Is pleurodesis compulsory for pleural effusion?

Question

Hi doctor,

The patient is a 52-year-old female. 25 days ago, a core biopsy of a retroperitoneal lymph node showed non-Hodgkin's mature B-cell lymphoma diffusely positive for CD10, CD20, BCL6, and BCL12. Bone marrow biopsy showed erythroid hyperplasia with focal micronormoblastic maturation. She is suffering with bilateral pleural effusions.

Repeated thoracentesis was done again, and pleural fluid formation caused breathlessness. The ICD tube drain was inserted seven days back. Two weeks ago, R-CHOP cycle 1 chemotherapy was given, but no response or effect was seen, as there was no drop in blood counts nor any side effects.

Our doubt is whether the chemo R-CHOP cycle 1 has shown an effect inside the body or not. If not, can we give R-CHOP chemo cycle 2 after 14 days instead of 21 days? PET-CT shows metabolically active nodal disease above and below the diaphragm, in the abdomen, mediastinal lymphadenopathy, and at the neck.

Pleural fluid cytology is positive with atypical lymphoid cells, atypical large cells in clusters, scattered singly and round with scant amount of cytoplasm and round nucleus with coarse chromatin. Does it mean malignant pleural effusion?

After removal of ICD tube drain, is pleurodesis compulsory or not? If pleurodesis is required, then please suggest talc pleurodesis. Also, do we need to consult any special surgeon for pleurodesis or general surgeon sufficient?

Kindly suggest.

Answer 1

Hello,

Welcome to icliniq.com.

Thank you very much for being specific in what you want to ask. I understand your concern about a core biopsy and thoracentesis. Based on your description, I suggest the following:

For lymphoma-associated effusion, we do not suggest pleurodesis (a procedure to remove excess fluid in the pleural space), as most of the patients respond to chemotherapy.

One cycle is a short time to know if there is a response. Moreover, only 12 days have passed. So, wait till the chemotherapy works. May go for tapping once again. If it is really not responding, then think only of pleurodesis.

Yes, biweekly CHOP has been tried and is found to be more effective (Cyclophosphamide, Doxorubicin, Vincristine, and prednisone). But it is not yet in the guidelines.

So, it is not a practice or a trial setup. Discuss with your oncologist because he has to take the responsibility to give it.

Also, can you reply with the dose utilized and GCSF (granulocyte-colony stimulating factor) support given or not?

Revert with the answers to the above questions, and also consult a medical oncologist.

I hope this helps.

Thank you.