A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether surgery could ever be justified in
non-small cell lung cancer patients with an unexpected
malignant pleural effusion at surgery. Eight papers were chosen to answer the question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. Study limitations included a lack of retrospective studies, the heterogeneous patient population and various treatments applied. Three papers found that surgery--compared to exploratory
thoracotomy--was associated with a survival advantage in cases of minimal
pleural disease. One paper showed that the median survival time of 58.8 months in patients with
pleural effusion was better than that of patients with more extensive pleural dissemination as pleural nodule (10 months; P=0.0001) or pleural nodule with effusion (19.3 months; P=0.019). Another study showed that
pleural effusion patients with N0-1 status had a median survival time more than 5 years longer than patients with similar or more extensive pleural dissemination but with N2-N3 status. A further study showed a better 5-year survival time in patients with
pleural effusion, than in patients with pleural nodule (22.9% vs 8.9%, respectively; P=0.45). In two papers, surgery vs exploratory
thoracotomy had better survival in cases of N0 status and of complete tumour resection independently of pleural dissemination. Different strategies were employed to obtain freedom from macroscopic
residual tumour, including
pneumonectomy, lobar resection or, to a lesser extent, pleurectomy in patients having pleural dissemination. Only one paper reported a worse median survival time after
pneumonectomy than for more limited resections (12.8 vs 24.1 months, respectively; P=0.0018). In the remaining papers, no comparison between the different resections was made. In all studies except one, surgery was a component of
multimodal treatment. Intrapleural
chemotherapy was largely applied with systemic
adjuvant chemotherapy and/or
radiotherapy. The study period and/or year of publication of most papers was 10 years or more, this may explain the different
chemotherapy regimens used in the various studies. No current guidelines support surgery over
conservative therapy and the identified studies in this review are not strong enough to change this recommendation.