DIAGNOSIS AND MANAGEMENT OF

PLEURAL METASTASES AND MALIGNANT

EFFUSION IN BREAST CANCER
GILANG DWIPA
PEMBIMBING : PROF.DR.AZAMRIS SP.B (K) ONK
• Pleural metastases and malignant pleural effusion may occur with metastatic breast
cancer.
• Presentation can vary widely from an incidental finding on imaging to a large
effusion with severe dyspnea.
• Any pleural effusion in a breast cancer patient can be suspected to be a malignant
effusion until proven otherwise.
• to provide the most efficient, accurate diagnosis with the least risk of complication
and pain for the patient.
EPIDEMIOLOGI

• Malignant pleural effusions account for approximately 20% to 25% of all effusions.
• Infectious or post infectious etiologies are the most common cause of exudative effusion and
pleural malignancies
• both primary and metastatic, are the second leading cause of exudative pleural effusions,
estimated to number approximately 150,000 annually in the United States.
• Breast cancer is second only to lung cancer as the leading cause of all pleural metastases and
thus accounts for approximately one-fourth of all malignant effusions.
• In women, it is the most common cause of a malignant effusion, accounting for up to 40%.
PATHOGENESIS

• The details of its pathogenesis are not clear.

• It appears to be a combination of factors leading to an overall increase in pleural fluid production that
overwhelms its removal, thereby causing an accumulation manifest as MPE.

• Interestingly, pleural effusion does not occur in every patient with pleural metastases.
• Current research has shed light on the fact there may be certain genetic characteristics or “secretomes”
carried by these tumors that do cause effusions. Tumor cells may produce vascular endothelial growth factor
(VEGF). These factors interact with inflammatory cells in the mesothelium and endothelium leading to capillary
leak into the pleural space that overwhelms the lymphatic system’s ability to reabsorb.

• There is also some thought that direct tumor invasion of the lymphatics may disrupt this drainage system.
CLINICAL PRESENTATION

• Local and systemic effects

• Dyspnea is the most common presenting symptom and is often related size of
the pleural effusion
• Up to one-fourth of patients may be asymtopmatic at presentation
• Dyspnea caused by restrictive pulmonary physiology and gas-exchange
abnormalities
• The incompressible pleural fluid collection and the limited outward chest wall
excursion result in compression and atelectasis of lung parenchyma
• The reduction of vital capacity reduces the effective gas exchange
DIAGNOSIS

• Radiographic Findings
• Plain chest radiography
• Decubitus/supine chest radiography
• CT Scan
• PET Scan
• Tissue Confirmation
• Thoracentecis and Studies of the plural fluid
• immunohistochemistri
• Tissue Biopsies
DIAGNOSIS

• Radiographic Findings
• Plain chest radiography
• Decubitus/supine chest radiography
• CT Scan
• PET Scan
• Tissue Confirmation
• Thoracentecis and Studies of the plural fluid
• immunohistochemistri
• Tissue Biopsies
TREATMENT: INDICATIONS, APPROACHES,AND
COMPLICATIONS
• Because the presence of malignant cells in the pleural space implies metastatic
and hence incurable disease, the goal of therapy is primarily to palliate
symptoms and to anticipate and thus avoid complications caused by pleural
involvement
INDWELLING PLEURAL CATHETER

• With the advent of readily accessible bedside imaging modalities such as ultrasound, placement of indwelling
pleural catheters(IPC) to an effusion is now a safe and efficient method for continued symptomatic relief of
MPE.
• this method has been shown to be superior to repeated thoracentesis in a variety of ways. It is generally safer
than repeated thoracentesis and has a higher success rate, specifically with smaller or loculated pleural fluid
collections.
• In a recent case series of 80 patients with MPE, ultrasound-guided catheter placement was met with success in
87% of the patients. this method is often found to be better tolerated from a patient care standpoint.
• It does not require a large skin incision or blunt dissection to accommodate a large-bore chest drain as used in
the tube thoracostomy method discussed next and has been shown to have fewer insertion-
relatedcomplications.
• Also in this case series of 124 patients with various etiologies of pleural effusions, larger bore size chest tube
was not found to have an improved benefit on treatment of the symptomatic effusion.
INDWELLING PLEURAL CATHETER

