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恶性胸腔积液治疗的中国专家共识（2023年版）
中华医学会呼吸病学分会
作者及单位信息
·
DOI： 10.3760/cma.j.cn112147-20230902-00126
Chinese expert consensus on treatment of malignant pleural effusion (2023 Edition)
Chinese Thoracic Society, Chinese Medical Association
Li Weimin
Authors Info & Affiliations
Chinese Thoracic Society, Chinese Medical Association
Li Weimin
Department of Pulmonary and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China
·
DOI： 10.3760/cma.j.cn112147-20230902-00126
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摘要

恶性胸腔积液（Malignant pleural effusion，MPE）是指胸膜原发恶性肿瘤或其他部位的恶性肿瘤转移至胸膜引起的胸腔积液，MPE患者的预后差。中华医学会呼吸病学分会胸膜与纵隔疾病学组（筹）组织相关领域专家，归纳遴选MPE治疗的临床问题，进行证据检索和评价，并结合我国临床实践，经过多次会议讨论和修订，形成推荐意见。本共识适用对象为年龄≥18周岁，除恶性胸膜间皮瘤以外的各种恶性肿瘤导致的MPE。共识分为四章：MPE的发病机制、MPE的预后评估、胸腔局部治疗、针对MPE的全身抗肿瘤治疗。本共识主要推荐意见如下：1. MPE的预后评估对治疗方案的制定有参考价值，建议结合患者的体力状态评分、肿瘤类型和实验室指标来综合评估患者预后。2. 对有症状的MPE，推荐尽早进行胸腔局部治疗，治疗性胸腔穿刺术可作为初始的治疗措施；穿刺排液后评估肺是否可复张，并据此制定后续的治疗措施。3. 无论肺是否可复张，推荐将胸腔置管引流作为MPE的一线治疗方法，置管后尽量每日引流。对肺可复张的MPE，在有条件的单位，推荐行滑石粉胸膜固定术，经胸腔镜滑石粉微粒喷洒或经胸腔置管滑石粉匀浆灌注均可；不具备条件的单位，可选择聚维酮碘、博来霉素、多西环素等胸膜硬化剂。4. 胸腔置管引流后建议酌情注入铂类药物行胸腔内化疗，或注入抗血管生成药物（重组人血管内皮抑制素或贝伐珠单抗）单药或联合胸腔化疗。胸腔介入治疗（电刀、氩气刀、冷冻、激光、射频消融等）能使部分MPE患者获益，但缺乏高质量的证据，建议有条件的单位，根据患者的具体情况酌情开展，或开展严格的临床研究。对于有症状的分隔性MPE，建议胸腔内注射纤维蛋白溶解剂（如链激酶、尿激酶）来促进积液排出。5. 对不同恶性肿瘤继发的MPE，若患者体力状态评分良好，推荐针对原发肿瘤进行全身抗肿瘤治疗。

ABSTRACT

Malignant pleural effusion (MPE) is a pleural effusion that is caused by a malignant tumor originating in the pleura or by a metastatic malignant tumor from another site that has invaded the pleura. MPE is associated with poor prognosis. Members of the Pleural and Mediastinal Diseases Working Group (preparatory) of Chinese Thoracic Society and some external experts selected clinical issues related to the management of MPE and conducted rigorous evidence retrieval and evaluation. After several meetings and revisions of the manuscript, recommendations were made. This consensus applies to patients aged≥18 years old with MPE caused by various malignancies except for pleural mesothelioma. It included four chapters: pathogenesis of MPE, prognostic evaluation of MPE, local thoracic treatment, and systemic anticancer therapy for MPE.The main recommendations of this consensus are as follows:1. Prognosis evaluation of MPE was valuable in formulating treatment options. It is suggested to comprehensively evaluate the patient′s prognosis by combining the patient′s performance status, tumor type, and laboratory examination.2. It is recommended that in patients with symptomatic MPE, therapeutic thoracentesis could be used as the initial therapeutic option. Evaluate whether the lung is expandable after thoracentesis and drainage, and then develop a therapeutic regimen.3. In patients with MPE and known expandable or nonexpandable lung, an indwelling pleural catheter (IPC) is recommended as a first-line pleural management. Daily IPC drainages are recommended. In patients with MPE and expandable lung, talc pleurodesis by talc poudrage or talc slurry is recommended if the drug is accessible. Other pleurodesis agents include povidone iodine, bleomycin, and doxycycline.4. After drainage, it is suggested to consider the option of intrapleural use of recombinant human endostatin or bevacizumab alone or in combination with intrapleural chemotherapy. Intrapleural intervention including electrocautery, argon knife, cryotherapy, laser and radiofrequency ablation, is recommended for use in patients who have undergone rigorous evaluation in eligible hospitals. The use of intrapleural urokinase or streptokinase via pleural catheter is recommended for patients with symptomatic MPE and loculated effusion.5. For patients with good performance status and metastatic malignancies, systemic anti-cancer treatment is recommended as standard of care.

