Management des malignen Pleuraergusses

Das Management des malignen Pleuraergusses beinhaltet eine frühzeitige Diagnostik, zu der die zytopathologische Beurteilung sowie die Evaluation der Ausdehnungsfähigkeit der Lunge nach Drainage des MPE zählt. Die therapeutischen Verfahren zur lokalen Ergusskontrolle entsprechen palliativen Maßnahmen zur Linderung der Symptome und sollten differenziert nach dem Allgemeinzustand sowie Prognoseabschätzung des Patienten angewendet werden.

Abstract

Malignant pleural effusion is a common diagnosis in metastasized cancers. It is always of palliative character. Main symptoms are dyspnoea and reduced quality of life. Diagnosis is made by ultrasound-guided puncture of the pleural effusion (cytology) and often video-assisted thoracic surgery with biopsy of the pleural surface (histology). The goal of treatment is a fast, sustainable, minimally invasive, patient-centred therapy that increases quality of life. Besides systemic therapy and best supportive care the patient can be treated with local therapy including either pleurodesis (via drainage or VATS) or an indwelling-pleural catheter (IPC). Decision for one of these procedures is made upon performance index (ECOG), expandability of the lung, prognosis and the patient’s wish. For the first technique, the lung must be expandable. The latter one (IPC) can be implanted both with expandable and trapped lung. Both are similarly effective in symptom control.

Kernaussagen

• Primäres Ziel beim Management des MPE besteht darin, die Symptomatik schnell, nachhaltig, schonend/minimalinvasiv und mit kurzer Hospitalisierung zu kontrollieren.

• Das therapeutische Lokalverfahren sollte individuell abhängig vom Allgemeinzustand des Patienten, von der Ausdehnungsfähigkeit der Lunge, der Prognose und vor allem abhängig vom Patientenwunsch ausgewählt werden.

• Eine erfolgreiche Pleurodese kann via Drainage, VATS oder IPC unter stationären wie ambulanten Bedingungen erfolgen, setzt jedoch eine möglichst erhaltene Ausdehnungsfähigkeit der Lunge voraus.

• Bei symptomatischen Patienten und fehlender Ausdehnungsfähigkeit der Lunge („Trapped Lung“) sollte der IPC zur Ergusskontrolle favorisiert werden.

• Sowohl die Pleurodese als auch der IPC sind effektive Verfahren zur Besserung der Symptomatik und der Lebensqualität der Patienten mit MPE.

Schlüsselwörter

maligner Pleuraerguss - Pleurakarzinose - Pleurodese - Pleurakatheter

Keywords

malignant pleural effusion - pleural carcinosis - pleurodesis - indwelling pleural catheter

