Pleural controversy: pleurodesis versus indwelling pleural catheters for malignant effusions

Malignant pleural effusions (MPE) are a common complication of advanced malignancy. The treatment of MPE should be focused on palliation of associated symptoms. The traditional approach to MPE has been to attempt pleurodesis by introducing a sclerosant into the pleural space. A more recent development in the treatment of MPE has been the use of indwelling pleural catheters (IPC) for ongoing drainage of the pleural space. Controversy exists as to which approach is superior. Pleurodesis approaches will have the advantage of a time-limited course of treatment and high pleurodesis rate at the cost of a more invasive procedure requiring a general anaesthetic or conscious sedation (for thoracoscopic approaches) and an inpatient hospital stay. Use of IPC will allow the patient to be treated on an outpatient basis with a minimally invasive procedure, at the cost of long-term need for catheter drainage and care. Symptom control appears similar between techniques. Complication rates between the two approaches cannot be easily compared, but studies suggest more frequent severe complications such as respiratory failure, arrhythmias and even mortality following pleurodesis, with infection rates similar between the two approaches. IPC will likely see increasing utilization in the future but patient preference and local resources and expertise will continue to play a significant part in treatment decisions. Randomized trials directly comparing the two approaches are needed and some are underway. Novel combination approaches utilizing both IPC and pleurodesis agents have the potential to further improve the care of these patients.     

Management of malignant pleural effusions

Abstract:   Malignant pleural effusion is a common clinical problem. Evacuation of the pleural fluid and prevention of its reaccumulation are the main aims of management. Pleurodesis should be attempted early, although considerable practice variations exist in the way it is performed. There is a lack of consensus among respiratory physicians worldwide on the optimal method and agent for pleurodesis. Talc remains the most commonly used pleurodesing compound in most countries. While talc produces a higher success rate than other compounds, it generates more side-effects. The association between talc and ARDS continues to be debated. Ambulatory small-bore pleural catheter drainage followed by intrapleural instillation of a pleurodesing agent is increasingly accepted as an alternative to conventional in-patient pleurodesis. Development of novel methods to control pleural fluid formation should be made a high priority in future pleural research.     

Diagnosis and management of malignant pleural effusions

Abstract:   Malignant pleural effusions (MPEs) complicate the clinical course of patients with a broad array of malignancies, which are most often due to lymphomas or carcinomas of the breast, lung, gastrointestinal tract or ovaries. Patients may present with a MPE as the initial manifestation of a cancer or develop an effusion during the advanced phases of a known malignancy. In either circumstance, the median survival after presentation with a MPE is 4 months. Effusions may result from direct pleural invasion (MPE) or indirect effects (paraneoplastic effusions), such as impairment of fluid efflux from the pleural space by lymphatic obstruction or pleural effects of cancer radiation or drug therapy. Because only 50% of patients with cancer who develop a pleural effusion during their clinical course have a MPE, careful evaluation of the effusion to establish its aetiology is required to direct therapy. Management is palliative with interventions directed towards decreasing the volume of intrapleural fluid and the severity of associated symptoms.     

Efficacy and safety of iodopovidone pleurodesis in malignant pleural effusions

Background and objective: Pleurodesis is one of the best methods of controlling malignant pleural effusions (MPE), a distressing complication of metastatic disease. In recent studies of a wide range of pleural diseases, iodopovidone was used as a sclerosing agent for pleurodesis and demonstrated good results with low morbidity. The aim of this study was to evaluate the efficacy and safety of iodopovidone pleurodesis in MPE. Methods: A retrospective analysis was performed on patients with MPE who underwent pleurodesis at our institution between 2005 and 2008. All patients underwent instillation of 20 mL of 10% iodopovidone, 80 mL of normal saline and 2 mg/kg of lidocaine through a chest tube, which was clamped for 2 h. The tube was removed when the daily output of fluid was <200 mL. Data on the requirement for additional pleural procedures, adverse events and survival were collected. Results: Sixty‐one pleurodesis procedures were performed in 54 patients. No procedure‐related mortality was observed. Adverse events occurred after 11 (18%) pleurodesis procedures. The most frequent complication was mild thoracic pain that occurred immediately after 10 (16.4%) procedures, and one patient developed pleural empyema that was treated with drainage and antibiotics. A success rate of 98.4% was observed. Except for the patient who developed pleural empyema, none of the other patients had recurrences of pleural fluid or required additional pleural procedures during the follow‐up period (mean of 5.6 months). Conclusions: Iodopovidone pleurodesis was successful and was associated with only a few minor complications. It appears to be a good option for the management of recurrent MPE.     

