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

Therapeutic Pleural Aspiration

Pleural aspiration is considered the first line in many investigation and management algorithms including the current BTS Pleural Disease Guidelines.[1] Repeated therapeutic aspiration may be considered as a management option in patients with a reduced life expectancy of less than 4 weeks or for frail or elderly patients of poor ECOG (Eastern Cooperative Oncology Group) performance status. This is unlikely to be an acceptable long-term management option in those with a prognosis of longer than 1 month due to associated risks, including the formation of adhesions and septations between the parietal and visceral pleuras. The individual risks associated with any pleural intervention such as postprocedural bleeding or pleural infection should be considered cumulative with each procedure, consequently reducing the acceptability of this approach, particularly when other treatment options are available.[1]

It has been suggested that in the context of systemic chemotherapy, management of MPE may be adequately achieved by therapeutic pleural aspiration alone. It may be possible to avoid further intervention in selected cases of small cell lung cancer, lymphoma, and highly chemosensitive breast cancer. However, there remains a high risk of reaccumulation with more than 90% of these effusions recurring and requiring further more definitive intervention. As a result, there is a lack of consensus with regard to the validity of this treatment option in most tumor types.[18]

Pleural aspiration is a simple and effective intervention that not only results in significant short-term benefit with low patient morbidity but it may also be used to direct future management options and patient selection when making decisions with regard to definitive management by allowing easy assessment of unexpandable lung.

Despite its current position in conventional algorithms, the role of therapeutic aspiration may be subject to change. The increasing popularity of IPCs has demonstrated their role as an alternative in those patients with limited prognoses. Drainage in the community may provide more appropriate palliation than recurrent day case hospital admissions for therapeutic aspiration, and IPCs also provide a longer term solution with little additional morbidity compared with aspiration. Their flexibility of use means that they may be inserted in patients with or without unexpandable lung and as a result could be considered as an alternative first-line investigation or intervention in the management of MPE.