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。     

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。     

力尔凡治疗恶性胸腔积液的临床研究

目的：观察力尔凡治疗恶性胸腔积液的疗效及副作用。方法：对60例恶性胸腔积液患者引流尽胸腔积液后，腔内注入力尔凡30mg，B超检查，观察效果。结果：控制胸腔积液cR18例，PR27例，有效率达75％。不良反应主要是胸痛和发热。结论：力尔凡能有效控制胸腔积液，提高患者的生活质量，是治疗恶性胸腔积液的有效药物之一。     

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.     

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.     

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.     

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.      

短小棒状杆菌菌苗治疗恶性胸腔积液临床观察

[目的]评价短小棒状杆菌菌苗治疗恶性胸腔积液的疗效和毒性。[方法]应用短小棒状杆菌菌苗胸腔内给药治疗46例恶性胸腔积液患者。[结果]有效率76．1％，其中完全缓解率47．8％；毒副反应主要为发热和胸痛，预防性用药后可控制。[结论]短小棒状杆菌菌苗治疗恶性胸腔积液疗效肯定，毒副反应可控制，充分引流、联合全身化疗可提高疗效。     

Small bore catheter drainage and sclerotherapy for malignant pleural effusions

The accumulation of large amounts of fluid in the pleural space is a common sequela of disseminated carcinomatosis. Traditional management has included therapeutic thoracentesis or the placement of a large bore chest tube for drainage with the subsequent installation of a sclerosing agent in an attempt to achieve pleural symphysis. An evaluation of all patients treated in this manner during a 4-year period was undertaken to assess the degree of success obtained with a large bore standard chest tube versus a small pigtail catheter. A study group consisting of 20 patients with a total of 24 pleural effusions was treated with drainage and sclerotherapy. In this group, eight of 13 effusions were adequately treated with pigtail catheter drainage and sclerotherapy, compared with four of 11 effusions adequately treated with standard chest tube drainage and sclerotherapy. Although the numbers are small, it appears that pigtail catheter drainage and sclerosis is at least as successful as the more traditional drainage with the standard chest tube.     

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.     

Video-Assisted Thoracoscopic Surgery for Malignant Pleural Effusions

Aim: To evaluate the efficacy of video-assisted thoracoscopic surgery (VATS) in the diagnosis and treatment ofmalignant pleural effusions (MPE) and to assess the results and complications of the procedure. Methods: A totalof 61 patients with the diagnosis of malignant pleural effusion were assessed retrospectively between 2004 - 2010,25 women (40.9%) and 36 men (59.1%), with an age range of 18-78 (mean: 61.3). Video-thoracoscopic surgerywas performed under general anesthesia or with local anesthesia in sedated patients. Results: No intraoperativecomplications were observed. In 6 cases, prolonged air leak developed. Pleurodesis was successfully implementedin malignant cases. The chest tube was removed when the amount of fluid was less 50cc/24h. The duration ofdrainage was significantly shorter in patients in whom VATS was performed. Conclusion: We believe that VATSis an effective method in the diagnosis and palliative treatment of cases with malignant pleural effusions.     

治疗用粘质沙雷氏菌菌苗（S511）治疗癌性胸腔积液的Ⅱ期临床研究

目的 评价S311治疗癌性腔积液的疗效及毒副作用。方法 经胸穿或闭式引流抽净胸水后,胸腔注入S311 0.32mg,每周1次,连续3周,停药手观察1个月评价疗效。结果 241例患者完成胸腔注入S311治疗,总有效率92．1％,主要的不良反应为发热和胸痛,发生率分别为81．0％和52．2％,少数患者出现寒战,呼吸困难,恶心,呕吐,个别患者出现肝功能异常。结论 粘质沙雷氏菌菌苗（S311）是一种治疗癌性胸腔积液的有效药物。     

A comparative trial of LC9018 plus doxorubicin and doxorubicin alone for the treatment of malignant pleural effusion secondary to lung cancer

