Cancerous pleural effusion, also known as malignant pleural effusion and malignant pleural fluid, is a common and difficult to control complication of tumor and is a sign of advanced disease. Once malignant pleural effusion appears clinically, it means that the disease has reached an advanced stage and the quality of life of patients will be significantly reduced, and the median survival time will not exceed 3 months.
Therefore, the aim of treatment is to effectively control the growth of effusion, relieve respiratory distress, improve the patient’s quality of life treatment and prolong the survival period.
1.Puncture and drainage
Most solid tumors with pleural fluid need local treatment to improve symptoms and control the fluid to achieve relief and improve the quality of life.
Drainage + intrathoracic drug therapy: the most common and preferred method.
(1) Thoracentesis aspiration: It is an effective method to relieve symptoms, but the control rate of pleural fluid by simple aspiration is low, and most of them recur within 1 to 3 days, and repeated aspiration causes large protein loss (4 g/100 mL). The amount of fluid pumped for the first time can be increased appropriately under close observation, and as much fluid as possible should be pumped to match the chest injection.
(2) Built-in chest drainage tube: In the past, the operation of thick chest tube drainage was more complicated and more damaged, and it was difficult to heal the wound after extraction for cancerous pleural fluid, so it is not advocated now. Fine tube drainage (3-5 mm outside diameter) is easy to operate, less damage, easy to inject drugs, and is now more widely used, the indications for extraction: drainage flow < 150 mL/day, chest X-ray shows pulmonary reopening.
If coughing and shortness of breath occur during puncture or fluid extraction, in addition to being alert to pneumothorax, attention should also be paid to pulmonary edema caused by decreased pressure in the chest cavity, re-expansion of the compressed lung, congestion and increased permeability of the unrecovered pulmonary vessels. In this case, the drainage or fluid extraction should be stopped, oxygen should be administered, diuretics should be used, and the patient should be drained or needled again on the second day after the symptoms are relieved until the pleural fluid is drained as much as possible.
2.Thoracic cavity intracavitary drug therapy
Since long-term drainage leads to a large amount of protein loss, promotes the deterioration of the systemic condition, and increases the risk of pneumothorax, chest infection and multiroom effusion, so it should be combined with chest medication.
Sclerotherapy or chemotherapy drugs are commonly used to treat malignant pleural effusions by the mechanism of anti-tumor and anti-pleural adhesions.
Chemotherapy-sensitive tumors including breast cancer, SCLC, seminoma and lymphoma are effective with systemic chemotherapy for pleural effusion, and patients with massive pleural effusion can be treated with systemic chemotherapy after simple aspiration. If the patient has a low KPS score, drainage with a simple built-in chest drain is used, while avoiding excessive drainage of pleural fluid at one time, which may cause mediastinal oscillation and post-relaxation pulmonary edema.
(1) Chemotherapeutic agents: commonly used bleomycin, doxorubicin, mitoxantrone, cisplatin, cytarabine, etoposide, fluorouracil, mitomycin, can be combined with thermotherapy, low toxicity, usually fever, nausea, bone marrow suppression.
(2) pleural sclerosing agents: such as tetracycline, talc, doxycycline, etc., high efficiency, but side effects and limited sources of drugs.
(3) Biological agents: such as IL-2, INF, TNF, etc., with low side effects.
Bleomycin thoracic injection
Bleomycin is one of the most effective drugs for the treatment of malignant pleural effusion, with an efficiency of about 83%. It has no myelosuppressive and immunosuppressive effects, long remission period, low local irritation, no toxicity to lung tissue, well tolerated by patients, and does not affect patients receiving concurrent combination chemotherapy.
Dosing method: 30~40 mg/m2 IP, using venipuncture placement technique, firstly, place the intravenous tube into the chest cavity to drain the chest water as much as possible, then dissolve 50~60 mg bleomycin in 50~60 mL injection water or saline into the chest cavity, and close the catheter with heparin cap.
The patient was instructed to change position every 5 minutes for more than 20 minutes to allow uniform contact between the drug and the pleural cavity.
After 5-7 days of observation, the catheter can be removed if pleural fluid is no longer produced, and if pleural fluid is produced again or increases, pleural fluid can be withdrawn and injected once again. This technique is simple and safe to use in clinical practice, and can be left in place for a longer period of time, repeatedly draining and treating, and has clinical promotion value.
Interleukin-2 (IL-2) thoracic injection
The efficiency of IL-2 treatment is 21%-95% in relation to cancer. The control rate of malignant pleural effusion in patients with non-small cell lung cancer is about 62%.
Dosage: 1 to 3 million IU/dose, injected once a week for 2 to 4 weeks. After the pleural fluid is drained as much as possible by thoracentesis or closed drainage with a chest catheter, interleukin-2 is dissolved in 10-20 mL of physiological saline, and then the drug is injected into the thoracic cavity.
Fenagin 25 mg intramuscularly and antipyretic analgesic such as anti-inflammatory pain 25 mg orally can be given half an hour before the intrathoracic administration to reduce the adverse effects of chills and fever caused by the intrathoracic administration.