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ABTS - Thoracic Surgery Notecards IA > Malignant Pleural Effusions and Malignant Pleural Mesothelioma > Flashcards

Malignant Pleural Effusions and Malignant Pleural Mesothelioma Flashcards

1
Q

Most common causes of malignant pleural effusions (MPE)

A
  • Lung cancer (40%)
  • Breast cancer (25%)
  • Lymphoma (10%)
  • Ovarian cancer (5%)
  • Gastric cancer (5%)
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2
Q

MOA of MPE

A

Pleural seeding (direct tumor extension, hematgoenous spread, lymphatic spread) accompanied by accumulation of pleural fluid.

  • Angiogenic factors
  • Increased vascular permiability
  • Lymphatic obstruction
    • disrupts normal absorption of 2-3L of pleural fluid per day
  • Direct production of fluid by tumor
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3
Q

Median survival for most patients with MPE after diagnosis

A

4-6 months

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4
Q

MC symptoms of MPE

A

Dyspnea

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5
Q

Systemic therapy for MPE

A

Malignancy specific chemotherapry and XRT to primary lung lesions (small effusions.

(not effective for moderate to large MPE)

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6
Q

All cancer patients with a pleural effusion should undergo _

A

Thoracocentesis

  • Diagnosis
  • Weight contribution of the effusion to the patient’s symptoms
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7
Q

Radiographic assessment after thoracocentesis importnat to determine what

A
  • Extent of disease
  • Degree of lung entrapment
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8
Q

T/F

Repeat thoracocentesis is an acceptable managment strategy for patients with an extremely short life expectancy (<2 months)

A

True

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9
Q

Surgical options for recurrent effusions

A
  • Pleurodesis (talc or doxycycline)
  • Indwelling pleural catheter
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10
Q

Essential for success of pleurodesis

A

Lung inflation with pleural apposition

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11
Q

Chemical sclerosants used for pleurodesis

A

Talc

Doxycycline

Bleomycin

*Patients must be medically fit to tolerate the systemic inflammatory reponse that occurs after chemical pleurodesis (especially after talc)

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12
Q

Success rate of talc pleurodesis

A

80-95% at 90 days

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13
Q

Potential serious complications associated with talc as a sclerosant for pleurodesis

A

ARDS

(Extreme caution in medically comprimised and elderly patients)

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14
Q

Surgical options for pleurodesis

A
  • VATS drainage of effusion and installation of sclerosant
  • Thoracostomy tube placement with sclerosant instillation
  • Indwelling pleural catheter placement followed by sclerosant instillation
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15
Q

MC indications for indwelling pleural catheter placement

A

Patients with trapped lung (d/t chronic fibropurulent effusion and fibrin peels) following thoracocentesis for MPE

*Pleural apposition is not possible

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16
Q

Techniques for indwelling pleural catheter placement

A
  • VATS
  • Open
  • Percutaneous (Seldinger technique)
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17
Q

MC primary pleural tumor

A

Malignant pleural mesothelioma (MPM)

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18
Q

Peak incidence of MPM occurs in what patient population

A

Sixth decade

Males (5:1 ratio)

Asbestos exposure (85%)

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19
Q

Exposure to asbestos accounts for __% of patients with MPM

A

85%

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20
Q

Latency period from exposure to development of MPM

A

15-50 years

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21
Q

Non-asbestos related causes of MPM

A
  • XRT
  • Non-asbestos mineral fibers
  • Simian virus 40
22
Q

MC symptoms of MPM

A
  • Dyspnea (MC)
  • Chest pain
    • poor prognostic indicator representing chest wall invasion
23
Q

Primary imaging modality for diagnosis and staging of MPM

A

PET/CT (provides insight into mets and nodal involvement)

*MRI useful to determine invasion into chest wall and transdiaphragmatic extension

