How should cancer presenting as a malignant pleural effusion be managed?

The objective of the study was to review the natural history of patients with a malignant pleural effusion but without obvious evidence of a primary, to assess the value of investigations used to look for a primary and to assess the response to palliative chemotherapy. This was done by a retrospective study of patients' notes at the Lung Unit, Royal Marsden Hospital, Sutton, Surrey. Improvement in tumour-related symptoms (and duration) on chemotherapy was assessed by the patient before the first course of chemotherapy and following each course using simple descriptive criteria as follows: (1) complete disappearance of symptoms (CR); (2) good improvement in symptoms (PR); (3) minor or no change in symptoms (NC); (4) worse symptoms (PD). Pleural effusion objective response (and duration) according to Hamed definition: success defined as a continued absence of reaccumulation of pleural fluid on all follow-up radiographs; any reaccumulation was regarded as a treatment failure. Overall survival was measured from the date of histological/cytological diagnosis to death. The study included 42 patients, 27 males and 15 females with a median age of 55 years. A primary was found in 15 patients (36%), and considered to be lung cancer. A total of 11/32 (34%) had a thoracic computed tomography (CT) scan with abnormalities compatible with a diagnosis of lung primary. When thoracic CT scan was negative, fibre optic bronchoscopy was always negative (0/13). Abdominal and pelvic CT scan, abdominal ultrasound, pelvic ultrasound and mammograms failed to reveal the primary. Twenty-three patients underwent local treatment and 37 received systemic chemotherapy. A total of 29/37 (78%) patients achieved symptomatic improvement (median duration, 6 months) and 32/37 (86%) an objective response of their pleural effusion on chemotherapy (median duration, 6 months). The median survival of the whole group was 12 months (3-60+ months). In this series the thoracic CT led to a diagnosis of lung primary in 34% of the cases. Other radiological examinations and bronchoscopy were unhelpful. Chemotherapy achieved symptom relief in 78% of patients.