Management of malignant pleural effusions and pneumothorax

Pneumothorax may occur spontaneously or result from underlying lung disease or as a complication of interventional thoracic procedures. Percutaneous catheter placement enables safe and effective drainage of pneumothoraces with rapid relief of symptoms and restoration of vital capacity and oxygenation.     

Thoracic computed tomography in patients with suspected malignant pleural effusions

AIM: To assess the role of contrast-enhanced computed tomography (CT) prospectively in patients with suspected malignant pleural effusions.MATERIALS AND METHODS: Forty consecutive patients referred for the investigation of a suspected malignant pleural effusion had contrast-enhanced thoracic CT, thoracoscopy, thoraco-centesis and pleural biopsy, either percutaneously or at thoracoscopy. Final diagnoses were based on histopathological or cytological analysis (n = 30), autopsy findings (n = 3) or clinical follow-up (n = 7). The pleural surfaces were classified at contrast-enhanced CT as normal or abnormal and, if abnormal, as benign or malignant in appearance using previously established CT criteria for malignant pleural thickening by two observers unaware of the pathological diagnosis.RESULTS: Pleural effusions were malignant in 32 patients and benign in eight patients. Pleural surfaces assessed at CT showed features of malignancy in 27 out of 32 patients with a malignant effusion (sensitivity 84%, specificity 100%). Overall, CT appearances indicated the presence of malignancy in 28 of 32 (87%) patients. All eight patients with benign pleural disease were correctly diagnosed by CT.CONCLUSION: Contrast-enhanced CT is of value in patients with suspected malignant pleural effusions. The previously established criteria for malignant pleural thickening of nodularity, irregularity and pleural thickness >1 cm are reliable in the presence of a pleural effusion.     

Treatment of malignant pleural effusions with tunneled long-term drainage catheters

PURPOSE: To assess the effectiveness of tunneled pleural catheters (TPCs) in the treatment of malignant pleural effusions (MPEs). MATERIALS AND METHODS: Twenty-eight patients with symptomatic MPEs had 31 hemithoraces treated with TPCs placed under image guidance. Chemical sclerotherapy had failed in two patients and two had symptomatic locules. Drainage was accomplished by intermittent connection to vacuum bottles. Pleurodesis was considered achieved when three consecutive outputs were scant and imaging showed no residual fluid. RESULTS: All catheters were successfully placed. Dyspnea improved in 94% (29 of 31 hemithoraces) at 48 hours and 91% (20 of 22 patients) at 30 days. Control of the MPE was achieved in 90% of hemithoraces (28/31), although five required ancillary procedures. Pleurodesis occurred in 42% (13 of 31) of hemithoraces, including both that underwent an earlier attempt at chemical sclerotherapy and one treated locule. Continued drainage without pleurodesis controlled the effusion in 48% (15 of 31). In only 7% was hospital time necessary for care related to the TPC. Early, transient catheter-related pain was common, but only three complications (in two patients) occurred. Neither of these altered patient care. CONCLUSIONS: Regardless of whether pleurodesis is achieved, TPCs provide effective long-term outpatient palliation of MPEs.     

HRCT在检出恶性胸腔积液中胸膜病变的价值

目的 探讨HRCT检出恶性胸腔积液中胸膜病变的价值.方法 回顾分析恶性胸腔积液合并胸膜病变患者40例,复习恶性胸腔积液中胸膜病变的HRCT影像学表现.结果 本组40例患者CT平扫显示胸腔大量积液者12例,中等量或少量积液者28例.CT增强扫描,胸膜病变明显强化,主要表现为结节状强化.结论 HRCT主要用于肺部弥漫性病变的检出,通过本组病例发现HRCT对于检出恶性胸腔积液中的胸膜病变亦有较高价值.     

Accumulation of 99mTc-diphosphonate in malignant pleural effusions: detection and verification.

Increased accumulation of radioactivity was observed in two cases of malignant pleural effusions during the performance of routine bone scans with 99mTc-diphosphonate. This previously unreported finding was verified both qualitatively and quantitatively by appropriate scanning and laboratory techniques.     

MR imaging of pleural effusions

To investigate the in vivo magnetic resonance (MR) characteristics of pleural effusions, MR imaging was performed on 22 patients who also underwent thoracentesis. Correlation of the MR scans with results of thoracentesis revealed significant differences among three types of effusions: transudates (T) (n = 4), simple exudates (SE) (n = 9), which did not have malignant cells or infection, and complex exudates (CE) (n = 9), which did have malignant cells or infection. Using normalized MR intensities, CE were more intense than SE, which were brighter than T. The second and third echoes (TE 66 and 99 ms) provided the best differentiation for these three classes of effusions, with p less than 0.06 and p less than 0.006, respectively. Qualitative visual assessment of the increase in signal intensity was also useful in differentiating among the three types of effusions (p less than 0.02). Effective T2 values (normalized to fat) were significantly shorter for exudates than for T (p less than 0.02). Heterogeneity, loculation, and size of effusions were well evaluated on MR. Magnetic resonance is not specific for the etiology of effusions. Nevertheless, with analysis of both quantitative and qualitative parameters, MR may provide an effective noninvasive means for the initial characterization and serial follow-up of pleural effusions.     

