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.     

Rapid pleurodesis is an outpatient alternative in patients with malignant pleural effusions: a prospective randomized controlled trial

Background

Chemical pleurodesis can be palliative for recurrent, symptomatic pleural effusions in patients who are not candidate for a thoracic surgical procedure. We hypothesized that effective pleurodesis could be accomplished with a rapid method of pleurodesis as effective as the standard method.

Methods

A prospective randomized ‘non-inferiority’ trial was conducted in 96 patients with malignant pleural effusion (MPE) who are not potentially curable and/or not amenable to any other surgical intervention. They were randomly allocated to group 1 (rapid pleurodesis) and to group 2 (standard protocol). In group 1, following complete fluid evacuation, talc slurry was instilled into the pleural space. This was accomplished within 2 h of thoracic catheter insertion, unless the drained fluid was more than 1,500 mL. After clamping the tube for 30 min, the pleural space was drained for 1 h, after which the thoracic catheter was removed. In group 2, talc-slurry was administered when the daily drainage was lower than 300 mL/day.

Results

No-complication developed due to talc-slurry in two groups. Complete or partial response was achieved in 35 (87.5%) and 33 (84.6%) patients in group 1 and group 2 respectively (P=0.670). The mean drainage time was 40.7 and 165.2 h in group 1 and group 2 respectively (P<0.001).

Conclusions

Rapid pleurodesis with talc slurry is safe and effective and it can be performed in an outpatient basis.     

The clinical utility of pleural YKL-40 levels in diagnosing pleural effusions

Background and objective

Recent evidence suggests that YKL-40 is a relatively new biomarker of inflammation and it is involved in the pathogenesis of several pulmonary diseases. Details of serum and pleural YKL-40 in pleural effusions however, remain unknown. We aimed to assess whether serum and pleural YKL-40 is an accurate biomarker of pleural effusions.

Methods

This clinical study was prospective, observational and cross-sectional. The concentrations of serum and pleural fluid YKL-40 and conventional pleural marker levels were measured in 80 subjects with pleural effusions, including 23 transudates caused by congestive heart failure (CHF), and 57 exudates including 23 parapneumonic, 22 malignant and 12 tuberculous pleural effusions (TBPEs).

Results

Median pleural fluid YKL-40 levels were higher in exudates than in transudates (219.4 and 205.9 ng/mL, respectively, P<0.001). High pleural YKL-40 levels, with a cutoff value of >215 ng/mL, yielded a 73% sensitivity, 73% specificity, likelihood ratio 2.8 for diagnosing exudate, with an area under the curve of 0.770 [95% confidence intervals (CI): 0.657-0.884]. Pleural YKL-40/serum YKL-40 ratio >1.5 yielded a 75% sensitivity, 72% specificity and likelihood ratio 2.6 for diagnosing TBPE, with an area under the curve of 0.825 (95% CI: 0.710-0.940).

Conclusions

High concentrations of pleural YKL-40 level may help to differentiate exudate from transudate and a high pleural YKL-40/serum YKL-40 ratio may be helpful in seperating TBPE from non-tuberculous effusions.KEYWORDS : Exudate, pleural effusion, transudate, tuberculosis, YKL-40     

Role of medical thoracoscopy in the treatment of tuberculous pleural effusion

Background

Fibrous tuberculous pleural effusion (TPE) represents common disease in tuberculous clinic. Medical thoracoscopy has been used to treat pleural empyema and shown promising outcomes, but data of its use in multiloculated and organized TPE remains limited to know.

Methods

The study was performed on 430 cases with TPE. The cases were divided into free-flowing, multiloculated effusion and organized effusion group. Each group was subdivided into two or three types of therapeutic approaches: ultrasound guided pigtail catheter, large-bore tube chest drainage and medical thoracoscopy. Patients with multiloculated or organized effusions received streptokinase, introduced into the pleural cavity via chest tubes. The successful effectiveness of the study was defined as duration of chest drainage, time from treatment to discharge days and no further managements.

Results

Patients with organized effusion were older than those with free-flowing effusion and incidence of organized effusion combined with pulmonary tuberculosis (PTB) was higher than those of multiloculated effusion and free-flowing effusion respectively. Positive tuberculosis of pleural fluid culture was higher in organized effusion than that in free-flowing effusion. Sputum positive for acid-fast bacillus (AFB) in organized effusion was higher than that in multiloculated effusion and free-flowing effusion. Medical thoracoscopy showed significant efficacy in the group of multiloculated effusion and organized effusion but free-flowing effusion. No chronic morbidity and mortality related to complications was observed.

