Malignant Pleural Effusions are common. 

● can complicate most cancers, esp lung and breast carcinomas and malignant mesothelioma.

● It is associated with a significant healthcare cost and its incidence is rising.

Diagnosis:
● Pleural fluid cytology and thoracoscopic biopsy are usually diagnostic.

● PET guided CT biopsy of the most avid area of pleural thickening is an emerging option in difficult cases.

● Mesothelin is a FDA-approved test for the diagnosis and monitoring of mesothelioma. It is useful in some cases. Elevated pleural fluid mesothelin levels suggest epithelioid or biphasic mesothelioma or occasionally metastatic carcinomas.

Treatment:
● Three RCTs have shown that thoracoscopic talc poudrage has no advantage over bedside instillation of talc slurry. One additional trial showed no benefits of talc poudrage over povoiodine instillation.

● Indwelling pleural cathter is a new concept that allows ambulatory management of pleural effusions. It has pros and cons over talc pleurodesis. Clinicians need to be able to manage common IPC complications before using this device.

● Hybrid modalities combining IPC and pleurodesis are under investigation.

Limitations and future directions:
● Talc poudrage was first published in 1935. No significant advances have been made on patient selection and better application of this therapy.

● Malignant effusions are often treated as a single entity without stratifying patients for their underlying malignancy, staging and comorbidity. It is increasingly recognized that malignant pleural effusions of different primary cancers follow different clinical courses and their optimal management may vary.