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Wong T, Fuld AD, Feller-Kopman DJ. Malignant Pleural Effusions in the Era of Immunotherapy and Antiangiogenic Therapy. Semin Respir Crit Care Med 2023. [PMID: 37308114 DOI: 10.1055/s-0043-1769092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Malignant pleural effusions (MPE) have historically been associated with a poor prognosis, and patients often require a series of invasive procedures and hospitalizations that significantly reduce quality of life at the terminus of life. However, advances in the management of MPE have coincided with the era of immunotherapies, and to a lesser extent, antiangiogenic therapies for the treatment of lung cancer. Landmark studies have shown these drugs to improve overall survival and progression-free survival in patients with lung cancer, but a paucity of phase III trial data exists for the impact of immune checkpoint inhibitors (ICI) on lung cancers associated with MPE. This review will focus on the leading studies investigating the impact of ICI and antiangiogenic therapies in patients with lung cancer and MPE. The diagnostic and prognostic values of vascular endothelial growth factor and endostatin expression levels in malignancy will also be discussed. These advancements are changing the paradigm of MPE management from palliation to treatment for the first time since 1767 when MPE was first reported. The future holds the promise of durable response and extended survival in patients with MPE.
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Affiliation(s)
- Terrence Wong
- Department of Medicine, Geisel School of Medicine, Dartmouth, Hanover, New Hampshire
- Division of Pulmonary and Critical Care Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Alexander D Fuld
- Department of Medicine and Medical Education, Geisel School of Medicine, Dartmouth, Hanover, New Hampshire
- Department of Medical Oncology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - David J Feller-Kopman
- Department of Medicine, Geisel School of Medicine, Dartmouth, Hanover, New Hampshire
- Division of Pulmonary and Critical Care Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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52
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Agrawal A, Chaddha U, Shojaee S, Maldonado F. Intrapleural Anticancer Therapy for Malignant Pleural Diseases: Facts or Fiction? Semin Respir Crit Care Med 2023. [PMID: 37308112 DOI: 10.1055/s-0043-1769094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Malignant pleural diseases involves both primary pleural malignancies (e.g., mesothelioma) as well as metastatic disease involving the pleura. The management of primary pleural malignancies remains a challenge, given their limited response to conventional treatments such as surgery, systemic chemotherapy, and immunotherapy. In this article, we aimed to review the management of primary pleural malignancy as well as malignant pleural effusion and assess the current state of intrapleural anticancer therapies. We review the role intrapleural chemotherapy, immunotherapy, and immunogene therapy, as well as oncolytic viral, therapy and intrapleural drug device combination. We further discuss that while the pleural space offers a unique opportunity for local therapy as an adjuvant option to systemic therapy and may help decrease some of the systemic side effects, further patient outcome-oriented research is needed to determine the exact role of these treatments within the armamentarium of currently available options.
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Affiliation(s)
- Abhinav Agrawal
- Division of Pulmonary, Critical Care and Sleep Medicine, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Udit Chaddha
- Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Samira Shojaee
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Fabien Maldonado
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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53
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Davidson R, Carling M, Jackson K, Aujayeb A. Indwelling pleural catheters: evidence for and management. Postgrad Med J 2023; 99:416-422. [PMID: 37294731 DOI: 10.1136/postgradmedj-2021-141200] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 12/31/2021] [Indexed: 12/13/2022]
Abstract
The incidence of pleural disease is increasing, and pleural medicine is increasingly recognised as a subspecialty within respiratory medicine. This often requires additional training time. Once underresearched, the last decade has seen an explosion in evidence related to the management of pleural disease. One of the cornerstones of pleural effusion management is the insertion of an indwelling pleural catheter. This allows patient-centred outpatient management and now has a robust evidence base. This article summarises evidence as well serves as a practical guide to the management of any complications related to an indwelling pleural catheter that might present on an acute take.
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Affiliation(s)
- Richard Davidson
- Respiratory Department, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Michael Carling
- Respiratory Department, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Karl Jackson
- Respiratory Department, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Avinash Aujayeb
- Respiratory Department, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
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54
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Sidhu C, Davies HE, Muruganandan S, Lui MMS, Lau EPM, Lee YCG. Indwelling Pleural Catheter: Management of Complications. Semin Respir Crit Care Med 2023. [PMID: 37257836 DOI: 10.1055/s-0043-1769093] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Multiple randomized clinical trials have established the advantages of indwelling pleural catheter (IPC) in the management of malignant pleural effusions, resulting in its widespread adoption in clinical practice. Complications can occur with IPC use and must be recognized and managed effectively. This review provides a comprehensive overview of IPC complications and their best care. Pain postinsertion or during drainage of IPC is easily manageable and must be distinguished from tumor-related chest wall pain. IPC-related infections require systemic antibiotics and often intrapleural fibrinolytic/deoxyribonuclease therapy. The removal of IPC for infection is usually unnecessary. Symptomatic loculation usually responds to fibrinolytics but may recur. Catheter tract metastases are common in mesothelioma patients and usually respond to radiotherapy without inducing damages to the IPC. Less common complications include dislodgement, irreversible blockage, and fractures (upon removal) of the catheter. Recommendations on the management of IPC complications by recent consensus statement/guideline are discussed. Expert opinions on management approaches are included in areas where evidence is lacking to guide care.
