Multidisciplinary management of malignant pleural effusion

Approximately 50% of patients with metastatic disease develop a malignant pleural effusion (MPE). Prompt clinical evaluation and treatment to achieve successful palliation are the main goals of management of MPE. Optimal treatment is still controversial and there is no universal standard approach. Management options include observation, thoracentesis, indwelling pleural catheter (IPC) or chest tube placement, pleurodesis, and surgical pleurectomy. The treatment for each patient should be based on symptoms, general condition, and life expectancy.     

良恶性胸腔积液的临床特征及预测因素分析

目的:对比分析良恶性胸腔积液的临床特征,筛选恶性胸腔积液可能的预测因素。方法:收集良性胸腔积液患者30人和恶性胸腔积液患者32人的临床资料,分析胸腔积液及血液学相关指标（胸腔积液物理性状、胸腔积液和血液学生化、肿瘤标志物）。结果:恶性胸腔积液患者的年龄明显高于良性胸腔积液患者,但二者在性别分布上无差异。恶性胸腔积液的乳酸脱氢酶（LDH）、腺苷脱氨酶（ADA）、γ-干扰素（γ-IFN）显著低于良性胸腔积液,而癌胚抗原（CEA）、糖类抗原（CA19-9）、神经特异性烯醇化酶（NSE）显著高于良性胸腔积液（P均<0.05）。两组患者血液LDH、ADA、CEA、CA19-9的差异也具有统计学意义。条件Logistic回归分析发现CEA>10ng/ml、血性胸腔积液、ADA<15U/ml、CA19-9>20U/ml为恶性胸腔积液的预测因素。结论:非肿瘤标志物（如胸水颜色、ADA值）也有助于胸腔积液性质的判断。恶性胸腔积液的预测作用由大到小依次为CEA、血性胸腔积液、ADA、CA19-9。     

Malignant pleural effusion of multiple myeloma: prognostic factors and outcome

Malignant pleural effusion (MPE) in multiple myeloma (MM) is rare. Approximately 80 cases have been reported. To delineate optimal treatment and prognostic variables in these patients, we reviewed 11 MM patients with MPE. MPE developed at median of 12 months from diagnosis of MM. All the patients had high-risk disease based on complex karyotypic abnormalities including deletions of chromosome-13 (n = 9), elevated beta-2 microglobulin (B2M) (n = 9), high C-reactive protein (CRP) (n = 8), high plasma cell labeling index (n = 5) or high LDH (n = 5). A significant increase in B2M, LDH, and CRP was observed at the onset of MPE. The initial diagnosis of MPE was based on positive cytology (n = 9), pleural fluid cIg/DNA (n = 9) or pleural fluid cytogenetics (n = 4). Pleural tissue infiltration was found on pleural biopsy and autopsy in one patient each. Systemic chemotherapy comprising dexamethasone, cyclophosphamide, etoposide and cisplatin (DCEP) (n = 7) and pleurodesis (n = 7) were effective in resolving MPE but survival was short. High dose chemotherapy with peripheral blood stem cell support for MPE in six patients conferred no clear survival advantage. These patients died at median of four months from onset of MPE. Patients with bone marrow complex karyotypic abnormalities including deletion-13 (n = 9) had a shorter (median-18 months) overall survival compared to patients with normal cytogenetics (median-38 months). MPE in patients with MM is often associated with high-risk disease including deletion 13 chromosomal abnormality and heralds a poor prognosis despite aggressive local and systemic treatment.     

