Pleural carcinomatosis

What is a pleural carcinomatosis? 

In pleural carcinomatosis, the pleura, also known as the pleural lining, is affected by metastases of a malignant tumor. It is considered a sign of an advanced or even generalized stage of cancer. The frequency of pleural carcinomatosis in Germany is about 56,000 cases per year.

The pleura is in the chest and composes of two layers: the parietal pleura, which lines the inside of the chest, and the visceral pleura, which covers the lungs. Between these layers is the pleural space which contains serous fluid and is only a few millimeters wide.

Patients with pleural carcinomatosis generally have a poor prognosis, with an average survival time of about four months and a one-year survival rate of 18%. However, the prognosis strongly depends on the type of underlying cancer. For example, the median survival for breast cancer can even extend to several years.

How does pleural carcinomatosis develop? 

Any malignant tumor that spreads metastases can lead to pleural carcinomatosis. The tumor can spread either directly by growing in neighbouring organs or by spreading through blood or lymph vessels.

The most common cause of pleural carcinomatosis is bronchial carcinoma (lung cancer). The second most common tumor to metastasize to the pleura, and the most common in women, is breast cancer (mammary carcinoma). This is followed by malignant lymphomas, ovarian cancer, and gastric cancer.

What are the symptoms of pleural carcinomatosis?  

Pleural carcinomatosis often leads to a pleural effusion (a significant increase in the amount of fluid in the pleural cavity, which can lead to the compression of lung tissue) through various mechanisms, including an inflammatory reaction and impaired drainage due to lymph node involvement.

Patients who are affected often experience shortness of breath on exertion. Large pleural effusions can also cause shortness of breath at rest. A non-productive cough and chest pain may also occur because of pleural carcinomatosis. However, in around a quarter of those affected, pleural carcinomatosis does not cause any symptoms.

Moreover, each underlying cancer can trigger the following symptoms:

• weight loss
• fatigue / tiredness
• night sweats
• other symptoms depending on the primary tumor (e.g. skin changes or secretions in breast cancer, severely swollen lymph nodes in lymphomas, etc.)

How is pleural carcinomatosis diagnosed by the doctor?

The diagnostic process starts with a detailed medical history, during which symptoms of cancer and pleural carcinomatosis, as well as risk factors for the development of malignant tumors (e.g., smoking, genetic predisposition), are gathered.

During the physical examination, a locally reduced breath sound may be heard when auscultating over a pleural effusion with a stethoscope, as well as a reduced percussion sound. Further examination findings may point to the underlying tumor.

With the help of an X-ray examination, fluid amounts as small as 200 ml in the pleural space can be detected. This helps identify a large portion of pleural effusions in pleural carcinomatosis, as these are only smaller than 500 ml in 10% of cases. Ultrasound can detect even smaller effusions.

An unexplained pleural effusion requires diagnostic pleural puncture. After applying a local anesthetic, the pleural space is punctured with a needle, and the fluid is drained. This fluid is then examined to determine the cause of the effusion. In malignant pleural effusions due to pleural carcinomatosis, tumor cells are found in 50-90% of cases during histological examination of the puncture sample. The accuracy of this test depends, among other factors, on the stage of the cancer and the experience of the examiner.

A thoracoscopic biopsy may be conducted to verify the diagnosis of pleural carcinomatosis when it is suspected or to conduct further tests on tumor cells to predict whether the disease will respond to specific therapies. In this minimally invasive procedure, thin instruments are inserted through small incisions between the ribs, and a tissue sample is taken. If cancer cells are present, they are almost always detectable in this sample.

How can pleural carcinomatosis be treated? 

The causal therapy for pleural carcinomatosis is the treatment of the underlying cancer. Several therapies such as chemotherapy, hormone therapy or antibody therapy have a systemic effect on all cancer cells in the body, including in the pleural cavity. Pleural metastases can also be irradiated during radiotherapy.

Pleural carcinomatosis is often diagnosed at an advanced stage. Therefore, the treatment goal is typically palliative, so chemotherapy with many side effects is not preferred. Instead, the focus is on symptomatic treatment. In addition to the need-based medication for pain relief, the following therapies are considered to control the other symptoms of pleural carcinomatosis as effectively as possible:

• Pleural punctures to drain the effusion.
• Insertion of a temporary or permanent pleural catheter to allow fluid to drain continuously and prevent recurrent symptomatic effusions.
• Pleurodesis (adhesion of the two pleural layers to prevent a recurrent effusion).
• Pleurectomy (resection of the pleura to reduce the tumor mass and prevent further effusions).

When is surgery required and how does it work?

A minimally invasive surgery may be needed if there's a strong suspicion of pleural carcinomatosis but no tumor cells are found in the fluid sample. In this case, a tissue sample can be taken to confirm or rule out the diagnosis.

For recurring malignant pleural effusions, a chest drain is required. If the lung can fully expand, pleurodesis can be done to prevent further fluid buildup and improve the patient's quality of life. During this procedure, a substance like bleomycin or talc is introduced into the pleural space to close it off.

If several attempts at pleurodesis have failed, because the pleural effusion is running back faster than the sclerosing substances can work, for instance, a pleurectomy can be performed. This is also a minimally invasive procedure.

If several attempts at pleurodesis have failed, because the pleural effusion is running back faster than the sclerosing substances can work, for instance, a pleurectomy can be performed. This is also a minimally invasive procedure.

Procedures inside the chest that are minimally invasive are known as thoracoscopic procedures and are performed under general anesthesia.

First, small incisions are made. Then, a camera with a light source and special surgical instruments are inserted between the ribs and into the chest. The surgical team watches everything on a large screen. Afterward, patients experience much less pain compared to open surgery, thanks to the small cuts and faster healing.

If surgery successfully prevents further pleural effusions, symptoms like shortness of breath, coughing, and pain can improve.

Which doctors & clinics specialize in pleural carcinomatosis?

Pleural carcinomatosis is a manifestation of cancer and is therefore part of the field of oncology. The treatment often involves doctors specialized in thoracic surgery, anesthesiology, intensive care, and palliative care.

Anyone in need of a doctor would expect the best possible medical care for themselves. Therefore, patients are looking for the most suitable clinic for their needs. Since this is not an objective decision and a respectable doctor would refrain from claiming to be the best, patients must trust the experience of a doctor.

We can help you find an appropriate expert for your condition. All the doctors and clinics listed have undergone extensive review and have been verified by us for their outstanding expertise in the field of pleural carcinomatosis. They are looking forward to and are ready to address your questions and treatment requests.