If the effusion is due to extension of tumor or due to a metastatic process, the lesion is inoperable. However, effusions in patients with lung cancer could be due to pneumonia, atelectasis, lymphatic obstruction, etc. Here it becomes important to establish the etiology of effusion. Negative diagnosis following thoracentesis does not establish with certainty that it is not due to malignancy. At present, three independent pleural cytologies will detect close to 90% of malignant effusions. In centers who perform thoracoscopy, this would be an ideal indication.
My Recommendation:
If a patient has a surgically resectable lesion and in him the effusion is detected only by CT, not by chest x-ray, I send the patient for thoracotomy without any further work up of pleural space.
If he has significant effusion on chest x-ray and, if pleural fluid cytologies are not diagnostic, I would send him for thoracoscopy.
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