细管胸腔闭式引流与常规胸腔穿刺控制恶性胸腔积液随机对照研究

背景与目的恶性胸腔积液是晚期恶性肿瘤常见的一个问题。治疗多为姑息性，常采用胸腔穿刺或粗管闭式引流。粗管闭式引流损伤大，易感染，患者活动受限。本研究的目的是观察细孔径导管胸腔闭式引流后注药治疗恶性胸腔积液的临床疗效。方法将恶性胸腔积液患者随机分成两组，分别进行中心静脉导管闭式引流和常规胸腔穿刺，并均于胸腔内注入顺铂（cisplatin，DDP）和白介素-2（interleukin-2，IL-2）。结果细孔径导管闭式引流组胸腔积液的控制率为80．00％，明显优于常规穿刺组的36．67％（P〈0．01）。细孔径导管闭式引流组的不良反应少于常规穿刺组。结论应用细孔径导管装置引流恶性胸腔积液操作安全、简便，能最大限度地排净胸腔积液，对控制癌性胸腔积液有较好的疗效，能显著改善患者生活质量。     

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

Many patients with various forms of cancer develop sooner or later malignant pleural effusions, resulting in feelings of discomfort and reduced quality of life. Several palliative options exist, including repeated thoracocentesis and pleurodesis with a sclerosing agent. However, these "therapeutic" possibilities are not always successful and sometimes even contraindicated. Also, patients need to visit the hospital regularly or have to stay hospitalised for several days. A chronic indwelling pleural catheter could provide a simple, completely outpatient way to provide respiratory relief and improvement in quality of life in patients with malignant pleural effusions. We evaluated retrospectively the course of 17 patients with malignant pleural effusions who were treated with a chronic indwelling pleural catheter (PleurX). Eligible patients were selected in the years 2001-2003 from a single institution. In 70-80% of patients, catheter use was uncomplicated and provided significant symptom relief. Mean duration of catheter use was 2.3 (range 1-6) months. Mean fluid removal was 360 (range 150-1000 cc) per 24 h in the first weeks of treatment. Infection was seen in two (12%) patients, dislocation of the catheter in three (18%). In the final analysis, catheter use was unsatisfactory in two patients (12%). We conclude that a chronic indwelling catheter is a very useful tool in the management of recurrent malignant pleural effusions. Treatment can be accomplished completely at home, whereas complications are rare.     

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.     

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.     

Long-term indwelling pleural catheter (PleurX) for malignant pleural effusion unsuitable for talc pleurodesis

Aims

Talc pleurodesis using talc slurry via chest tube is a primary option in malignant pleural effusion, since life expectancy is short and surgical decortication is hazardous. Incomplete lung expansion after fluid evacuation, and/or excessive fluid secretion predicts failure of pleurodesis. A mini-invasive alternative was investigated.

Methods

Between March 2004 and September 2005, 51 consecutive patients with malignant pleural effusion, and clinically considered unsuitable for talc pleurodesis, received an indwelling pleural catheter (Denver PleurX). In 47, implantation was done bedside using local anaesthesia. There were 24 men and 27 women, median age 63 (range 36–85) years, receiving 39 right side, 10 left side, and 2 bilateral catheters. There were 19 non-small cell lung cancer cases, 7 mesothelioma, and 25 with other malignancy. Chemotherapy was being given to 18 patients and was not interrupted.

Results

Discharge to home was possible in 71% (36 of 71 patients) on the following day. At 2 years follow-up in September 2007, one patient was alive. Mean survival was 3 months (range 5 days to 37+ months) for all patients, with best median survivals of 5.5–6 months in breast and ovarian cancer. Catheter was removed or replaced in 15% (8 of 51 patients) due to infection, air leak, or blockage. One patient requested decortication for excessive fluid secretion. None required surgery or died due to catheter-related complications. Pleural fusion with subsequent catheter removal was achieved in 21% (11 of 51 patients).

Conclusions

An indwelling pleural catheter is a safe alternative for patients with malignant pleural effusion unsuitable for talc pleurodesis. In some, pleural fusion may be achieved.     

