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Education in Palliative and End-of-life Care - Oncology

The. EPEC-O. TM. Education in Palliative and End-of-life Care - Oncology. Project. The EPEC-O Curriculum is produced by the EPEC TM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.

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Education in Palliative and End-of-life Care - Oncology

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  1. The EPEC-O TM Education in Palliative and End-of-life Care - Oncology Project The EPEC-O Curriculum is produced by the EPECTM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.

  2. EPEC – Oncology Education in Palliative and End-of-life Care – Oncology Module 3m Symptoms –Malignant Pleural Effusions

  3. Malignant pleural effusions . . . • Definition: fluid accumulation in the potential space between the visceral (inner) layer covering the lungs and the parietal (outer) layer covering the chest wall

  4. . . . Malignant pleural effusions Impact: • Dyspnea • Cough • Chest pain • Decreased mobility and fear

  5. Overview • Scope of the problem • Causes • Pathophysiology • Diagnosis • Prognosis • Management options • Treatment strategies

  6. Impact • > 25 % of newly diagnosed pleural effusions are due to malignancy • 50 % of cancer patients will develop a pleural effusion • In US, approx. 100,000 malignant effusions / yr • Life expectancy 4 – 12 months

  7. Causes • Breast and lung cancer 50 – 65 % • Lymphoma, GU, GI 25 % • Unknown primary 7 – 15 %

  8. Prognosis • Mortality 54 % at 1 month, 84% at 6 months • Survival ~ 10 months where pleural effusion is first evidence of cancer • Known CA, exudate, negative cytology poor prognosis compared to positive cytology • Role of pH, Karnofsky Performance Scale?

  9. Key points • Pathophysiology • Assessment • Management

  10. Pathophysiology • Fluid production = fluid resorption • Causes • Tumor cells blocking lymphatic drainage • Changes in colloid osmotic pressure due to hypoalbuminemia

  11. Assessment • History of dyspnea, chest pain, cough • Physical examination of decreased breath sounds, dullness to percussion

  12. . . . Assessment • Symptoms: dyspnea, dry cough, pleuritic pain, chest discomfort, limited exercise tolerance • Exam: decreased breath sounds, dullness to auscultation and percussion • CXR PA, lateral and decubitus films • Chest CT or U / S if loculated

  13. Differential diagnosis • Parapneumonic effusion • Empyema • Chylothorax • Transudate

  14. Benign vs. malignant effusions . . . • Light’s criteria • Pleural fluid LDH > 0.6 • Serum LDH • Pleural fluid protein > 0.5 • Serum protein • Pleural fluid LDH > 2 / 3 ULNserum LDH

  15. . . . Benign vs. malignant effusions . . . • Heffner meta-analysis: • Pleural LDH > 0.45 ULN • Pleural cholesterol > 45 mg / dl • Pleural protein > 2.9 gm / dl Heffner 1997.

  16. . . . Benign vs.malignant effusions • Cytology • Positive in approximately 55 – 65 % initially • Yield up to 77 % on three pleural fluid samples

  17. Management Putnam 1999.

  18. Management options • Thoracentesis • Tube thoracostomy • Small-bore chest tubes • Pleurodesis • Thoracoscopy • Intrapleural catheters • Pleuroperitoneal shunting • Subcutaneous access ports

  19. Thoracentesis • Diagnostic, therapeutic • Temporary relief • Many contraindications • Risks: • Pneumothorax • Reexpansion pulmonary edema (especially if > 1,500 cc removed)

  20. Treatment recommendations • Thoracentesis: diagnosis, palliation until more definitive procedure, medically ill, short-life expectancy • Tube thoracostomy: free-flowing effusions, unable to tolerate general anesthesia • Thoracoscopy: life expectancy > 3 mos, loculated effusions, biopsies • Intrapleural catheters: outpatient pleurodesis

  21. Thoracoscopy benefits • Direct visualization of lung re-expansion • Identify loculated areas and drain • Administration of dry talc, chest tube placement • Confirm equal distribution of talc • Shorter hospital stay than tube thoracostomy • Diagnostic yield 90 %,pleurodesis success rate 90%

  22. Tube thoracostomyand pleurodesis . . . • More definitive than repeated thoracentesis for recurrent effusions • Chest tube 12 – 24 hr or until drainage < 250 ml / 24 hr

  23. . . . Tube thoracostomyand pleurodesis • Sclerosing agent when dry • Talc, bleomycin, doxycycline • Tube clamping controversial • Rotation vs. nonrotation • Failure rate 10 – 40 % • Most widely used and cost effective method

  24. Summary Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve the cancer experience

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