Conclusions

Medical thoracoscopy was a safe and successful method in treating multiloculated and organized TPE.     

Uso del drenaje pleural permanente en el manejo ambulatorio del derrame pleural maligno recidivante

Background and objective

To analyse the effectiveness and safety of the indwelling pleural catheter in the management of recurrent malignant pleural effusion.

Patients and methods

A prospective multicentre study was performed in 63 consecutive outpatients from four Spanish hospitals. A total of 43 men and 20 women were included, with a median age of 67 years. In seven of the cases treatment with pleurodesis had failed; in five other cases their lung was trapped; in another five cases after repeat therapeutic thoracocentesis, and the rest of them as a preference choice to pleurodesis. All patients had an indwelling pleural catheter inserted (PleurX^®, Denver Biomedical).

Results

Most of patients (94.5%) reported an improvement in their respiratory symptoms (cough and dyspnoea) and their ability to function independently. Average length of the catheterisation was 45 days (6–222). Average amount of drained pleural effusion was 75 ml, with a frequency of drainage of between 3 and 4 times per week and once fortnightly. Spontaneous pleurodesis was achieved following 34.9% of procedures. No complications occurred during the insertion of the catheter. The post-catheterisation complications were empyema (3 cases), chest pain (2 cases), and tumour metastasis (3 cases).

Conclusions

The use of an indwelling pleural catheter is an effective palliative treatment in the outpatient management for patients suffering malignant pleural effusion. It is also a simple treatment that can be easily applied, does not require hospitalisation and can be easily managed by the patient at home, with a low rate of complications.     

Role of blind closed pleural biopsy in the management of pleural exudates

INTRODUCTION:

The performance of blind closed pleural biopsy (BCPB) in the study of pleural exudates is controversial.

OBJECTIVE:

To assess the diagnostic yield of BCPB in clinical practice and its role in the study of pleural exudates.

METHODS:

Data were retrospectively collected on all patients who underwent BCPB performed between January 1999 and December 2011.

RESULTS:

A total of 658 BCPBs were performed on 575 patients. Pleural tissue was obtained in 590 (89.7%) of the biopsies. A malignant pleural effusion was found in 35% of patients. The cytology and the BCPB were positive in 69.2% and 59.2% of the patients, respectively. Of the patients with negative cytology, 21 had a positive BCPB (diagnostic improvement, 15%), which would have avoided one pleuroscopy for every seven BCPBs that were performed. Of the 113 patients with a tuberculous effusion, granulomas were observed in 87 and the Lowenstein culture was positive in an additional 17 (sensitivity 92%). The overall sensitivity was 33.9%, with a specificity and positive predictive value of 100%, and a negative predictive value of 71%. Complications were recorded in 14.4% of patients (pneumothorax 9.4%; chest pain 5.6%; vasovagal reaction, 4.1%; biopsy of another organ 0.5%).

CONCLUSIONS:

BCPB still has a significant role in the study of a pleural exudate. If an image-guided technique is unavailable, it seems reasonable to perform BCPB before resorting to a pleuroscopy. These results support BCPB as a relatively safe technique.     

PleurX? Catheter for the Management of Refractory Pleural Effusions in Congestive Heart Failure

