Management of Malignant Pleural Effusion

This survey was based on the scenario that participants were asked to consult on a hospitalized middle-aged patient who has been diagnosed with stage IV non-small cell lung cancer with a symptomatic uniloculated unilateral malignant pleural effusion (MPE).

Most of the survey respondents were from North America or Europe, and the vast majority of respondents are actively involved in managing MPE.  In most respondents’ institutions either pulmonologists or thoracic surgeons, in relatively equal proportions, were the first specialists consulted for management of MPE.

Indications for intervention varied somewhat.  The most common response was that definitive intervention should follow an attempt at therapeutic thoracentesis, although an almost equal number of respondents indicated that definitive intervention was appropriate at the time of diagnosis.

Over half of respondents recommended VATS pleurodesis as the optimal intervention, whereas about 30% indicated that chest tube and sclerosis was their treatment of choice.  The degree of symptoms experienced by the patient had some influence on the type of treatment recommended for two thirds of respondents.  Talc was by far the most preferred sclerosing agent.  The most common chest tube management strategy was removal after 2-4 days.

Readers may find these results interesting in that the data support their practice preferences, or may wish to examine their practice patterns in light of these results.

1. Do you manage patients with malignant pleural effusion?
	answered question		545
	skipped question		5
		Response Percent	Response Count
Yes		98.3%	536
No		1.7%	9

2. When do you believe definitive management of this effusion is appropriate?
	answered question		548
	skipped question		2
		Response Percent	Response Count
Immediately		35.4%	194
After a single attempt at thoracentesis to completely drain the effusion		39.8%	218
After more than one attempt at thoracentesis to completely drain the effusion		19.0%	104
Other		5.8%	32

3. In your institution, which specialist is most commonly consulted first for this problem?
	answered question		546
	skipped question		4
		Response Percent	Response Count
Thoracic surgeon		47.4%	259
Pulmonologist		42.1%	230
General surgeon		2.2%	12
Intensive care specialist		0.4%	2
Medical oncologist		7.9%	43

4. What is your preferred method for definitively managing this effusion?
	answered question		546
	skipped question		4
		Response Percent	Response Count
Chest tube and sclerosis		28.0%	153
Small bore drainage tube and sclerosis		7.5%	41
Pleurx catheter insertion		8.2%	45
VATS pleurodesis		55.3%	302
Other		0.9%	5

5. If you perform chemical pleural sclerosis, what substance do you use to accomplish this?
	answered question		531
	skipped question		19
		Response Percent	Response Count
Talc		78.5%	417
Doxycycline		10.4%	55
Other		11.1%	59

6. If you perform sclerosis, for how long do you drain the pleural space afterwards?
	answered question		545
	skipped question		5
		Response Percent	Response Count
The tube is removed almost immediately		3.9%	21
Overnight		9.9%	54
2-3 days		24.8%	135
For a few days, until the drainage reaches a reasonably low volume		61.5%	335

7. Does the degree of symptoms reported by the patient influence your choice of surgical intervention for such effusions?
	answered question		547
	skipped question		3
		Response Percent	Response Count
Yes		66.9%	366
No		33.1%	181

8. In what region is your surgical practice based?
	answered question		547
	skipped question		3
		Response Percent	Response Count
North America		40.2%	220
Europe		28.9%	158
South America		8.6%	47
Asia		17.6%	96
Africa		4.8%	26