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Affiliation(s)
- Calvin Sidhu
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia
- School of Medical and Health Sciences, Edith Cowan University, Perth, Australia
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Helen E Davies
- Department of Respiratory Medicine, University Hospital of Wales, Cardiff, United Kingdom
| | - Sanjeevan Muruganandan
- Department of Respiratory Medicine, Northern Health, Melbourne, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Victoria, Australia
| | - Macy M S Lui
- Division of Respiratory Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Estee P M Lau
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia
- School of Medical and Health Sciences, Edith Cowan University, Perth, Australia
| | - Y C Gary Lee
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Australia
- School of Medicine, University of Western Australia, Perth, Australia
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55
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MacRosty CR, Wright A, Ceppe A, Ghosh S, Burks AC, Akulian JA. Pleural Fluid Resolution Is Associated with Improved Survival in Patients with Malignant Pleural Effusion. Life (Basel) 2023; 13:life13051163. [PMID: 37240808 DOI: 10.3390/life13051163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 05/05/2023] [Accepted: 05/08/2023] [Indexed: 05/28/2023] Open
Abstract
Malignant pleural effusion is associated with a poor prognosis and, while risk stratification models exist, prior studies have not evaluated pleural fluid resolution and its association with survival. We performed a retrospective review of patients diagnosed with malignant pleural effusion between 2013 and 2017, evaluating patient demographics, pleural fluid and serum composition, and procedural and treatment data using Cox regression analysis to evaluate associations with survival. In total, 123 patients were included in the study, with median survival from diagnosis being 4.8 months. Resolution of malignant pleural fluid was associated with a significant survival benefit, even when accounting for factors such as placement of an indwelling pleural catheter, anti-cancer therapy, pleural fluid cytology, cancer pheno/genotypes, and pleural fluid characteristics. Elevated fluid protein, placement of an indwelling pleural catheter, and treatment with targeted or hormone therapies were associated with pleural fluid resolution. We conclude that the resolution of pleural fluid accumulation in patients with malignant pleural effusion is associated with a survival benefit possibility representing a surrogate marker for treatment of the underlying metastatic cancer. These findings support the need to better understand the mechanism of fluid resolution in patients with malignant pleural effusion as well as the tumor-immune interplay occurring with the malignant pleural space.
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Affiliation(s)
- Christina R MacRosty
- Section of Interventional Pulmonology and Pulmonary Oncology, Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Carolina Center for Pleural Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Amber Wright
- Section of Interventional Pulmonology and Pulmonary Oncology, Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Agathe Ceppe
- Marsico Lung Institute/Cystic Fibrosis Research Center, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Sohini Ghosh
- Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, Allegheny Health Network, Pittsburgh, PA 15222, USA
| | - A Cole Burks
- Section of Interventional Pulmonology and Pulmonary Oncology, Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Carolina Center for Pleural Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Jason A Akulian
- Section of Interventional Pulmonology and Pulmonary Oncology, Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Carolina Center for Pleural Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
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Wang CQ, Xu J, Jiang H, Zheng XT, Zhang Y, Huang XR, She F, Fan TY, Zhan L, Feng JH, Gong QH, Xiao X, Chen XF, Xiao Z. The evidence framework of traditional Chinese medicine injection (Aidi injection) in controlling malignant pleural effusion: A clustered systematic review and meta-analysis. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2023; 115:154847. [PMID: 37149965 DOI: 10.1016/j.phymed.2023.154847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 04/05/2023] [Accepted: 04/30/2023] [Indexed: 05/09/2023]
Abstract
INTRODUCTION Aidi injection (Aidi), a traditional Chinese medicine injection, is often practiced to control malignant pleural effusion (MPE). OBJECTIVES We performed a registered systematic review and meta-analysis (PROSPERO: CRD42022337611) to clarify the clinical role of Aidi in MPE, reveal optimal combinations of Aidi and chemical agents, their indications, therapeutic route and usage, and demonstrate their clinical effectiveness and safety. METHODOLOGY All randomized controlled trials (RCTs) about Aidi in controlling MPE were collected from Chinese and English databases (up to October 2022). We clustered them into multiple homogenous regimens, evaluated the risk-of-bias at outcome level using a RoB 2, extracted and pooled the data using meta-analysis or descriptive analysis, and finally summarized their evidence quality. RESULTS All 56 studies were clustered into intrapleural administration with Aidi alone or plus chemical agents, and intravenous administration with Aidi for MPE. Intrapleural administration with Aidi alone displayed similar clinical responses on Cisplatin (DDP) alone. Only administration with Aidi plus DDP significantly improved complete response and quality of life, and displayed a low pleurodesis failure, disease progression, hematotoxicity, gastrointestinal and hepatorenal toxicity. For patients with moderate to massive effusion, Karnofsky Performance Status score ≥ 50 or anticipated survival time ≥3 months, Aidi (50 ml to 80 ml each time, one time each week and three to eight times) plus DDP (20 to 30 mg, 40 to 50 mg, or 60 to 80 mg each time) significantly improved clinical responses. Most results had moderate to low quality. CONCLUSIONS Current evidences indicate that Aidi, a pleurodesis agent, plays an interesting clinical role in controlling MPE. Aidi plus DDP perfusion is a most commonly used regimen, which shows a significant improvement in clinical responses. These findings also provide an indication and possible optimal usage for rational drug use.
