b_enrico cortesi_management of malignant pleural effusions-1.ppt

8/11/2019 B_Enrico Cortesi_Management of malignant pleural effusions-1.ppt

1/67

Rome, May 15-16, 2009

Enrico Cortesi, Martina PuglisiSapienza, Universit di Roma


2/67

0%

0%

100%

0%

0%

Which rate of patients with Malignant Pleural

Effusion (MPE) experiences reaccumulation of

fluid within 30 days after thoracentesis?

28 / 30 Cross-tab label

1. 30-40%

2. 80-90%

3. 95-100%

4. 10-20%

5. 0%


3/67

In which cases should pleurodesis be

considered as a valid therapeutic option?

1. Adeguate PS and patients life

expectancy (eg longer than 3

months)

2. Patients dyspnea improved after

therapeutic thoracentesis3. The underlying tumor and

resulting Malignant Pleural

Effusion are not responsive to

chemotherapy or radiotherapy4. All the answers above

5. None of the answers above


1

24%

2

17%3

3%

4

52%

5

3%


4/67

The presence of Malignant Pleural Effusion is

required to stage a NSCLC as :

1. Stage III B

2. Stage III A

3. Stage IV

4. It is not arleady

established

5. Malignant Pleural Effusionis not considered for

staging


0% 0%

97%

3% 0%

1 2 3 4 5


5/67

Malignant Pleural Effusion (M.P.E.)

An M.P.E. is defined by the presenceof cancer cellsin the pleural space


6/67



Underlying Primary Cancer1.Lung tumors (including malignant pleural

mesothelioma) NSCLC:14% at the time of

diagnosis, 50% with advanced disease2.Breast cancer

3.Ovarian cancer, gastric cancer

4. Hodgkins and non-Hodgkins lymphoma


7/67



Cancer cells reach thevisceral pleura(throughthe pulmonary

vasculature)or theparietal pleura(through hematogenous spread)

Cancer cells in the pleural space

(tumor deposit along parietal pleura)

A. Obstruct lymphatic stromata (which drain intrapleural fluid)

B. Release chemockines ( increasing vascular permeability)


8/67


Paramalignant Effusion

1.Mediastinal lymph node tumor infiltration2. Bronchial obstruction/Atelectasis

3. Pulmonary embolism

4.Superior vena cava syndrome

5. Decreased oncotic pressure (cachexia)

6. Radiotherapy/Chemotherapy


9/67

Malignant Plural EffusionAndDiagnosis


10/67

M.P.E. and Diagnosis

Cytologicor tissue biopsyconfirmation isrequired to establish a diagnosis of MPE


11/67



Diagnostic thoracentesis:Diagnostic yield ofPF cytologyranging from 62 to 90%Positive results on cytology might not differentiate

between adk subtypes or between pleural adk and

mesothelioma

Additional PF studies could complement standardcytology: Electrochetoluminescence fortumor markers,

genetic analysis


12/67



Diagnostic thoracentesis, if cytology not diagnostic:


13/67



Diagnostic thoracentesis, if cytology not diagnostic:

Pleural Biopsy:Closed-needle pleural biopsy (sensitivity of 40-75%)Ultrasonography or chest CT-guided percutaneous

pleural biopsy (higher sensitivities and specificities)

Medical thoracoscopy, orVideo Assisted Thoracoscopic Surgery (VATS)


14/67


Is diagnosis with cytologyor histology

always requested (and useful) in our

clinical practice?


15/67


Does the presence of M.P.E. addprognosticand therapeuticinformations?


16/67


Non Small Cell Lung Cancer

Does the presence of M.P.E. addprognosticand therapeuticinformations?


17/67



Poor PSKnown advanced cancer

DIAGNOSIS NOT NECESSARY


18/67



Poor PSKnown advanced cancer

DIAGNOSIS NOT NECESSARY

Good PSmultimodality treatment

DIAGNOSIS IS CRITICAL

FOR TREATMENTPLANNING


19/67

NSCLC with M.P.E:PrognosisPatients with M.P.E. (without other metastatic disease) had a

median OS of 8 months Versus 13 monthsof other cT4 M0Versus 6 monthsof patients with distant metastases

Postmus, JTO 2007


20/67

NSCLC with M.P.E:Prognosis

Goldstraw, JTO 2007

TNM stagingSix Edition:

T4(Stage III B)

TNM stagingSeventh Edition:

M1 a(Stage IV)


21/67

NSCLC with M.P.E:Prognosis

Goldstraw, JTO 2007

TNM stagingSix Edition:

T4(Stage III B)

TNM stagingSeventh Edition:

M1 a(Stage IV)If P.E. is cytologically negative.

and is evaluated as not related tothe tumor by clinical judgment,patient should be classified as

T1, T2, T3, T4.


