Pleural Malignancy Flashcards
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
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
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
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
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
What can the pleural fluid look like?
Straw-coloured Bloody Turbid/milky Foul smelling Food particles
What does straw-coloured pleural fluid indicate?
Cardiac failure
Hypoalbuminemia -level of albumin in the blood is abnormally low
What does bloody pleural fluid indicate?
Trauma
Malignancy
Infection
Infarction
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.
What does foul smelling pleural fluid indicate?
Anaerobic empyema
What does food particles in the pleural fluid indicate?
Oesophageal rupture
What does bilateral pleural effusion indicate?
Left ventricular failure
PTE
Drugs
Systemic path
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
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
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
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
What marker will favour neoplasia over hyperplasia in a pleural tap?
Thick membrane staining with EMA and negative with desmin
What does C4 mean?
Suspicious of malignancy but not confirmed
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
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
