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Pleural Carcinosis Caused by Extrathoracic Malignancies

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Pleural Carcinosis Caused by Extrathoracic Malignancies 8 Review Article Page 1 of 8 Pleural carcinosis caused by extrathoracic malignancies Marcello Migliore1, Misel Milosevic2, Bojan Koledin2 1Thoracic Surgery, Department of Surgery and Medical Specialities, University of Catania, Catania, Italy; 2Institute for Lung Disease of Vojvodina, Sremska Kamenica, AP Vojvodina, Serbia Contributions: (I) Conception and design: M Migliore; (II) Administrative support: None; (III) Provision of study materials or patients: M Migliore; (IV) Collection and assembly of data: M Migliore; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors. Correspondence to: Marcello Migliore, MD, PhD. Professor Thoracic Surgery, Thoracic Surgery, Policlinic University Hospital, Via Santa Sofia 78, Catania, Italy. Email: [email protected]. Abstract: Most of malignant tumors at an advanced stage can affect the pleural cavity creating malignant pleural effusion (MPE). Pleural carcinosis secondary to extrathoracic malignancies has not been extensively reported, and different treatments have been described. Although 40% of all cases of MPE are due to lung cancer, the second-most common is breast cancer (25%), lymphoma (10%), ovarian cancer (5%), and gastro- intestinal cancers (5%). For approximately 5% to 10% of MPE, no primary tumor can be found (cancer of unknown primary). Definite evidence of a MPE can be obtained by cytological or histological confirmation of cancer cells. Uniportal surgery increases diagnostic accuracy as large biopsies could be taken and used to perform supplementary tests for more advanced management such as immunotherapy or hormone receptor status for breast cancer. Conventional thoracic treatments such as thoracocentesis, chest tube drainage, pleurodesis, video-assisted thoracic surgery (VATS) procedure have shown extremely limited effect on quality of life and long-term survival which ranges between 4–12 months. New technology procedures such as hyperthermic intrathoracic chemotherapy (HITHOC) or immunotherapy have shown some potentiality. With an eye toward the future, the main aim of this article is to provide a summary of the well-known treatments for pleural carcinosis caused by extrathoracic malignancies with the main intention to contribute to clarify decisions making. Keywords: Malignant pleural effusion (MPE); uniportal video-assisted thoracic surgery (VATS); extrathoracic malignant effusion; Talc pleurodesis; hyperthermic intrathoracic chemotherapy (HITHOC); hyperthermic chemotherapy Received: 16 April 2020; Accepted: 10 July 2020; Published: 25 September 2021. doi: 10.21037/amj-2019-mpe-07 View this article at: http://dx.doi.org/10.21037/amj-2019-mpe-07 Introduction pancreas, prostate, soft tissues, and genital tracts. It has been estimated that 15% of all kinds of cancer patients will Pleural carcinosis is caused by the implantation of develop pleural effusion as a result of pleural metastasis malignant cells to the visceral and/or parietal pleura, and of the primary cancers (1). Patients with metastatic lung the most common result is the development of malignant cancers may present clinically with signs and symptoms pleural effusion (MPE). Metastasis to the pleura (carcinosis), related to pleural involvement or may be initially along with pleural effusion, is a late event in the course asymptomatic. Diagnosis is never simple and treatment is of many malignancy. Almost all malignant tumors at an unfortunately only symptomatic and palliative. Established advanced stage can affect the pleural cavity; however, praxis for treatment of MPE is well known, based on certain malignancies are more prone to involve the chest. standardised guidelines (2,3). It is evident that all the These are malignancies of colon, breast, kidney, stomach, conventional thoracic treatments such as thoracocentesis, © AME Medical Journal. All rights reserved. AME Med J 2021;6:27 | http://dx.doi.org/10.21037/amj-2019-mpe-07 Page 2 of 8 AME Medical Journal, 2021 Table 1 Clinical experience with 23 patients with extrathoracic cancers pleural fluid is around 0.26 mL/kg body-weight. When in Metastatic cancer Number (n=23) the chest the balance between production and absorption Breast 9 of the pleural fluid is compromised, pleural effusion is unavoidable. Pleural carcinosis creates an irritation of the Thymus 2 pleura leading to increase development of interstitial pleural Malignant lymphoma 2 fluid as a consequence of augmented permeability. Bladder 2 Rhabdomyosarcoma 1 Clinical symptoms Kidney 1 The extent of the effusion is the main responsible for the Larynx 1 symptoms and signs, progressive dyspnea, accompanied Idiopathic 5 or not by chest pain, and cough is a common