Pleural Malignancy Flashcards by Joanna Mitchell

What is the anatomy of the pleura?

Serous membrane
The visceral pleural covers the lungs and form the interlobar fissures
The parietal pleura covers the mediastinum, diaphragm and inner surface of the thorax
Inferior margins of the pleura considerably lower than the corresponding border of the lung
Usually contains approx 4mls
Need approx. 200mls of fluid to be detected on a plain CXR

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What is the purpose of the pleural fluid?

Lubricates the 2 pleural surfaces allowing the pleura to slide smoothly during respiration. The surface tension allow the lung surface to stay touching the thoracic wall creating a seal between the 2 surfaces

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Where do the 2 layers combine?

Around the hila of the lung, so the hila has no pleural coverage
The pleural layers combine to form the pulmonary ligament which runs inferiorly and attaches the root of the lung to the diaphragm

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What is a pleural effusion?

An abnormal collection of fluid in the pleural space. It is a common presentation of numerous diseases but does not always require drainage or sampling (cardiac failure) but a large unilateral effusion should raise concern

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How is a pleural effusion diagnosed?

History and examination 
PA CXR
Pleural aspirate if it is not convincingly cardiac failure 
Biochemistry - is it a transudate or exudate (Transudate is fluid pushed through the capillary due to high pressure within the capillary. Exudate is fluid that leaks around the cells of the capillaries caused by inflammation)
Cytology 
Culture 
Contrast enhanced CT chest 
Pleural tap
Pleural biopsy

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What can the pleural fluid look like?

Straw-coloured 
Bloody
Turbid/milky
Foul smelling
Food particles

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What does straw-coloured pleural fluid indicate?

Cardiac failure

Hypoalbuminemia -level of albumin in the blood is abnormally low

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What does bloody pleural fluid indicate?

Trauma
Malignancy
Infection
Infarction

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What does turbid/milky pleural fluid indicate?

Empyema
Chylothorax - lymph formed in the digestive system called chyle accumulating in the pleural cavity due to either disruption or obstruction of the thoracic duct.

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What does foul smelling pleural fluid indicate?

Anaerobic empyema

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What does food particles in the pleural fluid indicate?

Oesophageal rupture

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What does bilateral pleural effusion indicate?

Left ventricular failure
PTE
Drugs
Systemic path

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What will the biochemistry show for a transudate pleural effusion?

Protein <30 g/L
Heart failure 
Liver cirrhosis
Hypoalbuminaemia
Atelectasis 
Peritoneal dialysis 
Does not always have a benign aetiology

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What will the biochemistry show for an exudate pleural effusion?

Protein >30 g/L 
Malignancy 
Infection inc TB
Pulmonary infarct 
Asbestos 
Always look for a serious pathology

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What will you look for in cytology and cell counts?

Look 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

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What will be looked for in microbiology?

Gram stain and microscopy
Culture
PCR, AFB stain and liquid culture
Put in blood culture bottles for higher yield

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What marker will favour neoplasia over hyperplasia in a pleural tap?

Thick membrane staining with EMA and negative with desmin

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What does C4 mean?

Suspicious of malignancy but not confirmed

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What does it mean if the pleural effusion clears up in less than 2 months?

CHF (congestive heart failure) 
Acute pancreatitis 
Post CABG
Post Tx
Pulmonary embolism 
Sarcoisodid 
Traumatic chylothorax

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What does it mean if the pleural effusion clears up in 2-6 months?

TBC - not sure
Post CABG
Cardiac injury 
Sarcoidosis 
Benign asbestos 
Chronic pancreatitis

What does it mean if the pleural effusion clears up in 6-12 months?

Rheumatoid

Benign asbestos

What does it mean if the pleural effusion is benign persistent?

YNS - yellow nail syndrome
Trapped lung
Lymphangiectasia

What is an ancillary effusion?

Systemic tumour effects:
Embolism, hypoalbuminaemia 
Local tumour effects:
Postobstructive infection
Lymphatic obstruction 
Atelectasis

What is meothelioma?

An uncommon malignant tumour of the lining of the lung or very occasionally of the lining of the abdominal cavity

What are the chances of developing mesothelioma?