Pleural effusions that are caused by congestive heart failure and refractory to medical management are rare, and the options for treating them are few and sometimes ineffective. We report here our experience, over a 2-year period, with a novel device, the Denver Biomedical PleurX® pleural catheter, in treating a series of 5 patients who had chronic, refractory, heart-failure–associated pleural effusions. The PleurX catheter is a small-bore chest tube designed to remain in place for prolonged periods, through which drainage of pleural fluid can be performed easily on a daily or less frequent outpatient basis. Placement of the catheter, in our series, was associated with no complications. In all patients, the catheter effectively drained the pleural space initially, thereby controlling the effusions and alleviating New York Heart Association functional class IV symptoms. The catheters remained in place for a period of 1 to 15 months. In 2 of the patients, the catheter was associated with no complications during the time that it remained in place. One of these patients had the catheter removed at heart transplantation, and 1 retained the catheter until death from underlying heart disease. For 1 patient, the catheter resulted in a partially loculated pleural space, and it was removed. In 2 patients, after prolonged use, it was associated with empyema, for which it was removed. We conclude that the PleurX catheter can effectively control refractory congestive-heart-failure–associated pleural effusions temporarily, but that its prolonged use can cause significant complications, most importantly empyema.Key words: Ambulatory care, catheters, indwelling, drainage/methods, heart failure, congestive, pleural effusionPleural effusions are a common complication of congestive heart failure (CHF).^1–4 Standard medical management of CHF, especially with diuretic agents, is generally very effective in treating these effusions.^5,6 For symptomatic effusions that do not respond adequately or rapidly enough to medical management, thoracentesis is typically performed, with excellent results.^5,6 Rarely, however, pleural effusions due to CHF, particularly in the settings of advanced cardiac failure or impaired renal function, prove to be recurrent or refractory to even the most aggressive medical regimens. Efforts to control such effusions have been limited to serial thoracenteses and pleurodesis.^5,6 Serial thoracenteses, depending upon the frequency, are generally unsatisfactory to patients and, of course, the more frequently they are performed, the greater the risk of complication. Although pleurodesis is the preferred alternative to serial thoracenteses, it also has serious potential limitations and complications,^7–11 whether performed by the traditional “closed” chest tube technique or by state-of-the-art video-assisted thoracoscopic surgery (VATS). Therefore, alternative solutions to this very difficult clinical problem are needed.¹²The PleurX® Pleural Catheter (Denver Biomedical, Inc., part of Cardinal Health, Inc.; Golden, CO) was recently developed for use in patients who cannot tolerate VATS pleurodesis or who have malignant pleural effusions that traditional, closed pleurodesis often cannot control adequately.¹³ The PleurX catheter is essentially a small-bore chest tube that is designed to remain in place for prolonged, intermittent drainage of the pleural space through a one-way valve. The PleurX has proved to be very effective for such drainage, and complication rates have been relatively low.^13–16We hypothesized that the PleurX might be an effective tool for the medical management of refractory pleural effusions caused by CHF. We therefore placed the catheter in 5 of our CHF patients who were poor candidates for traditional pleurodesis. Herein we report our experience with the PleurX catheter, which we believe to be the 1st use of a chronically indwelling catheter system for the management of recurrent pleural effusions in CHF.     

Outcomes of total cavopulmonary connection for single ventricle palliation

Background

The aim of this study was to review the early and mid-term outcomes of the total cavopulmonary connection (TCPC) procedure and evaluate risk factors for prolonged pleural effusions.

Methods

The clinical records of 82 consecutive patients, who underwent a TCPC operation between January 2008 and December 2013, were reviewed for incidence of prolonged pleural effusions, duration of ventilation time and pleural drainage, length of intensive care unit (ICU) stay, and early and mid-term morbidity and mortality.

Results

The median age at surgery was 3.0 years. The main single ventricle diagnoses included 18 cases of a double-inlet single ventricle, 17 cases of heterotaxy, 16 cases of tricuspid atresia, 4 cases of mitral atresia, 12 cases of unbalanced complete atrioventricular canal (CAVC), 5 cases of double-outlet right ventricle (DORV) combined with ventricular septal defect (VSD) and pulmonary stenosis (PS), 4 cases of transposition of the great arteries (TGA) combined with VSD and PS, 4 cases of corrected transposition of great arteries (cTGA) combined VSD and PS, and 2 cases of criss-cross heart. Preoperative mean pulmonary artery pressure (mPAP) was 13.66±2.21 mmHg with 23.2% (n=19) higher than 15 mmHg. A total of 61 (74.4%) patients underwent a fenestration. The perioperative mortality was 4.9%. The median duration of pleural effusion was 10 days (range, 3−80 days), and prolonged pleural effusions occurred in 16 (19.5%) patients. Multivariable analysis revealed that mPAP >15 mmHg was independently associated with prolonged pleural effusions (OR, 8.33; 95% CI, 2.33−29.74; P=0.001), and creation of a fenestration was associated with decreased odds of effusion (OR, 0.21; 95% CI, 0.06−0.74; P=0.015). Five-year estimated Kaplan-Meier survival of two-stage TCPC was significantly higher than that of one-stage group(96.7% vs. 79.7%, P=0.023). Patients with heterotaxy or obstructed totally anomalous pulmonary venous connection (TAPVC) had significantly worse mid-term survival.

