Canadian HealthCare Mall: Discussion of Thoracentesis in Patients With Hematologic Malignancy

LymphomaPleural effusions occur regularly during the hospitalization of patients with hematologic malignancies, and thoracentesis is frequently performed. Most of the effusions in which a thoracentesis was undertaken were moderate to large in size (87%) and were associated with parenchymal pulmonary abnormalities (69%). Both bilateral effusions (62%) and unilateral effusions (38%) were subject to thoracentesis. Although fluid overload, cardiac dysfunction, and hypoalbuminemia were a concern in this population, only 10% of the effusions that had been analyzed using thoracentesis were documented to be transudates. Exudates were documented in 83% of patients, and 7% were unclassified because of a lack of data. A specific etiology for the effusions was identified in only 21 patients, with 20 effusions due to malignancy or chylous effusions, while only 1 effusion was due to infection. The yield for a malignant or chylous effusion was highest in patients with lymphoma (yield, 31%) compared to the other patient groups. This higher yield is not unexpected since, among the hematologic malignancies, lymphomas have been most commonly associated with the development of malignant effusions. In patients with Hodgkin lymphoma and non-Hodgkin lymphoma, pleural involvement due to the underlying disease is seen in up to 20 to 30% of patients, while malignant involvement is much less common in patients with the acute and chronic leukemias.

The most common reason to perform thoracentesis was to identify an infection and exclude a complicated parapneumonic effusion (69%). Documented infection was unusual, with only one case (1%) of empyema reported. A total of 13 other patients had fever and a new infiltrate with an ipsilateral pleural effusion, but in only 3 of these patients was a neutrophil-predominant effusion found. Given the high risk of pulmonary infection in this population, and the significant immunosuppression from the underlying disease or treatments given, it is somewhat surprising how infrequently parapneumonic effusions were documented. Studies of thoracentesis in ICU patients have shown a higher incidence of parapneumonic effusions and empyema. One study of 82 patients in a medical ICU in whom a thoracentesis was performed found empy-emain 17% of patients and parapneumonic effusions in 26% of patients. Another study of 100 consecutive medical ICU patients found an uncomplicated parapneumonic effusion in 23% of patients, but empyema in only 1 patient. To prolong the life and enjoy it you may together with the web site of Canadian HealthCare Mall. For this purpose you should follow the link – More info about diseases and hot news โ€“ Canadian health&care Mall โ€“ aboutcanadianhealthcaremall.com.

immunosuppressed patientsThe reason for the infrequency of infection is not known, but we think that it is likely that the very early institution of therapy with antibiotics in patients with hematologic malignancies sterilizes the pleural fluid early and also decreases the likelihood of obtaining positive sputum or other respiratory specimens. Additionally, in these immunosuppressed patients, inflammatory cells such as neutrophils may be less likely to be recruited to the pleural space, resulting in fewer neutrophil-predominant effusions, and possibly in less fibrin deposition and pleural loculation with the resultant complicated parapneumonic effusions. It would be helpful to have the results of additional studies of the yield of thoracentesis for infection in this patient population from other centers to further assess the applicability of our findings.

At the time of discharge from the hospital, only 6% of patients required pleurodesis for the management of their effusions, while effusions in 62% of patients resolved or significantly improved, even though a diagnosis was not established. Most effusions due to the hematologic malignancy itself will respond to therapeutic agents for the underlying disease. Our hospitalized patients needing thoracentesis appeared to represent a group with a poor prognosis, as 22% of this group died during the hospitalization in which the procedure was performed. The deaths were not directly related to the effects of the effusion or the thoracentesis but were probably a marker for the seriousness of the underlying disease.

The etiology of many of the effusions remains unknown. They may represent parapneumonic effusion that could not be diagnosed using the standard criteria. Studies in animals have shown that following acute lung injury lung edema with increased permeability and high-protein pleural effusions can occur. It is possible that noninfectious lung injury in the immunocompromised host can contribute to the development of bilateral exudative effusions.

The complications of thoracentesis in our patients were consistent with the rates reported in other nonimmunocompromised patients. We found that 7% of patients had a pneumothorax and 2% had a hemothorax, with tube thoracostomy required in 4% of patients. Pneumothorax is reported to occur in 8 to 12% of patients undergoing the procedure.โ€™ Bleeding was of concern in only two patents without clearly identified coagulation defects. All complications were successfully treated.

Conclusions

In 100 consecutive thoracenteses performed in hospitalized patients with hematologic malignancies, a specific diagnosis was made in only 21% of cases.

Almost all of the diagnoses were related to malignancy. Infection was rarely documented, and the results of the thoracenteses led to a change in treatment for infection in only one case. Although this population of patients has a high incidence of pulmonary infection, our results suggest that complicated pleural effusions are uncommon. Studies are needed to assess the reasons for the development of effusions in this population and to determine better criteria for the need for diagnostic thoracentesis.

Category: Thoracentesis

Tags: Cancer, empyema, pleural effusions, thoracentesis