Prognosis
The prognosis of the patient with a pleural effusion depends on the underlying condition. If due to heart failure, cirrhosis, or malignancy, the effusion is likely to recur. However, most patients with a pleural effusion have no long-term sequelae. Malignant effusions may change the staging and subsequent prognosis of the underlying cancer. Complicated parapneumonic effusions and empyema can result in long-term complications such as pleural thickening or trapped lung, with consequent restrictive lung defects. A clinical risk score for empyema (RAPID score) was derived and validated from two large, randomised controlled trials (first Multicenter Intrapleural Sepsis Trial [MIST] 1 and 2).[110] These trials categorised patients into low, intermediate, and high risk of 3-month mortality, surgery, and extended hospital stay on the basis of renal function, age, purulence, infection source, and dietary factors (albumin). In the validation cohort, a low-risk score was associated with 3% mortality, an intermediate-risk score with 9% mortality, and a high-risk score with 31% mortality.[110] The RAPID score may permit risk stratification of patients with pleural infection at presentation.
A prognostic score in malignant pleural effusions (LENT score) has been developed from three large cohorts in the UK, Australia, and the Netherlands, and validated in a smaller cohort from the UK.[111] This categorised patients into low, intermediate, and high risk of mortality on the basis of pleural fluid LDH level, Eastern Cooperative Oncology Group (ECOG) performance status, blood neutrophil-to-lymphocyte ratio, and tumour type. In the validation cohort, 92% of low-risk patients, 57% of intermediate-risk patients, and 17% of high-risk patients were alive at 6 months. This was found to have significantly greater accuracy than performance status alone.
The PROMISE score is a prospectively validated prognostic marker that uses eight variables to predict 3-month mortality in patients with malignant pleural effusion, these are haemoglobin, C-reactive protein, white blood cell count, Eastern Cooperative Oncology Group performance status, cancer type, pleural fluid tissue inhibitor of metalloproteinases 1 (TIMP1) concentrations, and previous chemotherapy or radiotherapy.[112] The European Respiratory Society (ERS) and the European Association for Cardio-Thoracic Surgery (EACTS) suggest that the Brims' decision tree is the most clinically useful for prognostication in mesothelioma.[55] An unselected cohort of sequential mesothelioma patients was used to develop the prognostic tree, which categorises patients into four prognostic groups. This was validated in a separate consecutive cohort, and showed 94.5% sensitivity and 76% positive predictive value for death at 18 months.[113]
Use of this content is subject to our disclaimer