Management of recurrent malignant pleural effusions with a tunneled indwelling pleural catheter

In this review, we report on the use of indwelling pleural catheters in the treatment of malignant pleural effusions. We describe the most commonly used catheter. Also, treatment with indwelling pleural catheters as compared to talc pleurodesis is reviewed. A comparison of efficacy, costs, effects on quality of life, and complications is made. Only one randomized controlled trial comparing the two is available up to date, but several are underway. We conclude that treatment for malignant pleural effusions with indwelling pleural catheters is a save, cost-effective, and patient-friendly method, with low complication rates.     

Osteopontin is upregulated in malignant and inflammatory pleural effusions

Background and objective:   Osteopontin (OPN) is an important mediator of inflammation and cancer progression. In the present study, we asked whether pleural fluid (PF) and serum OPN concentrations differed between patients with pleural effusions of different aetiologies, and whether assessment of OPN levels was useful for diagnostic purposes.
Methods:   One hundred and nine consecutive patients with pleural effusions of different aetiologies were recruited prospectively during daily clinics. OPN levels were measured by ELISA.
Results:   PF OPN levels were 10-fold higher in exudates than in transudates and were significantly correlated with markers of pleural inflammation and vascular hyper-permeability, such as PF/serum LDH or protein ratios, PF protein and PF vascular endothelial growth factor levels. Patients with malignant pleural effusions had higher PF and lower serum OPN concentrations than those with benign disease. The diagnostic accuracies of PF and PF/serum OPN for malignancy were 71.5% (95% CI: 64–80) and 70.6% (95% CI: 62–80), respectively.
Conclusions:   OPN levels were elevated in exudative pleural effusions, as compared with the levels in blood or transudative pleural effusions. While PF and PF/serum OPN were higher in patients with malignancies, the diagnostic accuracy of the tests was not sufficient to permit routine use in clinical practice.     

Prolonged survival after talc poudrage for malignant pleural mesothelioma: case series

OBJECTIVE: Malignant pleural mesothelioma is a fatal disease with a mean life expectancy of 6-12 months. Since 1982, we have performed thoracoscopic talc poudrage (TTP) as a primary therapy in mesothelioma patients presenting with pleural effusion. As the survival data for our patients surpassed that of many published series, the patient data was analyzed to determine whether talc poudrage can be considered as a contemporary palliative option. METHODOLOGY: We reviewed all 26 patients with a final diagnosis of malignant pleural mesothelioma from our prospective database of 228 consecutive patients who received thoracoscopy from the same physician for recurrent symptomatic pleural effusion. Patients were followed up until their death. RESULTS: Mean survival after TTP was 23.8 +/- 16.3 months (median 19.4, range 2.9-68). Pleurodesis palliated dyspnoea in all patients. No perioperative deaths and one postoperative complication (pneumonia) occurred. Mean hospital stay was 3.9 +/- 2.7 days. CONCLUSION: TTP remains a safe, low-morbidity, inexpensive primary palliative treatment option for malignant pleural mesothelioma and a valid control arm option for therapeutic trials. TTP is ideal for patients who wish to avoid thoracotomy, long hospital stays and morbidity from multimodality therapy. Prospective randomized studies are needed to compare quality of life and survival after talc poudrage and other therapies.     