Conclusions

Staged TCPC improved the early and mid-term survival of patients with a single ventricle. mPAP >15 mmHg was independently associated with prolonged pleural effusions and a fenestration significantly associated with a lower odds of effusion.     

Endoscopic ultrasound-guided transesophageal thoracentesis for minimal pleural effusion

Background

Pleural effusion is a common finding both in patients with benign and malignant diseases of pleura and lung with diagnostic thoracentesis establishing the diagnosis in the majority of cases. The diagnostic thoracentesis can be done either blindly or under the guidance of ultrasound or computed tomography. However, minimal pleural effusion is difficult to sample even under image guidance. Endoscopic ultrasound (EUS) is known to detect smaller volume of pleural effusion and, thus, can help in guiding thoracentesis.

Aim

To analyze the safety and efficacy of EUS-guided diagnostic thoracentesis in patients with undiagnosed minimal pleural effusion retrospectively.

Methods

Retrospective analysis of the data of patients with minimal pleural effusion, who underwent EUS-guided transesophageal diagnostic thoracentesis over last 2 years, was performed.

Results

Thirteen patients (11 male; mean age 46.7?±?16.2 years) with undiagnosed minimal pleural effusion underwent successful EUS-guided transesophageal diagnostic thoracentesis using a 22-G needle. Seven (53%) patients had fever on presentation whereas two presented with cough and loss of appetite. Eight to 54 mL fluid was aspirated with an attempt to completely empty the pleural cavity. There were no complications of the procedure.

Conclusions

EUS-guided diagnostic thoracentesis is a safe and effective alternative for evaluating patients with minimal pleural effusion.

     

Effectiveness and safety of diagnostic flexi-rigid thoracoscopy in differentiating exudative pleural effusion of unknown etiology: a retrospective study of 215 patients

Background

The aim of this study was to evaluate the effectiveness and safety of diagnostic flexi-rigid thoracoscopy in differentiating exudative pleural effusion of unknown etiology.

Methods

A total of 215 patients with undiagnosed exudative pleural effusion were consecutively recruited between January 2011 and February 2013. Thoracoscopy was carried out under local anesthesia, and multisite pleural biopsies were performed using a flexi-rigid thoracoscope. The tolerance of the patients, surgical complications and postoperative pathological diagnosis rate were used to evaluate the effectiveness and safety of the thoracoscopy procedures.

Results

All patients, Karnofsky performance status (KPS) >70, could tolerate both the thoracoscopic surgery and pleural biopsy; there were no severe complications. Thoracoscopic findings included pleural hyperaemia, fibrinous adhesion, nodular bulge and fester. The pathological biopsy confirmed diagnoses of malignant tumor (97 cases), tuberculous pleuritis (91 cases), tuberculous empyema (one case), pulmonary schistosomiasis (one case) and unknown etiology (25 cases). The total diagnosis rate was 88.4%. Subcutaneous emphysema occurred in ten cases and fever in six cases, all of which recovered completely with conservative treatment.

Conclusions

Flexi-rigid thoracoscopy had a high diagnosis rate, differentiating exudative pleural effusion of unknown etiology with satisfactory effectiveness and safety. There was high degree of relationship between thoracoscopic appearance and primary disease or tumor classification.     

Real-time polymerase chain reaction for microbiological diagnosis of parapneumonic effusions in Canadian children

BACKGROUND:

Community-acquired pneumonia (CAP) complicated by parapneumonic effusion/empyema is an infectious syndrome commonly encountered by physicians caring for children in Canada.

OBJECTIVE:

To investigate the incremental benefit of novel molecular testing for the microbiological diagnosis of pediatric CAP complicated by parapneumonic effusion/empyema in Canada.

METHODS:

A convenience sample of pleural fluid from 56 children who had been admitted to hospital in Ontario with CAP complicated by parapneumonic effusion between 2009 and 2011 was examined. Multiple uniplex real-time polymerase chain reaction (PCR) testing was performed on these pleural fluids and compared with traditional culture-based testing of blood and pleural fluid samples.