The efficacy and safety of intrapleural LC9018 (Yakult Co. Ltd., Tokyo, Japan) with or without doxorubicin (Adriamycin; Adria Laboratories, Columbus, OH) were evaluated in a randomized, controlled trial performed in 95 patients with malignant pleural effusions secondary to lung cancer. Seventy-six patients were eligible for the assessment of efficacy. The response rate for treatment with intrapleural doxorubicin plus LC9018 (38 patients) was 73.7%, which was significantly higher than the response rate of 39.5% for the control group treated with doxorubicin alone (38 patients) (P less than 0.01). The LC9018 group also showed a significantly greater improvement in performance status (PS) and symptoms (chest pain, chest discomfort, and anorexia) than the control group (P less than 0.05). A significant prolongation of survival was noticed in the LC9018 group (P less than 0.05). The main side effects of LC9018 were fever and transient hepatic dysfunction, but there were no serious adverse reactions. These results suggest that the intrapleural instillation of LC9018 can be recommended for the treatment of malignant pleural effusions.     

Intracavitary bleomycin in the management of malignant effusions.

Instilled bleomycin and thoracostomy were utilized in 38 patients with malignant pleural effusions; the therapy produced a complete or partial response rate of 63%. Toxicity was minimal. In patients with intraperitoneal effusions, bleomycin instillation after drainage produced a complete or partial response in 36%. One patient had severe hypotension and fever. Patients with ovarian and breast carcinoma responded best, among them, effusions were controlled in greater that 70%. Because of its low systemic toxicity, absence of marrow toxicity, and virtual absence of discomfort, we think that the local instillation of bleomycin is indicated in the management of malignant effusions.     

A phase I clinical and pharmacokinetic study of paclitaxel liposome infused in non-small cell lung cancer patients with malignant pleural effusions

PurposeTo investigate the feasibility, pharmacokinetics, efficacy and toxicity of intrapleural paclitaxel liposome injection in non-small cell lung cancer (NSCLC) patients with malignant pleural effusions.Patients and methodsTwelve of 15 NSCLC patients with malignant pleural effusions were treated with paclitaxel liposome and three were treated with free paclitaxel. Adequate pleural fluid, blood and urine were collected for pharmacokinetic study. The clinical efficacy and toxicity were synthetically evaluated according to the correlative criteria.ResultsThe overall toxicity of paclitaxel liposome was lower than that of free paclitaxel. In the patients treated with paclitaxel liposome, there were minimal local chest pain, anaphylaxis, anaemia, neutropaenia and hepatotoxicity. The complete response rates of pleural effusion at the first, second, third and sixth month were, respectively, 27.3%, 18.2%, 9.1% and 9.1%, and overall response rates were 90.9%, 72.7%, 63.6% and 54.5%, respectively. Pharmacokinetic study showed that mean C_max,IP, T_1/2 and AUC_0→96,IP in pleural fluid were, respectively, about 2-fold, 2-fold and 2.5-fold than those of free paclitaxel, and AUC_0→96,Pla in plasma was also much higher than that of free paclitaxel, however, excretory rate in 24 h from urine was lower than that of free paclitaxel.ConclusionsThis study demonstrated that paclitaxel liposome was a more useful agent than free paclitaxel for the treatment of malignant pleural effusions because of its relatively low toxicity and distinct pharmacokinetic characteristics. The phase II study of a large number of patients was recommended to confirm this finding.     