Closing faucets: the role of anti-angiogenic therapies in malignant pleural diseases

Malignant pleural effusion (MPE) represents 15–35 % of pleural effusions and markedly worsens the prognosis and quality of life of patients with cancer. Malignant mesothelioma (MM) and lung adenocarcinoma are the most frequent primary and secondary causes, respectively, of MPE. Effective treatments for cancer-related MPE are warranted in order to improve symptoms, reduce the number of invasive pleural procedures, and prolong patient life. Since angiogenesis plays a key role in MPE development, the potential role of bevacizumab and other anti-angiogenic therapies have been explored in this review. No relevant phase III trials have specifically analysed the benefit from adding bevacizumab to platinum-based chemotherapy in lung cancer-related MPE. However, small retrospective series reported 71.4–93.3 % MPE control rate, a reduction in invasive procedures, and a safe profile with this combination. Being approved for the first-line treatment of non-squamous advanced NSCLC, the addition of bevacizumab should be considered for patients presenting with MPE. In addition, further studies in this are recommended. In MM, the addition of bevacizumab to platinum-based chemotherapy did not meet primary endpoints in two phase II trials. However, the beneficial results on OS reported in comparison with historical cohorts and the statistically significant benefit on PFS and OS observed in the phase III MAPS trial foretell an eventual role for the combination of platinum/pemetrexed/bevacizumab as front-line systemic therapy for pleural MM. To date, no other anti-angiogenic drug has showed significant benefit in the treatment of patients with either MPE or MM. However, new promising drugs such as ramucirumab or recombinant human endostar warrant further investigation.     

Therapeutical effect of intrapleural perfusion with hyperthermic chemotherapy on malignant pleural effusion under video-assisted thoracoscopic surgery

Background: Patients with malignant pleural effusions (MPEs) have limited life expectancy. This study aims to investigate the feasibility of intrapleural perfusion with hyperthermic chemotherapy (IPHC) under video-assisted thoracoscopic surgery on MPE patients.

Methods: MPE patients were enrolled in the study and treated with IPHC. The treatment response was classified as complete response (CR, no re-accumulation of pleural fluid for 4?weeks), partial response (PR, re-accumulation above the post-IPHC level but below the pre-IPHC level for four weeks), no response (NR; re-accumulation or above the pre-IPHC level). The change of Karnofsky performance score (KPS) and tumour markers were also recorded. Follow-up was done every two weeks during first month and monthly thereafter until death.

Results: Eighty patients included 46 males and 34 females were included in the study. The total response rate was 100%, with 71.3% of CR and 28.7% of PR. The KPS scores were significantly elevated and the level of tumour markers in pleural effusion were dramatically decreased after IPHC. The median survival was 16.8?months ranged from 2.1 to 67.4?months. One-year and two-year survival rates were 82.5% and 23.8%, respectively. There were no serious clinical compilations during IPHC treatment.

Conclusions: IPHC is a safety, effective and promising approach for MPE patients. It provides well survival benefit and minor toxicities.     

Management of malignant pleural effusion

Malignant pleural effusion (MPE) often presents in patients with cancer at an advanced stage and thus carries a poor prognosis. This review updates the current knowledge on the management of MPE, focusing on recent literature about the efficacy and safety of the most common methods, including pleurodesis by either thoracoscopy with talc insufflation or thoracostomy with talc slurry, use of an indwelling pleural catheter, and intrapleural chemotherapy. Talc remains the agent of choice in pleurodesis, although the use of alternative agents continues to be explored. The choice of procedure to achieve pleurodesis depends on careful patient selection based on predictive factors and individual characteristics. Talc pleurodesis is relatively well tolerated and safe, as is an indwelling pleural catheter, in an appropriate patient population. Because MPE is a common problem in cancer patients, future research with more randomized, prospective designs and innovative interventions is needed.     

A randomized comparison of indwelling pleural catheter and doxycycline pleurodesis in the management of malignant pleural effusions

