**1. Introduction**

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eral Thoracic Surgery. 7th Edition 2009, page 558

Pleural effusions can form basing on the disease of the pleural membranes themselves or thoracic or abdominal organs [1]. The pleura is also important to maintain local fluid homeo‐ stasis. The exact mechanisms of pleural fluid production and absorption are complex and not fully understood [2, 3].

The normal pleural space is approximately 18 to 20 μm in width, although it widens at its most dependent areas. It has been shown that the pleural membranes do not touch each other and that the pleural space is a real gap, not a potential space [1].

Classically described; pleural effusion is the accumulation of fluid in the pleural gap that may be caused by any reason [4]. If there is an evidence of invasion by the tumor or any malignant cells detected in this fluid, it is described as malignant pleural effusion. Although there has been no epidemiologic study with respect to pleural effusion yet, it is a common clinic problem which is estimated to be a million cases in the United States of America every year. Malignant diseases account for over 22% of all cases that means; approximately 220 000 new patients in the United States and 40 000 in the United Kingdom [5].

Primary tumours of the pleural space are less common [6]. Pleural metastasis may be caused by any organ. Malignant pleural effusions (MPE) are most frequently produced by carcinomas of the lung (37%), breast (25%), and ovary (10%). Other reasons include malignancies of the genitourinary (7%) or gastrointestinal tract (9%) and lymphoma (10%) [7]. Even today, in up to 10% of the malignant pleural effusions, the origin of tumour is not identified [8].

The incidence and prevalence of mesothelioma may vary from region to region. Interestingly, despite its grim reputation, mesothelioma whose curative treatments are not yet available, offers better survival than does metastatic pleural disease, with a median survival of less than 12 months [6].

© 2013 Esme and Calik; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Asymptomatic patients with either a malignant or a paramalignant effusion need not be treated initially [9]. Malignant pleural effusion will eventually develop into cancer in the majority of patients. It often recurs challenging the physicians, patients and the patient's family in balancing the benefits of symptomatic improvement with the risk and inconvenience of therapy [10, 11].

obstruction, cheilothorax caused by the invasion of thoracic duct, trapped lung, pulmonary embolism, hypoalbuminemia, cachexia, radiotherapy and, chemotherapeutics such as bleo‐ mycin, methotrexate and cyclophosphamide are the well known causes of para-malignant

Management of Malignant Pleural Effusion http://dx.doi.org/10.5772/54441 87

The first and most common presenting symptom is dyspnea (96%) [12, 18]. The pathogenesis of dyspnea caused by a large pleural effusion has not been clearly elucidated, but several factors may be involved including a decrease in the compliance of the chest wall, contralateral shifting of the mediastinum, a decrease in the ipsilateral lung volume, and reflex stimulation from the lungs and chest wall [19]. After other causes of dyspnea have been excluded; detailed anamnesis, physical examination and radiological monitoring are required. As many as a third of patients with malignant pleural effusions present with weight loss and cachexia and appear debilitated by chronic illness [20]. Malignant causes should be excluded firstly in the list of differential diagnosis in patients diagnosed as exudates. A complete medical history and physical examination should be done considering any potential causes or risk factors of

Other bothersome symptoms are cough [44%) and chest pain (56%) [18]. The majority of patients with MPE are symptomatic while less than 25% have no respiratory complaints [12]. Other symptoms include sharp pleuritic pain, dull ache with a feeling of pressure, and heaviness in the chest. A physical examination can reveal decreased breath sounds, and

Although standard chest radiographs can detect as little as 50 mL of PF on a lateral view,[21] it provides only suggestive findings for the diagnosis of MPE. A massive effusion increases the probability of a malignant aetiology and commonly produces a meniscus sign with fluid tracking up the lateral chest wall, a shift of the mediastinum to the contralateral side, and an inversion of the diaphragm. Radiographic signs of an MPE include circumferential lobulated pleural thickening, crowding of ribs, and elevation of the hemidiaphragm or ipsilateral mediastinal shift consistent with lung atelectasis due to airway obstruction by a tumor [22]. Due to resembling the other causes of pleural effusion other imaging studies may be necessary

Ultrasound is an important device during evaluating the presence of an effusion and may be used as a guide during thoracentesis. Ultrasound also may aid in distinguishing an exudates (echogenic) from a transudate (anechoic) although this finding is not definitive [24]. Ultra‐ sound is, in fact, more sensitive than radiography and can detect as little as 5 mL of pleural

such as ultrasound and computed tomography (CT) scan [23].

effusion [17].

malignancy.

dullness to percussion [12].

**4. Imaging techniques**

**3. Clinical presentations**