胸腔持续闭式引流联用高聚生治疗恶性胸腔积液的疗效观察

目的：观察胸腔持续闭塞引流联用高聚生治疗恶性胸腔积液的疗效。方法：随机选择57例患者分为治疗组31例，对照组26例。治疗组采用胸腔持续闭塞引流联用高聚生的方法，对照组采用常规抽液并注入顺铂的方法，观察二组疗效。结果：治疗组有效率达100％，对照组80．77％。结论：应用胸腔持续闭式引流联用高聚生的方法治疗恶性胸腔积液方便可行，疗效理想，值得临床推广及进一步研究。     

Malignant pleural effusions

Opinion statement Malignant pleural effusions contribute to considerable morbidity in cancer patients and generally portend an overall poor prognosis. Treatment of malignant pleural effusions is palliative; therefore, quality of life issues, as well as the risks and benefits of the therapeutic options, become more critical. In my opinion, factors such as in patient versus outpatient management and associated procedural discomfort are important in the decision-making process, and the patient should participate in these subjective con-siderations. It is difficult to compare results and determine the true efficacy of different techniques and agents because endpoints and response criteria as well as the extent and method of follow-up vary. In addition, the etiology of the primary complaint, dyspnea, is frequently multifactorial. However, malignant effusions recur, and therefore repeated thoracentesis, especially if the fluid rapidly reaccumulates, is usually not a good long-term solution unless the patient’s overall prognosis and current condition prohibits a more invasive option. The standard option for recurrent effusions is insertion of a chest tube. If the lung re-expands, chemical pleurodesis is attempted to achieve adherence of the visceral to the parietal pleura. Sterilized talc is the best sclerosant; it has good efficacy and cost effectiveness and can be administered easily as a slurry at the bedside via a chest tube with minimal patient discomfort and without more aggressive and invasive procedures.     

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.      

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.     

Intracavitary bleomycin and tetracycline in the management of malignant pleural effusions: a randomized study

Both bleomycin and tetracycline have been suggested as the sclerosing agent of choice in the management of malignant pleural effusions. To determine if one drug is superior to the other in this role, patients with malignant pleural effusions were randomly assigned to receive either bleomycin or tetracycline in the previously evacuated pleural space through a thoracostomy tube. Following instillation of the assigned agent, the tube was clamped for 8 hours and then reattached to suction. When the chest tube drainage had slowed to less than 40 ml in a 24-hour period or if 7 days had passed, the tube was removed. Pleural sclerosis was attempted 42 times in 34 patients. No statistically significant differences were found between the two treatment groups when prevention of effusion reaccumulation and time to removal of the chest tube (efficiency) were compared. Side effects including pleural pain and fever, occurred with both agents, but were manageable. Since one drug was not clearly superior to the other, and bleomycin is more costly, we suggest that tetracycline rather than bleomycin be used when pleural sclerosis is needed to manage malignant pleural effusions.     

微创中心静脉导管留置治疗恶性胸腔积液34例观察

目的 观察利用微创中心静脉导管留置胸腔在恶性胸腔积液的诊断和治疗中的作用.方法 2002年～2003年2月在外院内科治疗的大量或中等恶性胸腔积液的患者34例,利用微创技术应用美国ARROW公司中心静脉导管留置胸腔抽取胸液脱落细胞学检查,待结果阳性,给予胸腔注药,顺铂50mg～80mg,力尔凡100mg或胞必佳1 000u,地塞米松10mg,注药结束后,给予止吐药静点或静推,观察疗效及并发症.另选30例恶性胸腔积液患者常规穿刺、注药治疗为对照组,在疾病、病期、治疗药物方面与治疗组一致,没有分组差异,疗效分析采用χ2检验,平均确诊时间采用t检验.结果 在治疗效果中,治疗组CR 9例、PR 19例,有效率达82.35%,对照组CR 2例、PR 11例,有效率为40.33%,χ2＝10.539,P＜0.01.确诊时间治疗组1～8天,平均5.0天;对照组1～24天,平均14.5天,t＝8.7,P＜0.05.具有显著差异.无严重并发症.结论 利用微创技术采用中心静脉导管留置胸腔在诊断和治疗恶性胸腔积液方面具有优势,值得临床推广.     

胸腔镜在恶性胸腔积液诊断和治疗上的应用

目的　探讨胸腔镜在恶性胸腔积液诊断和治疗上的价值。方法　对15例原因不明的胸腔积液患者作胸腔镜检查,并经胸腔镜喷入滑石粉及顺铂治疗。结果　所有病例经胸腔镜行活检均确诊为恶性病变,总诊断率为100%。经滑石粉喷入和顺铂局部治疗后14例获得完全的胸膜固定,持久的成功率为93.3%。结论　胸腔镜对胸腔积液病因诊断有较高临床实用价值,滑石粉胸膜固定加顺铂治疗是控制恶性胸腔积液、治疗晚期癌症的一种有效方法。     

Intrapleural palliative treatment of malignant pleural effusions with mitoxantrone versus placebo (pleural tube alone).

From 11/87 until 7/90 103 patients entered a prospective randomized trial on the treatment of malignant pleural effusions (MPE) with intrapleural mitoxantrone versus placebo (pleural tube alone with instillation of isotonic NaCl). Our data suggest no statistically significant difference between the two arms with respect to response and response duration. There is no influence on survival time. The toxicity is moderate, with only fever occurring more often in the mitoxantrone arm. We recommend performance of pleurodesis in patients with MPE first by sufficient drainage with a tube of 16-20 char. Only in instances of failure it is necessary to add sclerosing agents such as tetracycline, etc.     

