Editing Pleural effusions (section)

== Treatment ==

* Benign effusions
** Most benign pleural effusions are transudates, free-flowing, without loculation
** Treat underlying cause (CCF, ascites, malnutrition)
** Completely drain for diagnosis and treatment (14Fr or smaller if leaving a drain in)
** CXR to confirm complete drainage
** 'Trapped lung' may require decortication, especially if remaining symptomatic
** If no improvement in symptoms, look for alternative causes
** Recurrences
*** Consider repeat thoracentesis, tube thoracostomy or pleurodesis (mechanical vs chemical)
*** Don't need to continuously drain unless significant respiratory compromise is present
* Unilateral effusions
** Parapneumonic, empyema, inflamed parietal pleura, chylothorax, haemothorax, pleural infection
** Drain effusion and correct consequences
** Indications for VATS:
*** Recurrent effusion following earlier drainage
*** Trapped lung (lack of re-expansion following drainage)
*** Loculated or multiloculated effusions
*** Parietal pleural tissue biopsies are required for diagnosis
*** Very large unilateral effusion (consider VATS vs drainage - higher recurrence rate and malignancy rate)
** Role for VATS
*** Complete drainage of effusion
*** Parietal pleural biopsies
*** Re-expansion of lung and de-cortication if necessary
*** Pleurodesis
* Malignant pleural effusions
** An effusion with positive cytopathology
** Median survival 90 days (5 months in breast cancer, and longer in lymphoma)
** Not all effusions associated with malignancy are caused by direct or metastatic pleural involvement (consider bronchial or lymphatic obstruction, hypoproteinaemia, and accumulation from infra-diaphragmatic involvement)
** Consider pleurX catheter or pleurodesis
* Tension pleural effusion
** Drain immediately
* Drainage
** Need CT or USS prior to drainage, since CXR can get it wrong
** Typically needle thoracocentesis under USS-guidance, with a catheter sometimes being left in 
** Dogma states don't remove more than 1-1.5L in one sitting to prevent re-expansion pulmonary oedema, however the veracity of this is unknown. Larger volumes can be removed if the benefits of symptom improvement are thought to outweigh the risks.
** Those who respond well to drainage should also respond well for drainage of reaccumulations
** Drain on the larger side, or the right side if both are equal

'''Survival with malignant pleural effusions according to cancer type'''
{| class="wikitable"
|'''Cell type'''
|'''Median survival in days (95% CI)'''
|'''n'''
|-
|Mesothelioma
|339 (267 to 422)
|170
|-
|Hematological malignancy
|218 (160 to 484)
|35
|-
|Gynecological malignancy
|230 (97 to 279)
|59
|-
|Breast cancer
|192 (133 to 271)
|140
|-
|Renal cell carcinoma
|114 (33 to 334)
|22
|-
|Adenocarcinoma of unknown primary
|87 (13 to 286)
|11
|-
|Lung cancer
|74 (60 to 92)
|215
|-
|Other
|71 (46 to 102)
|33
|-
|Gastrointestinal cancer
|61 (44 to 73)
|61
|-
|Sarcoma
|44 (19 to 76)
|12
|-
|Melanoma
|43 (23 to 72)
|23
|-
|Urological cancer (bladder, prostate, testis, penile)
|33 (22 to 168)
|8
|-
|Overall
|136 (119 to 167)
|789
|}


'''LENT score'''
{| class="wikitable"
| 
|'''Variable'''
|'''Score'''
|-
|'''L'''
|'''LDH level in pleural fluid (IU/L)'''
|
|-
|
|<1500
|0
|-
|
|>1500
|1
|-
|'''E'''
|'''ECOG PS'''
|
|-
|
|0
|0
|-
|
|1
|1
|-
|
|2
|2
|-
|
|3 to 4
|3
|-
|'''N'''
|'''NLR'''
|
|-
|
|<9
|0
|-
|
|>9
|1
|-
|'''T'''
|'''Tumor type'''
|
|-
|
|Lowest risk tumor types

** Mesothelioma
** Hematological malignancy
|0
|-
|
|Moderate risk tumor types

** Breast cancer
** Gynecological cancer
** Renal cell carcinoma
|1
|-
|
|Highest risk tumor types

** Lung cancer
** Other tumor types
|2
|-
| 
|'''Risk categories'''
|'''Total score (median survival in days)'''
|-
|
|Low risk
|0 to 1 (319)
|-
|
|Moderate risk
|2 to 4 (130)
|-
|
|High risk
|5 to 7 (44)
|}
LDH: lactate dehydrogenase; ECOG PS: Eastern Cooperative Oncology Group performance score; NLR: neutrophil to lymphocyte ratio.