancies, including those of lung and gastrointestinal cancers, portends a poor prognosis with a usual median survival ranging from 3 to 12 months3,4; however, complete remission and even cure are possible, despite the presence of pleural effusions with germ cell tumors and certain types of lymphomas.5
PATHOPHYSIOLOGY The pleural space lies between the visceral pleura, which covers the lung; interlobar fissures; and the parietal pleura, which covers the chest wall, diaphragm, and mediastinum. The origin of malignant pleural effusions is complex and multifactorial. Effusions result from both increased entry and decreased exit of fluid within the pleural space. Impaired lymphatic drainage causes fluid to accumulate6 by direct tumor invasion of the pleurae or by lymph node involvement. Under most circumstances, tumor has spread to the parietal and visceral pleurae, leading to fluid accumulation. Seeding of the pleurae with tumor cells increases pleural fluid formation, leading to increased fluid in the pleural space.7
CLINICAL MANIFESTATIONS Patients present with various symptoms, including dyspnea, chest pain, cough, or orthopnea. Hemoptysis is rare. A pleural effusion may also be a purely incidental finding on imaging
Pleural and pericardial effusions Ani Balmanoukian and Julie R. Brahmer
Malignant pleural effusions 354 Pathophysiology 354 Clinical manifestations 354
with choosing from a menu of various therapeutic options and need to take into consideration the patient’s underlying medical condition, the tolerability of the procedure, and life expectancy. Management of pleural and pericardial effusions and ascites will be discussed in this chapter.
Diagnosis and evaluation 355 Management 355 Thoracentesis 355 Pleurodesis 356 Indwelling catheter 356 Pleurectomy 357 Shunt 357 Pericardial effusion 357 Pathophysiology 357 Clinical manifestations 357 Diagnosis and evaluation 358 Management 358 Pericardiocentesis 358 Evaluation of pericardial fluid 358 Surgical approaches 358 Sclerosing therapy and chemotherapy 359 Percutaneous balloon pericardiotomy 359 Conclusion 359
Common complications of advanced malignancy are pleural effusions and pericardial effusions. Under most circumstances, these fluid accumulations occur secondary to advanced disease and may be refractory to multiple therapeutic regimens. Oftentimes, they are the initial presentation of a malignancy. Clinically, patients present with various symptoms and severity, ranging from asymptomatic to significant degrees of discomfort and end-organ damage. Physicians are often faced 354
MALIGNANT PLEURAL EFFUSIONS One of the most common complications of advanced malignancy is the development of pleural effusion. The estimated annual incidence is 150,000 patients.1,2 In most instances, the presence of a pleural effusion is indicative of advanced disease and of unresponsiveness to systemic therapy; however, pleural effusions are caused by a variety of diseases and complications, including pneumonia, congestive heart failure, pulmonary embolus, and atelectasis (Table 32-1). Careful workup of the underlying cause is necessary before any decisions regarding therapy are made. The development of malignant pleural effusion for most malignancies, including those of lung and gastrointestinal cancers, portends a poor prognosis with a usual median survival ranging from 3 to 12 months3,4; however, complete remission and even cure are possible, despite the presence of pleural effusions with germ cell tumors and certain types of lymphomas.5
PATHOPHYSIOLOGY The pleural space lies between the visceral pleura, which covers the lung; interlobar fissures; and the parietal pleura, which covers the chest wall, diaphragm, and mediastinum. The origin of malignant pleural effusions is complex and multifactorial. Effusions result from both increased entry and decreased exit of fluid within the pleural space. Impaired lymphatic drainage causes fluid to accumulate6 by direct tumor invasion of the pleurae or by lymph node involvement. Under most circumstances, tumor has spread to the parietal and visceral pleurae, leading to fluid accumulation. Seeding of the pleurae with tumor cells increases pleural fluid formation, leading to increased fluid in the pleural space.7
CLINICAL MANIFESTATIONS Patients present with various symptoms, including dyspnea, chest pain, cough, or orthopnea. Hemoptysis is rare. A pleural effusion may also be a purely incidental finding on imaging