Vincristine (Vinca-alkaloid) as a sclerosing agent for malignant pleural effusions

Vincristine, extracted from Vinca rosea Linn., is an effective antineoplastic chemotherapeutic drug used in oncology practice. This drug has never been used as a sclerosing agent for the treatment of malignant pleural effusion for reasons unknown. A study was conducted to examine the use of Vinca-Alkaloid as a sclerosing agent (pleurodesis) for the palliative treatment of malignant pleural effusions. The study included 15 patients, all diagnosed to have cytology-proven malignant pleural effusions. Intercostal tube drainage followed by chemical sclerotherapy with 2 mg vincristine was performed on all patients and a high success rate was noted. Twelve procedures out of 15 (12/15) achieved complete resolution of pleural fluid with a success rate of 80%. In two procedures the pleural effusion was reduced and then recurred but did not require re-aspiration. One procedure failed and repeated pleural aspiration was required. In this study, with adequate pleural drainage and the proper technique, vincristine was found to be an effective sclerosing agent for malignant pleural effusion. Further randomized trials are necessary in order to establish the role of this drug.     

Prospective randomized trial of intrapleural bleomycin versus interferon alfa-2b via ultrasound-guided small-bore chest tube in the palliative treatment of malignant pleural effusions.

PURPOSE: To compare bleomycin pleurodesis and immunotherapy with intrapleural interferon alfa-2b (IFN) in the palliation of malignant pleural effusions. PATIENTS AND METHODS: One hundred sixty patients with rapidly recurrent malignant pleural effusion were randomly assigned to intrapleural bleomycin (83 patients) or IFN (77 patients). A 9-French intrapleural catheter was placed under sonographic guidance, and pleural effusion was completely drained before starting the treatment. Bleomycin 0.75 mg/kg was administered as a single dose. An additional dose was given if daily fluid output did not drop to less than 100 mL/d within 3 days. IFN 1 million units/10 kg was administered for six courses at 4-day intervals. Thirty-day and long-term responses were evaluated under the intention-to-treat principle. RESULTS: Thirty-day response was 84.3% in the bleomycin arm and 62.3% in IFN arm (P =.002). Median time to progression was 93 days (range, 12 to 395 days) in bleomycin group, and 59 days (range, 7 to 292 days) in the IFN group (P <.001). Median survival was 96 days (range, 15 to 395) and 85 days (range, 16 to 292) in the bleomycin and IFN groups, respectively. Twenty-three patients received two doses of bleomycin, as their daily fluid output remained higher than 100 mL after the first dose. Thirteen of them had complete response, which lasted until death. CONCLUSION: Intrapleural bleomycin is more effective than IFN and is a valid option for the palliative treatment of massive, rapidly recurrent malignant pleural effusions. The administration of a second dose of bleomycin to patients not responding to the first one can remarkably improve the overall outcome of the treatment.     

Malignant pleural effusion, current and evolving approaches for its diagnosis and management

Malignant pleural effusion is a common and debilitating complication of advanced malignant diseases. This problem seems to affect particularly those with lung and breast cancer, contributing to the poor quality of life. Approximately half of all patients with metastatic cancer develop a malignant pleural effusion at some point, which is likely to cause significant symptoms such as dyspnea and cough. Evacuation of the pleural fluid and prevention of its re-accumulation are the main goals of management. Optimal treatment is controversial and there is no universally standard approach. Intervention options range from observation in the case of asymptomatic effusions through simple thoracentesis to more invasive methods such as chemical and mechanical pleurodesis, pleur-X catheter drainage, pleuroperitoneal shunting, and pleurectomy. The best results are reported with thoracoscopy and talc insufflation, with an acceptable morbidity. Development of novel methods to control malignant pleural effusion should be a high priority in palliative care of cancer patients. This article reviews the current, as well as, novel approaches that show some promise for the future. The aim is to identify the proper approach for each individual patient.     