symptom. Nevertheless, symptoms of the underlying malignancy are frequently associated, and the patent’s overall physical condition is often reduced. chest tube drainage, pleurodesis, video-assisted thoracic surgery (VATS) procedure have highly limited effect. Mechanical decompression and creation of adhesions in Diagnosis case of pleurodesis result in a 4 to 12 months length of life, The main question is if histopathological confirmation of and some improve of QOL, according to most published pleural carcinosis is mandatory in a patient with previous data. cancer elsewhere. In the real life when MPE is suspected This article provides a summary of the well-known a chest X-ray is the first diagnostic step, and patients treatments for pleural carcinosis caused by extrathoracic with pleural carcinosis usually have medium-large pleural malignancies with the main intention to contribute to effusions. For some authors ultrasound (US) is not only clarify decisions making for this common clinical problem. complementary to radiological investigations of the chest but often provides better results, and therefore, should Incidence be the first imaging examination method after chest radiography in presumed pleural disease. Nevertheless, The incidence of MPE with pleural carcinosis in Europe recently, US has been demonstrated to be unreliable for is approximately 375,000 to 400,000 new patients/year, establishing this method as the first diagnostic tool (4). and has been found at autopsy in 15% of patients with Computed tomography scan (CT) and magnetic malignant tumors and in 42–77% of exudative pleural resonance offer more data in many patients with suspected effusion. Although 40% of all cases of MPE are due to tumors of the chest. Moreover, MPE is not rare findings on lung cancer, the second-most common is breast cancer the follow up HRCT in final stage of malignant diseases, (25%), lymphoma (10%), ovarian cancer (5%), and gastro- even yet in asymptomatic patients. In case of massive intestinal cancers (5%). For approximately 5% to 10% of effusion, thoracocentesis should performed to confirm the MPE, no primary tumor can be found (cancer of unknown presence of bloody MPE, and to permit the lung to expand primary). In our previous experience with 23 patients with as it is important to evaluate the presence of a trapped lung malignant disease and pleural effusion due to extrathoracic or lobe to individualize the treatment. Nevertheless, definite disease 39.1% were due to breast cancer and 21.7% were evidence of a MPE can be obtained only by cytological or idiopathic (Table 1). histological verification of cancer cells. The accuracy of cytological proof of cancer cells range, from 50% to 90%. Diagnostic accuracy increases by a large biopsy taken using Pathophysiology uniportal video-assisted thoracic surgery (U-VATS) (5-7). The parietal pleura has a more significant impact to Moreover, the large biopsy can also be used to perform pleural fluid exchange than the visceral pleura, and this is supplementary tests for more advanced management such probably secondary to the closeness of the parietal pleura as immunotherapy or hormone receptor status for breast to microvessels and lymphatics. The regular volume of cancer. © AME Medical Journal. All rights reserved. AME Med J 2021;6:27 | http://dx.doi.org/10.21037/amj-2019-mpe-07 AME Medical Journal, 2021 Page 3 of 8 Table 2 Medical and surgical procedures sensitive primary tumor (e.g., lung, breast, prostate cancer, Thoracocentesis lymphoma), systemic chemotherapy may be used while Indwelling pleural catheter the effects of such therapy on pleural metastases is highly questioned in case of synchronous or metachronous cancer. Chest drain Furthermore, radiotherapy may further improve survival. VATS pleurodesis Pleurodesis and permanent pleural catheters have been Cytoreductive surgery P/D showed in retrospective studies to improve quality of life in patient with MPE. Nevertheless, there exist only one HITHOC prospective randomized trial comparing indwelling pleural HITHOC, hyperthermic intrathoracic chemotherapy. catheters to talc pleurodesis (10). Prognosis Thoracentesis In general, patients with pleural carcinosis and MPE have Thoracentesis is fundamental for two reasons. Firstly, poor quality of life, prognosis is dismal, with a mean survival because it is useful to perform an accurate diagnosis in two- of approximately 4–12 months survival rate of around 18%. thirds of patients with pleural carcinosis and malignant Karnofsky performance status (KPS) represents the only effusion, and secondly because it alleviates dyspnea. Patients statistically significant predictor of survival, and it is useful with complete post thoracocentesis pulmonary expansion in choosing the type of treatment/palliation in patients with are eligible
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