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Malignant Pleural Effusion (M.P.E.) "as defined by the presence of cancer cells in the pleural space" "adeguate PS and patient's life expectancy (eg longer than 3 months) 2. Patient's dyspnea improved after therapeutic thoracentesis 3. 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 arle
Deskripsi Asli:
Judul Asli
B_Enrico Cortesi_Management of malignant pleural effusions-1.ppt
Malignant Pleural Effusion (M.P.E.) "as defined by the presence of cancer cells in the pleural space" "adeguate PS and patient's life expectancy (eg longer than 3 months) 2. Patient's dyspnea improved after therapeutic thoracentesis 3. 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 arle
Malignant Pleural Effusion (M.P.E.) "as defined by the presence of cancer cells in the pleural space" "adeguate PS and patient's life expectancy (eg longer than 3 months) 2. Patient's dyspnea improved after therapeutic thoracentesis 3. 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 arle
Sapienza, Universit di Roma 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%
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 thoracentesis 3. 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
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 Effusion is not considered for staging
29 / 30 Cross-tab label 0% 0% 97% 3% 0% 1 2 3 4 5
Malignant Pleural Effusion (M.P.E.) An M.P.E. is defined by the presence of cancer cells in the pleural space Malignant Pleural Effusion (M.P.E.) An M.P.E. is defined by the presence of cancer cells in the pleural space Underlying Primary Cancer 1.Lung tumors (including malignant pleural mesothelioma) NSCLC: 14% at the time of diagnosis, 50% with advanced disease 2. Breast cancer 3. Ovarian cancer, gastric cancer 4. Hodgkins and non-Hodgkins lymphoma Malignant Pleural Effusion (M.P.E.) An M.P.E. is defined by the presence of cancer cells in the pleural space Cancer cells reach the visceral pleura (through the pulmonary vasculature)or the parietal 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) Malignant Pleural Effusion (M.P.E.)
Malignant Plural Effusion And Diagnosis M.P.E. and Diagnosis Cytologic or tissue biopsy confirmation is required to establish a diagnosis of MPE M.P.E. and Diagnosis Cytologic or tissue biopsy confirmation is required to establish a diagnosis of MPE Diagnostic thoracentesis: Diagnostic yield of PF cytology ranging 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 standard cytology: Electrochetoluminescence for tumor markers, genetic analysis
M.P.E. and Diagnosis Cytologic or tissue biopsy confirmation is required to establish a diagnosis of MPE Diagnostic thoracentesis, if cytology not diagnostic:
M.P.E. and Diagnosis Cytologic or tissue biopsy confirmation is required to establish a diagnosis of MPE 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, or Video Assisted Thoracoscopic Surgery (VATS) M.P.E. and Diagnosis Is diagnosis with cytology or histology always requested (and useful) in our clinical practice? M.P.E. and Diagnosis Does the presence of M.P.E. add prognostic and therapeutic informations? M.P.E. and Diagnosis Non Small Cell Lung Cancer Does the presence of M.P.E. add prognostic and therapeutic informations? M.P.E. and Diagnosis Non Small Cell Lung Cancer Poor PS Known advanced cancer
DIAGNOSIS NOT NECESSARY M.P.E. and Diagnosis Non Small Cell Lung Cancer Poor PS Known advanced cancer
DIAGNOSIS NOT NECESSARY Good PS multimodality treatment
DIAGNOSIS IS CRITICAL FOR TREATMENT PLANNING NSCLC with M.P.E: Prognosis Patients with M.P.E. (without other metastatic disease) had a median OS of 8 months Versus 13 months of other cT4 M0 Versus 6 months of patients with distant metastases Postmus, JTO 2007 NSCLC with M.P.E: Prognosis Goldstraw, JTO 2007 TNM staging Six Edition:
T4 (Stage III B) TNM staging Seventh Edition:
M1 a (Stage IV) NSCLC with M.P.E: Prognosis Goldstraw, JTO 2007 TNM staging Six Edition:
T4 (Stage III B) TNM staging Seventh Edition:
M1 a (Stage IV) If P.E. is cytologically negative. and is evaluated as not related to the tumor by clinical judgment, patient should be classified as T1, T2, T3, T4. Malignant Pleural Effusion And Treatment M.P.E. and Treatment 1) THERAPEUTIC THORACENTESIS
2) PLEURODESIS M.P.E. and Treatment Management of MPE is palliative... 1) THERAPEUTIC THORACENTESIS
2) PLEURODESIS M.P.E. and Treatment When to proceed with treatment of Pleural Effusion? M.P.E. and Treatment When to proceed with treatment of Pleural Effusion? Patient is symptomatic (for dyspnea or cough or chest pain), and symptoms are considered to be caused from pleural effusion.