Pleuroperitoneal shunting for malignant pleural effusions

Traditional therapy for malignant pleural effusions includes thoracentesis or tube drainage with instillation of irritants to achieve pleurodesis. This can require a lengthy hospitalization, causes pain and discomfort, and has an appreciable failure rate. Because of these drawbacks, the authors used a shunting device to transfer fluid to the peritoneal cavity in 17 patients with malignant pleural effusions. Eleven patients had undergone previous therapeutic thoracenteses and three had chest tube placement with failed sclerosis. The shunt was a subcutaneous valved pump chamber with attached pleural and peritoneal catheters, which used manual compression to transfer fluid against the normal abdominal/pleural pressure gradient. Operative placement under local or general anesthesia was performed without complication. Five patients achieved minimal benefit, either because of moribund status or their inability to compress the pump effectively. In the other 12 patients, there was radiographic evidence of diminished or stabilized pleural effusion; respiratory symptoms were effectively palliated, and no further treatment for their effusion was required. Peritoneal dissemination of malignant cells has not been clinically detected. We feel that pleuroperitoneal shunting is a valid new method for treatment of malignant pleural effusions which can effectively palliate respiratory symptoms with low morbidity. Advantages include the absence of external tubing and the possibility for only a short hospitalization or even outpatient placement. Shunting is applicable for patients who are able to perform the requisite pumping and is particularly suitable for those with trapped lungs or who have failed attempted pleural sclerosis.     

Distribution of talc suspension during treatment of malignant pleural effusion with talc pleurodesis

Talc pleurodesis is an effective technique for the management of symptomatic malignant pleural effusions. It is assumed that a good dispersion of talc suspension contributes to the final success of this treatment. For this purpose, guidelines often advise to rotate the patient after intra-pleural instillation of the sclerosant. This prospective, randomized study analyses the dispersion of talc suspension and the overall success rate in patients with malignant effusions. After instillation of 99mTc-sestamibi-labeled talc suspension ten subjects were rotated for 1 h, while the ten other patients remained in a stable supine body position. Scintigraphic imaging was done in two directions immediately after instillation and after 1 h with a clamped drain. The overall success of the treatment was assessed 1 month after the pleurodesis. The dispersion of talc was limited and unequal in 75% of the subjects. In two patients with apparently good distribution on anterior views, the lateral views of the scintigraphy showed only limited distribution. Rotation of the patients did not influence the dispersion of sludge after 1 min or 1 h. Pleurodesis was successful in 85% of the patients after 1-month follow-up. Standard rotation protocols for patients with malignant pleural effusion do not affect the overall dispersion of talc suspension and should be abolished because of the discomfort caused to the patients.     

Intrapleural cisplatin and cytarabine in the management of malignant pleural effusions: a Lung Cancer Study Group trial

Malignant pleural effusions are a common and significant problem in patients with advanced malignancies. Pleurodesis with tetracycline or other sclerosing agents is the usual treatment for malignant pleural effusions. In contrast to this approach, intrapleural chemotherapy has the potential advantage of treating the underlying malignancy in addition to controlling the effusion. Intracavitary cisplatin-based chemotherapy, which is cytotoxic rather than sclerosing, has proven safe and effective via the intraperitoneal route in ovarian cancer and malignant mesothelioma. There has been little previous experience, however, with intrapleural cisplatin-based chemotherapy. As part of a planned series of trials in malignant mesothelioma, the Lung Cancer Study Group first evaluated intrapleural cisplatin and cytarabine in patients with malignant pleural effusions from a variety of solid tumors. From April 1986 to November 1987, 46 patients with cytologically proven, symptomatic, and previously untreated malignant pleural effusions were entered on study. A single dose of cisplatin 100 mg/m2 plus cytarabine 1,200 mg was instilled into the pleural space via a chest tube, which was then immediately removed. Patients were evaluated for toxicity and response at 24 hours; 1, 2, and 3 weeks; and then monthly. No recurrence of the effusion was considered a complete response (CR). Partial response (PR) was defined as a 75% or greater decrease in the amount of the effusion on serial chest radiographs. One patient experienced reversible grade 4 renal toxicity, four patients had grade 3 hematologic toxicity, and five patients had grade 3 cardiopulmonary toxicity. The overall response rate (CR plus PR) at 3 weeks was 49% (18 of 37 patients). The median length of response was 9 months for a CR and 5.1 months for a PR. The outcome of this trial was sufficiently encouraging that this regimen has been incorporated into subsequent trials for malignant pleural mesothelioma.     

博莱霉素联合白细胞介素- 2治疗非小细胞肺癌胸腔积液的临床观察

 目的 观察博莱霉素（BLM）联合白细胞介素- 2（IL-2）治疗非小细胞肺癌（NSCLC）胸腔积液的疗效及毒副反应。方法 采用中心静脉导管建立闭式引流，在胸腔积液基本干净、肺复张基础上注入BLM 60 mg加生理盐水50 ml， IL-2 200万U。结果 36例患者中完全缓解（CR）20例占55.5 %，部分缓解（PR）12例占33.3 %，稳定（SD）4例占11.1 %， CR+PR 88.5 %，仅部分病例有发热，胸痛，皮疹，恶心。结论 BLM联合IL-2治疗NSCLC胸腔积液疗效好，毒副反应小，易为患者所接受。