120: Thoracoscopy with Intrapleural Sclerosis for Malignant Pleural Effusion

Introduction

Malignant pleural effusion is a common clinical problem in neoplastic diseases. Approximately half of all patients with metastatic cancer develop a malignant pleural effusion as a consequence of their disease.¹ Although there have been no epidemiologic studies, the annual incidence of malignant pleural effusion in the United States is estimated to be more than 200,000 cases.² The main problem that patients who develop such effusions experience is a reduction in the quality of life owing to symptoms such as dyspnea, chest pain (primarily related to involvement of the parietal pleura and chest wall), and cough.²

Treatment options for malignant pleural effusions are determined by the symptoms and performance status of the patient, the primary tumor and its response to systemic therapy, lung reexpansion after pleural fluid evacuation, and expected survival. The therapeutic goal of palliative treatment is permanent resolution of the pleural effusion. For patients who are symptomatic from pleural effusions, dramatic improvement or complete resolution of symptoms with remaining or limited recurrence of the effusion can be called a partial success. It must always be remembered that controlling a malignant pleural effusion is a local phenomenon that has no effect on the underlying systemic disease.

A number of different techniques have been used over the past 20 years to treat malignant pleural effusion.³ The most common method is pleurodesis (i.e., obliteration of the pleural space), effected by instilling a chemical sclerosant in the pleural space after the effusion has been drained completely, either during thoracoscopy (under sedation or general anesthesia) or at bedside thoracostomy.^1,4 There is no single unified approach to thoracoscopy. It can be performed by using flexible or rigid thoracoscopes, with or without video assistance, under local, regional, or general anesthesia, and with or without selective one-lung ventilation.⁵ It provides access to the entire pleural cavity, permits biopsy under direct visualization, and by means of a video-assisted procedure, enables optimal preparation of the pleural surface and homogeneous distribution of the sclerosing agent under visual guidance, thereby maximizing the chances for complete pleurodesis.^6,7

Preoperative Assessment

Malignancy must always be in the differential diagnosis of an undiagnosed unilateral or bilateral pleural effusion, and a thoracentesis must be performed. Complete drainage of the effusion is important for evaluating the underlying lung. If the lung remains collapsed after drainage, it usually indicates trapped lung syndrome. Options in cases involving trapped lung are tailored to the individual patient and include either implantation of a chronic indwelling pleural catheter,^8,9 internal drainage from the pleura to peritoneum using a Denver pleuroperitoneal shunt,¹⁰ or pleurectomy (which is performed rarely for effusion control).

It is important to perform bronchoscopy when endobronchial lesions are suspected with accompanying symptoms of hemoptysis and atelectasis, or for large effusions without contralateral mediastinal shift. Moreover, is it important to exclude endobronchial obstruction ...