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Affiliation(s)
- Cheng-Qiong Wang
- Department of General Practice, Affiliated Hospital of Zunyi Medical University, Zunyi 563003, Guizhou, China; Evidence-Based Medicine Center, MOE Virtual Research Center of Evidence-based Medicine at Zunyi Medical College, Affiliated Hospital of Zunyi Medical University, Zunyi 563003, Guizhou, China
| | - Jiao Xu
- Department of General Practice, Affiliated Hospital of Zunyi Medical University, Zunyi 563003, Guizhou, China; Evidence-Based Medicine Center, MOE Virtual Research Center of Evidence-based Medicine at Zunyi Medical College, Affiliated Hospital of Zunyi Medical University, Zunyi 563003, Guizhou, China
| | - Hong Jiang
- Department of General Practice, Affiliated Hospital of Zunyi Medical University, Zunyi 563003, Guizhou, China; Evidence-Based Medicine Center, MOE Virtual Research Center of Evidence-based Medicine at Zunyi Medical College, Affiliated Hospital of Zunyi Medical University, Zunyi 563003, Guizhou, China
| | - Xiao-Tian Zheng
- Department of General Practice, Affiliated Hospital of Zunyi Medical University, Zunyi 563003, Guizhou, China; Evidence-Based Medicine Center, MOE Virtual Research Center of Evidence-based Medicine at Zunyi Medical College, Affiliated Hospital of Zunyi Medical University, Zunyi 563003, Guizhou, China
| | - Yan Zhang
- Department of General Practice, Affiliated Hospital of Zunyi Medical University, Zunyi 563003, Guizhou, China; Evidence-Based Medicine Center, MOE Virtual Research Center of Evidence-based Medicine at Zunyi Medical College, Affiliated Hospital of Zunyi Medical University, Zunyi 563003, Guizhou, China
| | - Xiao-Rong Huang
- GCP Center, Affiliated Hospital of Zunyi Medical University, Zunyi 563003, Guizhou, China
| | - Fei She
- Department of General Practice, Affiliated Hospital of Zunyi Medical University, Zunyi 563003, Guizhou, China; Evidence-Based Medicine Center, MOE Virtual Research Center of Evidence-based Medicine at Zunyi Medical College, Affiliated Hospital of Zunyi Medical University, Zunyi 563003, Guizhou, China
| | - Teng-Yang Fan
- Department of General Practice, Affiliated Hospital of Zunyi Medical University, Zunyi 563003, Guizhou, China
| | - Lin Zhan
- Laboratory Research Center, Guizhou Provincial People's Hospital, Guizhou University, Guiyang, 550002, Guizhou, China
| | - Ji-Hong Feng
- Department of Oncology, Lishui People's Hospital, Sixth Affiliated Hospital of Wenzhou Medical University, Lishui, Zhejiang, China
| | - Qi-Hai Gong
- Key Laboratory of basic pharmacology, Ministry of Education, Zunyi Medical University, Zunyi, China
| | - Xue Xiao
- Department of General Practice, Affiliated Hospital of Zunyi Medical University, Zunyi 563003, Guizhou, China; Evidence-Based Medicine Center, MOE Virtual Research Center of Evidence-based Medicine at Zunyi Medical College, Affiliated Hospital of Zunyi Medical University, Zunyi 563003, Guizhou, China.
| | - Xiao-Fan Chen
- Evidence-Based Medicine Research Centre, Jiangxi University of Traditional Chinese Medicine, Nanchang 330004, Jiangxi, China.
| | - Zheng Xiao
- Department of General Practice, Affiliated Hospital of Zunyi Medical University, Zunyi 563003, Guizhou, China; Evidence-Based Medicine Center, MOE Virtual Research Center of Evidence-based Medicine at Zunyi Medical College, Affiliated Hospital of Zunyi Medical University, Zunyi 563003, Guizhou, China.
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57
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Malcolm KB, Seeley EJ, Gesthalter YB. Impact of a Dedicated Pleural Clinic on Indwelling Pleural Catheter Related Outcomes: A Retrospective Single Center Experience. J Bronchology Interv Pulmonol 2023; 30:114-121. [PMID: 36192832 DOI: 10.1097/lbr.0000000000000901] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 08/31/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Recurrent pleural effusions are a major cause of morbidity and frequently lead to hospitalization. Indwelling pleural catheters (IPCs) are tunneled catheters that allow ambulatory intermittent drainage of pleural fluid without repeated thoracentesis. Despite the efficacy and safety of IPCs, data supporting postplacement follow-up is limited and variable. Our study aims to characterize the impact of a dedicated pleural clinic (PC) on patient outcomes as they relate to IPCs. METHODS Patients who underwent IPC placement between 2015 and 2021 were included in this retrospective study. Differences in outcomes were analyzed between patients with an IPC placed and managed by Interventional Pulmonology (IP) through the PC and those placed by non-IP services (non-PC providers) before and after the PC implementation. RESULTS In total, 371 patients received IPCs. Since the implementation of the PC, there was an increase in ambulatory IPC placement (31/133 pre-PC vs. 96/238 post-PC; P =0.001). There were fewer admissions before IPC placement (18/103 vs. 43/133; P =0.01), and fewer thoracenteses per patient (2.7±2.5 in PC cohort vs. 4±5.1 in non-PC cohort; P <0.01). The frequency of pleurodesis was higher in the PC cohort (40/103 vs. 41/268; P <0.001). A Fine and Gray competing risks model indicated higher likelihood of pleurodesis in the PC cohort (adjusted subhazard ratio 3.8, 95% CI: 2.5-5.87). CONCLUSION Our experience suggests that the implementation of a dedicated PC can lead to improved patient outcomes including fewer procedures and admissions before IPC placement, and increased rates of pleurodesis with IPC removal.