• One common pleural drainage system is the PleurX drain (Denver Biomaterials, Golden, CO), a tunnelled
pleural catheter with a fabric cut hat promotes ingrowth and is suitable for permanent placement.
• It is easily inserted either in the operating room or with local anesthetic at the bed side.
• These systems offer continued drainage of the refractory pleural effusion as well as being smaller, more
comfortable, and more portable than the traditional chest tube.
• The catheter can be easily used at home by home health nurses, family members, or by the patient them self.
• It is easily connected to disposable plastic evacuated bottles to drain the effusion whenever it becomes
symptomatic. Repeated drainage can improve dyspnea and promote symphysis of the visceral pleura to the
parietal pleura thus obliterating the space for recurrent effusions to develop. If no longer desired, the
catheters can be removed at the bedside with local anesthetic if removal is desired, but permanent placement
is also common.
TUBE THORACOSTOMY

• Classically, tube thoracostomy was employed as first-line treatment of MPE that did
not resolve after thoracentesis drainage and systemic therapy. .
• With increasing availability of ultrasound or CT guided drainage, indications for
large bore chest tube placement are decreasing.
• One possible indication may be a patient presenting to an emergency department in
distress, without availability of percutaneous drainage.
• In this case a 20- to 24-French chest tube is inserted at the bedside, usually with the
patient under intra venous sedation and local analgesic infiltration.
• The chest tube is placed to water seal drainage reservoir, serial chest radiographs
obtained, and chest drainage recorded.
TUBE THORACOSTOMY

• Pleurodesis can then be performed through the tube if the lung has re-
expanded and the pleural drainage has been sufficiently low (<200 mL per
24 hours, as is typical of our practice). Pleurodesis can be successful only if the
lung is completely re expanded so that the parietal and visceral pleura can
oppose, otherwise pleurodesis will further “trap” the lung in a partly
collapsed state, and sclerosing agent such as talc could become infected,
which would present a clinical challenge.
PLEURODESIS

• Pleurodesis variety of methods with the introduction of the IPC and VATS but has
classically been accomplished via tube thoracostomy.
• A 2016 Cochrane review of the different management options for MPE with regard
to pleurodesis compared 16 agents with a variety of methods for instillation and
administration showed that the most effective single agent was talc. The best
improvement in subjective dyspnea scores at 30 days post treatment was with talc
slurry administered through an IPC. This was associated with better patient tolerance
of the procedure and equivalent post procedural fever.
SURGICAL INTERVENTION: VIDEO-
ASSISTEDTHORACOSCOPIC SURGERY, PLEURAL
DECORTICATION,PERICARDIAL DRAINAGE
• If diagnosis is in question, or pleurodesis has failed and a malignant pleural
effusion recurs, thoracoscopy (VATS) is a useful diagnostic and therapeutic
tool.
• Options for therapeutic maneuvers include lysis of adhesions, limited
decortication, pleurectomy, mechanical and chemical pleurodesis, and visual
positioning of drainage tubes.
SURGICAL PLEURECTOMY

• With modern-day therapies available for MPEs, pleurectomy islargely

anachronistic.
• This procedure, with its high operative morbidity and mortality, cannot be
justified as a palliative measure and has been replaced by interventions with
lower morbidity rates.
PATIENTS WITH TRAPPED LUNG

• If the effusion has not been controlled or is loculated, the lung could be
trapped (>25% pleural dead space).
• A trapped lung that cannot expand leaves pleural dead space that will
rapidly reaccumulate fuid and nullify any attempts at pleurodesis. A
pleuroperitoneal shunt.
SCLEROSING AGENTS

• Many agents have been used to affect pleural symphysis.

Most have a direct irritant effect, usually eliciting an intense pleural
inflammation and subsequent fibrosis.
• A number of anti-neoplastic agents have also been administered locally into
the pleural space, with the purported dual cytotoxic and fibrotic action on the
involved pleural surfaces.
• Mitoxantrone
• radioactive phosphorus
• Thiotepa
• 5- fluorouracil
• Talc
PROGNOSIS

• The development of malignant effusion in a breast cancer patient generally

portends a poor prognosis, with a median survival time of 5 to 15.7 months.
Patients with metastatic pleural disease as the solo manifestation of relapse
have a significant survival advantage over those with more widespread
disease: 48months versus 12 months in one series. The concomitant presence of
invasion into other mesothelium-lined cavities, including the pericardium and
peritoneum, are especially ominous signs.