Usefulness of imaging-guided catheter drainage and talc sclerotherapy in patients with metastatic gynecologic malignancies and symptomatic pleural effusions

OBJECTIVE: The purpose of our study was to assess the usefulness of imaging-guided catheter drainage and talc sclerotherapy in patients with metastatic gynecologic malignancies and symptomatic pleural effusions and to assess the affect of ascites on the success rate of this treatment. MATERIALS AND METHODS: Twenty-five patients (mean age, 63 years) with metastatic gynecologic malignancies who had 26 symptomatic effusions treated at our institution over a 4-year period with imaging-guided catheter drainage and talc sclerotherapy were included in this study. Response to treatment was assessed by comparing pre-, immediate post-, and 30-day postsclerotherapy chest radiographs. Response to the treatment was graded as complete (no reaccumulation), partial (accumulation above immediate post- but below presclerotherapy level), or no response (reaccumulation to or above the presclerotherapy level). The presence of ascites on CT (n = 23), sonography (n = 1), direct intraoperative visualization (n = 1), or at physical examination (n = 1) was also noted. RESULTS: Of the 25 patients, 13 patients with 14 treated malignant effusions survived at least 30 days after sclerotherapy and formed the final study group. The remaining patients either died (n = 11) or were lost to follow-up (n = 1). At 30 days, 12 of the 14 treated effusions showed complete responses and one showed a partial response. The overall response rate was 86%. Abdominal ascites was present at the time of treatment in 11 patients (79%) and did not affect the success rate (p > 0.999). CONCLUSION: Imaging-guided catheter drainage and talc sclerotherapy are an effective treatment for symptomatic pleural effusions in patients with metastatic gynecologic malignancies. Ascites does not adversely affect the response to pleurodesis.     

1.5T磁共振1H-MRS鉴别良恶性胸腔积液的初步研究

目的：探讨磁共振波谱对良、恶性胸腔积液的鉴别诊断价值。方法收集行胸腔穿刺抽液的胸腔积液标本46例,其中原发病确诊为良性者20例（包括肺结核14例、肺炎6例）,原发病确诊为恶性者26例（包括原发性肺癌18例、乳腺癌5例、肝癌2例、胃癌1例）。对胸腔积液标本进行离心处理,然后利用1.5T磁共振对胸腔积液标本进行波谱采集,分析良恶性胸腔积液的波谱特征。结果胸腔积液的波谱图中主要的代谢峰有乳酸、胆碱、肌酸、肌醇及脂质等。主要代谢物波峰下面积比较：乳酸：结核性（5.19±1.31）、炎性（6.08±1.56）和恶性胸腔积液（2.40±0.43）的乳酸峰下面积差异有统计学意义（F=8.45,P<0.01）;胆碱：结核性（2.75±0.91）、炎性（3.27±1.21）和恶性胸腔积液（6.76±1.73）的胆碱峰下面积差异有统计学意义（F=2.98,P<0.01）;肌醇：结核性（2.71±1.19）、炎性（2.25±0.81）和恶性胸腔积液（5.83±2.08）的肌醇峰下面积差异有统计学意义（F=38.49,P<0.01）。结核性和炎性胸腔积液中乳酸（t=-1.04,P＞0.05）、胆碱（t=-0.58,P＞0.05）和肌醇（t=1.19,P＞0.05）波峰下面积差异无统计学意义。结论良、恶性胸腔积液具有不同的波谱特征,利用磁共振波谱对良、恶性胸腔积液进行鉴别具有一定的临床应用价值。     

Computed tomography of free pleural effusions

Forty-three CT examinations of the thorax of patients referred for pleural effusion were reviewed. Both normal and thin irregularly thickened pleurae were associated with either neoplastic or non neoplastic disease. In these cases surgery, fine needle biopsy or pleuroscopy may be recommended, their performance being facilitated by the knowledge of the CT findings. Focal pleural masses or thick irregular pleura were consistently associated with malignancies; however, it was not possible to differentiate between primary and secondary forms. The simultaneous imaging of pleura, lungs and mediastinum by CT is very useful for the diagnosis, prognosis, staging and therapeutic approach of neoplasms.     