Li Weimin, Department of Pulmonary and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China, Email: mocdef.3ab61300nimiew
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引用本文

中华医学会呼吸病学分会. 恶性胸腔积液治疗的中国专家共识（2023年版）[J]. 中华结核和呼吸杂志,2023,46(12)：1189-1203.

DOI:10.3760/cma.j.cn112147-20230902-00126

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恶性胸腔积液（malignant pleural effusion，MPE）是指胸膜原发恶性肿瘤或其他部位恶性肿瘤转移至胸膜引起的胸腔积液，胸腔积液样本或胸膜活检组织证实存在恶性肿瘤细胞可确诊 ［ 1 ］ 。常见病因包括肺癌、乳腺癌、血液系统肿瘤、胃肠道肿瘤、妇科恶性肿瘤以及恶性胸膜间皮瘤等，其中肺癌和乳腺癌相关的MPE占总数的50%以上 ［ 2 ］ 。据统计，美国每年MPE住院人数超过12.5万 ［ 2 ］ ；国内流行病学调查显示，MPE占全部胸腔积液病因的23.7% ［ 3 ］ 。MPE患者预后差，中位生存时间通常在3~12个月 ［ 4 ］ 。
既往国内外MPE管理指南推荐，针对MPE的处理以缓解症状的姑息性治疗为主 ［ 5 , 6 , 7 , 8 ］ 。近年来，随着新技术、新方案的研发和应用，推动MPE治疗理念的不断变更。为更好规范和指导国内医师的临床实践，结合我国国情及国内外研究成果，中华医学会呼吸病学分会胸膜与纵隔疾病学组（筹）组织专家，制定《恶性胸腔积液治疗的中国专家共识（2023年版）》。鉴于恶性胸膜间皮瘤的治疗方案与其他病因所致MPE存在较大差异，本共识内容仅针对常见病因的MPE，不包括恶性胸膜间皮瘤。恶性胸膜间皮瘤的诊疗可参考《中国恶性胸膜间皮瘤临床诊疗指南（2021版）》 ［ 9 ］ 。
本共识经过多次工作会议，确定了共识的框架，适用对象为年龄≥18周岁，除恶性胸膜间皮瘤以外的各种恶性肿瘤导致的MPE。共识主体分四章：MPE的发病机制、MPE的预后评估、胸腔局部治疗、针对MPE的全身抗肿瘤治疗。
围绕MPE的治疗，各位专家对相关循证医学证据进行了系统的检索、筛选、评价。经专家组成员反复讨论，形成统一意见，并广泛征求国内相关领域专家的意见后，经过多次修改，最终定稿，形成推荐意见。由中国循证医学中心提供方法学支持，证据和推荐意见的评价与GRADE分级原则保持一致 ［ 10 ］ ，具体推荐强度及证据质量分级和定义见 表1 、 2 。
推荐强度 说明 本共识表达方法 推荐强度表示方法
强推荐使用 干预措施明显利大于弊 推荐 1
弱推荐使用 干预措施可能利大于弊 建议 2
弱推荐反对使用 干预措施可能弊大于利或利弊关系不明确 不建议 2
强推荐反对使用 干预措施明显弊大于利 不推荐 1
GRADE推荐强度分级与定义 ［ 10 ］

注：GRADE为推荐分级的评估、制定与评价

质量等级 定义
高（A） 非常确信真实值接近观察值
中（B） 对观察值有中等程度信心：真实值有可能接近观察值，但仍存在两者不同的可能性
低（C） 对观察值的确信程度有限：真实值可能与观察值不同
极低（D） 对观察值几乎没有信心：真实值很可能与观察值不同
GRADE证据质量分级与定义 ［ 10 ］

注：GRADE为推荐分级的评估、制定与评价

恶性胸腔积液的处理流程见 图1 。
恶性胸腔积液的处理流程图
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备注信息
A
李为民，四川大学华西医院呼吸与危重症医学科，成都610041，Email： mocdef.3ab61300nimiew
B
中华医学会呼吸病学分会. 恶性胸腔积液治疗的中国专家共识（2023年版）[J]. 中华结核和呼吸杂志, 2023, 46(12): 1189-1203. DOI: 10.3760/cma.j.cn112147-20230902-00126.
C
所有作者声明无利益冲突
D
国家自然科学基金 (92159302)
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