Malignant Pleural Effusion (MPE)

• Shortness of breath or breathlessness
• Cough
• Chest pain, especially during deep breathing
• Fatigue

Your doctor may suspect that you have a MPE on physical examination. 

To see if you have a MPE and estimate how much fluid is present, you will have one or more of the imaging tests: 

• Chest X-Ray
• Computer tomography of the Chest: Providing more detailed information on the collection of fluid, including the adjacent structures in the chest and identifying source of primary cancer.
• Ultrasound of the Chest: One of the best methods of imaging the pleural space. Ultrasound does not involve any radiation and can also be used to help guide procedures to sample or drain pleural fluid.

When a pleural effusion is found, your doctor will need to take a sample of the fluid to look for the cause of it. This can be done in one of two ways:

• Thoracocentesis / pleural fluid aspiration (Pleural tapping): 
• This is a simple procedure done by inserting a small needle or tube into the pleural space to remove the fluid accumulated there. The fluid aspirated out will be tested to determine the cause of effusion and look for cancer cells.
• Usually, you will be sitting up and leaning forward over a table. The procedure is done using local anaesthesia medicine to reduce any discomfort or pain. Ultrasound is used to identify a safe place to insert a catheter. The fluid is drained over several minutes and the catheter is removed. When completed, a bandage is placed over the wound which then closes on its own without the need for stitches.
• Risk: The procedure is safe but there may still be risk of air in sucking into the pleural space (pneumothorax), bleeding, infection, etc.
• Pleural biopsy: This is a slightly more invasive procedure to obtain more tissue. This could either be done at bedside together with thoracocentesis or could be done in under medical thoracoscopy (a minor procedure, usually at a special operating room). For medical thoracoscopy, you will be given sedation. Your doctor will make a small incision on your side between the ribs, the effusion is drained and a camera is inserted into the chest cavity to visually examine the pleura and take biopsies to send for analysis. After the procedure, you will be put on a chest drain which could usually be removed in a few days.  

Treating the underlying cancer

• When malignant pleural effusion is confirmed, you will be referred to an oncologist (doctor specialized in treating cancers) and they may treat the underlying cancer with chemotherapy, immunotherapy and/or radiation therapy based on the type of cancer. 

Managing the pleural effusion

• If the pleural effusion if causing you symptom, there are a few ways to alleviate the symptoms / prevent accumulation of fluid:
  • Thoracocentesis / pleural fluid aspiration: the same procedure described above, could be done repeatedly to remove the fluid
  • Chest drain insertion: 
    • Your doctor will use a thoracic ultrasound scan to identify the best location to insert the chest drain tube. Your doctor will then clean the skin over the area (usually in the side of the chest) with antiseptic solution and inject a small amount of local anaesthetic, minimising the pain throughout the procedure. 
    • Then your doctor will make a small cut on your skin and insert a thin catheter into the pleural space under ultrasound guidance.
    • After confirming the catheter’s position, your doctor will connect the catheter with a collecting bottle which is kept lower than your chest and fluid drains out automatically.
    • The catheter will be sutured and secured in place.
    • Since the maximum amount of fluid drained per day is around 1-1.5L, it may take a few days to drain all the accumulated fluid from the pleural space.
    • Once all the fluid is drained, your doctor or nurse will take the catheter out.
    • Potential complications of pleural drainage include bleeding, blockage of drain, infection, direct injury to the lungs and abnormal air collecting in pleural space  (pneumothorax). 
• Indwelling pleural catheter (IPC): This device is a small catheter that is placed under your skin and into the pleural fluid, which allows repeated drainage at home to relieve symptoms, avoiding repeated thoracocentesis and shorten hospital stay. These catheters are placed using local anaesthesia. The catheter is safe, easy to use and may help allow the lung to eventually expand fully up to the chest wall. Once the fluid build-up resolves, the catheter can be removed in many patients after 2-3 months. The main disadvantage of the IPC is the need to care for the catheter (which is not that difficult). Potential complications include infection at the insertion site or within the pleural space, blockage and displacement of the catheter. 
• Pleurodesis: This is a procedure where a chemical, acting like a ‘glue’, is instilled into the chest cavity after the pleural fluid has been drained to help get the lung to stick up to the chest wall and reduce the risk of new build-up of fluid. Pleurodesis can be done after fluid was drained by a chest drain and injecting the chemical through the tube, or by spraying the chemical in the pleural space during thoracoscopy. You will need to stay in the hospital with a chest tube in place for a few days. The main advantage of this approach is to hopefully prevent future fluid build-up. You may need to take some analgesics as you may experience pain from the procedure.