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Affiliation(s)
- Katherine B Malcolm
- Division of Pulmonary, Department of Medicine, Critical Care, Allergy, and Sleep Medicine, University of California San Francisco, San Francisco, CA
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58
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Bauones S, Cazzato RL, Dalili D, Koch G, Garnon J, Gantzer J, Kurtz JE, Gangi A. Precision pain management in interventional radiology. Clin Radiol 2023; 78:270-278. [PMID: 36931782 DOI: 10.1016/j.crad.2022.09.135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 09/15/2022] [Indexed: 03/17/2023]
Abstract
Pain is a common manifestation of several benign and malignant conditions. Inadequate response to conservative therapies is often succeeded by incremental use of analgesics and opioids; however, such an approach is often ineffective, not well tolerated by patients, and carries the risk of addiction leading to the opioid crisis. Implementing minimally invasive percutaneous procedures, performed by interventional radiologists has proven to be successful in providing safe, effective, and patient-specific therapies across a wide range of painful conditions. In the present narrative review, we will review the repertoire of minimally invasive imaging guided interventions, which have been successfully used to treat common painful benign and malignant conditions. We briefly describe each technique, common indications, and expected results.
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Affiliation(s)
- S Bauones
- Medical Imaging Administration, Musculoskeletal Imaging Department (AlAwaji, Banuones), King Fahad Medical City, Riyadh, Saudi Arabia; Radiology and Medical Imaging Department (Alsaadi), College of Applied Medical Sciences, Prince Sattam Bin Abdulaziz Alkharj, Saudi Arabia
| | - R L Cazzato
- Department of Interventional Radiology, University Hospital of Strasbourg, 67000, Strasbourg, France; Department of Medical Oncology, Strasbourg-Europe Cancer Institute (ICANS), 67033, Strasbourg, France.
| | - D Dalili
- Academic Surgical Unit, South West London Elective Orthopaedic Centre (SWLEOC), Dorking Road, Epsom, London, KT18 7EG, UK; Department of Diagnostic and Interventional Radiology, Epsom and St Helier University Hospitals NHS Trust, Dorking Road, Epsom, KT18 7EG, UK
| | - G Koch
- Department of Interventional Radiology, University Hospital of Strasbourg, 67000, Strasbourg, France; Institut of Human Anatomy, University Hospital of Strasbourg, 67000, Strasbourg, France
| | - J Garnon
- Department of Interventional Radiology, University Hospital of Strasbourg, 67000, Strasbourg, France
| | - J Gantzer
- Department of Medical Oncology, Strasbourg-Europe Cancer Institute (ICANS), 67033, Strasbourg, France; Department of Cancer and Functional Genomics INSERM UMR_S1258, Institute of Genetics and of Molecular and Cellular Biology, 67400, Illkirch, France
| | - J E Kurtz
- Department of Medical Oncology, Strasbourg-Europe Cancer Institute (ICANS), 67033, Strasbourg, France
| | - A Gangi
- Department of Interventional Radiology, University Hospital of Strasbourg, 67000, Strasbourg, France; School of Biomedical Engineering and Imaging Sciences, King's College London, Strand, London, WC2R 2LS, UK
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59
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Alwakeel AJ, Shieh B, Gonzalez AV, Beaudoin S. Impact of a Pleural Care Program on the Management of Patients With Malignant Pleural Effusions. J Bronchology Interv Pulmonol 2023; 30:122-128. [PMID: 36476591 DOI: 10.1097/lbr.0000000000000907] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 10/27/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Malignant pleural effusions (MPEs) are common and associated with a poor prognosis. Yet, many patients face suboptimal management characterized by repeated, nondefinitive therapeutic procedures and potentially avoidable hospital admissions. METHODS We conducted a retrospective comparison of patients who underwent a definitive palliative intervention for MPE (indwelling pleural catheter or pleurodesis) at our center, before and after the implementation of a pleural care program. Targeted interventions included staff education, establishment of formal pleural drainage policies, a pleural clinic with weekday walk-in capacity, and a rapid access pathway for oncology patients. Outcomes assessed were the proportion of emergency room (ER) presentations, hospitalizations, number of nondefinitive pleural procedures, and time-to-definitive palliative procedure. RESULTS A total of 144 patients were included: 69 in the preintervention group and 75 in the postintervention group. Although there was no difference in the proportion of ER presentations before and after interventions (43.5% vs. 38.7%, P =0.56), hospital admissions declined significantly (47.8% vs. 24.0%, P =0.003). The proportion of patients undergoing chest drain insertion decreased significantly (46.4% vs. 13.3%, P <0.001), with a stable low number of nondefinitive procedures per patient (1.6±1.1 vs. 1.3±0.9, P =0.32). A 7-day decrease in median time from presentation-to-definitive palliative procedure ( P =0.05) was observed. CONCLUSION A targeted pleural care program improved MPE palliation through reduction in hospitalizations and chest drain use, and shorter time-to-definitive palliation, despite failing to reduce ER presentations.
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Affiliation(s)
- Amr J Alwakeel
- Department of Medicine, Pulmonary Medicine Division, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
- Department of Medicine, Respiratory Division
| | | | - Anne V Gonzalez
- Department of Medicine, Respiratory Division
- Respiratory Epidemiology and Clinical Research Unit, Research Institute, McGill University Health Centre, Montreal, Quebec, Canada
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Qureshi M, Thapa B, Muruganandan S. A Narrative Review-Management of Malignant Pleural Effusion Related to Malignant Pleural Mesothelioma. Heart Lung Circ 2023; 32:587-595. [PMID: 36925448 DOI: 10.1016/j.hlc.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 01/29/2023] [Accepted: 02/08/2023] [Indexed: 03/17/2023]
Abstract
Malignant pleural mesothelioma (MPM) is an aggressive, almost universally fatal cancer with limited therapeutic options. Despite efforts, a real breakthrough in treatment and outcomes has been elusive. Pleural effusion with significant breathlessness and pain is the most typical presentation of individuals with MPM. Although thoracentesis provides relief of breathlessness, most such pleural effusions recur rapidly, and a definitive procedure is often required to prevent a recurrence. Unfortunately, the optimal treatment modality for individuals with recurrent MPM-related effusion is unclear, and considerable variation exists in practice. In addition, non-expandable lung is common in pleural effusions due to MPM and makes effective palliation of symptoms more difficult. This review delves into the latest advances in the available management options (both surgical and non-surgical) for dealing with pleural effusion and non-expandable lung related to MPM. We discuss factors that determine the choice of definitive procedures that need to be tailored to the individual patient.