RESULTS:

Molecular methods detected a pathogen in 82% of cases, whereas traditional cultures of blood and pleural fluids detected a pathogen in only 25%. The majority of parapneumonic effusions were associated with pneumococcal infection; Streptococcus pneumoniae was detected in 62% of the samples using molecular methods but in only 14% of samples using culture-based methods. Streptococcus pyogenes, detected in 16% of samples using PCR, was the second most common pathogen found. No patients were found to have empyema caused by Staphylococcus aureus.

DISCUSSION:

The results showed that multiple uniplex real-time PCR performed substantially better than traditional culture methods for microbiological diagnosis of CAP complicated by effusion/ empyema. S pneumoniae and S pyogenes were found to be responsible for the majority of infections. The approach detected pathogens in a similar proportion of pleural fluid samples as previously reported nested PCR assays; furthermore, the real-time closed-well approach also minimized the risk of nonspecificity due to cross-contamination relative to nested PCR.

CONCLUSIONS:

Real-time PCR for the detection of bacterial DNA in pleural fluids has the potential to better define the microbiological cause of pediatric CAP. This approach could help clinicians provide targeted antimicrobial therapy.     

Indwelling catheter for the management of malign pleural effusions

Symptomatic malignant pleural effusions are most commonly managed by chemical pleurodesis. The primary disadvantage of chemical pleurodesis is that it requires hospitalization for approximately five days. An alternative to chemical pleurodesis is insertion of an indwelling catheter, which can be applied easily on an outpatient basis. Pleural fluid is drained at 24 to 48 hour intervals by inserting an external line connected to a vacuum container. In the present time, indwelling catheters are viable alternatives for the management of symptomatic malignant pleural effusions especially when length of hospitalization is to be kept to a minimum, and expertise and facilities exist outpatient management of these catheters.     

Predicting survival in patients with recurrent symptomatic malignant pleural effusions: an assessment of the prognostic values of physiologic, morphologic, and quality of life measures of extent of disease

PURPOSE: To determine the prognostic value of pleural fluid pH, pleural fluid glucose, extent of pleural carcinomatosis (EPC) score, and Karnofsky Performance Scale (KPS) score in patients with recurrent symptomatic malignant pleural effusions. DESIGN: Prospective 53-month study. SETTING: Referral center for interventional pulmonology. PATIENTS: Eighty-five consecutive patients (42 men and 43 women) with recurrent symptomatic malignant pleural effusions who were referred to the interventional pulmonary service for thoracoscopic pleurodesis. MEASUREMENTS: Pleural fluid pH, pleural fluid glucose, EPC score, and KPS score. RESULTS: The KPS score was the only statistically significant predictor variable. Patients with a KPS score >/= 70 had a median survival of 395 days, as opposed to a median survival of only 34 days for patients with a KPS score /= 70, it may be very reasonable to proceed with thoracoscopic talc pleurodesis for management of their malignant pleural effusions.     

Preservation of pleural integrity during coronary artery bypass surgery affects respiratory functions and postoperative pain: A prospective study

OBJECTIVE

To evaluate the role of preserved pleural integrity in postoperative pain and respiratory functional status in patients undergoing coronary revascularization.

METHODS

Two hundred forty patients undergoing on-pump coronary artery bypass grafting between March 2004 and February 2005 were included in the present study. The patients were prospectively randomized and divided into either an opened pleura (OP) group (n=120, patients with an OP) or a closed pleura (CP) group (n=120, patients whose pleural integrity was preserved). Preoperative patient characteristics were similar. Postoperative respiratory functions were compared between the groups by chest x-rays, respiratory functional tests and arterial blood gas analyses. Postoperative pain was compared by using a multidimensional pain score. All the tests were examined by the same blinded clinician.

RESULTS

The mean age of the patients was 60.4±8.8 years. Postoperative bleeding and the duration of hospital stay were markedly higher in the OP group than in the CP group. The incidences of atelectasis and pleural effusion were also significantly higher in the OP group (P<0.01). Respiratory functions and postoperative pain scores were better in the CP group (P<0.01 and P=0.008, respectively).

CONCLUSIONS

Preserving pleural integrity has beneficial effects on the respiratory functions and postoperative pain after coronary revascularization. The preservation of pleural integrity results in better respiratory function, decreased hospital stay and cost, and as a consequence, a better surgical outcome.     