Publication History

Article published online:
05 June 2024

• Literatur

• 1 Ried M, Hofmann HS. Behandlungskonzepte der Pleurakarzinose mit malignem Pleuraerguss. Dtsch Ärztebl Int 2013; 110: 313-318 DOI: 10.3238/arztebl.2013.0313.
• 2 Clive AO, Bhatnagar R, Preston NJ. et al. Cochrane corner: interventions for the management of malignant pleural effusions. Thorax 2016; 71: 964-966 DOI: 10.1136/thoraxjnl-2016-208989. (PMID: 27418604)
• 3 Roberts ME, Neville E, Berrisford RG. et al. Management of a malignant pleural effusion: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010; 65 (Suppl. 2) ii32-ii40 DOI: 10.1136/thx.2010.136994. (PMID: 20696691)
• 4 Dipper A, Jones HE, Bhatnagar R. et al. Interventions for the management of malignant pleural effusions: a network meta-analysis. Cochrane Database Syst Rev 2020; 4: CD010529 DOI: 10.1002/14651858.CD010529.pub3. (PMID: 32315458)
• 5 Kaifi JT, Toth JW, Gusani NJ. et al. Multidisciplinary management of malignant pleural effusion. J Surg Oncol 2012; 105: 731-738 DOI: 10.1002/jso.22100. (PMID: 21960207)
• 6 Roberts ME, Rahman NM, Maskell NA. et al. British Thoracic Society Guideline for pleural disease. Thorax 2023; 78: 1143-1156 DOI: 10.1136/thorax-2023-220304. (PMID: 37433578)
• 7 Bibby AC, Dorn P, Psallidas I. et al. ERS/EACTS statement on the management of malignant pleural effusions. Eur J Cardiothorac Surg 2019; 55: 116-132 DOI: 10.1093/ejcts/ezy258. (PMID: 30054348)
• 8 Egan AM, McPhillips D, Sarkar S. et al. Malignant pleural effusion. QJM 2014; 107: 179-184 DOI: 10.1093/qjmed/hct245. (PMID: 24368856)
• 9 Addala DN, Kanellakis NI, Bedawi EO. et al. Malignant pleural effusion: Updates in diagnosis, management and current challenges. Front Oncol 2022; 12: 1053574 DOI: 10.3389/fonc.2022.1053574. (PMID: 36465336)
• 10 Yang MF, Tong ZH, Wang Z. et al. Development and validation of the PET-CT score for diagnosis of malignant pleural effusion. Eur J Nucl Med Mol Imaging 2019; 46: 1457-1467 DOI: 10.1007/s00259-019-04287-7. (PMID: 30903197)
• 11 Hooper C, Lee YC, Maskell N. et al. Investigation of a unilateral pleural effusion in adults: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010; 65 (Suppl. 2) ii4-ii17 DOI: 10.1136/thx.2010.136978. (PMID: 20696692)
• 12 Arnold DT, De Fonseka D, Perry S. et al. Investigating unilateral pleural effusions: the role of cytology. Eur Respir J 2018; 52: 1801254 DOI: 10.1183/13993003.01254-2018. (PMID: 30262573)
• 13 Yanik F. Current overview of awake, non-intubated, video-assisted thoracic surgery. Wideochir Inne Tech Maloinwazyjne 2023; 18: 445-452 DOI: 10.5114/wiitm.2023.128070. (PMID: 37868284)
• 14 Zhang Q, Deng MM, Li XL. et al. Thoracic ultrasound-guided real-time pleural biopsy in the diagnosis of pleural diseases: a systematic review and meta-analysis. Expert Rev Respir Med 2023; 17: 805-813 DOI: 10.1080/17476348.2023.2266377. (PMID: 37787485)
• 15 Fazli Khalaf F, Asadi Gharabaghi M, Balibegloo M. et al. Pleural CEA, CA-15–3, CYFRA 21–1, CA-19–9, CA-125 discriminating malignant from benign pleural effusions: Diagnostic cancer biomarkers. Int J Biol Markers 2023; 38: 81-88 DOI: 10.1177/03936155231158661.
• 16 Zhang Y, Wang J, Liang B. et al. Diagnosis of malignant pleural effusion with combinations of multiple tumor markers: A comparison study of five machine learning models. Int J Biol Markers 2023; 38: 139-146 DOI: 10.1177/03936155231158125.
• 17 Marques M, Pont M, Hidalgo I. et al. MicroRNAs Present in Malignant Pleural Fluid Increase the Migration of Normal Mesothelial Cells In Vitro and May Help Discriminate between Benign and Malignant Effusions. Int J Mol Sci 2023; 24: 14022 DOI: 10.3390/ijms241814022.
