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General Thoracic Surgery > 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
Q

Pleural fluid cytology diagnostic in _ % of case of MPM

A

30-50%

*High levels of hyaluronic acid suggestive of MPM

26
Q

Most accurate and preferred approach to obtaining tissue for definitive diagnosis of MPM

A

VATS pleural biopsy

Location of incision needs to be carefully planned to permit subsequent resection and to avoid port site seeding

27
Q

3 major histologic subtypes of MPM

A
  • Epitheliod (most common, best prognosis)
  • Sarcomatoid
  • Mixed (biphasic)
28
Q

MC histologic subtype of MPM

A

Epitheliod (~ 66%, best prognosis)

29
Q

Definition of mixed (biphasic) MPM

A

Tissue must be composed of at least 10% epitheliod and sarcomatoid components

30
Q

Two most common staging systems for MPM

A

International Mesothelioma Interst Group TNM staging system

Brigham & Women’s Hospital staging system

31
Q

MPM TNM Staging System

T1-stage

A
  • T1: involvement of ipsilateral parietal pleura +/- focal visceral pleura
    • T1a: ipsilateral parietal pleura only
    • T1b: ipsilateral parietal pleura + focal visceral pleura
32
Q

MPM TNM Staging:

T2 - stage

A

T2: involvment of ipsilateral parietal pleura with one of following

  • Confluent visceral pleura (including fissue)
  • Diaphragmatic muscle
  • Lung parenchyma
33
Q

MPM TNM Staging:

T3 - stage

A

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
Q

MPM TNM Staging:

T4 - stage

A

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
Q

MPM TNM Staging:

N-staging

A
  • 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
Q

MPM TNM Staging:

M - staging

A
  • M0: no distant metastasis
  • M1: distant metastasis
37
Q

MPM Staging

Stage I

A

Stage I

  • T1 disease (N0M0)
    • Stage Ia: T1a
    • Stage Ib: T1b
38
Q

MPM Staging:

Stage II

A

Stage II

  • T2 disease (N0M0)
39
Q

MPM Staging:

Stage III

A

Stage III:

  • T3 or N disease
    • T3 (N0M0)
    • T1-2 + N1-2 (M0)
40
Q

MPM Staging

Stage IV

A

Stage IV:

  • T4 disease
  • T1-4 + N3 disease
  • M disease
41
Q

Palliative treatment options for MPM provide what benefits to patients

A
  • Improved quality of life
  • Median survival of 6-9 months
42
Q

MC chemotherapy used for MPM

A

Combination therpay: Cisplatin + premetrexed (12 month survival)

*Cisplatin alone (9-month surivial)

43
Q

Surgical approaches to MPM

A
  • Extrapleural pneumonectomy (EPP)
  • Pleurectomy/Decortication (P/D)
44
Q

Definiton of EPP

A

En bloc resection:

  • Lung
  • Parietal and visceral pleura
  • Pericardium
  • Ipsilateral hemidiaphragm

*3-4% operative mortality

45
Q

Defintion of P/D

A

Resection of parietal and visceral pleura +/- resection of pericardium and diaphragm

* 1-2% operative mortality

46
Q

Traditionally, pleurectomy and decortication utilized for which MPM patient population

A
  • High-risk
  • Advanced disease
47
Q

TOC for MPM

A

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
Q

Palliative chemotherapy appropriate for what MPM patients

A
  • Stage IV
  • Sarcomatoid histologic subtype
    • Epitheliod and mixed subtypes: multimodality therapy
49
Q

Other treatment options for MPM include the use of:

A

Intrapleural chemotherapy

50
Q

Median survival for MPM with multimodality therapy

A

9-26 months

(improved survival for epitheliod histology)

General Thoracic Surgery (36 decks)

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