Thoracoscopic pleural biopsy improves yield of Xpert MTB/RIF for diagnosis of pleural tuberculosis

Background and objective

Extrapulmonary tuberculosis (EPTB) accounts for ~15% of all TB patients, and TB pleural effusion is the second most common site of EPTB. The diagnosis of pleural TB is challenging due to the pauci‐bacillary nature of the disease. Histopathology of thoracoscopically obtained pleural biopsy provides the highest diagnostic yield. The Xpert MTB/RIF assay (Xpert) is a PCR test that can identify both Mycobacterium tuberculosis (MTB) and rifampicin resistance. Currently, there is a lack of clarity regarding the value of Xpert on pleural tissue. We report our experience of using Xpert on thoracoscopic pleural biopsy samples.

Methods

We retrospectively reviewed the records of patients who underwent thoracoscopy in our institution over a 1‐year period. Relevant clinical details; indications; and results of tests on pleural tissue and fluid, including histopathology, mycobacterial cultures and Xpert, were extracted.

Results

Of the 156 patients who underwent thoracoscopy, 73 (47%) had TB, 66 (42%) malignancy and 17 (11%) other conditions. Histopathology was diagnostic in all the 73 TB patients (100%). The yields of the microbiological tests against histopathology on thoracoscopic biopsy sample and pleural fluid were: pleural tissue Xpert 45%, pleural tissue culture 39%, pleural fluid culture 17% and pleural fluid Xpert 14%. Pleural tissue provided higher yields than fluid in both Xpert and culture (P < 0.05). Pleural tissue Xpert provided a higher yield than culture and substantially improved yield compared with closed pleural biopsy as we previously reported.

Conclusion

Thoracoscopic pleural biopsy results in increased sensitivity on Xpert testing.

     

Myelomatous pleural effusion as an initial sign of multiple myeloma—a case report and review of literature

Objective

Discuss and improve the understanding of the clinical characters and diagnostic methods of myelomatous pleurisy, particularly of the patients with pleural effusion as an initial manifestation.

Background

A 53-year-old male, who had been misdiagnosed as tuberculous pleurisy in a local hospital, was diagnosed as multiple myeloma (MM) with pleural infiltration. We reviewed the literature on clinical manifestations, serum and pleural effusion characters, treatment and diagnostic options of this exceptionally rare presentation of MM.

Methods

We conducted a search of the published medical literature since 2000 in MEDLINE and PubMed using search criteria [(“pleural effusion” and “MM”) or “myelomatous pleural effusions”]. The search led to 64 case reports, and 16 cases with pleural effusion as an initial manifestation were included in this review. We have also searched for recent advances in diagnosis.

Results and conclusions

Myelomatous pleurisy is a rare complication of MM. Its clinical and laboratory findings are non-specific. Definitive diagnosis relies on the histopathology of pleural biopsy or pleural effusion. Thoracoscopic pleural biopsy is reliable, safe and effective. Chemotherapy is the mainstay of treatment for myelomatous pleural effusion. However, the response rate is low with an overall median survival time of 4 months.     

Charlson comorbidity index and adult comorbidity evaluation-27 scores might predict treatment compliance and development of pleural effusions in elderly patients with chronic myeloid leukemia treated with second-line dasatinib

Background

Comorbidities may affect survival and choice of treatment among cancer patients. In fact, comorbidities have been identified as significant determinants of response to therapy in older patients with acute myeloid leukemia, breast cancer, head and neck cancer, and lung cancer. The Charlson comorbidity index and adult comorbidity evaluation-27 are lists of comorbidities with a weight assigned from 1 to 6 for the former and from 0 to 3 for the latter score, derived from relative risk estimates of a proportional hazard regression model using clinical data.

Design and Methods

We retrospectively evaluated the Charlson index and adult comorbidity evaluation-27 score in a cohort of 125 elderly (> 60 years) patients with chronic phase chronic myeloid leukemia who received dasatinib after showing resistance or intolerance to imatinib with the aim of establishing associations between comorbidities and the development of pleural effusions or compliance with the drug treatment.