24
Q

Presenting appaerance of MPM

A
  • Pleural effusion
  • Subtle pleural thickening
  • Discrete pleural-based masses
  • Thick, confluent pleural rind with lung encasement
25
Pleural fluid cytology diagnostic in _ % of case of MPM
30-50% \*High levels of **_hyaluronic acid_** suggestive of MPM
26
Most accurate and preferred approach to obtaining tissue for definitive diagnosis of MPM
VATS pleural biopsy Location of incision needs to be carefully planned to permit subsequent resection and to _avoid port site seeding_
27
3 major histologic subtypes of MPM
* Epitheliod (most common, best prognosis) * Sarcomatoid * Mixed (biphasic)
28
MC histologic subtype of MPM
Epitheliod (~ 66%, best prognosis)
29
Definition of mixed (biphasic) MPM
Tissue must be composed of at least _10% epitheliod and sarcomatoid components_
30
Two most common staging systems for MPM
International Mesothelioma Interst Group TNM staging system Brigham & Women's Hospital staging system
31
MPM TNM Staging System T1-stage
* T1: involvement of **ipsilateral parietal pleura** **+/- focal visceral pleura** * T1a: ipsilateral parietal pleura only * T1b: ipsilateral parietal pleura + _focal_ visceral pleura
32
MPM TNM Staging: T2 - stage
T2: involvment of ipsilateral parietal pleura with one of following * Confluent visceral pleura (including fissue) * Diaphragmatic muscle * Lung parenchyma
33
MPM TNM Staging: T3 - stage
T3: ipsilateral pleura with one of following: * Invasion of endothoracic fascia * Invasion of mediastinal fat * Focal invasion of chest wall soft tissue * Non-transmural involvement of pericardium
34
MPM TNM Staging: T4 - stage
T4: ipsilateral pleura with one of following: * Diffuse or multifocal invasion of chest wall soft tissue * Invasion of rib * Invasion through diaphragm into peritoneum * Contralateral pleura involvement * Spine invasion * Extension to internal surface of pericardium * Pericardial effusion with positive cytology * Invasion of myocardium * Invasion of brachial plexus
35
MPM TNM Staging: N-staging
* N1: Metastasis to ipsilateral **bronchopulmonary** and/or **hilar** lymph nodes * N2: Metastasis to **subcarinal** and/or **ipsilateral internal mammary** or **mediastinal LN** * N3: Metastasis to **contralateral** _mediastinal, internal mammary or hilar_ LN or **supraclavicular** or **scalene** LN
36
MPM TNM Staging: M - staging
* M0: no distant metastasis * M1: distant metastasis
37
MPM Staging Stage I
Stage I * T1 disease (N0M0) * Stage Ia: T1a * Stage Ib: T1b
38
MPM Staging: Stage II
Stage II * T2 disease (N0M0)
39
MPM Staging: Stage III
Stage III: * T3 or N disease * T3 (N0M0) * T1-2 + N1-2 (M0)
40
MPM Staging Stage IV
Stage IV: * T4 disease * T1-4 + N3 disease * M disease
41
Palliative treatment options for MPM provide what benefits to patients
* Improved quality of life * Median survival of 6-9 months
42
Most common chemotherapy used for Malignant pleural mesothelioma?
Combination therpay: Cisplatin + premetrexed (12 month survival) \*Cisplatin alone (9-month surivial)
43
Surgical approaches to MPM
* Extrapleural pneumonectomy (EPP) * Pleurectomy/Decortication (P/D)
44
Definiton of EPP
En bloc resection: * Lung * Parietal and visceral pleura * Pericardium * Ipsilateral hemidiaphragm \*3-4% operative mortality
45
Defintion of P/D
Resection of parietal and visceral pleura +/- resection of pericardium and diaphragm \* 1-2% operative mortality
46
Traditionally, pleurectomy and decortication utilized for which MPM patient population
* High-risk * Advanced disease
47
TOC for MPM
Multimodality therapy: * Surgical resection (EPP or P/D) * Chemotherapy * XRT * Generally employed for Stages I - III (epithelial and mixed) disease * Stage IV and sarcomatoid MPM palliated with chemotherapy alone
48
Palliative chemotherapy appropriate for what MPM patients
* Stage IV * Sarcomatoid histologic subtype * Epitheliod and mixed subtypes: multimodality therapy
49
Other treatment options for MPM include the use of:
Intrapleural chemotherapy
50
Median survival for MPM with multimodality therapy
9-26 months (improved survival for epitheliod histology)

ABTS - Thoracic Surgery Notecards IA (48 decks)

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