Table 1: Diagnosis of Malignant Pleural Effusion [2,4,7].

 

1

Chest X-ray - identification of effusion

2

CT scan - can identify parenchymal disease, metastasis, LN involvement

3

Ultrasound - can identify pleural lesions and adhesions, assist with thoracentesis

4

MRI - limited benefit, evaluate for chest wall involvement

5

Diagnostic thoracentesis- nucleated cell count and differential, total protein, lactate dehydrogenase, glucose, pH, amylase and cytology.

a)    Complications: pneumothorax, bleeding, infection, spleen or liver laceration.

b)    Relative contraindications: minimal effusion (less than 1 cm in thickness from fluid level to chest wall), bleeding diathesis, anticoagulation and mechanical ventilation.

6

Closed pleural biopsy - less sensitive than pleural fluid cytology

a)    Low yield: Distribution of tumor in areas not sampled by blind biopsy, operator inexperience, early stage disease with minimal pleural involvement.

b)    Contraindication: bleeding diathesis, anticoagulation, chest wall infection, lack of patient cooperation.

c)    Complications: pneumothorax, hemothorax, vasovagal reaction.

7

Medical Thoracoscopy - direct visual control with thoracosope or indirectly by video.

a)    Indication: evaluation of exudative effusion of unknown cause, staging, biopsy, treatment with pleurodesis.

8

Bronchoscopy - low yield. Used to exclude endo-bronchial obstruction, especially before pleurodesis if lung does not re-expand after thoracentesis.

9

Surgical Biopsy

a)    Video Assisted Thoracic Surgery

         Contraindication: mechanical ventilation, prior contralateral pneumonectomy, operator inexperience, pleural space adhesions

b)    Open biopsy