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Affiliation(s)
- Maryum Qureshi
- Department of Thoracic Surgery, Northern Hospital, Melbourne, Vic, Australia.
| | - Bibhusal Thapa
- Department of Thoracic Surgery, Northern Hospital, Melbourne, Vic, Australia
| | - Sanjeevan Muruganandan
- Department of Respiratory Medicine, Northern Hospital, Melbourne, Vic, Australia; School of Medicine, Health Sciences, Dentistry, University of Melbourne, Vic, Australia
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61
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Barroso D, Rego R. A Gelatinous Pleural Effusion as a Diagnostic Clue. Cureus 2023; 15:e35942. [PMID: 37038561 PMCID: PMC10082622 DOI: 10.7759/cureus.35942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2023] [Indexed: 03/11/2023] Open
Abstract
Pleural effusion is a common presentation of several pathologies, and the determination of its cause is facilitated by macroscopic, biochemical, microbiological, and cellular analysis. A systematic approach to analyzing the fluid allows for a reduction in clinical diagnoses. Only a select number of diagnoses can be established definitively by thoracentesis, including effusions because of malignancy. We report the case of an 84-year-old male with a right large-volume pleural effusion with an initial diagnostic thoracocentesis demonstrating an exudate with a gelatinous appearance and exudate characteristics. The physical characteristics of the pleural effusion quickly raised the suspicion of mesothelioma, a rare tumor associated with a poor prognosis. In most diseases related to pleural effusion, fluid analysis yields important diagnostic information, and in certain cases, fluid analysis alone is enough for diagnosis. Malignant pleural mesothelioma may present as a viscous pleural effusion with gelatinous characteristics, which may immediately raise suspicion and contribute as a diagnostic clue in the initial study of a pleural effusion. This article was previously presented as a meeting abstract at the 28º Congresso Nacional de Medicina Interna in October 2022.
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62
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Zhang Y, Wang J, Liang B, Wu H, Chen Y. Diagnosis of malignant pleural effusion with combinations of multiple tumor markers: A comparison study of five machine learning models. Int J Biol Markers 2023:3936155231158125. [PMID: 36847282 DOI: 10.1177/03936155231158125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
BACKGROUND To evaluate the diagnostic value of combinations of tumor markers carcinoembryonic antigen (CEA), carbohydrate antigen (CA) 125, CA153, and CA19-9 in identifying malignant pleural effusion (MPE) from non-malignant pleural effusion (non-MPE) using machine learning, and compare the performance of popular machine learning methods. METHODS A total of 319 samples were collected from patients with pleural effusion in Beijing and Wuhan, China, from January 2018 to June 2020. Five machine learning methods including Logistic regression, extreme gradient boosting (XGBoost), Bayesian additive regression tree, random forest, and support vector machine were applied to evaluate the diagnostic performance. Sensitivity, specificity, Youden's index, and the area under the receiver operating characteristic curve (AUC) were used to evaluate the performance of different diagnostic models. RESULTS For diagnostic models with a single tumor marker, the model using CEA, constructed by XGBoost, performed best (AUC = 0.895, sensitivity = 0.80), and the model with CA153, also by XGBoost, showed the largest specificity 0.98. Among all combinations of tumor markers, the combination of CEA and CA153 achieved the best performance (AUC = 0.921, sensitivity = 0.85) in identifying MPE under the diagnostic model constructed by XGBoost. CONCLUSIONS Diagnostic models for MPE with a combination of multiple tumor markers outperformed the models with a single tumor marker, particularly in sensitivity. Using machine learning methods, especially XGBoost, could comprehensively improve the diagnostic accuracy of MPE.
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Affiliation(s)
- Yixi Zhang
- Department of Biostatistics, 33133School of Public Health, 12465Peking University, Beijing, China
| | - Jingyuan Wang
- Department of Biostatistics, 33133School of Public Health, 12465Peking University, Beijing, China
| | - Baosheng Liang
- Department of Biostatistics, 33133School of Public Health, 12465Peking University, Beijing, China
| | - Hanyu Wu
- Department of Biostatistics, 33133School of Public Health, 12465Peking University, Beijing, China
| | - Yangyu Chen
- Department of Respiration and Critical Care Medicine, 74639Beijing Chaoyang Hospital, Beijing, China
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Han G, Li J, Liu X, Guo R. Diagnostic value of pleural fluid SMRP, CA125, MMP-7, and MMP-9 in malignant pleural effusion. Medicine (Baltimore) 2023; 102:e32759. [PMID: 36705352 PMCID: PMC9875977 DOI: 10.1097/md.0000000000032759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
This study aimed to investigate the clinical value of mesothelin soluble related peptide (SMRP), cancer antigen 125 (CA125), matrix metalloproteinase-7 (MMP-7), and matrix metalloproteinase-9 (MMP-9) in benign and malignant pleural exudative effusion. A total of 105 adult patients with pleural exudative effusion admitted in our hospital from December 2019 to December 2020 were selected. Patients were divided into the benign group (n = 60) and the malignant group (n = 45) according to their condition. The levels of SMRP, CA125, MMP-7, and MMP-9 in the pleural effusion were determined by enzyme linked immunosorbent assay. Receiver operating characteristic curves were used to analyze the individual and combined predictive value of SMRP, MMP-7, MMP-9, and CA125 levels. In the malignant group, the SMRP, CA125, MMP-7, and MMP-9 levels were all significantly higher than those in benign group (P = .01). The detection efficiency of the 4 indicators in the combined diagnosis were higher than that of single index and combination of any 2 indices. There was a moderate positive correlation between SMRP and CA125 and MMP-7 in malignant pleural effusion. The correlation between MMP-7 and MMP-9 was moderately positive. The diagnostic efficacy of SMRP combined with CA125, MMP-7, and MMP-9 in pleural effusion for malignant pleural effusion and BPE are better than single index, which has certain clinical values for the selection of early intervention scheme for BPE patients.
