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.

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Malignant Effusive Disease of the Pleura and Pericardium: Conclusion

Controversy surrounds the mechanism for a successful pericardial window. Some investigators cite autopsy evidence fliat windows remain open long after the effusive process is over. Sugimoto et al believe that obliteration of the space is the goal of therapy and maintain pericardial drains on suction for between 3 and 28 days to effect visceral to parietal pericardial symphysis. These observations have led other groups to explore simple catheter drainage with the instillation of a sclerosant, much as is done with MPEs. One study with tetracycline showed control of effusions in 15 of 19 patients surviving longer than 1 month. Maher et al recently reported similar results using tetracycline sclerotherapy given via a percutaneously placed catheter in 85 of 93 patients referred with symptoms related to pericardial effusions. Read the rest of this entry »

Malignant Effusive Disease of the Pleura and Pericardium: Treatment

Malignant Effusive Disease of the Pleura and Pericardium: TreatmentTreatment
The presence of symptomatic pericardial fluid is an indication for drainage, not surgery. Suspected or proven tamponade is best treated by pericardiocentesis which is accomplished easily under local anesthesia. General anesthesia for an emergent drainage procedure or window in this clinical setting is dangerous and should be avoided. Patients suffering from tamponade need increased endogenous catecholamines for circulatory support. The induction of general anesthesia inhibits these protective autonomic responses and may lead to circulatory collapse before drainage can be effected. With drainage, the acute crisis of tamponade is at least postponed. Read the rest of this entry »

Malignant Effusive Disease of the Pleura and Pericardium: Presentation

In cases of malignant pericardial tamponade, symptoms are nearly ubiquitous. Patient complaints are often dramatic and include syncope, chest pain, or palpitations; more subtle symptoms include dyspnea, chest heaviness, and simple fatigue. Components of the often-described clinical triad of hypotension, tachycardia, and muffled heart tones are usually present. These physical findings, along with distended neck veins and a pulsus paradoxus, lead to a diagnosis of tamponade. Impaired venous return from elevated pericardial pressure leads to inadequate right heart filling and decreased stroke volume. In an effort to maintain cardiac output, the host manifests a chronotropic response until preload becomes limiting. Without intervention at this advanced stage, patients may show all the hallmarks of a low-output shock state, including cold, clammy skin, oliguria, and altered mental status. The severity of these signs and symptoms and the history of a prior malignancy will dictate the urgency for diagnostic and therapeutic intervention.
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Malignant Effusive Disease of the Pleura and Pericardium: Malignant Pericardial Effusions

Malignant Effusive Disease of the Pleura and Pericardium: Malignant Pericardial EffusionsTalc is also a more attractive sclerosing agent when cost is analyzed. Review of our inpatient pharmacy charges for the currently available sclerosing agents showed bleomycin (60 U, $3,680) was 65 times as costly as talc (4 g, $56). Doxycycline (1,000 mg, $120) was more reasonably priced but still more than two times the talc expense.

As talc appears to be the most efficacious and cost-effective sclerosant, the remaining controversies center on the route of delivery. Most of the published experience with talc involves intraoperative insufflation of the agent as a fine powder. The operator can, at the same time, ensure all fluid has been drained, lyse any restricting adhesions, break up loculated collections, and visually confirm adequate disbursal of the talc. In contrast, Chambers in 1958 and Webb et al in 1992 demonstrated 85 to 100% effective control of MPE administering talc as a slurry through a chest tube at the patient’s bedside. Read the rest of this entry »

Malignant Effusive Disease of the Pleura and Pericardium: Therapy

Cytogenetic analysis of pleural fluids has proved beneficial in difficult-to-diagnose cases. This process involves analyzing the chromosomes of cells in an effort to determine rearrangements or deletions that characterize certain tumors. We have also found cytogenetic analysis useful to differentiate carcinomas from the epithelial subtype of mesothelioma. These studies may increase diagnostic sensitivity to close to 90%. The assay, however, is not universally available and takes 5 to 7 days to complete.

Despite all currently available fluid analyses, the etiology of a small percentage of effusions remains unknown. Thoracoscopy or pleuroscopy is then indicated to establish a definitive diagnosis. Over a 3-year period, we used this minimally invasive technique to evaluate and treat 196 patients with symptomatic pleural processes. A definitive etiology was confirmed for each case (though some were known preoperatively). Half of these cases involved malignancy. Read the rest of this entry »

Malignant Effusive Disease of the Pleura and Pericardium: Presentation and Diagnosis

Malignant Effusive Disease of the Pleura and Pericardium: Presentation and DiagnosisSimple posteroanterior and lateral chest radiographs mav detect effusions as small as 200 mL. In addition, viewing the chest with the patient in a lateral decubital position allows better localization of small to moderate fluid accumulation and may guide diagnostic sampling. When the fluid does not layer dependently with change in patient position, loculation should be suspected. Ultrasound or CT is then particularly useful in defining the anatomy, as well as the safest approach to diagnosis and therapy. Read the rest of this entry »


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