• 18 Hofmann HS, Scheule AM, Markowiak T. et al. The treatment of malignant pleural effusion with permanent indwelling pleural catheters. Dtsch Arztebl Int 2022; 119: 595-600 DOI: 10.3238/arztebl.m2022.0229.
• 19 Rahman NM, Pepperell J, Rehal S. et al. Effect of Opioids vs NSAIDs and Larger vs Smaller Chest Tube Size on Pain Control and Pleurodesis Efficacy Among Patients with Malignant Pleural Effusion: The TIME1 Randomized Clinical Trial. JAMA 2015; 314: 2641-2653 DOI: 10.1001/jama.2015.16840.
• 20 Zahid I, Routledge T, Bille A. et al. What is the best treatment for malignant pleural effusions?. Interact Cardiovasc Thorac Surg 2011; 12: 818-823 DOI: 10.1510/icvts.2010.254789.
• 21 Van Meter ME, McKee KY, Kohlwes RJ. Efficacy and safety of tunneled pleural catheters in adults with malignant pleural effusions: a systematic review. J Gen Intern Med 2011; 26: 70-76 DOI: 10.1007/s11606-010-1472-0. (PMID: 20697963)
• 22 Wilshire CL, Chang SC, Gilbert CR. et al. Association between Tunneled Pleural Catheter Use and Infection in Patients Immunosuppressed from Antineoplastic Therapy. A Multicenter Study. Ann Am Thorac Soc 2021; 18: 606-612 DOI: 10.1513/AnnalsATS.202007-886OC.
• 23 Song YG, Lee MO, Nam Y. et al. Tract seeding in indwelling pleural catheter placement for the drainage of malignant pleural effusions: Incidence and related clinical and imaging factors. Eur J Radiol 2023; 166: 110976 DOI: 10.1016/j.ejrad.2023.110976. (PMID: 37459688)
• 24 Frost N, Brünger M, Ruwwe-Glösenkamp C. et al. Indwelling pleural catheters for malignancy-associated pleural effusion: report on a single centre’s ten years of experience. BMC Pulm Med 2019; 19: 232 DOI: 10.1186/s12890-019-1002-8. (PMID: 31791305)
• 25 Demmy TL, Gu L, Burkhalter JE. et al. Optimal management of malignant pleural effusions (results of CALGB 30102). J Natl Compr Canc Netw 2012; 10: 975-982 DOI: 10.6004/jnccn.2012.0102. (PMID: 22878823)
• 26 Davies HE, Mishra EK, Kahan BC. et al. Effect of an indwelling pleural catheter vs chest tube and talc pleurodesis for relieving dyspnea in patients with malignant pleural effusion: the TIME2 randomized controlled trial. JAMA 2012; 307: 2383-2389 DOI: 10.1001/jama.2012.5535.
• 27 Thomas R, Fysh ETH, Smith NA. et al. Effect of an Indwelling Pleural Catheter vs Talc Pleurodesis on Hospitalization Days in Patients with Malignant Pleural Effusion: The AMPLE Randomized Clinical Trial. JAMA 2017; 318: 1903-1912 DOI: 10.1001/jama.2017.17426.
• 28 Iyer NP, Reddy CB, Wahidi MM. et al. Indwelling Pleural Catheter versus Pleurodesis for Malignant Pleural Effusions. A Systematic Review and Meta-Analysis. Ann Am Thorac Soc 2019; 16: 124-131 DOI: 10.1513/AnnalsATS.201807-495OC. (PMID: 30272486)
• 29 Wahidi MM, Reddy C, Yarmus L. et al. Randomized Trial of Pleural Fluid Drainage Frequency in Patients with Malignant Pleural Effusions. The ASAP Trial. Am J Respir Crit Care Med 2017; 195: 1050-1057 DOI: 10.1164/rccm.201607-1404OC.
• 30 Muruganandan S, Azzopardi M, Fitzgerald DB. et al. Aggressive versus symptom-guided drainage of malignant pleural effusion via indwelling pleural catheters (AMPLE-2): an open-label randomised trial. Lancet Respir Med 2018; 6: 671-680 DOI: 10.1016/S2213-2600(18)30288-1. (PMID: 30037711)
• 31 Markowiak T, Ried M, Grosser C. et al. Postoperative outcome after palliative treatment of malignant pleural effusion. Thorac Cancer 2022; 13: 2158-2163 DOI: 10.1111/1759-7714.14534. (PMID: 35748347)