BACKGROUND: The purpose of this study was to compare the effectiveness and safety of a chronic indwelling pleural catheter with doxycycline pleurodesis via tube thoracostomy in the treatment of patients with recurrent symptomatic malignant pleural effusions (MPE). METHODS: In this multi-institutional study conducted between March 1994 and February 1997, 144 patients (61 men and 83 women) were randomized in a 2:1 distribution to either an indwelling pleural catheter or doxycycline pleurodesis. Patients receiving the indwelling catheter drained their effusions via vacuum bottles every other day or as needed for relief of dyspnea. RESULTS: The median hospitalization time was 1.0 day for the catheter group and 6.5 days for the doxycycline group. The degree of symptomatic improvement in dyspnea and the quality of life was comparable in each group. Six of 28 patients who received doxycycline (21%) had a late recurrence of pleural effusion, whereas 12 of 91 patients who had an indwelling catheter (13%) had a late recurrence of their effusions or a blockage of their catheter after the initially successful treatment (P = 0.446). Of the 91 patients sent home with the pleural catheter, 42 (46%) achieved spontaneous pleurodesis at a median of 26.5 days. CONCLUSIONS: A chronic indwelling pleural catheter is an effective treatment for the management of patients with symptomatic, recurrent, malignant pleural effusions. When compared with doxycycline pleurodesis via tube thoracostomy, the pleural catheter requires a shorter hospitalization and can be placed and managed on an outpatient basis.     

Prognostic value of aberrant hypermethylation in pleural effusion of lung adenocarcinoma

Lung adenocarcinoma is one of the most frequent causes of malignant pleural effusions (MPE). The presence of MPE bears a poor prognosis. Although epigenetic changes are commonly related to human neoplasia, scarce date is available on patients with MPE. We aimed to estimate the prognostic value of DNA methylation of tumor suppressor genes from pleural fluid. Thirty patients with MPE due to lung adenocarcinoma were prospectively included. Methylation-specific (MS) PCR was used to study the methylation status of the promoter region of tumor suppressor genes p16/INK4a, MGMT, BRCA1 and RARβ in pleural fluid. Clinical data and survival were collected. Survival analysis was performed using Kaplan-Meier plots and Cox regression. Hypermethylation in at least one gene was detected in 25 patients (83.3%). On multivariate analysis factors significantly associated with shorter survival were the lack of hypermethylation in any of the studied genes (hazard ratio = 9.3; p = 0.001), Charlson index ≥ 3 (hazard ratio = 9.6, p = 0.002) and no oncological treatment (hazard ratio = 11.1; p < 0.001). Analysis of aberrant promoter hypermethylation of tumor suppressor genes may be useful in predicting prognosis, but further studies are needed to validate our findings.     

Diagnostic value of pleural interleukin 17 and carcinoembryonic antigen in lung cancer patients with malignant pleural effusions

Interleukin 17 (IL-17) has been found to be increased in some human cancers; however, the possible implication of IL-17 in regulating antitumor responses in lung cancer patients with malignant pleural effusions (MPE) remains to be elucidated. This study aimed to investigate the diagnostic value of pleural IL-17 and carcinoembryonic antigen (CEA) in MPE and benign pleural effusions (BPE). Pleural effusion samples from 108 patients were classified on the basis of diagnosis as MPE (n?=?56) and BPE (n?=?52). The concentration of IL-17 was determined by enzyme-linked immunosorbent assay (ELISA). The CEA levels were also determined in all patients. A significant difference was observed in the levels of CEA (P?<?0.01) between MPE and BPE. The concentration of IL-17 in MPE was significantly higher compared to that in BPE (P?<?0.01). With a cutoff point of 15.7 pg/ml, IL-17 had a sensitivity of 76.8 % and a specificity of 80.8 % for differential diagnosis. The combined detection of IL-17 and CEA had a sensitivity of 96.4 % and a specificity of 92.3 % to distinguish MPE from BPE. The combined detection of IL-17 and CEA may be more valuable in the differential diagnosis between MPE and BPE.     

