Malignant pleural effusion is the result of malignant metastases or malignant tumors originating from the pleura, and is one of the common complications of malignant tumors. 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 symptoms such as chest tightness, shortness of breath, palpitation and inability to lie down. Therefore, rapid and effective treatment of malignant pleural effusion is an important part of the overall multidisciplinary treatment of tumors.
Treatment 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 to control and reduce pleural effusion first; for non-small cell lung cancer and other metastatic malignant pleural effusions of moderate amount or above, chest tube drainage should be considered first, and after complete drainage of pleural effusion, chest X-ray and ultrasound should be used to determine the drainage of pleural effusion and lung dilation to determine whether to treat the patient. After complete drainage of pleural effusion, chest X-ray and ultrasound will be used to determine the drainage of pleural effusion and lung reopening, 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 placement of a tube. However, multiple punctures may cause fibrous segregation of pleural effusion and risk of chest wall implantation and invasion. Therefore, puncture should be minimized for diagnosed malignant pleural effusion, and chest tube placement for drainage is appropriate.
(2) Internal chest tube drainage
It is suitable for patients with a moderate amount of pleural effusion or above. Thoracic internal tube drainage should completely drain the pleural fluid and make the lungs 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. At the same time, the patient should be encouraged to cough lightly, change position and squeeze the drainage tube as often as possible, so that all the pleural fluid can be drained, and generally control the drainage of pleural fluid within 24~48, and give intrathoracic drug injection; close the silicone tube immediately after drug injection, and the patient should make various position rotation, so that the drug can be evenly distributed throughout the chest cavity. After 24 hours of tube clamping, the tube will be released to drain the fluid, and if there is still more fluid in the pleural cavity, it is feasible to inject drugs into the cavity again until the pleural fluid is basically controlled.
There are various ways of drainage of the intrathoracic tube: minimally invasive central venous catheter is commonly used in clinical practice, but for malignant pleural effusion with high viscosity, a silicone tube with larger inner diameter should be used to drain the effusion to prevent obstruction.
(3)Thoracoscopic drainage
Under direct vision, pathological diagnosis can be obtained, fluid can be aspirated, adhesions can be interrupted and the fluid can be more thoroughly aspirated, and drugs can be injected or talcum powder can be sprayed under direct vision to close the chest cavity.
(4) Intrathoracic 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. Currently, the types of drugs commonly used in clinical practice are tetracycline, bleomycin, cisplatin, mushroom polysaccharide, interleukin-2, interferon, etc.; for those who are not well controlled by drugs, powdered sterilized talc can be sprayed into the thoracoscope, which can effectively control malignant pleural effusion with an efficiency of 96% .
(5) Radiotherapy of malignant pleural effusion
(6)Partial pleurodesis
It is only suitable for those who are in good health 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 treatments. 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 be actively treated with systemic chemotherapy and radiotherapy to make the pleural effusion absorb or completely subside; while other types of malignant pleural effusion are mainly treated with palliative therapy, and the primary disease should be actively treated after surgery.
(7) Targeted therapy
Targeted therapy is the newest treatment method in the field of lung cancer treatment in recent years. It has a high efficiency for the target benefit group such as adenocarcinoma and non-smokers, and has been shown to have a better effect for those with a small amount of combined malignant pleural effusion.
(8) Body cavity control techniques
It is gratifying that the progress of the discipline has gradually changed the understanding of this issue, and metastatic cancer in body cavity is no longer considered as a manifestation of widespread metastasis, but a kind of regional metastasis; for patients who are carefully selected, active and appropriate treatment can not only control the progress of the disease, but also may achieve better clinical efficacy. Director Deng Yunzong of the Second Department of Oncology of the Third Affiliated Hospital of Henan College of Traditional Chinese Medicine has proposed and implemented “tumor body cavity control technology” combining Chinese and Western medicine for a long time, which has achieved good clinical effect and accumulated rich clinical experience.
After years of exploration and practice, they defined “tumor body cavity control technology” as: taking high-precision body cavity continuous circulation thermal perfusion treatment system as the main treatment pathway, together with related auxiliary treatment facilities and treatment means, organically integrating Chinese medicine and combined Chinese and Western medicine characteristic treatment measures, surgical treatment, radiotherapy, lumpectomy technology, intracavitary immunotherapy, minimally invasive interventional treatment, and the treatment of tumor cavity control. The combination of surgical treatment, radiotherapy, lumpectomy, endoluminal immunotherapy, minimally invasive interventional therapy and Chinese and Western medicine combined with the practice and method of integrated internal medicine treatment forms a comprehensive tumor treatment model with intracorporeal treatment to control the tumor invasion area and related symptoms and systemic treatment to enhance the functional status.