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ICI Pleural Effusion — SCE Medical Oncology MCQ

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HardLung CancerICI Pleural EffusionSCE Medical Oncology

A 65-year-old woman with NSCLC on immunotherapy has a surveillance CT showing a new pleural effusion. Pleural fluid cytology is negative for malignant cells. pH is 7.45. Protein is 40 g/L (exudate). Lymphocyte-predominant. What should be considered?

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Correct answer: D — Both immune-related pleuritis and malignant pleural effusion are possible — the lymphocyte-predominant exudate without malignant cells raises the possibility of irAE pleuritis; clinical context, serial imaging and sometimes pleural biopsy are needed to distinguish

New pleural effusions during ICI can represent: malignant progression, immune-related pleuritis (irAE), or unrelated causes (heart failure, infection). Lymphocyte-predominant exudative effusions without malignant cells may be immune-related. Clinical correlation (other irAE signs, response at other sites, timing) guides management. If irAE pleuritis is suspected, a trial of corticosteroids with repeat imaging may be diagnostic and therapeutic. Pleural biopsy (thoracoscopy) provides definitive diagnosis if uncertainty persists.

Reference: ESMO 2024 irAE Management; ESMO NSCLC