39-26: Malignant Effusions

The development of an effusion in the pleural, pericardial, or peritoneal space may be the initial finding in a patient with cancer, or an effusion may appear during the course of disease progression. Direct involvement of the serous surface with tumor is the most frequent initiating cause of the accumulation of fluid. The most common malignancies causing pleural and pericardial effusions are lung and breast cancers; the most common malignancies associated with malignant ascites are ovarian, colorectal, stomach, and pancreatic cancers.

A. Symptoms and Signs

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 and can be life-threatening. Signs of tamponade include tachycardia, muffled heart sounds, pulsus paradoxus, and hypotension. Signs of pleural effusions include decreased breath sounds, egophony, and percussion dullness.

B. Laboratory Findings

Malignancy is confirmed as the cause of an effusion when analysis of the fluid specimen shows malignant cells in either the cytology or cell block specimen.

C. Imaging

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

The differential diagnosis of a malignant exudative pleural or pericardial effusion includes nonmalignant processes, such as infection, pulmonary embolism, heart failure, and trauma.

The differential diagnosis of malignant ascites includes similar benign processes, such as heart failure, cirrhosis, peritonitis, and pancreatic ascites.

Bloody effusions are usually due to cancer, but a bloody pleural effusion can also be due to pulmonary embolism, trauma and, occasionally, infection. Chylous pleural or ascitic fluid is generally associated with obstruction of lymphatic drainage as might occur in lymphomas.

In some cases, treatment of the underlying cancer with chemotherapy can cause regression of the effusions; however, not uncommonly, the development of an effusion is an end-stage manifestation of the cancer. In this situation, decisions regarding management are in large part dictated by the patient’s symptoms and goals of care.

A. Pleural Effusion

A pleural effusion that is symptomatic may be managed initially with a large volume thoracentesis. With some patients, the effusion slowly reaccumulates, which allows for periodic thoracentesis when the patient becomes symptomatic. However, in many patients, the effusion reaccumulates quickly, causing rapid return of shortness of breath. For those patients, two other management options exist: pleurodesis or indwelling pleural catheter. Chest tube drainage followed by pleurodesis involves placement of a chest tube that is connected to closed water seal drainage. After lung expansion is confirmed on a chest radiograph, a sclerosing agent (such as talc slurry or doxycycline) is injected into the catheter. Patients should be premedicated with analgesics. Pleurodesis will not be successful if the lung cannot be reexpanded. These patients are better managed with placement of an indwelling catheter that can be drained by a family member or a visiting nurse. This procedure is often preferable for patients with short life expectancies or for those who do not respond to pleurodesis. Chest tube drainage followed by pleurodesis or placement of an indwelling catheter have essentially equivalent outcomes in terms of cost, relief of symptoms, and other measures of quality of life.

B. Pericardial Effusion

Fluid may be removed by a needle aspiration or by placement of a catheter for more thorough drainage. As with pleural effusions, most pericardial effusions will reaccumulate. Management options for recurrent, symptomatic effusions include prolonged catheter drainage (for several days until drainage has decreased to 20–30 mL/day) or surgical intervention such as a pericardiotomy or pericardiectomy.

C. Malignant Ascites

Patients with malignant ascites not responsive to chemotherapy are generally treated with repeated large-volume paracenteses. As the frequency of drainage to maintain comfort can compromise the patient’s quality of life, other alternatives include placement of a catheter or port so that the patient, family member, or visiting nurse can drain fluid as needed at home. 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.