22/67

Malignant Pleural EffusionAndTreatment


23/67

M.P.E. and Treatment

1)THERAPEUTIC THORACENTESIS

2)PLEURODESIS


24/67


Management of MPE is palliative...

1)THERAPEUTIC THORACENTESIS

2)PLEURODESIS


25/67


When to proceed with treatment ofPleural Effusion?


26/67


When to proceed with treatment ofPleural Effusion?

Patient is symptomatic

(for dyspnea or cough or chest pain), andsymptoms are considered to be caused frompleural effusion.

Patient is not suitable forspecific cancertreatment (eg. chemotherapy), or PleuralEffusion is resistant to specific cancer treatment.


27/67


Is patient symptomatic?


28/67


Is patient symptomatic? No interventionNo


29/67


Is patient symptomatic? No intervention

Yes

No

Therapeutic Thoracentesis


30/67


THERAPEUTIC THORACENTESIS

Symptoms can improve after thoracentesis

But 98% to 100%of patients experience

reaccumulation of fluidand recurrence of

symptomswithin 30 days


31/67







RepeatedTHORACENTESES

PLEURODESIS


32/67








PLEURODESIS


33/67


PLEURODESIS

Selection of patients should be based on:.

Patients characteristics

Tumors characteristics

1

2


34/67


PLEURODESIS


Patient characteristics

Tumor characteristics

1

2

Does the patients lifeexpectancy warrantpleurodesis? *

(PShas the most value)

*

32% of p. do not survive 30 days after pleurodesis


35/67


PLEURODESIS


Patient characteristics

Tumor characteristics

1

2

Does the patients lifeexpectancy warrantpleurodesis? *

(PShas the most value)

*

32% of p. do not survive 30 days after pleurodesis


36/67


PLEURODESIS

Pleural Effusion is unlikely to respond to

pleurodesis if:

There is an airway obstruction from an

endobronchial tumor (the lung does not expand

to the chest wall after therapeutic thoracentesis)

Effusion is multiloculated

There are large tumor masses along pleural surfaces


37/67


PLEURODESIS

Chest-catheter Pleurodesis

Thoracoscopic Pleurodesis

TALC is considered a superior pleurodesis agent

when compared with other commonly used sclerosant

(as Bleomycin or tetracycline)

Cochrane Review, 2004


38/67



Yes

No



39/67



Yes

No


Improvement in symptoms?


40/67



Yes

No


Improvement in symptoms?No


41/67



Yes

No



Adequate Re-expansion?

Yes


42/67



Yes

No




Good PS?

Yes

Yes


43/67



Yes

No




Good PS?

Yes

Yes

PleurodesisYes


44/67



Yes

No




Good PS?

Yes

Yes

Pleurodesis

No

Yes


45/67



Yes

No




Good PS?

Yes

Yes

Pleurodesis

No

NoYes


46/67



Yes

No




Good PS?

Yes

Yes

Repeated Thoracentesis

Pleural Catheter

Pleurodesis

No

NoYes


47/67



Should be reserved for patients who:

(1)Appear unlikely to survive beyond 1 to 3 months(2)Cannot tolerateother more interventional

procedures to control pleural fluid, such as pleurodesis.(3)Have a PE that does not respondto pleurodesis


48/67



Should be reserved for patients who:

(1)Appear unlikely to survive beyond 1 to 3 months(2)Cannot tolerateother more interventional

procedures to control pleural fluid, such as pleurodesis.(3)Have a PE that does not respondto pleurodesis

(4)Have cancers that commonly respond to therapywith resolution of the associated effusions

...OR...


49/67



Yes

No




Good PS?

Yes

Yes


Pleural Catheter

Pleurodesis

No

NoYes


50/67



Yes

No


Is tumor likelyto respond to

chemotherapy?



Good PS?

Yes

Yes


Pleural Catheter

Pleurodesis

No

NoYes


51/67

SCLC

M.P.E. and TreatmentIs tumor likelyto respond tochemotherapy

?

SCLC is an aggressive disease associated with earlyloco-regional and distant metastases Extensive Stage (ED-

SCLC)is present at diagnosis in more than 60%70%of cases[median OS of 9 months]

Highly sensitive to both chemotherapy and RTPlatinum/Etoposide regimens are usually associated with a rapid

objective response in 50% to 80%of patients with ED-SCLC

Patients who not respond to initial chemotherapy (Refractorydisease) have a worse prognosis, with an expected median survivalof 2-3 months


52/67

SCLC

M.P.E. and TreatmentIs tumor likelyto respond tochemotherapy

?