Results

We found a significant association between the Charlson index as well as the adult comorbidity evaluation-27 score and the rate of drug reduction or suspension: with regards to the Charlson index, 49% of score 0 patients had a dose reduction compared to 63% of patients with score 1, 74% of those with score 2 and 100% of patients with score 3–5 (P=0.03); with regards to the adult comorbidity evaluation-27 score, 45% of patients had score 0–1 and 69% of patients with score 2–3 had a dose reduction. Of the 65 patients with Charlson score 0, 29% had at least one suspension of treatment (79% for hematologic and 21% for non-hematologic toxicity), compared to 46% of patients with score 1 (37% for hematologic and 69% for non-hematologic toxicity), 58% of patients with score 2 (36% for hematologic and 64% for non-hematologic toxicity) and 100% of patients with score 3 or 4 (all patients for both types of toxicity). High adult comorbidity index-27 scores identified patients at high risk of grade 3/4 hematologic toxicity. Forty-one patients (32.8%) experienced pleural effusion during treatment: the highest scores for both indices were associated with an increased risk of pleural effusions.

Conclusions

In elderly patients with chronic myeloid leukemia treated with dasatinib, the rate of drug reduction or suspension and the incidence of pleural effusions seem to be associated with the presence of comorbidities: stratification according to the Charlson index and adult comorbidity evaluation-27 score before dasatinib therapy may enable the identification of patients at risk of major toxicities.     

Efficacy of percutaneous pigtail catheters for thoracostomy at bedside

Objective

Given the potential morbidity of traditional chest tube insertion, use of pigtail is desirable. The purpose of this case series is to determine the efficacy of bedside pigtail thoracostomy catheters in Adult population by using bedside ultrasound by the pulmonologists.

Methods

It is a retrospective case series, which describes the importance of bedside pigtail catheters placements for emergent symptomatic relief for the patients. Predicting a successful drainage, procedure is a complex and multifactorial process based on size, location, character and configuration of the abscess.

Results

Our experience shows that the use of standard size (7-8.5 F) pigtail catheters is usually very successful in draining of the pleural fluids. Less time consumption, lower cost and bedside technique makes it superior to conventional chest tube placement in many aspects.

Conclusions

Percutaneous pigtail catheters are useful in the drainage of pleural fluids. The pigtail catheters can be placed successful at bedside by the pulmonologists under ultrasound guidance with minimal complications and marked clinical improvement. The cost effectives of this procedure over the conventional chest tube placement, makes this procedure more desirable in most of the hospital settings.Key words: Pigtail thoracostomy catheters, bedside procedure, cast effective     

Catheter-tract metastases associated with chronic indwelling pleural catheters

Indwelling pleural catheters are increasingly being used for ambulatory treatment of malignant pleural effusion, particularly for patients unsuitable for pleurodesis. These catheters are often left in situ for the rest of the patient's life. Tumor metastasis along the tract between pleura and skin surface is a potential complication in patients with chronic indwelling pleural catheters that has seldom been reported. We describe four cases of catheter-tract metastasis that developed between 3 weeks and 9 months after catheter insertion. Catheter-tract metastasis occurred in two patients with mesothelioma despite prophylactic irradiation at time of insertion, and in two patients with metastatic adenocarcinoma. All cases were successfully treated using external-beam radiotherapy without necessitating catheter removal. A retrospective audit in our center showed that catheter-tract metastasis occurred in 6.7% of 45 patients treated with indwelling pleural catheters for malignant pleural effusions. Both clinicians and patients should be aware of this potential complication.     

A comparative study of pleurodesis using talc slurry and bleomycin in the management of malignant pleural effusions

Differing success rates of various pleurodesis agents have been reported in the management of malignant pleural effusions. A randomized clinical trial was conducted to compare the efficacy of two commonly used agents, talc and bleomycin, for the pleurodesis of malignant pleural effusions. Methodology : Inclusion in the study required proof of a malignant pleural effusion by fluid cytology or pleural biopsy. Exclusion criteria included trapped lung, loculated effusions, recurrent effusions and life expectancy < 1 month. Five grams of talc or 1 unit per kilogram bodyweight of bleomycin mixed in 150 mL of normal saline was administered via tube thoracostomy after complete drainage of the pleural effusion in each patient. Treatment success was defined as the absence of recurrent pleural effusion on the chest radiograph 1 month after pleurodesis. Results : Treatment success was achieved in 16 out of 18 patients (89%) in the talc slurry group versus 14 out of 20 patients (70%) in the bleomycin group (P = 0.168). Fever and pain were the only side‐effects of pleurodesis in both groups. Conclusion : These results indicate that talc slurry is as effective as bleomycin in preventing early recurrence of malignant pleural effusions. Pleurodesis with talc instead of bleomycin can result in significant cost savings.