the mentioned patient has no sign of pneumonia or cardiovascular disease.

You have to make thoracentisis and citology of the pleural effusion. If positive for malignant cell pleurodesis would be an effective option to treat the pleural effusion

Thanks dr Tiziano

as i mentioned the cytology of plural effusion was negative.

MFH is the most common type of soft tissue sarcoma in adult. The most common pattern of spread is hematogenous to lung. The massive pleura effusion could also be caused by some inflammatory diseases. Could it be pulmonary T.B.? Did you check his sputum culture? From your description, metastatic work up was negative. Did  your metastatic work up  include MRI of chest or integrated PET/CT scan ? Or is there any sign of pleura nodules from CT scan of chest? Is it possible to do Video-assisted thoracoscopic surgery to check out the lung mass or nodules or pleura nodules?

I have an experience of radiation therapy to pleura seeding from thymic carcinoma in a patient 1 years ago. I use volumetric modulated arc therapy (VMAT) to deliver radiation doses to the pleura nodules. The patient tolerated well the whole treatment course. There was no obvious pulmonary toxicity after the treatment.

chest tube insertion intraoperative

Dear Hui-Ling

we evaluated thorax with ct scan and MRI ,despite of massive plural effusion ,there was no plural nodule no lung mass.primary work up for TB also was negative

its indicated thoracoscopy and biopsy of any lessons. If the biopsy is positive for sarcoma a new line of chemotherapy is indicated. After this, we have to reevaluated the patient by MRI and PET, if the disease is localized in pleura only, maybe a citoreduction surgery with HITOC could be an option for radical treatment. 

Dear Dr ALVARO

thanks for your reply, if thoracoscopy was negative ,what is your next step?

Cytology of pleural effusion makes any difference?

If cytology is positive for malignant cell , it means metastatic condition.

repeat cytology again....

thoracoscopic pleural biopsy ...

and then PET CT may find some another lesion to diagnose metastatic disease...

if nothing can be found......pleurodesis through ICD insertion after pleural drainage.

Very worrisome, I agree with Vikas.  I like the idea of a PET.  However, if PET is negative, I would repeat scans at close intervals (e.g. every 6 weeks) before doing something invasive.