Prolonged pleural catheters in the management of pleural effusions due to breast cancer

Background

Breast cancer is the second most common etiologic cause in malignant pleural effusions (MPE). The aim of this study was to investigate the efficacy of long term pleural catheters in inducing self sclerosis in pleural effusions of breast cancer patients.

Methods

In this study, 26 patients with breast cancer relapleural effusions that occurred between January 2011 and July 2013, who were considered not to undergo any other treatments and managed with prolonged pleural catheters (Jackson-Pratt silicone flat drain), were retrospectively analyzed. Thirty pleural catheters were inserted in 26 patients. All patients were female, mean age was 52 (range, 37-66) years old. Drainage over 1,500 mL per day was not allowed in order to avoid a lung edema. The catheters were removed in patients who had restoration of lung expansion and drainage under 50 mL/day.

Results

The histologic subtypes in pleural effusions were invasive ductal carcinoma in 18 patients, ductal carcinoma in situ in 4, invasive lobular carcinoma in 2, tubular carcinoma in 1, and medullary carcinoma in 1. Three of the 26 patients underwent bilateral catheter insertion, and one patient underwent a reinsertion of the catheter into the same hemithorax due to a recurrence. The catheters were retained for a mean period of 18 days (range, 11-38 days). In one patient with invasive ductal carcinoma and paramalignant pleural effusion (PMPE) (3.8%), a recurrent pleural effusion was seen 34 days after removal of the catheter. There were no complications. One patient died while the catheter was in place.

Conclusions

Prolonged catheters for the management of pleural effusions in selected patients have become more popular than other treatment alternatives due to a shorter length of stay and lower costs. We recommend the use of Jackson Pratt (JP) silicone flat drains which in our opinion provide effective pleurodesis in addition to easy application in recurrent effusions caused by breast cancer.     

Pleural controversies: indwelling pleural catheter vs. pleurodesis for malignant pleural effusions

Malignant pleural effusions (MPE) are frequent consequences of malignant disease and significantly impair the quality of life (QoL) of patients. There are two main options for the palliation of MPE-related symptoms: obliterating the pleural space by pleurodesis to prevent further fluid reaccumulation, or chronically draining the pleural fluid with an indwelling pleural catheter (IPC). There is controversy as to which approach is superior each having advantages and drawbacks. Pleurodesis offers a higher chance of rapid resolution of the pleural effusion with an intervention that is time limited but at the expense of a more invasive procedure, the need for a hospital stay and a higher need for repeat procedures. IPC offers an outpatient solution which is less invasive but at the cost of prolonged catheter drainages and care in a significant portion of patients who will not achieve pleurodesis. Impact on QoL, symptom relief and costs do not appear to be significantly different between the two options. Treatment of MPE should be tailored to the patient’s functional status, comorbidities, prognosis and personal preferences as well as local expertise. Hybrid approaches using pleurodesis techniques and IPC concomitantly may come into play in the near future to further improve patient care.     

Macrophage-derived chemokine in malignant and tuberculous pleural effusions

BACKGROUND AND OBJECTIVES: Macrophage-derived chemokine (MDC/CCL22) is recognized as a T-helper (Th) 2-type chemokine. Both malignant and tuberculous pleural effusions are typically lymphocytic pleural effusions. Tuberculous pleural effusions have a more polarized Th1 reaction than malignant effusions, which are predominantly Th2 in nature. The aim of this study was to compare the levels of MDC in malignant pleural effusions with those in tuberculous pleural effusions to help delineate the role of MDC in Th2 versus Th1 effusions. METHODS: Forty-three patients with pleural effusions (32 malignant, 11 tuberculous) were studied. The concentration of MDC in the pleural effusion was measured by ELISA. RESULTS: The median concentration of MDC was lower in malignant pleural effusions than in tuberculous pleural effusions (P < 0.005). CONCLUSIONS: MDC has been reported to both promote and suppress antitumour immunity. The low concentration of MDC in malignant effusions is likely to minimise its antitumour activity but the precise role of MDC in malignant and tuberculous effusions needs to be investigated further.     

