My Patient with Malignant Pleural Effusion
I remember one of the patients I was assigned to during my surgery 1 posting.
After so much stay at home, one tends to relive past experiences. I remember the day we resumed Cardio-Thoracic Surgery Unit (CTSU). We have already been warned against the strictness of the consultants in the unit and so we had to clerk our patients against the following day which was consultant ward-round. I can’t forget the patient I clerked that evening. His expression, his face and all are still very much fresh in my memory like it all happened yesterday.
When I met him, he was in pain and asked if I could come back at a later time which I did after I checked his case note and called the attention of the HO that his morphine injection was due.
I remember this case very well because it was a most exceptional one to me. He had malignant pleural effusion and then, I barely knew what it was, not to talk of knowing how it presents or what investigations will be required. All I got from that clerking was a history of breathlessness and pain in a known cancer patient. Funny right? that on the night before my consultant ward-round, this was what I can come off with. I had to open the patient's case note again to read more. And I saw words like Talc, Pleurodesis, etc. The case note was not useful to me asides telling me the patient had a chest tube insertion which was obvious on inspection.
That night I had to read malignant pleural effusion. If you have been to any of our consultant ward-rounds, you will understand why I couldn’t sleep until I was convinced in myself that I can discuss my patients' diagnosis.
Pleural effusion is collection of fluid within the pleural space, a potential space. And when there are malignant cells found in the effusion, it's called a Malignant pleural effusion (MPE). MPE are exudative fluids associated with malignancies like lung cancer (the commonest cause and also what my patient had), breast cancer, lymphoma, gynaecological malignancies etc.
Pleural effusion occurs when there's loss of the normal balance between fluid entering and leaving the pleural space. Fluid enters the pleural space either by transudation or exudation and leaves the space to enter the lymphatic system. Left heart failure, where there is increased hydrostatic pressure on pulmonary vessels, infections like tuberculosis or anything that compromises lymphatic drainage of pleura can lead to Pleural Effusion. It presents with dyspnea, cough, chest discomfort or asymptomatic depending on the amount of fluid in the space.
When there's malignant infiltration into lymphatics, in mesotheliomas or cancer metastasis to pleura, MPE can result.
I still remember that by the following morning, I was very ready to present my patient and answer any questions around his diagnosis. Well, ready enough to talk about pathophysiology, the reason why my patient had a chest tube insertion, differential diagnosis and all the usual questions you can meet during a round. But that morning, the consultant round didn't hold and no one asked after my newest knowledge. It happens, I told myself. My patient was discharged a few days after. I didn't communicate much with him but I had a reason why I can't forget about him.
What made me not to forget about that particular patient was that a few days after his discharge, I attended a grand round where a case of MPE was being discussed. I suspected it was the patient I had talked to. Talc as a better sclerosing agent over bleomycin was being debated.
Talc is a sclerosing agent that can be used for pleurodesis. Pleurodesis is the management procedure for MPE. It's the process of obliterating the pleural space by causing extensive adhesion of the visceral and parietal pleural surfaces. This can be achieved either by chemical or surgical means.
Slurry Talc is a widely used sclerosing agent for chemical pleurodesis. It can be injected into the pleural space via a chest tube. It causes adhesion of the two pleural surfaces. There are many other sclerosing agents that can be used alternatively including bleomycin, tetracycline derivative, povidone-iodine, silver nitrate etc.
Alternatively to chemical management, surgical pleurodesis can be performed via thoracotomy or thoracoscopy (pleuroscopy). It involves mechanically irritating the parietal pleura, often with a rough pad. Surgical removal of parietal pleura is also an effective way of achieving stable pleurodesis. Thoracocentesis can be used to relieve symptoms temporarily. pleuroperitoneal shunt, and tunneled pleural catheters (TPCs) are other surgical options for achieving pleurodesis.
Read also: Basic Mnemonics in Surgery
I remember that when the Grandround was about to end, I took out my phone to google what talc was. It was dusting powder!