Malignant pleural effusions · pnea and loss of function. Treatment goals for these patients...
17
Malignant pleural effusions Joe B. Putnam Jr, MD Department of Thoracic and Cardiovascular Surgery, The University of Texas, M.D. Anderson Cancer Center, 1515 Holcombe Boulevard, Box 445 Houston, TX 77030-4095, USA Pleural effusions are a significant public health problem. Diagnosis of over 1 million pleural effusions is estimated to occur yearly in the United States. Patients with pleural effusions are frequently symptomatic with dys- pnea and loss of function. Treatment goals for these patients should focus on relief or elimination of dyspnea, restoration of normal activity and func- tion, minimization or elimination of hospitalization, and efficient use of medical care resources [1,2]. Medical management, with treatment of the underlying cause, may be effective in some transudates. For exudates, man- agement may be more difficult. Malignant pleural effusions (MPE; those effusions associated with primary, concurrent, or distant neoplasms) may be more complex, with frequent recurrence. The arbitrary view of requiring pleural symphysis, achieved by in-hospital drainage, with pleurodesis achieved by sclerosis with chemical or other agents, may subject the patient to a prolonged hospitalization or to other interventions that may signifi- cantly reduce quality of life and remaining survival outside the hospital. Pathophysiology Pleural effusions occur between two membranes: the visceral (inner) layer of the pleura attached to the lungs, and the parietal (outer) layer attached to the chest wall. The ‘‘pleural space’’ normally is nonexistent and is lubricated by a slight amount of pleural fluid (10–20 cc) that provides lubrication between the pleura. Fluid (sera) continuously moves from the parietal pleura through the pleural space to be absorbed by the visceral pleura. The fluid is then drained into the lymphatic system. The fluid in the pleural space is minimized by a balance of Starling forces, oncotic pressure in the circula- tion, and negative pressure in the lymphatics of the lungs. E-mail address: [email protected] (J.B. Putman). 0039-6109/02/$ - see front matter Ó 2002, Elsevier Science (USA). All rights reserved. PII: S 0 0 3 9 - 6 1 0 9 ( 0 2 ) 0 0 0 3 6 - 1 Surg Clin N Am 82 (2002) 867–883 dentaladhæsiv teknikker
