Pleural Malignancy Flashcards
1
Q
What are pleura?
A
Serous membranes
2
Q
What does the visceral pleura cover?
A
Lungs
3
Q
What do visceral pleura form?
A
Interlobar fissures
4
Q
What do parietal pleura cover (4 types of parietal pleura)?
A
* Mediastinum * Diaphragm * Cervical pleura * Costal pleura
5
Q
Where are the pleura considerably lower than the corresponding border of the lung?
A
Inferior margins
6
Q
How much pleural fluid does the pleural cavity normally contain?
A
Usually contains around 4ml (depends on weight)
7
Q
How much pleural fluid must be present in the pleural cavity in order for it to be detected via CXR?
A
200 ml
8
Q
What is the function of pleural fluid?
A
* Lubricates the 2 pleural surfaces * Allows the pleura to slide smoothly during respiration
9
Q
What allows lung surface to stay touching thoracic wall?
A
Surface tension
10
Q
Which part of the lung has no pleural coverage?
A
The hila
11
Q
What is formed by the combination of the 2 pleural layers?
A
Pulmonary ligament
12
Q
What is the pulmonary ligament?
A
Runs inferiorly and attaches the root of the lung to the diaphragm
13
Q
What is pleural effusion?
A
Abnormal collection of fluid in pleural space?
14
Q
What common techniques are used to make a diagnosis of pleural effusion? (6)
A
* History and examination
* PA CXR
* Pleural aspirate
* Biochemistry (is it a transudate or an exudate?)
* Cytology
* Culture
15
Q
What other tests can be carried out if cause of pleural effusion is still unclear?
A
* Contrast enhanced CT chest
* Repeat pleural tap (thoacentesis)
* Pleural biopsy (blind or thoracoscopy)
16
Q
What problem is seen on this CXR?
A
Right lower lobe pleural effusion - as there is no mediastinal shift, which could indicate tumour instead
17
Q
What is often indicative of pleural effusion on CXR?
A
Meniscus sign
18
Q
What is often indicative of both fluid and air in lung tissue on CXR?
A
Flat line rather than meniscus
19
Q
What can straw-coloured pleural fluid indicate?
A
* Cardiac failure
* Hypoalbuminaemia
20
Q
What can bloody pleural fluid indicate?
A
* Trauma
* Malignancy
* Infection
* Infarction
21
Q
What can turbid/milky pleural fluid indicate?
A
* Empyema
* Chylothorax
22
Q
What can foul-smelling pleural fluid indicate?
A
Anaerobic empyema
23
Q
What can food particles in pleural fluid indicate?
A
Oesophageal rupture
24
Q
What can cause a bilateral pleural effusion?
A
* Left ventricle failure
* Pulmonary thromboembolism
* Drugs
25
What is the purpose of biochemical tests in pleural effusion?
To determine whether fluid is transudate or exudate
26
In biochemical tests, what is indicative of transudate?
Protein \<30g/l
27
In biochemical tests, what is indicative of exudate?
Protein \>30g/l
28
What is transudate fluid indicative of?
\* Heart failure
\* Liver cirrhosis \*
Hypoalbuminaemia
\* Atelectasis (ITU or post surgery)
\* Peritoneal dialysis
29
What is exudate fluid indicative of?
\* Malignancy - cancer
\* Infection inc TB
\* Pulmonary infarct
\* Asbestos
30
What should be done if fluid is found to be exudate?
Always look for serious pathology
31
What can fluid pH tell us in biochemical testing?
\* Normal 7.6 (only valid if plasma pH normal)
\* \< 7.3 suggests pleural inflammation (malignancy/rheumatoid arthritis)
\* \< 7.2 requires drainage in the setting of infection
32
What can glucose levels in biochemical testing tell us?
Glucose levels are low in:-
\* infection
\* TB
\* Rheumatoid arthritis
\* Malignancy
\* oesophageal rupture
\* Systemic lupus erythematosus (SLE)
33
What are cytology and cell counts used for in regards to pleural effusion?