Evaluation of CT findings for diagnosis of pleural effusions

Computed tomography studies are usually used to assess patients with pleural effusions, and radiologists should be aware of the significance of different CT findings for the diagnosis of the effusion. The purpose of this study was to evaluate CT findings for etiological diagnosis of pleural effusions. Contrast-enhanced CT of the chest of 211 patients with pleural effusion of definite diagnosis were evaluated. The CT images were evaluated for the presence and extent of pleural effusion, thickening or nodules, extrapleural fat and other changes in the mediastinum or lung. The CT scans were read by two independent observers and correlation between them was evaluated. Comparison of CT findings between benign and malignant effusions, between exudates and transudates, and between empyemas and the other parapneumonic effusions were carried out. Kappa values for most CT findings were > 0.85. Loculation, pleural thickening, pleural nodules, and extrapleural fat of increased density were only present in exudative effusions. Multiple pleural nodules and nodular pleural thickening were the only pleural findings limited to malignant pleural effusions. The signs were also more frequently seen in empyemas than in other parapneumonic effusions. Computed tomography findings can help to distinguish between transudates and exudates. Although there is some overlap between benign and malignant pleural effusions, pleural nodules and nodular pleural thickening were present almost exclusively in the latter. Although differences between CT findings of empyemas and the other parapneumonic effusions exist, there is no finding which can definitely differentiate between them. Received: 27 January 1999; Revised: 24 June 1999; Accepted: 24 August 1999     

Image-guided catheter drainage of infected pleural effusions

PURPOSE: To evaluate the safety and efficacy of image-guided drainage of infected pleural effusions. MATERIALS AND METHODS: The clinical outcomes of 93 patients who underwent image-guided drainage of infected pleural effusions between 1998 and 2003 were retrospectively analyzed. Among the 93 patients, 31 (33.3%) were younger than 16 years of age. In all, 129 catheters (8F-14F pigtail catheters) were placed under ultrasonography (US) or computed tomography guidance. In 27 patients (29.0%) intracavitary fibrinolytic therapy with streptokinase was employed to improve drainage. The patients were followed up during daily rounds and, when drainage problems occurred, catheters were exchanged or repositioned. New catheters were placed for undrained loculations. RESULTS: The success, failure, and recurrence rates were 92.5% (86/93), 7.5% (7/93), and 6.4% (6/93), respectively. In the pediatric age group the success rate was significantly higher. Intracavitary fibrinolytic therapy significantly improved daily output, but did not significantly reduce drainage duration or hospital stay. There was no significant difference between the successful and failed treatment cases in terms of US findings, gross appearance, or culture positivity. The only major complication was anaphylactic reaction due to intracavitary instillation of streptokinase (n = 1, 1.1%). The 30-day mortality rate was 2%. CONCLUSION: Image-guided catheter drainage of infected pleural collections is a safe and effective method. Addition of intracavitary fibrinolytic instillation improves drainage, but early intervention prior to collections becoming more complicated remains an important factor in determining prognosis. Non-loculated anechoic collections without septa have a high probability of favorable outcome.     

胸腔穿刺置管引流联合顺铂腔内注射治疗恶性胸腔积液

目的:探讨胸腔穿刺置管引流联合顺铂腔内注射治疗恶性胸腔积液的疗效及机制。方法:50例恶性胸腔积液患者分为观察组(27例)和对照组1(18例)对照组2(5例),观察组患者放尽胸水后经胸腔内注入顺铂进行治疗;对照组1患者单纯胸腔置管引流治疗,对照组2未行胸腔置管引流。结果:观察组有效率(85.19%)高于对照组1(55.55%)及对照组2(20.00%),差异具有统记学意义(P<0.01)。结论:胸腔置管引流联合顺铂腔内注射治疗恶性胸腔积液疗效显著。     

Accumulation of 99m Tc-Sn-pyrophosphate in pleural effusions

Accumulation of 99m Tc-Sn-pyrophosphate in pleural effusions has been evaluated in 56 patients grouped as follows: 8 with bacterial effusion (Group A), 27 with malignant effusion treated by local and/or parenteral antitumor chemotherapy (Group B), 21 with malignant effusion treated only by supportive therapy (Group C).Results, expressed as effusion to plasma PPi ratio, ranged from 0.1 to 0.28 in group A, from 0.04 to 0.64 in group B and from 0.60 to 1.73 in group C, with significant differences among the three groups. In no case was uptake found in cells of the sediment. Chemical analysis (including total and ionized calcium, total protein, acid and alkaline phosphatase) of plasma and exudate in neoplastic patients showed a slight, but significant, difference between groups B and C as regards plasma-effusion gradient for total calcium and acid phosphatase. Negative correlation also exists between effusion to plasma PPi ratio and plasma-exudate gradient for ionized calcium in neoplastic patients.The data support the hypothesis that acid phosphatase content and calcium gradient are among the factors involved in the mechanism of PPi accumulation in pleural effusions.