Clinical implications of pleural effusions in ovarian cancer

The pleural cavity constitutes the most frequent extra‐abdominal metastatic site in ovarian carcinoma (OC). In patients with OC and pleural effusions, a positive fluid cytology is required for a stage IV diagnosis. Unfortunately, about 30% of malignant pleural effusions exhibit false‐negative cytological pleural fluid results. In those circumstances, exploratory video‐assisted thoracoscopic surgery (VATS) serves as a diagnostic, staging and even therapeutic modality. Maximal (no visible disease) or, at least, optimal (no residual implant greater than 1 cm) cytoreduction should be the primary surgical goal in stage IV OC patients. This is due to residual tumour after cytoreductive surgery being one of the most important factors impacting on survival. Although malignant pleural effusions do not preclude abdominal surgical debulking, excision of gross pleural nodules may be necessary to achieve optimal cytoreduction. VATS quantifies pleural tumour burden and allows for intrathoracic cytoreduction or, if the latter is not feasible, ensures that abdominal surgery is not unnecessarily performed on women in whom gross tumour would still remain in the pleural space afterwards. Taxane‐platinum neoadjuvant chemotherapy should be offered to this group. Patients with tumour extension into the pleural space have a median overall survival of 2 years.     

Effectiveness of tunneled pleural catheter placement in patients with malignant pleural effusions

Pleural effusions (PE) occur frequently among patients with various types of advanced malignancies, resulting in remarkably decreased quality of life. Treatment of malignant PE includes placement of a chest tube with subsequent placement of a tunneled pleural catheter. We reviewed our experience with tunneled pleural catheter use to assess outcomes and resource utilization of this intervention. A retrospective study of consecutive patients (n = 163, including 41 outpatients) who were treated between July 2001 and April 2008 with tunneled pleural catheters was performed to evaluate operative and discharge outcomes. The average age of the patients was 59.32 years (range: 24 to 89). Lung cancer, breast cancer, and ovarian cancer were common primary diseases in this patient population. The mean hospital stay after tunneled pleural catheter placement was 3.19 days (range: 0 to 56), with 41 patients treated as outpatients. Thirteen inpatient deaths were related to the patients'' primary diseases, but no deaths were due to drain placement itself. Eight patients (4.91%) required reoperation to replace a nonfunctioning drain or to add an additional drain, and six patients underwent a second procedure to place a contralateral drain. One hundred twenty-six patients (77.30%) were discharged home following the procedure and hospital stay. Fifty-five people achieved spontaneous pleurodesis. Tunneled pleural catheter placement is a safe and effective approach to the treatment of PE. The advantages of tunneled pleural catheter placement include symptomatic relief and improved quality of life. This method allows patients to spend time at home with their family and avoid prolonged hospitalization.     

可弯曲内科胸腔镜术对恶性胸腔积液的诊治价值

目的探讨可弯曲内科电子胸腔镜在诊治恶性胸腔积液中的价值。方法经可弯曲内科电子胸腔镜检查确诊的118例恶性胸腔积液的临床资料进行了分析,118例中55例经内科胸腔镜行滑石粉喷洒胸膜固定术。结果 118例均经胸膜活检病理确诊,包括肺癌胸膜转移106例(腺癌74例、鳞癌22例、小细胞癌7例、大细胞癌1例、病理未能分型2例),其他部位胸膜转移6例,胸膜间皮瘤4例,胸膜淋巴瘤2例。胸膜病变主要表现为大小不等的结节、肿块、扁平隆起、白斑、胸膜充血等。胸腔镜下滑石粉胸膜固定术组的胸水控制率为96.4%(53/55),通过胸腔闭式引流管注药的对照组胸水控制率为67.3%(37/55),两组疗效相差显著(P0.01)。胸膜固定术患者术后出现胸痛52例、发热45例,均对症治疗后好转,118例均未发现严重并发症。结论可弯曲内科电子胸腔镜术诊治恶性胸腔积液是一种安全、微创、高效而实用的方法,值得临床广泛推广。     