\* Mostly looking for malignant cells
\* Also lymphocytes
\* Neutrophils
34
What does the presence of lymphocytes in cytology of pleural effusion suggest?
\* Tuberculosis
\* Malignancy
\* However, any long-standing infection will eventually become lymphocytic
35
What does the presence of neutrophils in cytology of pleural effusion suggest?
An acute inflammatory process
36
What are the tests for Tuberculosis?
\* PCR
\* Ziehl-Neelsen stain (acid-fast stain)
\* Culture
37
What microbiology techniques are used in the diagnosis of pleural effusion?
\* Gram stain and microscopy
\* Culture
\* PCR, AFB stain and liquid culture
38
How can the liquid culture produce higher diagnostic yield?
Placing in blood culture bottles
39
What is repeat pleural tap/thoracentesis the same as?
Pleural aspiration
40
Is thoracentesis/pleural aspiration useful diagnosing malignant pleural effusion?
Pleural aspiration will diagnose malignancy in approx. 60% of patients with malignant pleural effusion
41
What can be done to increase the diagnostic yield of a pleural tap?
\* A second sample may increase the yield slightly, third and subsequent samples are non-contributory \* Increasing the volume of the aspirate does not increase yield
42
What has a very poor chance of being diagnosed via Pleural fluid cytology?
Mesothelioma - a positive result is obtained in less than a third of cases
43
What are types of tissue biopsy?
\* Blind percutaneous pleural biopsy - Abrams
\* CT guided pleural biopsy
\* Thoracoscopy
\* Thoracotomy
44
How is a blind percutaneous pleural biopsy carried out?
Pleural aspiration using a needle with a special head - when it is pulled back, it takes a section of pleural membrane with it
45
Why are biopsies so often negative?
\* Wrong technique - biopsy doesn't contain pleura
\* The involvement of pleural disease is discontinuous (biopsies section of pleura not affected by disease)
\* The effusion is ancillary to malignancy but not malignant
46
What is the advantage of using CT imaging to guide needle pleural biopsy?
Increases diagnostic sensitivity of Abrams needle biopsy from 47% to 87%
47
What is a mesothelioma?
Uncommon malignant tumour of the lining of the lung or very occasionally of the lining of the abdominal cavity
48
What increases the chance of developing mesothelioma?
Likelihood of developing mesothelioma increases with the degree and the length of time exposed to asbestos (may occur in people who have not worked with asbestos but have been associated with people who have)
49
How often does mesothelioma take to develop?
Often takes 30–40 years to develop
50
What are symptoms of mesothelioma?
May cause breathlessness, chest pain, weight loss, fever, sweating and cough
51
What investigations are involved in diagnosis of mesothelioma?
\* Imaging \* Pleural fluid aspiration \* Biopsy
52
What does imaging for mesothelioma involve?
Looking at:- \* Pleural nodularity \* Circumferential pleural thickening \* Local invasion \* Lung entrapment
53
What does pleural fluid aspiration for mesothelioma involve?
\* Low cytological diagnostic yield (larger with biopsy) \* Avoid repeated aspiration
54
What does biopsy for mesothelioma involve?
Thoracoscopy or CT/US guided
55
What are the treatment options for mesothelioma?
\* Pleurodesis (adhesion of pleural layers to obliterate pleural cavity)
\* Radiotherapy
\* Surgery
\* Chemotherapy
\* Palliative care
\* Report deaths to fiscal (compensation, asbestos etc)
56
What cancers can metastasise to the pleura?
Virtually all cancers but especially:-
\* lung cancer
\* breast cancer
\* Upper GI
\* lymphoma
\* melanoma
\* ovary
57
What is the medial survival rate of mesothelioma sufferers?
3-12 months
58
What is a TALC slurry used for?
Pleurodesis
59
What is pleurodesis?
Procedure to obliterate the space between the pleura (the pleural cavity) so that fluid (water, blood, or pus) can no longer build up between the layers
60
What is TALC?
A sclerosing agent
61
What is a Talc slurry?