It increases with the degree and 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 Often takes 30-40

What are some symptoms of mesothelioma?

Breathlessness, chest pain, weight loss, fever, sweating and cough

What are the 3 types of asbestos fibers?

Chystotile (white powder) Amosite (brown) Crocidolite (most dangerous)

What investigations can be done to diagnose meothelioma?

Imaging - pleural nodularity, cicumferential pleural thickening, local invasion, lung entrapment Pleural fluid aspiration - low cytological yield, avoid repeated aspiration Biopsy - thoracoscopy

What is the treatment of mesothelioma?

``` Pleurodese effusions Radiotherapy Surgery Chemo Paliative care Report deaths to the fiscal ```

Where do all cancers metastasize to?

The pleura, this includes: Lung cancer, breast cancer, upper GI, lymphoma, melanoma, ovary The median survival is 3-12 months but there is large variation

What are treatment options for malignant pleural effusion?

``` Nothing and palliate symptoms Repeated pleural taps Drain and/or pleurodesis Long term pleural catheters Surgical options (abrasion, pleurectomy) ```

What are the complications to using a talc slurry?

``` Minor pleuritic pain and fever Pneumonia Respiratory failure Talc pneumonitis/ARDS Secondary empyema Local tumour implantation at port site in messthelioma ```

What is the purpose of a long term plueral catheter?

To allow patients to control their effusion and therefore symptoms Inserted mostly in patients with malignant effusions The drain is designed to remain in place for life though some will stop producing pleural fluid

What are some complications of a long term pleural catheter?

Incorrect placement Bleeding Infection Patients however can shower and fly

How is survival predicted in MPE (malignant pleural effusion)

``` The LENT score: LDH ECOG PS Neutrophil to lymphocyte ratio Tumour type ```

What are the treatment options for MPE?

Depends on underlying cause LVF- diuretics Infection - drain, antibiotics, may require surgery Malignancy - drain, pleurodesis, long term pleural cathater Watchful waiting of unilateral effusions will sometimes (10%) result in cancer being found

Who is more likely to get a pneumothorax?

``` More common in: Tall thin men Smokers Cannabis Underlying lung disease ```

What causes a primary pneumothorax?

Normal lungs | Apical bullae rupture

What causes a secondary pneumothorax?

Underlying lung disease (COPD)

What is the presentation of a pneumothorax?

``` Acute onset pleuritic chest pain SOB, hypoxia Signs: Tachycardia Hyper-resonant percussion note Reduced expansion Quiet breath sounds on auscultation Hamman's sign (click on auscultation left side) ```

What investigations can be done to diagnose a pneumothorax?

CXR - small <2cm rim of air Large - >2cm of air 2cm rim is approx 50% pneumothorax by volume, it is measured at hilar level not apex CT chest - useful to differentiate bullous lung disease or small pneumothorces

How can pneumothoraxes be managed?

Oxygen even if no drain is inserted No treatment is needed if the pneumothorax is asymptomatic and small Aspirations is the 1st line in PSP - this avoids chest drain, but is time consuming and may fail Chest drain May need suction Surgical intervention

What indications are there for surgical intervention?

``` Second ipsilateral ptx First contralateral ptx Bilateral spontaneous ptx Persistent air leak Risk professions (pilots, drivers) after first ptx ```

What is the follow-up protocol for ptx?

CXR until resolution Discuss flying and driving after Risk of recurrence Smoking cessation

What is a tension pneumothorax?

An emergency that can lead to cardiac arrest One-way valve that progressively increases pressure in the pleural space that pushes other chest organs to the opposite side to the affected side

What are the signs of a tenion ptx?

``` Acute respiratory distress Trachea deviated to opposite side Hypotension Raised JVP Reduced air entry on affected side ```

What can cause a tension pneumothorax?

``` Ventilated patient Trauma CPR especially PEA Blocked, kinked or misplaced drain Pre-existing airway disease Patients undergoing hyperbaric treatment ```

Where is the needle placed for relief of a tension ptx?

2nd intercostal space in the midclavicular line