胸腔热灌注治疗对肺癌胸水患者Th1/Th2免疫反应状态的影响

背景与目的:胸腔热灌注术是治疗肺癌胸水的独特方法,辅助性T细胞亚群(Th1/Th2)的平衡消长是反映机体抗肿瘤免疫功能的重要指标。本研究评价胸腔热灌注治疗肺癌胸水的临床综合疗效,同时观察胸腔热灌注治疗对肺癌胸水患者Th1/Th2免疫反应状态的影响。方法:在电视胸腔镜辅助下用43℃温盐水循环胸腔灌注60min,治疗24例肺癌胸水患者,观察随访胸水控制效果、副作用和生存时间。收集热疗前后患者外周血和胸水,用酶联免疫吸附法(ELISA)检测Th1型细胞因子白细胞介素2(interleukin-2,IL-2)、γ-干扰素(interferon-gamma,IFN-γ)和Th2型细胞因子白细胞介素4(IL-4)、白细胞介素10(IL-10)的浓度,同时用RT-PCR方法检测这些细胞因子mRNA的表达。结果:无手术死亡,无明显并发症。全组胸水控制总有效率达100%,完全缓解率为95.8%(23/24),部分缓解率为4.2%(1/24)。热疗后无胸水复发,生活质量有明显提高。全组中位生存期达18.3个月,1年生存率91.7%,2年生存率16.7%。与热疗前比较,热疗后肺癌胸水患者外周血或胸水中Th1型细胞因子浓度和mRNA阳性率均显著升高,而Th2型细胞因子则相反(P<0.05)。结论:电视胸腔镜辅助下胸腔热灌注术是一种安全、有效、微创的肺癌胸水治疗方法。胸腔热灌注治疗可促使肺癌胸水患者Th2免疫反应优势向Th1方向逆转。     

奈达铂胸腔灌注治疗恶性胸水的临床观察

目的：观察胸腔内注射奈达铂（ＮＤＰ）和顺铂（ＤＤＰ）治疗恶性胸水的疗效。方法：收集６１例晚期各种肿瘤引起的恶性胸水患者,随机分为ＮＤＰ组和ＤＤＰ组,两组患者均先排尽胸水,ＮＤＰ组采用ＮＤＰ（１００ｍｇ／次）溶于２０～４０ｍｌ生理盐水中注入胸腔,ＤＤＰ组用ＤＤＰ（８０ｍｇ／次）溶于２０～４０ｍｌ生理盐水中注入胸腔,观察两组胸水治疗的有效率、胸水复发时间,以及患者生存质量变化和中位生存时间。结果：ＮＤＰ组治疗胸水有效率８０.０％,优于ＤＤＰ组５４.５％（Ｐ＝０.０１２）;呼吸困难缓解程度ＶＡＳ评分ＮＤＰ组优于ＤＤＰ组（Ｐ＜０.０５）;中位生存期ＮＤＰ组４１３天,ＤＤＰ组４０４天,两组无统计学差异。结论：ＮＤＰ治疗恶性胸水安全有效,其治疗效果优于顺铂。     

经多色流式细胞术确诊多发性骨髓瘤并发恶性胸腔积液6例临床特征分析

目的:分析由多色流式细胞术(flow cytometry,FCM)诊断的多发性骨髓瘤(multiple myeloma,MM)并发恶性胸腔积液(my-eloma pleural effusion,MPE)患者的临床特点。方法:回顾性分析江苏省苏北人民医院2016年7月至2020年5月经FCM确诊的6例MM并发MPE患者的临床特征、实验室指标和转归情况。结果:6例患者中位发病年龄为62(49～72)岁,男女比为2:1。其中,IgA型3例,IgG型2例,轻链型1例,所有患者常规脱落细胞学检查均为阴性,但FCM均能找到浆细胞。随访截至2020年5月1日,4例患者死亡,2例患者存活。FCM检测胸水浆细胞比例与胸水总蛋白、白蛋白、球蛋白、乳酸脱氢酶(lactate dehydrogenase,LDH)水平、腺苷脱氨酶(adenosine deaminase,ADA)及初诊时骨髓浆细胞比例成正相关(P<0.05),与胸水常规红细胞数、单个核细胞数、白细胞数以及血清血红蛋白、血小板、总蛋白、白蛋白、LDH水平、ADA、β2-微球蛋白均无明显相关性(P>0.05)。结论:MM并发MPE的患...     

