Management of Malignant Pleural Effusion (MPE) in a Tertiary Hospital in a low-income-country: Challenges and Prospects

Background: In the West African sub-region, significant morbidity and mortality are known to affect patients with malignant pleural effusion (MPE) but are highly under reported unlike USA, Europe or South Africa. Aim/Objective: To review cases of MPE in our tertiary hospital in the last 13 years with a view to determining the challenges and prospects. Materials and Method: This is a retrospective study spanning over a decade from January, 2007 to December, 2019. Malignant pleural effusion from various neoplasms constitutes the commonest thoracic malignancy in our tertiary hospital. After 13 years of management of such patients, we reviewed the data from the hospital record’s department. The data obtained were demography, aetiology, total number of pleural fluid specimens for cytology and pleural biopsies submitted for histology, pleurodesis and other treatment modalities. Result: 211 patients with MPE were admitted and managed during the period under review. Of these numbers, 135(64.0%) were confirmed cytologically positive (MPE). 76(36.0%) tested falsely negative and were initially regarded as paramalignant, later confirmed MPE. The age affected was from 7 to 81 years with a mean of 44 years. Of 211 patients with MPE, 94 were males while 117 were females, with a male to female ratio of 4:5. Aetiologically, metastatic breast cancer was the highest followed by advance lung cancer. Conclusion: Submission of insufficient samples resulted in false negative cytology. Review of recurrent pleural effusion and exophytic tumour at the sites of CTTD resulted in late diagnosis of MPE. Additionally, prolonged hospital stay awaiting CTTD and cytology results are among the challenges.


Introduction
Pleural effusion is divided into 3 categories, namely malignant (MPE), nonmaligant and paramalignant.The effusion can accumulate freely in the pleural space or may be loculated.In either case, when massive, it leads to passive atelectasis of the underlying lung and eventual displacement of the mediastinum to the contralateral side, producing 1 cardiorespiratory embarrassment.MPE is defined as pleural fluid containing malignant cells.Paramalignant effusion is defined as an effusion that is not a direct result of neoplastic involvement of the pleura, but rather indirectly related, including but not limited to post obstructive pneumonia, lymphatic obstruction secondary to mediastinal lymphadenopathy, or effusion secondary to pulmonary embolism in a patient with pulmonary malignancy.Nonmalignant effusion is the one occurring in patients without malignancy and itself contains no malignant cells.MPE is a complication of a number of cancers, most commonly lung, followed by breast, lymphoma, 2 gyneacological malignancies, and mesothelioma.Malignant pleural effusion (MPE) is a sign of advanced cancer and is associated with significant symptom burden and mortality.Given that patients with MPEs are heterogeneous with respect to their cancer type and response to systemic therapy, functional status, and pleural milieu, response to MPE therapy is also heterogeneous and difficult to 3,4 predict.It is estimated to affect 150,000 people each year in the US and over 100,000 people in

Materials and Method:
This is a retrospective study spanning over a decade from January, 2007 to December, 2019.After 13 years of managing such patients, we reviewed the data from the hospital record's department.The data obtained were demography, aetiology, total number of pleural fluid and or pleural biopsy specimens submitted for cytology/histopathology, pleurodesis and other treatment modalities.Others included were success rate of pleurodesis and complications as well as the overall outcome of patients managed.Data were analyzed using SPSS version 20 (Chicago) and proportion was set as P < 0.5.

Table 1: Age ranges with gender distribution of patients with malignant pleural effusion (MPE)
Table 1: Here pleural fluid specimens were positive.They were 72 females and 44 males.Among the age range affected, 61-70 years were most affected followed by 31-40 years.Blind pleural biopsy was also confirmed positive and the specific neoplastic types were as described in table 3. growth on the sites of the CTTD.The tumours were excised for histology and the results came out positive with the varied neoplastic growths as described in table 3. Pleural biopsy was subsequently repeated in those patients with recurrent effusion, this time under ultrasound guided in a peripheral referral center.The results also, all came out positive.In this table, females were 53 and males were 42 and the age ranges were mostly affected were 31-40 and 51-60.

Table 3: Aetiology of malignant pleural effusion (MPE)
Table 3 showed the distribution of all the types of neoplasms that resulted in MPE.Breast cancer was the highest followed by advanced lung cancer.The least was metastatic lung cancer from unknown primaries.

Table 6: Overall outcome of pleurodesis for MPE
Table 6 shows the distribution of the overall outcome pleurodesis.In this review, most patients who did not have recurrence for more than 6 months after the initial pleurodesis were unlikely to have one because the constitutional effects from the particular neoplasms was overwhelming that added recurrence could have caused the demise of the patients.Partial response was described as those that had minimal recurrence or full recurrence between 6-12 months of the initial procedure while partial response within 2 weeks to 5 months.Pleurodesis can be achieved using surgical, mechanical, biologic or 24 chemical method.The overall outcome of pleurodesis in this review was divided into 3 groups, namely complete response, partial response and failed response.See table 6. Patients were regarded as having complete response if they had no recurrence after 6 months.On the other hand, those who had recurrence within 3 to 6 months were grouped as partial response while those who had recurrence in less than 3 months were regarded as failed response.Prior the use of IPC, failed pleurodesis was significant owing to the presence of trapped lung.Other authors carried out pleural fluid evacuation using CTTD and pleurodesis and followed the patients up for 3-12 months.Failure 25 rate was noted in 3-30%.

Prospects:
The treatment of MPE in our center initially was not multicentered which largely led to submission of insufficient samples of pleural fluid (<250 ml) with 26 consequently many false negative results.Currently its management rests squarely on the shoulders of multidisciplinary oncology team.MPE treatment is purely aimed at palliation, improvement in quality of life and reducing dyspnoea.To that extent, pleural fluid drainage (CTTD) followed by pleurodesis eliminated dyspnoea.
Accordingly, the primary role of thoracocentesis or chest-tube thoracostomy is to evacuate the pleural space prior instillation of a sclerosant, with the goal of obliterating the 27 visceral/parietal space and preventing recurrence.Also the use of indwelling pleural drainage catheter(IPC) in cases of lung entrapment resulting in failure of lung expansion and consequent discharge of patients to family physicians resulted in reduced hospital stays, reduced financial and physical stress from family care givers and overall improvement in quality of life of patients.See table 7. IPCs alone have been found to cause spontaneous pleurodesis and in a randomized multicenter study with aggressive daily drainage, it was 54 days There is an inherent infectious risk and pleural tract metastasis with IPCs as well as the need [31][32][33] for assistance with home drainage.

Conclusion:
MPE is a continuous challenge to multidisciplinary oncology team.At present, the use of large or sufficient pleural fluid samples increases the diagnostic yield of pleural fluid cytology.The use of ultrasound guided pleural membrane biopsy has increased the yield of true positivity for malignancy.The use of indwelling pleural catheter drainage has equally improved the outlook of palliative care and quality of life of patients with MPE.

Table 4
shows the distribution of the types of pleurodesis done in this review.Chemosclerosis and surgical pleurodesis were employed.As a developing country, the availability of biological agent like corynebacterium parvum and other chemical agents like doxycycline, minocycline and bleomycin were not available.Cytotoxic drugs like doxorubicin, etoposide or cisplatin were not used in the patients encountered in this review.The failure rate of the types of pleurodesis used is as shown.