1.Malignant pleural effusion is caused by malignant metastasis or malignant tumor originating from the pleura, which is one of the common complications of malignant tumor. According to statistics, 24%~50% of exudative pleural effusions originate from malignant lesions, and 50% of patients with cancer metastases eventually develop malignant pleural effusions. The top 3 malignant pleural effusions are lung cancer, breast cancer, and lymphoma. Malignant pleural effusion grows rapidly and is often accompanied by chest tightness, shortness of breath, palpitation, inability to lie down, etc. If not treated in time, it can cause respiratory and circulatory dysfunction, hypoproteinemia, anemia, and even life-threatening in serious cases. Thus, rapid and effective treatment of malignant pleural effusion is an important part of the whole multidisciplinary treatment of tumors. Jin Minghua, Department of Thoracic Surgery, Shandong Provincial Chest Hospital
2.Disposal of malignant pleural effusion
The treatment of malignant pleural effusion should be based on the primary tumor site, pathological type, amount of pleural effusion, the speed of increase of pleural effusion and the patient’s general condition to choose the best plan.
For patients with a clear diagnosis of malignant tumor, a small amount of pleural effusion and a low growth rate of pleural effusion, and no obvious clinical respiratory symptoms, systemic chemotherapy can be considered first to control and reduce pleural effusion; for non-small cell lung cancer and other metastatic malignant pleural effusions of moderate amount or above, first consider thoracic tube drainage, and after complete drainage of pleural effusion, determine the drainage of pleural effusion through chest X-ray and ultrasound. After complete drainage of the pleural effusion, chest X-ray and ultrasound will be used to determine the drainage of the pleural effusion and lung dilation, and decide whether to treat locally.
(1) Thoracentesis
As a means of diagnosis and temporary relief of pleural effusion symptoms, it is suitable for patients whose primary tumor is not yet clear, whose pleural effusion test is used as a diagnostic tool, or whose condition is critical and difficult to be drained by tube. However, multiple punctures may cause fibrous separation of pleural effusion and risk of chest wall implantation and invasion. Therefore, for diagnosed malignant pleural effusion, punctures should be minimized and chest tube drainage is appropriate.
(2) Thoracic internal tube drainage
It is suitable for patients with a moderate amount of pleural effusion or above. The intrathoracic tube drainage should completely drain the pleural effusion and make the lung expand. For patients aged 70 years or older and weak patients, the drainage rate and daily drainage flow should be reduced to prevent the occurrence of mediastinal oscillation and redundant pulmonary edema. The patient should be encouraged to cough lightly, change the position and squeeze the drainage tube as often as possible to make all the pleural fluid drainage, and generally control the drainage of the pleural fluid within 24~48, and give the intrathoracic drug injection; close the silicone tube immediately after drug injection, and the patient should make various position rotation to make the drug evenly distributed in the whole chest cavity. After 24 hours of tube clamping, the tube will be released and the fluid will be drained. If the pleural fluid is still large, intrapleural drug injection is feasible again until the pleural fluid is basically controlled.
There are various ways of drainage by built-in chest tube: minimally invasive central venous catheter is commonly used in clinical practice, but for malignant pleural effusion with high viscosity, silicone tube with larger inner diameter should be used to prevent obstruction.
(3) Thoracoscopic drainage
It can obtain pathological diagnosis, aspirate fluid and break the adhesion separation under direct vision, and the aspiration is more thorough, and drugs can be injected or talcum powder can be sprayed to close the chest cavity under direct vision.
3.Intra-thoracic drug injection
When the fluid in the chest cavity is basically drained, intra-thoracic drug injection can be carried out, the purpose of which is to promote pleural adhesions or kill tumor cells. At present, the commonly used drugs include tetracycline, bleomycin, cisplatin, mushroom polysaccharide, interleukin-2, interferon, etc. If the drugs are not well controlled, powdered sterilized talc can be sprayed into the thoracoscope, which can effectively control malignant pleural effusion with an efficiency of 96%.
4.Radiation therapy for malignant pleural effusion
Radiotherapy for malignant pleural effusion can be used: (1) mediastinal radiotherapy, (2) pleural radiotherapy.
5.Pleural partial resection
It is only suitable for those who are in good physical condition and have limited lesions, such as limited malignant pleural mesothelioma. The prognosis of malignant pleural effusion is poor, and treatment should be considered comprehensively, taking into account both local and subsequent systemic and local treatment. Treatment should first determine whether the pleural effusion is treatable or palliative; those sensitive to chemotherapy such as small cell lung cancer and malignant lymphoma should actively take systemic chemotherapy and radiotherapy to make the pleural effusion absorb or completely subside; while other types of malignant pleural effusion should be treated mainly with palliative therapy and the primary disease should be actively treated after surgery.
6. Targeted therapy
Targeted therapy is the newest treatment method in the field of lung cancer treatment in the past three years. It has a high efficiency for those who benefit from targeting, such as adenocarcinoma and non-smokers, and for those who have a small amount of combined malignant pleural effusion, studies have shown that it has a better effect.