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Affiliation(s)
- Gaohua Han
- Department of Oncology, Taizhou People’s Hospital of Nanjing Medical University, Taizhou, Jiangsu, China
- * Correspondence: Gaohua Han, Department of Oncology, Taizhou People’s Hospital of Nanjing Medical University, Jiangsu, China (e-mail: )
| | - Jun Li
- Department of Oncology, Dalian Medical University, Dalian, Liaoning, China
| | - Xinbo Liu
- Department of Oncology, Dalian Medical University, Dalian, Liaoning, China
| | - Ruyue Guo
- Department of Oncology, Dalian Medical University, Dalian, Liaoning, China
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Zhao Y, Yu L, Wang L, Wu Y, Chen H, Wang Q, Wu Y. Current status of and progress in the treatment of malignant pleural effusion of lung cancer. Front Oncol 2023; 12:961440. [PMID: 36818672 PMCID: PMC9933866 DOI: 10.3389/fonc.2022.961440] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 12/30/2022] [Indexed: 01/22/2023] Open
Abstract
Malignant pleural effusion (MPE) is a common complication in the late stage of malignant tumors. The appearance of MPE indicates that the primary tumor has spread to the pleura or progressed to an advanced stage. The survival time of the patients will be significantly shortened, with a median survival of only a few months. There are a variety of traditional treatments, and their advantages and disadvantages are relatively clear. There are still many problems that cannot be solved by traditional methods in clinical work. The most common one is intrapleural perfusion therapy with chemotherapy drugs, but it has a large side effect of chemotherapy. At present, with the development of medical technology, there are a variety of treatment methods, and many innovative, significant and valuable treatment methods have emerged, which also bring hope for the treatment of refractory and recurrent MPE patients. Several clinical trials had confirmed that drug-carrying microparticles has less adverse reactions and obvious curative effect. However, there is still a long way to go to completely control and cure MPE, and the organic combination of clinical work and scientific research results is needed to bring dawn to refractory MPE patients.
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Affiliation(s)
| | | | | | | | | | | | - Yufeng Wu
- *Correspondence: Qiming Wang, ; Yufeng Wu,
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Wang Y, Zhou T, Zhao S, Li N, Sun S, Li M. A Novel Clinical Prognostic Model for Breast Cancer Patients with Malignant Pleural Effusion: Avoiding Chemotherapy in Low-Risk Groups? Cancer Manag Res 2023; 15:409-422. [PMID: 37197007 PMCID: PMC10184893 DOI: 10.2147/cmar.s409918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 05/04/2023] [Indexed: 05/19/2023] Open
Abstract
Purpose Malignant pleural effusion (MPE) is a severe complication in patients with advanced cancer that is associated with a poor prognosis. Breast cancer is the second leading cause of MPE after lung cancer. We therefore aim to describe clinical characteristics of the patients with MPE combined with breast cancer and construct a machine learning-based model for predicting the prognosis of such patients. Methods This study is a retrospective and observational study. Least absolute shrinkage and selection operator (LASSO) and univariate Cox regression analyses were applied to identify eight key clinical variables, and a nomogram model was established. Model performance was evaluated by receiver operating characteristic (ROC) curve, calibration curve, and decision curve analyses. Results 196 patients with both MPE and breast cancer (143 in the training group and 53 in the ex-ternal validation group) were analyzed in this study. The median overall survival in two cohorts was 16.20 months and 11.37 months. Based on the ROC curves for 3-, 6-, and 12-month survival, the areas under the curves were 0.824, 0.824, and 0.818 in the training set and 0.777, 0.790, and 0.715 in the validation set, respectively. In the follow-up analysis, both systemic and intrapleural chemotherapy significantly increased survival in the high-risk group compared to the low-risk group. Conclusion Collectively, MPE confers a poor prognosis in breast cancer patients. We have developed a first-ever survival prediction model for breast cancer patients with newly diagnosed MPE and validated the model using an independent cohort.
