Management of a malignant pleural effusion: British Thoracic Society Pleural Disease Guideline 2010.

INTRODUCTION The discovery of malignant cells in pleural fluid and/or parietal pleura signifies disseminated or advanced disease and a reduced life expectancy in patients with cancer. Median survival following diagnosis ranges from 3 to 12 months and is dependent on the stage and type of the underlying malignancy. The shortest survival time is observed in malignant effusions secondary to lung cancer and the longest in ovarian cancer, while malignant effusions due to an unknown primary have an intermediate survival time. Historically, studies showed that median survival times in effusions due to carcinoma of the breast are 5e6 months. However, more recent studies have suggested longer survival times of up to 15 months. A comparison of survival times in breast cancer effusions in published studies to 1994 calculated a median survival of 11 months. Currently, lung cancer is the most common metastatic tumour to the pleura in men and breast cancer in women. 11 Together, both malignancies account for 50e65% of all malignant effusions (table 1). Lymphomas, tumours of the genitourinary tract and gastrointestinal tract account for a further 25%. 12e14 Pleural effusions from an unknown primary are responsible for 7e15% of all malignant pleural effusions. 13 14 Few studies have estimated the proportion of pleural effusions due to mesothelioma: studies from 1975, 1985 and 1987 identified mesothelioma in 1/271, 3/472 and 22/592 patients, respectively, but there are no more recent data to update this in light of the increasing incidence of mesothelioma. 13 14 Attempts have been made to predict survival based on the clinical characteristics of pleural fluid. None has shown a definite correlation: a recent systematic review of studies including 433 patients assessing the predictive value of pH concluded that low pH does not reliably predict a survival of <3 months. 16 In malignant mesothelioma, one study has shown an association between increasing pH and increasing survival. Burrows et al showed that only performance status was significantly associated with mortality: median survival was 1.1 months with a Karnofsky score <30 and 13.2 months with a score >70. An algorithm for the management of malignant pleural effusions is shown in figure 1.