Patient is not suitable for specific cancer treatment (eg. chemotherapy), or Pleural Effusion is resistant to specific cancer treatment. M.P.E. and Treatment Is patient symptomatic? M.P.E. and Treatment Is patient symptomatic? No intervention No M.P.E. and Treatment Is patient symptomatic? No intervention Yes No Therapeutic Thoracentesis M.P.E. and Treatment THERAPEUTIC THORACENTESIS Symptoms can improve after thoracentesis But 98% to 100% of patients experience reaccumulation of fluid and recurrence of symptoms within 30 days M.P.E. and Treatment THERAPEUTIC THORACENTESIS Symptoms can improve after thoracentesis But 98% to 100% of patients experience reaccumulation of fluid and recurrence of symptoms within 30 days Repeated THORACENTESES PLEURODESIS M.P.E. and Treatment THERAPEUTIC THORACENTESIS Symptoms can improve after thoracentesis But 98% to 100% of patients experience reaccumulation of fluid and recurrence of symptoms within 30 days Repeated THORACENTESES PLEURODESIS M.P.E. and Treatment PLEURODESIS Selection of patients should be based on:. Patients characteristics
Tumors characteristics 1 2 M.P.E. and Treatment PLEURODESIS Selection of patients should be based on:. Patient characteristics
Tumor characteristics 1 2 Does the patients life expectancy warrant pleurodesis? * (PS has the most value) * 32% of p. do not survive 30 days after pleurodesis M.P.E. and Treatment PLEURODESIS Selection of patients should be based on:. Patient characteristics
Tumor characteristics 1 2 Does the patients life expectancy warrant pleurodesis? * (PS has the most value) * 32% of p. do not survive 30 days after pleurodesis M.P.E. and Treatment 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 M.P.E. and Treatment 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 M.P.E. and Treatment Is patient symptomatic? No intervention Yes No Therapeutic Thoracentesis M.P.E. and Treatment Is patient symptomatic? No intervention Yes No Therapeutic Thoracentesis Improvement in symptoms? M.P.E. and Treatment Is patient symptomatic? No intervention Yes No Therapeutic Thoracentesis Improvement in symptoms? No M.P.E. and Treatment Is patient symptomatic? No intervention Yes No Therapeutic Thoracentesis Improvement in symptoms? No Adequate Re-expansion? Yes M.P.E. and Treatment Is patient symptomatic? No intervention Yes No Therapeutic Thoracentesis Improvement in symptoms? No Adequate Re-expansion? Good PS? Yes Yes M.P.E. and Treatment Is patient symptomatic? No intervention Yes No Therapeutic Thoracentesis Improvement in symptoms? No Adequate Re-expansion? Good PS? Yes Yes Pleurodesis Yes M.P.E. and Treatment Is patient symptomatic? No intervention Yes No Therapeutic Thoracentesis Improvement in symptoms? No Adequate Re-expansion? Good PS? Yes Yes Pleurodesis No Yes M.P.E. and Treatment Is patient symptomatic? No intervention Yes No Therapeutic Thoracentesis Improvement in symptoms? No Adequate Re-expansion? Good PS? Yes Yes Pleurodesis No No Yes M.P.E. and Treatment Is patient symptomatic? No intervention Yes No Therapeutic Thoracentesis Improvement in symptoms? No Adequate Re-expansion? Good PS? Yes Yes Repeated Thoracentesis Pleural Catheter Pleurodesis No No Yes M.P.E. and Treatment Repeated THORACENTESES Should be reserved for patients who:
(1) Appear unlikely to survive beyond 1 to 3 months (2) Cannot tolerate other more interventional procedures to control pleural fluid, such as pleurodesis. (3) Have a PE that does not respond to pleurodesis
M.P.E. and Treatment Repeated THORACENTESES Should be reserved for patients who:
(1) Appear unlikely to survive beyond 1 to 3 months (2) Cannot tolerate other more interventional procedures to control pleural fluid, such as pleurodesis. (3) Have a PE that does not respond to pleurodesis
(4) Have cancers that commonly respond to therapy with resolution of the associated effusions
...OR... M.P.E. and Treatment Is patient symptomatic? No intervention Yes No Therapeutic Thoracentesis Improvement in symptoms? No Adequate Re-expansion? Good PS? Yes Yes Repeated Thoracentesis Pleural Catheter Pleurodesis No No Yes M.P.E. and Treatment Is patient symptomatic? No intervention Yes No Therapeutic Thoracentesis Is tumor likely to respond to chemotherapy? Improvement in symptoms? No Adequate Re-expansion? Good PS? Yes Yes Repeated Thoracentesis Pleural Catheter Pleurodesis No No Yes SCLC M.P.E. and Treatment Is tumor likely to respond to chemotherapy ?