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Affiliation(s)
- Yichen Wang
- Department of Oncology, The Second Affiliated Hospital of Dalian Medical University, Dalian, 116023, People’s Republic of China
| | - Tao Zhou
- Department of Oncology, The First Affiliated Hospital of Dalian Medical University, Dalian, 116011, People’s Republic of China
| | - Shanshan Zhao
- Department of Oncology, The Second Affiliated Hospital of Dalian Medical University, Dalian, 116023, People’s Republic of China
| | - Ning Li
- Department of Foreign Language, Dalian Medical University, Dalian, 116050, People’s Republic of China
| | - Siwen Sun
- Department of Oncology, The Second Affiliated Hospital of Dalian Medical University, Dalian, 116023, People’s Republic of China
| | - Man Li
- Department of Oncology, The Second Affiliated Hospital of Dalian Medical University, Dalian, 116023, People’s Republic of China
- Correspondence: Man Li; Siwen Sun, Department of Oncology, The Second Affiliated Hospital of Dalian Medical University, Dalian, 116023, People’s Republic of China, Tel +86-17709873580; +86-17709891126, Email ;
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Gao L, Wang W, Zhang Y, Hu X, An J, Li Y, Chen M, Shen Y. Adenosine deaminase-based measurement in the differential diagnosis of pleural effusion: a multicenter retrospective study. Ther Adv Respir Dis 2023; 17:17534666231155747. [PMID: 36846945 PMCID: PMC9972043 DOI: 10.1177/17534666231155747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 01/23/2023] [Indexed: 03/01/2023] Open
Abstract
INTRODUCTION The differential diagnosis of pleural effusion is difficult, and studies have reported on the potential role of adenosine deaminase (ADA) in the differential diagnosis of undiagnosed pleural effusion. This retrospective study aimed to investigate the diagnostic role of ADA in pleural effusion. METHODS 266 patients with pleural effusion from three centers were enrolled. The concentrations of ADA and lactate dehydrogenase (LDH) were measured in pleural fluids and serum samples of the patients. The diagnostic performance of ADA-based measurement for tuberculous pleural effusion (TPE), malignant pleural effusion (MPE), and parapneumonic effusion (PPE) was examined by receiver operating characteristic (ROC) curve analysis. RESULTS An area under the ROC curve (AUC) value of 0.909 was obtained using the pleural ADA values as the indicator for TPE identification (sensitivity: 87.50%, specificity: 87.82%). The ratio of serum LDH to pleural ADA (cancer ratio) provided the predictive capacity with an AUC of 0.879 for MPE diagnosis (sensitivity: 95.04%, specificity: 67.06%). At a cut-off value of 14.29, the pleural ADA/LDH ratio showed a sensitivity and specificity of 81.13% and 83.67%, respectively, and a high AUC value of 0.888 for the differential diagnosis of PPE from TPE. CONCLUSION ADA-based measurement is helpful for the differential diagnosis of pleural effusion. Further studies should be performed to validate these results.
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Affiliation(s)
- Lijuan Gao
- Department of Respiratory and Critical Care
Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Wujun Wang
- Department of Respiratory and Critical Care
Medicine, Affiliated Hospital of Chengdu University of Traditional Chinese
Medicine, Chengdu, China
| | - Ying Zhang
- Department of Respiratory and Critical Care
Medicine, Army Medical Center of PLA, Chongqing, China
| | - Xueru Hu
- Department of Respiratory and Critical Care
Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Jing An
- Department of Respiratory and Critical Care
Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Yang Li
- Department of Respiratory and Critical Care
Medicine, Chengdu Fifth People’s Hospital, Chengdu, China
| | - Mei Chen
- Department of Respiratory and Critical Care
Medicine, Chengdu Fifth People’s Hospital, Chengdu 611130, China
- School of Medical and Life Sciences, Chengdu
University of Traditional Chinese Medicine, Chengdu 611130, China
| | - Yongchun Shen
- Department of Respiratory and Critical Care
Medicine, West China Hospital of Sichuan University, Chengdu 610041,
China
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Zhang S, Chen L, Zong Y, Li Q, Zhu K, Li Z, Meng R. Research progress of tumor-derived extracellular vesicles in the treatment of malignant pleural effusion. Cancer Med 2023; 12:983-994. [PMID: 35861052 PMCID: PMC9883446 DOI: 10.1002/cam4.5005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 06/11/2022] [Accepted: 06/19/2022] [Indexed: 02/02/2023] Open
Abstract
Vesicles, also known as "microparticles", are vesicle-like structures that are released outside the cell in a "sprouting" manner when the cytoskeleton is changed during cell activation or apoptosis, with a diameter of about 100-1000 nm, and are carriers of material information exchange between cells. Tumor-derived extracellular vesicles can effectively deliver drugs to the nucleus of tumor stem cells, thus effectively killing them without toxic side effects. The underlying mechanism involves the soft nature of tumor stem cells that allows better uptake of vesicles, and the entry of drug-carrying vesicles into lysosomes and facilitation of lysosomal movement toward the nucleus to deliver drugs to the nucleus. Drug-loaded vesicles have unique advantages, such as low immunogenicity, homing targeting ability, and the ability to break through the physiological barrier to tumor therapy. Tumor-derived drug-delivery vesicles have entered clinical trials for the treatment of malignant pleural effusions. In this review, we summarized the progress of basic and clinical research on tumor cell-derived drug-loaded vesicles for the treatment of malignant pleural effusion in recent years.
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Affiliation(s)
- Sijia Zhang
- Cancer Center, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Leichong Chen
- Cancer Center, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Yan Zong
- Cancer Center, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Qianwen Li
- Cancer Center, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Kuikui Zhu
- Cancer Center, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Zhenyu Li
- Cancer Center, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Rui Meng
- Cancer Center, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
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Hughes SM, Carmichael JJ. Malignant Pleural Effusions: Updates in Diagnosis and Management. LIFE (BASEL, SWITZERLAND) 2022; 13:life13010115. [PMID: 36676064 PMCID: PMC9861375 DOI: 10.3390/life13010115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 12/26/2022] [Accepted: 12/28/2022] [Indexed: 01/04/2023]
Abstract
Malignant pleural effusions remain a significant clinical problem resulting in greater than 125,000 hospitalizations per year and leading to over 5 billion dollars in healthcare utilization costs. Not only are health care expenditures related to malignant pleural effusion significant, but malignant pleural effusions also often result in significant patient discomfort and distress, largely at the end of life. Advances in management over the past several years have provided patients with greater autonomy as they are able to provide self-aid at home either alone or with family assistance. Additionally, practice changes have allowed for fewer interventions allowing patients to spend more time out of the clinic or inpatient wards.