Autocrine IL-6-induced Stat3 activation contributes to the pathogenesis of lung adenocarcinoma and malignant pleural effusion

Malignant pleural effusion (MPE) is a poor prognostic sign for patients with non-small-cell lung cancer (NSCLC). The generation of MPE is largely regulated by vascular endothelial growth factor (VEGF), and upregulation of VEGF by Stat3 has been observed in several types of tumor cells. In this study, we demonstrate constitutively activated Stat3 in several human lung cancer cell lines and in tumor cells infiltrated in the pleurae of patients with adenocarcinoma cell lung cancer (ADCLC) and MPE. The observations suggest that activated Stat3 plays a role in the pathogenesis of ADCLC. In PC14PE6/AS2 cells, a Stat3-positive human ADCLC cell line, autocrine IL-6 activated Stat3 via JAKs, not via Src kinase. PC14PE6/AS2 cells express higher VEGF mRNA and protein than do Stat3-negative PC14PE6/AS2/dnStat3 cells. In an animal model, PC14P6/AS2/dnStat3 cells produced no MPE and less lung metastasis than did PC14P6/AS2 cells. PC14PE6/AS2 cells also expressed higher VEGF protein, microvessel density, and vascular permeability in tumors than did PC14P6/AS2/dnStat3 cells. Therefore, we hypothesize that autocrine IL-6 activation of Stat3 in ADCLC may be involved in the formation of malignant pleural effusion by upregulating VEGF. Higher levels of IL-6 and VEGF were also found in the pleural fluids of patients with ADCLC than in patients with congestive heart failure. The autocrine IL-6/Stat3/VEGF signaling pathway may also be activated in patients with ADCLC and MPE. These findings provide novel targets for the management of MPE.     

胸膜固定术治疗恶性胸腔积液的研究进展

恶性胸腔积液（malignant pleural effusion,MPE）是癌症患者的一种常见并发症,预后普遍较差。随着全球癌症发病率的不断增高以及多数癌症患者预期寿命的延长,MPE的发病率和相关医疗费用呈现逐渐上升趋势。虽然针对MPE的姑息性治疗方案众多,但是其效果并不确切,MPE的临床管理仍存在较大挑战。胸膜固定术是MPE的主要治疗方式之一,可有效缓解积液相关症状,降低胸膜再次干预的风险。本文将从胸膜固定术治疗MPE的机制、硬化剂种类和硬化剂输注途径三个方面展开综述,为临床实践中开展更加有效、合理、个体化的MPE管理方案提供思路。      

Bevacizumab plus chemotherapy for advanced non-squamous non-small-cell lung cancer with malignant pleural effusion

Purpose

The presence of malignant pleural effusion (MPE) indicates a poorer prognosis for patients with non-small-cell lung cancer (NSCLC) and impairs their quality of life. Because vascular endothelial growth factor (VEGF) is the key mediator MPE production, we evaluated the efficacy and safety of chemotherapy plus bevacizumab, an anti-VEGF antibody, in non-squamous NSCLC patients with MPE, especially regarding the control of pleural effusions.

Methods

From November 1, 2009 to September 30, 2011, medical charts of 13 consecutive patients with MPE who received bevacizumab plus chemotherapy as the initial or secondary treatment were retrospectively analyzed.

Results

Of the 13 patients, 6 did not undergo pleurodesis, 3 were unsuccessfully treated by pleurodesis, 2 had encapsulated pleural effusion, and 2 had no re-expansion of the lung. Twelve patients (92.3 %) achieved MPE control lasting >8 weeks following bevacizumab plus chemotherapy. Five of 10 patients with measurable lesions had confirmed partial responses. Of 3 patients without measurable lesions, one had confirmed CR. Median progression-free survival time without re-accumulation of MPE was 312 days. Grade 3 or 4 neutropenia, thrombocytopenia, hypertension, or proteinuria was observed in 2, 2, 1, or 1 patient, respectively.

