Chapter 105

Malignant pleural effusion is usually the consequence of an advanced cancer that has spread to the pleura. The presence of a malignant pleural effusion represents an ominous finding for the patient and a formidable challenge for the treating physician. Depending on the nature of the underlying malignancy and applicable treatments, the presence of a malignant effusion commonly portends a survival measured only in months. Malignant effusions are most commonly a manifestation of advanced cancers that have spread to the pleura, although they may result from primary cancers of the pleura. Primary cancers of the pleura are very rare. Pleural mesotheliomas comprise the majority of these unusual tumors. Advanced cancers of the lung, breast, ovary, or various lymphomas account for 75% of all malignant effusions. Most of the remaining malignant pleural effusions represent metastatic spread of a variety of gastrointestinal and genitourinary malignancies, tumors of other solid organs, or the spread of cancers of unknown origin.1,2

The most common role for the surgeon in treating malignant pleural effusions is palliation. Depending on many factors, this can take the form of thoracentesis, pleurodesis, external drainage with a long-term drainage catheter, or internal drainage with a pleuroperitoneal shunt (see Chaps. 100 and 101). Given that malignant pleural effusions usually represent some form of metastasis, any intervention beyond palliation most commonly involves a systemic approach.

When surgery is to be performed with “curative intent” for a malignant pleural effusion, it is virtually without exception part of a multimodality treatment approach. The reason for this is that it is nearly impossible to achieve true negative margins when resecting the pleura, even with an aggressive operation such as extrapleural pneumonectomy (EPP; see Chap. 103). Achieving negative margins for pleural malignancies is analogous to attempting to scrape paint off a brick wall and then subjecting the wall to microscopic examination To the naked eye, the wall may appear pristine, but examined under a microscope, there almost certainly would be residual paint. With pleural surgery, the microscopic “paint chips” represent viable cancer cells. Any attempt at a curative resection for malignant pleuritis without complementary modalities to address the problem of residual microscopic disease almost certainly will be met by an extraordinarily high rate of local recurrence. The modalities used most commonly to treat the pleural space locally are hemithoracic radiation, hyperthermic intraoperative chemotherapy lavage (see Chap. 104), and photodynamic therapy (PDT), a light-based cancer treatment. Radiation of the hemithorax mandates removal of the lung to avoid radiation toxicity to the lung. Chemotherapeutic lavage and PDT can be performed intraoperatively and do not necessarily mandate lung removal.

For the purposes of this chapter, the term malignant pleuritis will be used to include all conditions ranging from a malignant pleural effusion with no visible or palpable pleural tumor to a gross, bulky pleural cancer. As a general rule, I would only consider PDT for malignant pleuritis if it were part of a ...

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