Malignant effusion - Oncological emergencies
Oncological emergencies- Malignant effusion
Around 40% cases of pleural effusion is associated with cancer, The present of pleural effusion is associated with advanced and incurable cancer. Pleural effusion is not strictly an oncological emergencies.
Normally around 10- 40 ml of hypoproteinaceous plasma fills the pleural spaces. The hypoproteinaceous is originated from capillary and drain through the parietal pleural lymphatics.Malignant pleural effusion may present with cough, dyspnoea or pleuritic chest pain in nature or even asymptomatic at all. The malignant effusion is an exudate. The exudate can be confirm with the level of fluid lactate dehydrogenase (LDH) more than 200 U/ml, fluid : serum LDH > 0.6. fluid: serum protein > 0.5 and fluid :serum glucose < 0.5.
Fluid is hypercellular, blood stained, lymphocytes, reacitve mesothelial cells, monocytes and tumor cell that is exfoliated may present.
The management of malignant pleural effusion depend on the patient ‘s symptoms as only half of the patient will stay alive for the next 3 months and pleural effusion will recur within 30 days of thoracocentesis. The reccurence and accumulation of pleural effusion is treated with pleurodesis ( using talc or tetracycline) or ( VATS) or video associated thoracic surgery with pleurodectomy and insufflation of talc, If the above measure seems unsuccessful , the patient may required chronic indwelling catheter or pleuroperitoneal shunts.
Pericardial effusion is the accumulation of fluid in the pericardial space which as pleural effusion may be divided onto transudate , exudate and hemorrhage. The present of pericardial effusion may exert a pressure on the heart which later leads to cardiac tamponade. Cardiac tamponade is a condition when the pressure on the ventricles during diastole prevent the filling of the heart during diastole. This will reduce the stroke volume and cardiac output . Cardiac tamponade is associated with Beck’s triad which are classical signs of cardiac tamponade. Beck’s triad include hypotension due to reduction in stroke volume, jugular venous distention as an impairment of venous return and muffled heart sound due to fluid in the pericardium.
Primary tumor such as breast, lung, stomach, pancreas, colon and ovaries are the most frequent malignant that cause ascites. The symptoms of ascites are associated with abdominal pain, abdominal distention, dyspnoea or shortness of breath as a result of diaphragmatic splinting, a “ squashed stomach syndrome” and the odema and swelling of the leg, perineum and lower trunk. Paracentesis is indicated when these symptoms appear distressing as it provides quick/fast symptoms relief but poor long term controls. The re accumulation of ascites may be treated with anticancer therapy but if it is unsuccessful diuretics are given. If the ascites cannot be controlled peritoneovenous shunt may be surgically placed under radiologically guidance.
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