Lung cancer

Malignant pleural effusions: the jury is still out on definitive management

An ERS statement on definitive management of malignant pleural effusions has stopped short of recommending either talc pleurodesis or indwelling pleural catheters ahead of the other procedure.

The joint European Respiratory Society (ERS) and the European Association for Cardio-Thoracic Surgery (EACTS) summary of the literature statement found talc poudrage may be slightly more effective than talc slurry but the jury is still out.

Speaking at the ERS International Congress 2018, Dr Anna Bibby from the UK’s University of Bristol said indwelling pleural catheters had the advantage of home drainage but about 8.5% had to be removed due to complications.

Surgical options such as pleurectomy were associated with longer hospital stays and increased morbidity and mortality.

The taskforce found a lack of evidence for combined procedures but noted this was a potential direction for the future.

Indwelling pleural catheters were noted as an effective option in the management of malignant pleural effusions with trapped lung.

“There is a lack of quality data but the best evidence is for indwelling pleural catheters,” she said.

Intra-pleural fibrinolytic agents improve the radiological findings in loculated malignant pleural effusions but did not appear to improve patient reported outcomes including dyspnoea.

Dr Bibby said there was only one validated prognostic scoring system – the LENT score – at the time of their literature review, but a second score had since been published. The Brim’s decision tree was the most clinically useful in mesothelioma.

She said there were no randomised controlled trials suggesting patients with malignant pleural effusions and cancer that might be responsive to chemotherapy, immunotherapy or targeted therapy should receive systemic cancer therapy prior to management of the effusion.

The statement confirmed pleural biopsy as the gold standard over cytology for diagnosis and to guide therapeutic decisions.

Dr Bibby said malignant pleural effusions affect about 15% of patients with cancer and the incidence was likely to rise as cancer rates and overall survival rates increased.

However the presence of malignant pleural effusions represented metastatic disease and survival was poor.

Speaking in the same session, Professor Gary Lee from the University of Western Australia added that aggressive, daily drainage of indwelling pleural catheters was superior to symptom-guided drainage.

The AMPLE-2 study found daily drainage was more effective in promoting spontaneous pleurodesis and associated with an improved quality of life although similar levels of breathlessness.

He told the limbic management of malignant pleural effusions was a rapidly progressing field.

“What the European statement has shown is up to the point of cut off of their literature review and since then there has been new papers published and quite a few randomised controlled trials in the very late stage of the pipeline. So I think you are going to see a lot more changes in the next few years.”

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