Conclusions

This is the first study to report that bevacizumab plus chemotherapy is highly effective for the management of MPE in non-squamous NSCLC patients. Prospective clinical trials are warranted to investigate the efficacy of bevacizumab for MPE.     

Pleuritis carcinomatosa

The most used standard therapy for malignant pleural effusion(MPE)is tube thoracostomy drainage, except in cases where there are few pleural effusions or no symptoms. It has been reported that instilling an intrapleural agent is necessary for producing pleurodesis after tube thoracostomy drainage. To date, numerous chemical agents for the treatment of MPE have been studied. These include antibiotics, antineoplastic agents, biological response modifiers and others, that showed various degrees of chemical sclerosis. It was entered on a randomized comparison of tetracycline and bleomycin for treatment of MPE. The rate and time to recurrence were both significantly greater with bleomycin. In comparison, Talc was superior to bleomycin for control of MPE. Therefore, thoracoscopic pleurodesis with talc is now considered to be the gold standard treatment for MPE. However, talc has not been commercially available in Japan. We sought to evaluate the efficacy and toxicity of three intrapleural therapy regimens consisting of bleomycin, OK-432 or cisplatin plus etoposide(PE), for the management of malignant pleural effusion in previously untreated non-small cell lung cancer. The primary endpoint, pleural progression-free survival did not differ significantly between groups. Intrapleural treatment using OK-432 in the management of MPE was selected because it had the highest 4-week pleural progression-free survival rate and toxicity was tolerable. At present, OK- 432 is the standard agent used in Japan.     

Optimal therapy of malignant pleural effusions

A randomized phase III trial of bleomycin, tetracycline and talc following chest tube drainage and a meta-analysis of relative benefit of bleomycin and tetracycline as sclerosing agents were performed to determine the optimal approach to malignant pleural effusion (MPE). Fifty patients were randomized to receive bleomycin (n=16), tetracycline (n=19) or talc (n=16) following chest tube drainage. Treatment groups were balanced for pretreatment characteristics. The study was ended prematurely because of the removal of parenteral tetracycline from the market. Overall, 52% of randomized patients had successful control of effusion 30 days after sclerosis. There were no differences between any of the three treatment groups in terms of 30 day control of effusion, overall survival (6 months), resclerosis rate, pain with sclerosis, fever, or duration of hospitalization (6 days). A meta-analysis was performed using the four previously reported trials of tetracycline vs. bleomycin and revealed a 20.6% advantage to the use of bleomycin (95% C.I. 7.9%-33.3%) (p=0.002). This phase III failed to demonstrate a significant difference between the three agents in terms of control of MPE at 30 days, side effects or survival. However, because of small sample size, this study lacks sufficient power to observe potentially clinically important differences between treatment groups. Inclusion of data from four previous trials in a meta-analysis showed that bleomycin may be superior. The median duration of hospitalization and the overall success rate of all three sclerosing agents in this study argue convincingly that new approaches to palliate MPE are needed.     

Plasma and pleural fluid pharmacokinetics of erlotinib and its active metabolite OSI-420 in patients with non-small-cell lung cancer with pleural effusion

Background: Erlotinib is orally active and selectively inhibits the tyrosine kinase activity of the epidermal growth factor receptor. The pleural space penetration and exposure of erlotinib is poorly understood. Thus, we investigated the pharmacokinetics (PK) of erlotinib and its active metabolite OSI-420 in non–small-cell lung cancer (NSCLC) of malignant pleural effusion (MPE). Patients and Methods: We analyzed the PK of erlotinib and OSI-420 on days 1 and 8 after beginning erlotinib therapy in 9 patients with MPE. Their concentrations were determined by high-performance liquid chromatography with ultraviolet detection. Blood samples were obtained five times per day: before administration, and 2, 4, 8, and 24 hours after administration. Pleural effusions were obtained once per day, 2 hours after administration on day 1, and before administration on day 8. The exceptions were cases 2 and 4, which had pleural effusions obtained just before drug administration, and 2, 4, 8, and 24 hours after administration. Results: The mean percentage of penetration from plasma to pleural effusion for erlotinib was 18% on day 1 and 112% on day 8, while these values for OSI-420 were 9.5% on day 1 and 131% on day 8. The area under the drug concentration-time curve of pleural fluid for erlotinib was 28,406 ng-hr/mL for case 2 and 45,906 ng-hr/mL for case 4. Conclusions: There seems to be a significant accumulation of both erlotinib and OSI-420 in MPE with repeated dosing. Although larger studies will be necessary to determine the true impact of erlotinib MPE accumulation on plasma PK and safety, erlotinib can be administered safely to patients with MPE with respect to efficacy and side effects.     