TALC in suspension
62
What is the success rate of TALC slurry in plerodesis?
60% success
63
What are complications of TALC?
\* 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
64
What are long term pleural catheters?
Designed to allow patients control their effusion and therefore symptoms
65
When are long term pleural catheters used?
Inserted mostly in patients with malignant effusions
66
Is long term pleural catheter eventually removed?
Drain is designed to remain in place for life though some people will stop producing pleural fluid
67
In long term pleural catheters, what provides the suction to drain pleural fluid?
Vacuum in drainage bottle
68
How much fluid is drained by long term pleural catheter per day?
Never drain more than 1 litre a day
69
What are the complications of long term pleural catheters?
\* Incorrect placement
\* Bleeding
\* Infection
\* Flying can be tricky
70
What are the advantages of long term pleural catheters?
\* Controls symptoms of pleural effusion
\* Patients can shower
\* Some will even bathe or swim though this is not really recommended
71
What is used to predict survival in malignant pleural effusion?
LENT score
72
What is a LENT score?
L - LDH level in pleural fluid
E - ECOG performance status
N - neutrophil to lymphocyte ratio
T - Tumour type
73
What does treatment of malignant pleural effusion involve?
\* LVF – diuretics
\* Infection – drain, antibiotics, may require surgery
\* Malignancy – drain, pleurodesis, long term pleural catheter
74
What does treatment of malignant pleural effusion depend on?
Depends on the underlying cause
75
When is pneumothorax more common?
\* Tall thin men
\* Smokers
\* Cannabis
\* Underlying lung disease
76
What is primary pneumothorax?
\* Initially normal lungs
\* Apical bullae rupture
77
What is secondary pneumothorax?
Underlying lung disease (e.g. COPD)
78
What are the presentations primary pneumothorax?
May be asymptomatic even if moderately sized
79
What are the presentations of secondary pneumothorax?
Usually symptomatic even if small
80
What are the symptoms of secondary pneumothorax?
\* Acute onset pleuritic chest pain
\* SOB
\* Hypoxia
81
What are the clinical signs of pneumothorax?
\* Tachycardia
\* Hyper-resonant percussion note
\* Reduced expansion
\* Quiet breath sounds on auscultation
\* Hamman’s sign (‘Click’ on auscultation left side)
82
What investigation techniques are used for pneumothorax?
\* Chest X-ray usually sufficient
\* CT chest
83
What is a small pneumothorax?
\<2cm rim of air (measured at hilar level, not apex)
84
What is a large pneumothorax?
\>2cm rim of air (measured at hilar level, not apex)
85
What is a CT scan of the chest used for in pneumothorax?
Used to differentiate between bullous lung disease and small pneumothoraces
86
How is pneumothorax managed?
\* Oxygen even if no drain
\* No treatment if asymptomatic and small
\* Aspiration 1st line treatment in primary pneumothorax
\* Chest drain
\* May need suction (air leak \>48 hours)
\* Surgical intervention
87
What are the advantages and disadvantages of aspiration for pneumothorax?
\* Advantages - avoids chest drain
\* Disadvantages - Time consuming May fail esp if age \>50 or secondary pneumothorax
88
What does the follow-up for a pneumothorax involve?
\* CXR until resolution
\* Discuss flying and diving after pneumothorax
\* Risk of recurrence
\* Smoking cessation
89
Why is tension pneumothorax an emergency?
Can lead to cardiac arrest
90
What are clinical signs of tension pneumothorax?
\* Trachea deviated to opposite side
\* Hypotension
\* Raised JVP
\* Reduced air entry on affected side
91
What can cause tension pneumothorax?
\* Over-ventilation of patient
\* Trauma
\* CPR
\* Blocked, kinked, misplaced drain
\* Pre-existing airway disease
\* Patients undergoing hyperbaric treatment
92
What is the treatment for tension pneumothorax?
Needle decompression
\* Usually with large bore venflon
\* Second intercostal space anteriorly, mid-clavicular line
