Pleural malignancy Flashcards
What is indicated with a pleural fluid that is:
- straw coloured
- bloody
- turbid/milky
- foul smelling
- food particles
- bilateral
Straw coloured:
- cardiac failure
- hypoalbuminaemia
Bloody:
- trauma
- malignancy
- infection
- infarction
Turbid/milky:
- empyema
- chylothorax: lymph accumalating due to obstruction of thoracic duct
Foul smelling:
-anaerobic empyema
Food particles:
-oesophageal rupture
Bilateral:
-LVF, PE, drugs, systemic pathology
What does it mean for pleural fluid to be a transudate?
What are some causes of this (5)
Protein < 30g/L -Heart failure -Liver cirrhosis -Hypoalbuminaemia -Atelectasis (ITU or post surgery) -Peritoneal dialysis (is not always benign)
What does it mean for a pleural fluid to be an exudate? What are some causes for this? (4)
Protein > 30g/L -Malignancy -Infection inc TB -Pulmonary infarct -Asbestos (always look for serious pathology)
What does the pH of pleural fluid suggest about the cause of the pleural effusion?
Normal 7.6 (only valid if plasma pH normal)
< 7.3 suggests pleural inflammation (malignancy/ Rh A)
< 7.2 requires drainage in the setting of infection
Do not check if frank pus!
When would glucose levels of pleural aspirate be low?
LOW in infection, TB, rheumatoid arthritis, malignancy, oesophageal rupture, SLE
What is suggested if: -malignant cells -lymphocytes -neutrophils are found in pleural aspirate?
Mostly looking for malignant cells (2 samples will dx up to 2/3 of malignant effusions)
Lymphocytes – think TB, malignancy although any long standing effusion will eventually become lymphocytic
Neutrophils suggest an acute process
If a pleural aspirate is suggestive of malignancy or there is a high suspicion - what is done and how?
Tissue biopsy:
- Blind percutaneous pleural biopsy (Abrams)
- Image (CT) guided cutting needle pleural biopsy (this is more sensitive)
- Thoracoscopy
- (Thoracotomy)
What is a mesothelioma and what is the main risk factor for mesothelioma?
Uncommon malignant tumour of the lining of the lung or very occasionally of the lining of the abdominal cavity.
Likelihood of developing mesothelioma increases with the degree and the length of time exposed to asbestos.
Occasionally may occur in people who have not worked with asbestos but have been associated with people who have.
Is mesothelioma quick or slow developing?
30-40years to develop
What are the clinical features of mesothelioma? (6)
- breathlressness
- chest pain
- wt loss
- fever
- sweating
- cough
What is looked for on imaging for mesothelioma?
Pleural nodularity
Circumferential pleural thickening
Local invasion
Lung entrapment
What is looked for on pleural fluid aspirate for mesothelioma?
Low cytological yield
Avoid repeated aspiration
What are the 5 different treatment options for mesothelioma?
Pleurodese effusions Radiotherapy Surgery Chemotherapy Palliative care
What are other causes of malignant pleural effusion? what is the survival?
Virtually all cancers may metastasize to the pleura esp.
lung cancer
breast cancer
(Upper GI, lymphoma, melanoma, ovary)
Median survival 3-12 months but large variation
What is pleurodesis? how can this be done? what are the complications? (6)
obliteration of the pleural space
can be done using talc as a sclerosing agent:
- Success about 60%.
- Involve a stay in hospital
Complications: Minor pleuritic pain and fever (Common). Pneumonia (Rare). Respiratory failure (Rare). Talc pneumonitis/ARDS ( Rare) Secondary empyema (Rare). Local tumor implantation at port site in mesothelioma.
When would a long term pleural catheter be used? Why? How long?
inserted mostly in patients with malignant effusions and it allows pt.s to control their effusion.
designed to remain in place for life although some pts. may stop producing pleural fluid
How does a pleural catheter work? how often do patients need to drain? complications?
Vacuum in drainage bottle that provides suction to drain pleural fluid
Initially people will need to drain daily for a week or so
Eventually most people drain twice to three times a week
Never drain more than 1 litre a day
Complications:
- incorrect placement
- bleeding
- infection
What is used to predict survival in mesothelioma?
LENT score
- LDH level in pleural fluid
- ECOG PS
- (serum) Neutrophil to lymphocyte ratio
- Tumour type
What is the treatment for pleural effusion due to:
- LVF
- Infection
- Malignancy
LVF - diuretic
Infection – drain, antibiotics, may require surgery
Malignancy – drain, pleurodesis, long term pleural catheter
Watchful waiting of unilateral effusions will sometimes (10%) result in cancer being found (empirical Rx sometimes appropriate eg TB)
What 4 risk factors exist for pneumothorax? what is a primary pneumothorax compared with a secondary?
Tall thin men
Smokers
Cannabis
Underlying lung disease
Primary is if lungs are normal, can be caused by apical bullae rupture
secondary is if there’s an underlying lung disease
What are 3 symptoms of pneumothorax? what are 5 signs?
- acute onset pleuritic chest pain
- SOB
- Hypoxia
- tachycardia
- hyper-resonant percussion note as is full of air not lung
- reduced chest expansion
- unequal breath sounds
- hamman’s sign (click on auscultation of left side)
what is classified as a small or large pneuomothorax on chest xray? what is CT useful for in pneumothorax?
<2cm = small
>2cm = large
measured at hilar level
CT useful to differentiate bullous lung disease or small pneumothoraces
What is the treatment of pneuomothorax?
Oxygen even if no drain
No treatment if asymptomatic and small
Aspiration 1st line in Primary spontaneous pneumothorax as avoids chest drain BUT is time consuming and may fail esp if age >50 or SSP
Chest drain
May need suction (air leak >48 hours)
Surgical intervention
When would surgery be implicated for pneumothorax?
Second ipsilateral ptx First contralateral ptx Bilateral spontaneous ptx Persistent air leak Risk professions (pilots, divers) after first ptx
What is involved in the follow up after treatment for pneumothorax?
CXR until resolution
Discuss flying and diving after pneumothorax
Risk of recurrence
Smoking cessation
