Table 1.
Existing MPE therapeutic options.
| Therapy | Advantages | Disadvantages | Mortality (30 days) | Morbidity | Success Rate | Ref. |
|---|---|---|---|---|---|---|
| Therapeutic Thoracentesis | Outpatient procedure, limited anesthesia is required; technical simplicity; drain large volume of fluid (approximately 1.5 liters without risk of reexpansion pulmonary edema) | Recurrent pleural effusion; 96% failure rate in 30 days | 37% | <1% | 4% | 14,15 |
| General Chemical Pleurodesis | Minimal insertion of tubes and decreased risk of frequent thoracentesis | Associated pain and fever; prolonged hospitalization (median time: 4 days); pleurodesis failure | 32% | 6–33% | 68–85% | 1,16-19 |
| Talc Pleurodesis | Minimal drainage following instillation; superior agent in comparison to bleomycin, doxycycline, and tetracycline; comparable to chemical pleurodesis, regarding: quality of life and symptomatic relief | Risk of ARDS ranging between 1–9%; pleurodesis failure; pain is a common post-operative complaint | 2% | 9–38% | 98% | 20-22 |
| Indwelling Pleural Catheter | Indicated for lung entrapment syndrome and failed pleurodesis; technical simplicity; outpatient management; drainage guided by symptoms (patients have more autonomy) | Risk of infection is higher than chemical pleurodesis; increased risk for catheter-tract metastases in patients with mesothelioma | x | 10% | 48–58% | 23-26 |
| Indwelling Pleural Catheter and Talc Pleurodesis | Outpatient management | Pain, empyema, hydropneumothorax are known adverse effects; remains under study. | x | 9% | 43–92% | 25,27,28 |
| Pleuro-peritoneal Shunt | Useful in refractory MPE or trapped lung; post-operative morbidity is low | Infectious risk due to infection of the peritoneal cavity with infected pleural fluid; shunt occlusion (12–25%), tumor seeding into the peritoneal cavity. | 21% | 14% | 95% | 29-32 |
| Thoracoscopy and Pleurodesis | Video-assisted thoracoscopic surgery allows surgeon to assess pleura, diaphragm and pericardium for tumor implants; perform concurrent procedures (mediastinal lymphadenectomy, pleurectomy, etc.); visualize pleural effusion; shorter interval for chest drainage in comparison to chest tube thoracostomy | Patient has to tolerate single lung ventilation; post-operative complications (3%-25%); Prolonged hospitalization (7–10 days) | 2.8% | 2.8% | 90% | 26,30,33 |
| Pleurectomy with Decortication/Extrapleural Pneumonectomy |
Indicated in refractory MPE and mesothelioma | Invasive; 12% mortality risk; prolonged hospitalization; offered based on patient selection per hospital and surgical experience; not standard of care | 4–12% | 10–19% | x | 14,34,35 |
| Chemotherapy | Intrapleural chemotherapy (IC) can treat the underlying malignancy and pleural effusion and has been used in mesothelioma; chemosenstive malignancies with associated MPE, may respond to chemotherapy | IC maybe inferior to existing chemical pleurodesis; patient may not tolerate systemic chemotherapy given functional and physiologic status | 50% at 1 year | 7–40% | 30–70% | 36-38 |
| Radiotherapy, alone | Reduce risk of needle tract metastasis; radiation targeted at underlying malignancy may treat associated MPE; used in multi-modal treatment approach for mesothelioma | Radiation pneumonitis; limited studies on efficacy for MPE and secondary malignant pleural effusions | 17% at 1 year | x | x | 39,40 |
| Immunotherapy | Most current studies involve mesothelioma; immune checkpoint inhibition appears very promising strategy in MM; IL-2 installation could be reconsidered for local therapy | Toxicity; limited studies regarding efficacy | x | 7–90% | 10–20% | 41,42 |