Malignant Pleural Effusions: Management Options

David J. McCracken, MRCP; Jose M. Porcel, MD; Najib M. Rahman, DPhil


Semin Respir Crit Care Med. 2018;39(6):704-712. 

In This Article

Overall Approach and Patient Perspective

The presence of a malignant pleural effusion (MPE) represents advanced metastatic disease and in the vast majority of cases is incurable, leading to the requirement of a predominantly palliative or symptom-control approach, with the primary aim of relieving dyspnea. It is associated with a significant reduction in life expectancy and an estimated median survival of between 3 and 12 months.[1,2] This figure is influenced by a number of factors, including performance status and tumor type, but can be risk stratified to predict prognosis using a number of tools including the LENT score and the more recently published and more accurate PROMISE tool.[2,3]

Interventions available to patients and clinicians in the management of MPE include therapeutic pleural aspiration, indwelling pleural catheters (IPCs), or talc pleurodesis either using talc slurry instilled via an intercostal chest drain or talc poudrage administered during thoracoscopy. Each management option has various indications, roles and sequelae, and is dependent on multiple factors including availability, the underlying pathophysiology and patient choice among others. The varied treatment options result in a complex pathway for patients in order to navigate difficult decision making (Figure 1).

Figure 1.

Management algorithm for malignant pleural effusion reproduced from 2010 British Thoracic Society Pleural Disease Guidelines. (Reproduced with permission.)