SCLC is an aggressive disease associated with early loco-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 RT Platinum/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 (Refractory disease) have a worse prognosis, with an expected median survival of 2-3 months SCLC M.P.E. and Treatment Is tumor likely to respond to chemotherapy ?
SCLC is an aggressive disease associated with early loco-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 RT Platino/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 (Refractory disease) have a worse prognosis, with an expected median survival of 2-3 months SCLC patients can occasionally be palliated with only 1 thoracentesis M.P.E. and Treatment SCLC About 30% of SCLC patients present with Limited Stage disease 8090% of these respond to combination chemotherapy, with or without thoracic radiation, and 40%70% achieve complete remission. [median OS of 1220 months, 5-year survival of 510%]
LD-SCLC with ipsilateral pleural effusion accounted for 9% of all the patients with SCLC and 17% of all the patients with LD SCLC M.P.E. and Treatment SCLC About 30% of SCLC patients present with Limited Stage disease 8090% of these respond to combination chemotherapy, with or without thoracic radiation, and 40%70% achieve complete remission. [median OS of 1220 months, 5-year survival of 510%]
LD-SCLC with ipsilateral pleural effusion accounted for 9% of all the patients with SCLC and 17% of all the patients with LD SCLC Which Treatment? Which Staging? M.P.E. and Treatment SCLC LD-SCLC with pleural effusion... Which staging? 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 controlateral hilar nodes Ipsilateral and controlateral mediastinal nodes Ipsilateral and controlateral supraclavicular nodes Ipsilateral pleural effusion regardless of the cytology
M.P.E. and Treatment SCLC 1957, VALG classification LD-SCLC with pleural effusion... Which staging? Retrospective study to compare the prognostic impact of the two staging systems (VALG vs IASLC) e.g. Pleural effusion Micke,2002 M.P.E. and Treatment SCLC LD-SCLC with pleural effusion... Which staging? LD-SCLC with pleural effusion... Which staging? SCLC The revised UICC/AJCC staging system: The survival of patients with LD with effusion is intermediate between those of patients with LD without effusion and patients with ED. (p value 0.0001)
Result of cytologic examination of PE (available for only 68 patients): The survival of patients with LD with effusion, whether cytologically negative or positive, remained intermediate Shepherd, 2007 M.P.E. and Treatment M.P.E. and Treatment SCLC LD-SCLC with pleural effusion... Which treatment?
The indication for definitive TRT in patients with LD-SCLC and ipsilateral pleural effusion have not been thoroughly investigated
Definitive TRT is contraindicated in patients with malignant pleural effusion M.P.E. and Treatment SCLC LD-SCLC with pleural effusion... Which treatment? M.P.E. and Treatment SCLC LD-SCLC with pleural effusion... Which treatment? 26 pz: CT + TRT
8 pz: Did not receive TRT in spite of the disappearance of pleural effusion after I-line CT 28 pz: Did not receive TRT, and pleural effusion persisted after I-line CT 3: TRT concurrently with I course 10: TRT concurrently with II or III or IV course 13: TRT sequentially
Niho, J Thorac Oncol 2008 M.P.E. and Treatment SCLC 62 LD-SCLC with ipsilateral pleural effusion (citologically negative and positive) Retrospective study Pleural effusion and Treatment 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.
62 LD-SCLC with ipsilateral pleural effusion (citologically negative and positive) Retrospective study M.P.E. and Treatment Is patient symptomatic? No intervention Yes No Therapeutic Thoracentesis Is tumor likely to respond to chemotherapy? Improvement in symptoms? No Adequate Re-expansion? Good PS? Yes Yes Repeated Thoracentesis Pleural Catheter Pleurodesis No No Yes 0% 0% 0% 0% 0% Which rate of patients with Malignant Pleural Effusion (MPE) experiences reaccumulation of fluid within 30 days after thoracentesis? 0 / 0 Cross-tab label
1. 30-40% 2. 80-90% 3. 95-100% 4. 10-20% 5. 0%
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 thoracentesis 3. 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
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 Effusion is not considered for staging