Effusions, Malignant

Key Features

• Development of a malignant effusion is a late-stage manifestation of the cancer

• Half of undiagnosed effusions in patients not known to have cancer are malignant

• Malignant effusions occur in pleural, pericardial, and peritoneal spaces

• Caused by direct neoplastic involvement of serous surface or obstruction of lymphatic drainage

Clinical Findings

• Patients with pleural and pericardial effusions complain of shortness of breath and orthopnea

• Patients with ascites complain of abdominal distention and discomfort

• Cardiac tamponade causing pressure equalization in the chambers impairs both filling and cardiac output can be life-threatening; signs of tamponade include

  • Tachycardia

  • Muffled heart sounds

  • Pulsus paradoxus

  • Hypotension

• Signs of pleural effusions include decreased breath sounds, egophony, and percussion dullness

• Differential diagnosis

  • Nonmalignant processes

    • Heart failure

    • Pulmonary embolism

    • Trauma

    • Infection

  • Malignant ascites

    • Heart failure

    • Cirrhosis

    • Peritonitis

    • Pancreatic ascites

  • Bloody effusions

    • Usually due to cancer

    • A bloody pleural effusion can also be due to pulmonary embolism, trauma, or occasionally, infection

  • Chylous pleural or ascitic fluid is generally associated with obstruction of lymphatic drainage as might occur in lymphoma

Diagnosis

• Presence of malignant cells in either the cytology or cell block specimen confirms malignancy as cause of effusion

• The presence of effusions can be confirmed with radiographic studies or ultrasonography

Treatment

• Treatment is tailored to the underlying cancer, whether with targeted therapy, chemotherapy, or immunotherapy

• Effective systemic treatment can lead to regression of the effusion

• Acute symptoms related to the effusion often require urgent intervention with drainage of the effusion

• Pleural effusion

  • Managed initially with a large volume thoracentesis

  • Chest tube drainage followed by pleurodesis

    • After lung expansion is confirmed on a chest radiograph, a sclerosing agent (such as talc poudrage or talc slurry) is injected into the catheter

    • Pleurodesis will not be successful if the lung cannot be reexpanded

  • An indwelling pleural catheter is often placed instead of pleurodesis due to

    • Non-expandable lung

    • Difficulties in successful pleurodesis

    • Loculated effusions

  • Fluid can be drained as needed at home by a family member or visiting nurse

• Pericardial effusion

  • Fluid may be removed by a needle aspiration or by placement of a catheter for more thorough drainage

  • Management options for recurrent, symptomatic effusions include prolonged catheter drainage for several days until drainage has decreased to 20–30 mL/day or pericardiotomy or pericardiectomy

• Malignant ascites

  • Patients not responsive to chemotherapy are generally treated with repeated large volume paracenteses

  • Placement of an indwelling peritoneal catheter or port so that the patient, family member, or visiting nurse can drain fluid as needed at home is an option

  • For patients with portal hypertension from large hepatic masses, diuretics (such as spironolactone 100 mg with furosemide 20–40 mg orally daily) may be useful to decrease the need for repeated paracentesis