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Clinical Investigations: CANCER |

Primary Intrathoracic Malignant Effusion*: A Descriptive Study

Peter Ang, MD; Eng-Huat Tan, MD; Swan-Swan Leong, MD; Linda Koh; Philip Eng, MD, FCCP; Thirugnanam Agasthian, MD; Foong Koon Cheah, MD
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*From the Departments of Medical Oncology (Drs. Ang, Tan, and Leong), Clinical Trials and Epidemiological Sciences (Ms. Koh), and Surgical Oncology (Dr. Agasthian), National Cancer Center, Singapore; and Departments of Respiratory and Critical Care Medicine (Dr. Eng) and Diagnostic Radiology (Dr. Cheah), Singapore General Hospital, Singapore.

Correspondence to: Eng-Huat Tan, MD, Department of Medical Oncology, National Cancer Center, 11 Hospital Dr, Singapore 169610; e-mail: dmoteh@nccs.com.sg



Chest. 2001;120(1):50-54. doi:10.1378/chest.120.1.50
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Published online

Background: Patients who present with malignant pleural/malignant effusion without a definite primary site are not well described in the medical literature. In the course of our clinical practice, we have observed certain traits that are peculiar to patients with such a presentation. We have applied the term primary intrathoracic malignant effusion (PIME) to describe this condition.

Study objectives: Patients must fulfill the following criteria before a diagnosis of PIME can be made: clinical presentation dominated by pleural/pericardial effusion; histologic proof of malignancy obtained from the pleura and/or pericardium; no definite primary site in the lungs or elsewhere from CT scan of the chest, chest radiograph, or physical and endoscopic examination; no history of malignancy; and no history of asbestos exposure. Exposure to environmental tobacco smoke (ETS) among the nonsmokers was examined in a case-control setting.

Methods: We conducted a retrospective search of our database of patients who were referred to the Department of Medical Oncology with a diagnosis of pleural/pericardial effusion from January 1993 to January 2000.

Results: Seventy-one of 200 patients from our database met the criteria. A significant majority of the patients were women (65%) and nonsmokers (72%). All patients had adenocarcinoma shown on biopsy. The majority of patients (63%) had disease localized to the intrathoracic serosal surfaces; the rest had distant metastases involving the lung (50%), bone (27%), liver (19%), brain (8%), and skin (4%). Six patients had two or more sites of distant metastases. There was a significant association with ETS exposure when compared to a control group comprised of patients with colonic cancer, matched for sex and age. The median survival was 10 months for patients with disease localized to the pleura/pericardium and 7 months for those with distant metastases. Thirty-eight patients (54%) received chemotherapy. All had platinum-based chemotherapy, except for three patients. The median survival for patients treated or not treated with chemotherapy was 12 months and 5 months, respectively. This difference in survival was statistically significant (p = 0.003).

Conclusions: PIME should be viewed as a distinct entity. Its etiology remains largely unknown, although exposure to environmental tobacco smoke may play a part. Platinum-based chemotherapy may have a positive biological effect on this disease. More studies are required to elucidate the epidemiology, possible etiologic factors, and treatment options for this group of patients.

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