SCLC is an aggressive disease associated with earlyloco-regional and distant metastases Extensive Stage (ED-

SCLC)is present at diagnosis in more than 60%70%of cases[median OS of 9 months]

Highly sensitive to both chemotherapy and RTPlatino/Etoposide regimens are usually associated with a rapid

objective response in 50% to 80%of patients with ED-SCLC

Patients who not respond to initial chemotherapy (Refractorydisease) have a worse prognosis, with an expected median survivalof 2-3 months

SCLC patients can occasionally be palliated with only 1 thoracentesis


53/67


SCLC

About 30% of SCLC patients present with Limited Stagedisease8090% of these respond to combination chemotherapy, with or

without thoracic radiation, and 40%70% achieve completeremission.[median OS of 1220 months, 5-year survival of 510%]

LD-SCLCwith ipsilateral pleuraleffusionaccounted for 9%of all

the patients with SCLC and 17%of all the patients with LD SCLC


54/67


SCLC

About 30% of SCLC patients present with Limited Stagedisease8090% of these respond to combination chemotherapy, with or

without thoracic radiation, and 40%70% achieve completeremission.[median OS of 1220 months, 5-year survival of 510%]

LD-SCLCwith ipsilateral pleuraleffusionaccounted for 9%of all

the patients with SCLC and 17%of all the patients with LD SCLC

WhichTreatment?

WhichStaging?

E


55/67


SCLCLD-SCLC with pleural effusion... Which staging?

P E d


56/67

1989, IALSC classification

LIMITED STAGE:disease confined to the

ipsilateral hemithorax, which

can be encompassed within a

tolerable radiation field

Loco-regional extension

Ipsilateral supraclavicular

nodes

LIMITED STAGE:

Ipsilateral and controlateralhilar nodes

Ipsilateral and controlateralmediastinal nodes

Ipsilateral and controlateralsupraclavicular nodes

Ipsilateral pleural effusion

regardless of the cytology


SCLC

1957, VALG classification

LD-SCLC with pleural effusion... Which staging?

M P E d T


57/67

Retrospective studyto compare the prognostic impact of the two staging systems

(VALG vs IASLC)

e.g. Pleural effusion

Micke,2002


SCLCLD-SCLC with pleural effusion... Which staging?

M P E d T


58/67

LD-SCLC with pleural effusion... Which staging?SCLC

The revised UICC/AJCC staging system:

The survival of patients with LD witheffusionis intermediate betweenthose of patients with LD withouteffusionand patients with ED.

(p value 0.0001)

Result of cytologic examinationofPE (available for only 68 patients):The survival of patients with LDwith effusion, whether cytologicallynegative or positive, remained

intermediate Shepherd, 2007


M P E d T


59/67


SCLCLD-SCLC with pleural effusion... Which treatment?


60/67

M P E d T t t


61/67


SCLCLD-SCLC with pleural effusion... Which treatment?

M P E d T t t


62/67

26 pz:

CT + TRT

8 pz:Did not receiveTRT in spite of

the disappearanceof pleural effusion

after I-line CT

28 pz:Did not receiveTRT, and pleural

effusionpersistedafter I-line CT

3: TRT concurrentlywith I course10:TRT concurrently

with II or III orIV course

13:TRT sequentiallyNiho, J Thorac Oncol 2008


SCLC62LD-SCLC with ipsilateral pleural effusion

(citologically negative and positive)

Retrospectivestudy

Pl l ff i d T t t


63/67

Pleural effusionandTreatment

Niho, J Thorac Oncol 2008

SCLC

long-term survival was achieved by LD-SCLC patients who underwent definitive

TRT after their ipsilateral pleural effusion disappeared after induction CT.

62LD-SCLC with ipsilateral pleural effusion(citologically negative and positive)

Retrospectivestudy

M P E d T t t


64/67



Yes

No


Is tumor likelyto respond to

chemotherapy?



Good PS?

Yes

Yes


Pleural Catheter

Pleurodesis

No

NoYes



65/67

0%

0%

0%

0%

0%


Effusion (MPE) experiences reaccumulation of

fluid within 30 days after thoracentesis?


1. 30-40%

2. 80-90%

3. 95-100%

4. 10-20%

5. 0%



66/67


considered as a valid therapeutic option?

1. Adeguate PS and patients lifeexpectancy (eg longer than 3

months)

2. Patients dyspnea improved after

therapeutic thoracentesis3. The underlying tumor and

resulting Malignant Pleural

Effusion are not responsive to

chemotherapy or radiotherapy

4. All the answers above

5. None of the answers above


1

20%

2

20%

3

20%

4

20%

5

20%

Th f M li t Pl l Eff i i


67/67

The presence of Malignant Pleural Effusion is

required to stage a NSCLC as :

1. Stage III B

2. Stage III A

3. Stage IV4. It is not arleady

established

5. Malignant Pleural Effusion

is not considered for

staging

20% 20% 20% 20% 20%

1 2 3 4 5

b_enrico cortesi_management of malignant pleural effusions-1.ppt

Documents