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 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.
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.
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