• 32 Fysh ETH, Waterer GW, Kendall PA. et al. Indwelling pleural catheters reduce inpatient days over pleurodesis for malignant pleural effusion. Chest 2012; 142: 394-400 DOI: 10.1378/chest.11-2657. (PMID: 22406960)
• 33 Psallidas I, Hassan M, Yousuf A. et al. Role of thoracic ultrasonography in pleurodesis pathways for malignant pleural effusions (SIMPLE): an open-label, randomised controlled trial. Lancet Respir Med 2022; 10: 139-148 DOI: 10.1016/S2213-2600(21)00353-2. (PMID: 34634246)
• 34 Bhatnagar R, Kahan BC, Morley AJ. et al. The efficacy of indwelling pleural catheter placement versus placement plus talc sclerosant in patients with malignant pleural effusions managed exclusively as outpatients (IPC-PLUS): study protocol for a randomised controlled trial. Trials 2015; 16: 48 DOI: 10.1186/s13063-015-0563-y.
• 35 Bhatnagar R, Keenan EK, Morley AJ. et al. Outpatient Talc Administration by Indwelling Pleural Catheter for Malignant Effusion. N Engl J Med 2018; 378: 1313-1322 DOI: 10.1056/NEJMoa1716883. (PMID: 29617585)
• 36 Boujaoude Z, Bartter T, Abboud M. et al. Pleuroscopic Pleurodesis Combined With Tunneled Pleural Catheter for Management of Malignant Pleural Effusion: A Prospective Observational Study. J Bronchology Interv Pulmonol 2015; 22: 237-243 DOI: 10.1097/LBR.0000000000000186.
• 37 Dresler CM, Olak J, Herndon 2nd JE. et al. Phase III intergroup study of talc poudrage vs talc slurry sclerosis for malignant pleural effusion. Chest 2005; 127: 909-915 DOI: 10.1378/chest.127.3.909. (PMID: 15764775)
• 38 Bhatnagar R, Piotrowska HEG, Laskawiec-Szkonter M. et al. Effect of Thoracoscopic Talc Poudrage vs Talc Slurry via Chest Tube on Pleurodesis Failure Rate Among Patients With Malignant Pleural Effusions: A Randomized Clinical Trial. JAMA 2020; 323: 60-69 DOI: 10.1001/jama.2019.19997.
• 39 Tan C, Sedrakyan A, Browne J. et al. The evidence on the effectiveness of management for malignant pleural effusion: a systematic review. Eur J Cardiothorac Surg 2006; 29: 829-838 DOI: 10.1016/j.ejcts.2005.12.025. (PMID: 16626967)
• 40 Mummadi S, Kumbam A, Hahn PY. Malignant pleural effusions and the role of talc poudrage and talc slurry: a systematic review and meta-analysis. F1000Res 2014; 3: 254 DOI: 10.12688/f1000research.5538.2. (PMID: 25878773)
• 41 Leitlinienprogramm Onkologie (Deutsche Krebsgesellschaft, Deutsche Krebshilfe, AWMF). S3-Leitlinie Prävention, Diagnostik, Therapie und Nachsorge des Lungenkarzinoms, Langversion 3.0, 2024, AWMF-Registernummer: 020/007OL. Accessed March 27, 2024 at: https://www.leitlinienprogramm-onkologie.de/leitlinien/lungenkarzinom/
• 42 Teixeira LR, Vargas FS, Acencio MM. et al. Influence of antiinflammatory drugs (methylprednisolone and diclofenac sodium) on experimental pleurodesis induced by silver nitrate or talc. Chest 2005; 128: 4041-4045 DOI: 10.1378/chest.128.6.4041. (PMID: 16354879)
• 43 Heffner JE, Nietert PJ, Barbieri C. Pleural fluid pH as a predictor of survival for patients with malignant pleural effusions. Chest 2000; 117: 79-86 DOI: 10.1378/chest.117.1.79. (PMID: 10631203)
• 44 Zamboni MM, da Silva jr CT, Baretta R. et al. Important prognostic factors for survival in patients with malignant pleural effusion. BMC Pulm Med 2015; 15: 29 DOI: 10.1186/s12890-015-0025-z.
• 45 Clive AO, Kahan BC, Hooper CE. et al. Predicting survival in malignant pleural effusion: development and validation of the LENT prognostic score. Thorax 2014; 69: 1098-1104 DOI: 10.1136/thoraxjnl-2014-205285. (PMID: 25100651)