Pleural Malignancy (DISEASE MECHANISMS) Flashcards
What is the plural cavity?
The space between the visceral and parietal pleura
How much fluid does the pleural cavity normally contain?
Approx. 4 ml
How much fluid is approximately needed, in the pleural cavity to be detected on plain CXR?
Approx 200 ml
The two layers of the pleura combine around the ______
hila (of the lung)
The layers of the pleural cavity combine to form the _________ _______ which runs inferiorly and attaches the lung root to the ______
pulmonary ligament
diaphragm
What is pleural effusion?
Abnormal collect not fluid in pleural space
Which type of pleural effusions are a particular cause of concern?
Large unilateral effusions
What tools can be used to diagnose pleural effusion?
History + Examination CXR Pleural aspirate Biochemistry (Exudate/Transudate) Cytology Culture Contrast CT chest Repeated pleural tap Pleural biopsy (blind or thoracoscopy)
What can straw-coloured pleural fluid suggest?
Cardiac failure
Hypoalbuminaemia
What can bloody pleural fluid suggest?
Trauma
Malignancy
Infection
Infarction
What can turbid/milky pleural fluid suggest?
Empyema
Chylothroax
What can foul-smelling pleural fluid suggest?
Anaerobic empyema
What can food particles in the pleural fluid suggest?
Oesophageal rupture
If pleural effusion is bilateral the likely causes include?
LVF
PTE
Drugs
What distinguishes transudate and exudate?
Transudate = < 30 g/L of protein Exudate = > 30 g/L of protein
Why can transudate pleural effusion occur?
Heart failure Hypoproteinaemia Hypoalbuminaemia Atelectasis peritoneal dialysis Hypothyroidism Meig's syndrome (right pleural effusion + ovarian fibroma
What causes an exudate pleural effusion?
Increased leakiness of pleural cavity secondary to: - infection - Inflammation - Injury caused by: - pneumonia - TB - pulmonary infarct - RA - SLE - Bronchogenic carcinoma - malignant metastase - lymphoma - mesothelioma - lymphogitis carcinoma - Asbestos
What does a pleural fluid pH < 7.3 indicate?
Pleural inflammation (malignany / empyema / TB / RA / SLE)
A pleural fluid pH requires …?
Drainage in the setting of infection
Pleural fluid glucose level of <3.3 mmol/L suggest…?
Empyema Malignancy TB RA SLE
What does SLE stand for?
Systemic lupus erythematosus
What does an increase in lymphocytes in pleural fluid indicate?
TB
Malignancy
SLE
Sarcoidosis
What does an increase in neutrophils in the pleural fluid indicate?
Para-pneumonic effusion
PE
How can microbiology be used to analyse pleural fluid?
Gram stain + microscopy
Culture
PCR, AFB stain + liquid culture
Put in blood culture bottles for greater yield
What are the signs of pleural effusion?
Decreased chest expansion
Stony dull percussion note
Reduced breath sounds on affected side
Decreased tactile vocal remits and vocal resonance
Above effusion where lung is compressed there may be bronchial breathing
Possible tracheal deviation if large effusion
Look are aspiration marks
Look for signs of associated disease
What are the associated diseases of pleural effusion?
Malignancy Stigmata of chronic liver disease Cardiac failure Hypothyroidism RA SLE (shows butterfly rash)
Which tests can be used to investigate pleural effusion?
CXR
US
Diagnostic Aspiration
Pleural Biopsy
What is a mesothelioma?
Uncommon tumour of mesothelial cells that usually occurs in the pleura and rarely in the peritoneum or other organs
What is the risk of developing a mesothelioma linked to ?
Asbestos exposure - often takes 30-45 yrs to develop
What are the symptoms of a mesothelioma?
Chest pain Dyspnoea Weight loss Finger clubbing Recurrent pleural effusions Fever Sweating Cough
Which investigations are possible for mesothelioma?
Imagina (plural nodularity / circumferential pleural thickening / lung invasion/ lung entrapments)
Pleural fluid aspiration ( low cytological yield / avoid repeated aspiration / biopsy (thoracoscopy or CT-guided)
How can mesotheliomas be treated?
Pleurdodese effusions Radiotherapy Surgery Chemotherapy Palliative care Report deaths to fiscal (compensation if occupational asbestos exposure)
What are the treatment options for malignant pleural effusion?
Palliative treatment of symptoms Repeated pleura leaps Drain and/or pleurodesis (TALC) Long-term pleural catheter Surgical: abrasions/pneumectomy
What are the advantages of TALC: sclerosing agent?
Success of 60%
What are the disadvantages of TALC: sclerosing agent?
Involves stay in hospital Common Complications - minor pleuritic pain & fever Rare Complications - Pneumonia - Respiratory failure - Talc pneumonitis/ARDS
- Secondary empyema
- Local tumour implantation at port site in mesothelioma
Malignant pleural effusions are due to ______ of many cancers to the _____
metastasis
pleura
What does a long-term pleural catheter involve?
Drain designed to stay for life
Vacuum in drainage bottle produces vacuum providing suction to drain
Drain fluid by demand
What is the maximum amount of a fluid a patient should drain using a long-term pleural catheter?
1 L a day
How is the prognosis of a patient with a malignant pleural effusion calculated?
LENT Score LDH level in pleural fluid (<1500 = 0 / > 1500 = 1) ECOG PS (0 = 0 / 1 = 1 / 2= 2 / 3-4 = 3) (serum) Neutrophil to Lymphocyte ratio (<9 = 0 / >9 = 1) Tumour type (Low risk: mesothelioma/haematological malignancy = 0 // Moderate risk: Breast / gynaecological / renal cell = 1 // High risk: lung cancer / other tumour types = 2)
How is the LENT score interpreted?
0-1 = low score 2-4 = Moderate risk 5-7 = Higher risk
Treatment for malignant pleural effusion depends on ________
underlying cause
How would each of the malignant pleural effusions be treated considering the underlying cause:
LVF
Infection
Malignancy
LVF - Diuretics
Infection - drain/antibiotics/maybe surgery
Malignancy - pleurodesis / long-term pleural catheter
What distinguishes primary and secondary pneumothoraces?
Primary = normal lungs; occurs due to apical bullae rupture / often asymptomatic Secondary = due to underlying lung disease / usually symptomatic
Under which patient category are pneumothoraces more common in?
Tall thin men
Smokers
Cannabis
Underlying lung disease
What are the symptoms of a pneumothorax?
Acute onset of pleuritic chest pain
Dyspnoea
Hypoxia
What are the signs of a pneumothorax?
Tachycardia
Hyper-resonant percussion notReduced chest expansion
Quiet breath sounds on auscultation
Herman’s sign - click on auscultation of left side
How can a pneumothorax be investigated?
CXR usually sufficient CT chest (differentiation between bullous lung disease and small pneumothorax)
How is a pneumothorax managed?
Oxygen even if no drain If small & asymptomatic = no treatment 1st line is aspiration in PSP Chest drain - may need suction Surgical intervention
What causes a tension pneumothorax?
One-way valve causing progressive increase in pleural space pressure
What are the clinical signs of a tension pneumothorax?
Trachea deviated to opp. side
Hypotension
Increased JVP
Reduced air entry on affected side
Why/when would a tension pneumothorax occur?
Patient ventilated Trauma CPR esp. PEA Blocked, kinked or misplaced drain Pre-existing airways disease Patients undergoing hyperbaric treatment
How is a tension pneumothorax treated?
Needle decompression usually with a large bore venflon
Insert at second intercostal space anteriorly & mid-clavicular line
