Chapter 35 Medical complications of malignant disease

Cancer can cause a wide variety of medical and metabolic problems. These can be due to the physical presence of the tumour causing obstruction of, for example, the bile duct or a ureter, secretion of fluid into a body cavity, such as the pleura (an effusion), or local invasion of adjacent structures. Cancer and its treatment frequently predispose the patient to infection. In addition, cancer may cause constitutional disturbances which are not due to the local effect of the tumour but the consequence of secreted tumour products resulting in paraneoplastic syndromes. The problems of invasion into neighbouring structures are discussed in Chapter 15. In this chapter, we discuss the problems caused by effusions, infection and paraneoplastic syndromes (Table 35.1) in malignancy.

Table 35.1 Endocrine and paraneoplastic manifestations of malignancy

Effusions secondary to malignant disease

Normally, the pleural, pericardial and peritoneal spaces contain only a few millilitres of fluid to lubricate the inner and outer surfaces of these membranous coverings. However, in cancer, the normal capillary and lymphatic vessels can become damaged and the hydrostatic pressures which regulate the transfer of fluid from one compartment of the body to another disturbed. A build-up of fluid at any of these three sites can cause unpleasant symptoms which may require treatment. Although effusions are usually a sign of advanced malignancy and treatment is only palliative, intervention is usually indicated as it can provide useful clinical benefit and improvement in quality of life.

Pleural effusions

The commonest malignancy to cause a pleural effusion is carcinoma of the bronchus. In addition, metastasis from carcinoma of the breast, other adenocarcinomas and lymphoma may also be implicated. Clinical detection is not possible until at least 500   ml has accumulated and, typically, a symptomatic effusion comprises 1000–4000   ml of fluid. This is usually straw coloured but may be blood stained and will cause increasing shortness of breath, a dry cough and sometimes pain as it increases in size. Diagnosis is usually made clinically and confirmed by chest x-ray. Ultrasound may occasionally be required to distinguish pleural fluid from a solid pleural mass.

Drainage of the fluid is required for relief of symptoms. This can be performed through a needle inserted into the pleural space, which provides good emergency management but, to prevent recurrence of the effusion, either effective treatment of the underlying cancer is required or the effusion should be drained to dryness and a pleurodesis performed. To achieve this, a flexible drainage tube needs to be inserted into the pleural space and the fluid allowed to drain via a sealed drainage system which prevents air from replacing the fluid. Increasingly often this is now performed with ultrasound guidance to reduce the risk of damage to underlying organs, and is particularly useful to identify the optimum site for drainage when the effusion is loculated. Drainage should be relatively slow as sudden removal of large volumes of fluid causes distress to the patient due to shift of the mediastinal structures, and this may precipitate acute pulmonary oedema. After 24–48 hours, when the effusion has drained to dryness, it is usual to inject a drug or chemical into the pleural space to effect a pleurodesis. This will inflame the pleural surfaces to encourage sticking together of the two layers and the development of fibrosis.

Tetracycline and bleomycin were the most commonly used agents for ward-based pleurodesis and will prevent recurrence of the effusion in 50–75% of patients. However, today, there is a much lower threshold for referral to a thoracic surgeon for drainage of the pleural fluid under general anaesthetic, breaking down of any adhesions causing loculation and insufflation of talcum powder. Overall, this more radical approach is more effective and probably both safer and more comfortable for the patient than traditional ward-based pleurodesis.

Pericardial effusions

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