冀东满族肺腺癌患者胸液与相应肿瘤组织EGFR基因突变检测对比分析

目的:分析冀东满族肺腺癌患者胸液与相应肿瘤组织EGFR基因突变检测结果。方法:选取2010年9月至2014年9月间在我院胸外科治疗的74例有胸液的冀东满族肺腺癌患者为研究对象,采用变性高效液相色谱法(DHPLC)检测肺腺癌患者胸液及相应肿瘤组织样本中是否发生EGFR基因突变。结果:肿瘤组织EFGR基因突变检出率为50.00%,胸液样本EGFR基因突变检出率为52.70%,两者间无统计学差异(P＞0.05)。胸液上清、胸液沉淀、胸液上清与沉淀以及肿瘤组织EGFR基因检测结果一致性均良好。结论:肺腺癌患者胸液与相应肿瘤组织EGFR基因突变检测结果一致性良好,临床可通过胸液检测代替肿瘤组织检测,以期能够持续监测患者EGFR基因突变状态,以指导患者添加或者实施EGFR-TKIs治疗。     

胸腔内灌注化疗癌性胸水

目的探讨胸腔内准注化疗治疗癌性胸水的临床效果。方法对56例癌性胸水患者（其中原发肿瘤为肺癌32例,乳癌17例,胃癌3例,大肠癌2例,恶性胸膜间皮瘤2例采用针吸法和胸腔内置管引流法使恶性胸水大部分排出。胸腔内注入化疗药：DDP70—100mg,ADM50-70mg,MMC15-20mg,5-Fu1000-1500mg。结果本组总有效率96.4％。随访时间均超过12个月。胸水缓解期超过6个月以上者为73.2％（41／56）。毒性反应食欲减退、恶心、呕吐者占72％,白细胞、血小板降低者19.8％。结论胸腔内灌注化疗治疗癌性胸水具有疗效好、毒性低、费用少、是值得推广的治疗方法。     

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。     

重组人血管内皮抑制素联合顺铂胸腔灌注化疗治疗恶性胸腔积液的Meta分析

目的 系统评价重组人血管内皮抑制素（恩度）联合顺铂胸腔灌注化疗与顺铂单药胸腔灌注化疗治疗恶性胸腔积液的有效性与安全性。方法 计算机检索PubMed、The Cochrane Library、Web of Science、万方数据库、中国期刊全文数据库（CNKI）、中国科技期刊数据库（VIP）,同时辅以手工检索,收集2005年至2015年比较恩度联合顺铂胸腔灌注化疗与顺铂单药胸腔灌注化疗治疗恶性胸腔积液的随机对照研究（RCT）。使用Cochrane系统评价指导手册50评价纳入的RCT质量,采用RevMan 5.2软件进行Meta分析,以胸腔积液控制有效率、生活质量改善率、不良反应发生率为结局指标。结果 本研究共纳入15项RCT,共936例患者。Meta分析结果显示,恩度联合顺铂组治疗的胸腔积液控制有效率（RR=1.54,95％CI：1.38～1.71,P＜0.000 01）、生活质量改善率（RR=1.61,95％CI：1.41～1.84,P＜0.000 01）均优于顺铂单药组,差异有统计学意义。两组在胃肠道反应、胸痛、发热、骨髓抑制、肝肾功能异常、乏力、心电图异常等不良反应的发生率方面,差异无统计学意义（P＞0.05）。结论 恩度联合顺铂胸腔灌注化疗较顺铂单药能够明显提高恶性胸腔积液患者治疗的有效率和生活质量,且不增加毒副反应。     

电视胸腔镜诊治恶性胸腔积液18例报告

[目的]评价电视胸腔镜手术（VATS）在恶性胸腔积液诊治中的应用价值,［方法］18例恶性胸腔积液患者行胸腔镜胸膜活检和滑石粉胸膜固定术,术后加低负压胸腔引流。［结果］18例均获病理确诊,其中恶性胸膜间皮瘤2例,乳腺癌胸膜转移6例,肺癌胸膜转移8例,卵巢癌和胃癌胸膜转移各1例。胸膜固定成功16例;失败2例,其原因为肺癌伴有肺不张。［结论］VATS可以大大提高恶性胸腔积液的确诊率和胸膜固定术的效果,术后低负压胸腔引流有利于胸腔粘连形成,缩短引流时间。