Ultrasound-guided small-bore Elecath tube insertion for the rapid sclerotherapy of malignant pleural effusion

BACKGROUND: Traditional pleurodesis for malignant pleural effusion is performed by large-bore chest tube insertion with the instillation of sclerosing agents after the compressed lung re-expansion and pleural fluid drainage of 100-150 ml/day. This study was carried out to evaluate the possibility of rapid sclerotherapy for malignant pleural effusions by insertion of a small-bore Elecath tube (12-French) under ultrasound guidance and intrapleural injection of bleomycin 60 IU. METHODS: Twenty-six patients, with 28 cytopathologically proven malignant pleural effusions (two patients had bilateral pleural effusions) and receiving the insertion of the Elecath tube for drainage, were included in our series. This rapid and short-term sclerosing method was performed and completed by intrapleural injection of bleomycin when the pleural effusion had been clearly drained by the small-bore Elecath tube and the compressed lung had fully re-expanded on follow-up chest radiographs. RESULTS: Twenty patients with 22 pleural effusions underwent the intrapleural injection of bleomycin, with the results of pleurodesis being complete response 41% (9/22), partial response 36% (8/22) and failure 23% (5/22). Interestingly, among the 17 successful procedures of pleurodesis (complete response and partial response), 71% (12) procedures could be completed within 2 days (seven within one day and five within 2 days). The remaining unsuccessful procedures carried out on six patients without the injection of bleomycin were due to a non-re-expanded lung (n = 3) and inadequate drainage (n = 3); of these, four patients also received the large-bore chest tube insertion after the removal of the Elecath tube, but the compressed lung still could not re-expand. The complications of the bleomycin injection were fever [77% (17/22)], vomiting [14% (3/22)] and hiccup [5% (1/22)]. CONCLUSION: The method of rapid sclerotherapy for malignant pleural effusions by small-bore Elecath tube is promising, with a success rate achieving 77%, usually within 2 days.      

Home-management of malignant pleural effusion with an indwelling pleural catheter: Ten years experience

Background

More than one half of patients with cancer have a malignant pleural effusion (MPE) at some time during their life span. Recurrent malignant pleural effusions impair respiratory functions and worsen the quality of life. Once a patient develops MPE, only fluid drainage relieves pulmonary compression and dyspnea. Optimal treatment is however, still controversial. In patients not suitable for pleurodesis, or with recurrent MPE after pleurodesis, or with trapped lung, the outpatient intermittent drainage through a subcutaneous tunneled indwelling pleural catheter (IPC) is a possible choice.

Methods

In ten years, we treated 90 patients by outpatient insertion of IPC. Eligibility for IPC required previous thoracentesis with histological confirmation of malignancy and chest roentgenogram evidence of effusion. All patients treated were made aware of their malignancy and positive cytology in the pleural effusion.

Results

Mean survival was 197 days (range 23–296 days). Median time of draining interval was 7.0 days with maximum amount of effusion drained off being 1000 ml. Pleurodesis occurred in 37 (41.1%) patients with a mean time of pleurodesis of 51 days (range 34–78 days). No major complication was recorded.

Conclusions

The IPC is a useful device in the management of recurrent MPE. Treatment can be entirely accomplished at home and the complication rate is low.