Use of indwelling pleural catheters for chronic pleural infection

Recurrent, chronic pleural infection creates difficult management issues. Surgical drainage is currently recommended for patients who have failed initial "medical treatment" (ie, tube thoracostomy and antibiotic therapy), but the options for patients not fit for surgery are limited. Prolonged closed tube drainage may be an option in this group, although concerns exist regarding the efficacy and risk of catheter blockage. Long-term indwelling pleural catheters are increasingly used for the treatment of recurrent malignant pleural effusion. Pleural infection is recognized as a complication and is cited as a contraindication to insertion of an indwelling pleural drain within the product literature. We report two patients with empyema in a fixed pleural space in whom the insertion of an ambulatory catheter produced successful drainage. Long-term indwelling pleural catheters may have a role in maintaining the drainage of a chronically infected pleural space that is not readily treated in other ways.     

胸腔镜下胸膜固定术治疗恶性胸腔积液的疗效分析

目的探讨内科胸腔镜下滑石粉胸膜固定术治疗恶性胸腔积液的疗效。方法我科收治的48例中-大量恶性胸腔积液患者随机分为两组,实验组25例行内科胸腔镜下滑石粉胸膜固定术,对照组23例经常规胸腔闭式引流后于胸腔内灌注滑石粉。经胸膜固定后,对于PS 0-2分的患者均予全身化疗2周期。随访复查胸CT及B超,观察12周的胸水控制情况,并对两组的疗效及不良反应进行统计学分析。结果实验组有效率92.0%（23/25）、完全缓解率84.0%（21/25）,对照组有效率60.9%（14/23）、完全缓解率43.5%（10/23）,二者具有显著性差异。不良反应中,胸痛实验组高于对照组,差异有统计学意义;发热两组无统计学差异。结论内科胸腔镜下滑石粉胸膜固定术治疗恶性胸腔积液疗效好,且具有安全、微创特点,值得临床推广。     

Pleural effusions and pneumothorax: Beyond simple plumbing

Pleural diseases affect millions of people worldwide. Pleural infection, malignant pleural diseases and pneumothorax are common clinical challenges. A large number of recent clinical trials have provided an evidence‐based platform to evaluate conventional and novel methods to drain pleural effusions/air which reduce morbidity and unnecessary interventions. These successes have generated significant enthusiasm and raised the profile of pleural medicine as a new subspecialty. The ultimate goal of pleural research is to prevent/stop development of pleural effusions/pneumothorax. Current research studies mainly focus on the technical aspects of pleural drainage. Significant knowledge gaps exist in many aspects such as understanding of the pathobiology of the underlying pleural diseases, pharmacokinetics of pleural drug delivery, etc. Answers to these important questions are needed to move the field forward. This article collates opinions of leading experts in the field in highlighting major knowledge gaps in common pleural diseases to provoke thinking beyond pleural drainage. Recognizing the key barriers will help prioritize future research in the quest to ultimately cure (rather than just drain) these pleural conditions.     

尿激酶治疗多房包裹性恶性胸腔积液的疗效观察简

目的 观察尿激酶治疗包裹性恶性胸腔积液的临床疗效.方法 收集73例肺腺癌伴包裹性恶性胸腔积液患者,随机分为两组,尿激酶组（n=37）经导管向胸腔内注入尿激酶25万U,连续3-5个周期;对照组（n=36）患者仅导管充分引流胸水.所有患者待肺完全复张后给予博莱霉素6万U胸腔注射,行胸膜固定术.比较两组患者一般特征、胸水引流量、肺复张情况和胸膜固定术成功率等;结果 两组患者一般特征无显著差异,其中尿激酶组86%患者（32例）肺完全复张,对照组61%（22例）患者肺完全复张,组间差异显著（P〈0.05）.两组的胸膜固定术成功率无差异（P〉0.05）.结论 胸腔内注射尿激酶可显著增加包裹性恶性胸腔积液患者的肺复张率,可作为恶性胸腔积液患者的常规处理方法.