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Martinez-Zayas G, Molina S, Ost DE. Sensitivity and complications of thoracentesis and thoracoscopy: a meta-analysis. Eur Respir Rev 2022; 31:31/166/220053. [PMID: 36543349 PMCID: PMC9879342 DOI: 10.1183/16000617.0053-2022] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 07/31/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Thoracentesis and thoracoscopy are used to diagnose malignant pleural effusions (MPE). Data on how sensitivity varies with tumour type is limited. METHODS Systematic review using PubMed was performed through August 2020 to determine the sensitivity of thoracentesis and thoracoscopy for MPE secondary to malignancy, by cancer type, and complication rates. Tests to identify sources of heterogeneity were performed. Study quality was assessed using Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 and National Institutes of Health quality assessment tools. Publication bias was tested using funnel plots. RESULTS Meta-analyses for sensitivity of thoracentesis for MPE secondary to malignancy, mesothelioma and lung and breast cancer included 29, eight, 12 and nine studies, respectively. Pooled sensitivities were 0.643 (95% CI 0.592-0.692), 0.451 (95% CI 0.249-0.661), 0.738 (95% CI 0.659-0.836) and 0.820 (95% CI 0.700-0.917), respectively. For sensitivity of thoracoscopy for MPE secondary to malignancy and mesothelioma, 41 and 15 studies were included, respectively. Pooled sensitivities were 0.929 (95% CI 0.905-0.95) and 0.915 (95% CI 0.871-0.952), respectively. Pooled complication rates of thoracentesis and thoracoscopy were 0.041 (95% CI 0.025-0.051) and 0.040 (95% CI 0.029-0.052), respectively. Heterogeneity was significant for all meta-analyses. Funnel plots were asymmetric. INTERPRETATION Sensitivity of thoracentesis varied significantly per cancer type. Pooled complication rates were low. Awareness of how sensitivity of thoracentesis changes across cancers can improve decision-making when MPE is suspected.
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Affiliation(s)
- Gabriela Martinez-Zayas
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Centre, Houston, TX, USA
| | - Sofia Molina
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Centre, Houston, TX, USA
| | - David E. Ost
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Centre, Houston, TX, USA,Corresponding author: David E. Ost ()
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Agrawal A, Chaddha U, Kaul V, Desai A, Gillaspie E, Maldonado F. Multidisciplinary Management of Chylothorax. Chest 2022; 162:1402-1412. [PMID: 35738344 DOI: 10.1016/j.chest.2022.06.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 05/04/2022] [Accepted: 06/10/2022] [Indexed: 12/14/2022] Open
Abstract
Chylothorax, the accumulation of chyle in the pleural space, is usually caused by the disruption of the thoracic duct or its tributaries. Etiologies are broadly divided into traumatic, including postsurgical, and nontraumatic, most commonly in the setting of malignancy. The management of chylothorax largely depends on the cause and includes dietary modification and drainage of the pleural space. A definitive intervention, whether surgical or a percutaneous lymphatic intervention, should be considered in patients with a persistently high volume of chylous output and in those with a prolonged leak, before complications such as malnutrition ensue. No methodologically robust clinical trials guiding management are currently available. In this article, we review the current literature and propose a stepwise, evidence-based multidisciplinary approach to the management of patients with both traumatic and nontraumatic chylothorax.
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Affiliation(s)
- Abhinav Agrawal
- Interventional Pulmonology, Division of Pulmonary, Critical Care & Sleep Medicine, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY.
| | - Udit Chaddha
- Interventional Pulmonology, Division of Pulmonary, Critical Care & Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Viren Kaul
- Division of Pulmonary and Critical Care Medicine, Crouse Health/SUNY Upstate Medical University, Syracuse, NY
| | - Ajinkya Desai
- Interventional Radiology, Department of Radiology, University of Mississippi Medical Center, Jackson, MS
| | - Erin Gillaspie
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Fabien Maldonado
- Interventional Pulmonology, Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
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Sundaralingam A, Aujayeb A, Akca B, Tiedeman C, George V, Carling M, Brown J, Banka R, Addala D, Bedawi EO, Hallifax RJ, Iqbal B, Denniston P, Tsakok MT, Kanellakis NI, Vafai-Tabrizi F, Bergman M, Funk GC, Benamore RE, Wrightson JM, Rahman NM. Achieving Molecular Profiling in Pleural Biopsies: A Multicenter, Retrospective Cohort Study. Chest 2022; 163:1328-1339. [PMID: 36410492 DOI: 10.1016/j.chest.2022.11.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 11/03/2022] [Accepted: 11/12/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Pleural biopsy findings offer greater diagnostic sensitivity in malignant pleural effusions compared with pleural fluid. The adequacy of pleural biopsy techniques in achieving molecular marker status has not been studied, and such information (termed "actionable" histology) is critical in providing a rational, efficient, and evidence-based approach to diagnostic investigation. RESEARCH QUESTION What is the adequacy of various pleural biopsy techniques at providing adequate molecular diagnostic information to guide treatment in malignant pleural effusions? STUDY DESIGN AND METHODS This study analyzed anonymized data on 183 patients from four sites across three countries in whom pleural biopsy results had confirmed a malignant diagnosis and molecular profiling was relevant for the diagnosed cancer type. The primary outcome measure was adequacy of pleural biopsy for achieving molecular marker status. Secondary outcomes included clinical factors predictive of achieving a molecular diagnosis. RESULTS The median age of patients was 71 years (interquartile range, 63-78 years), with 92 of 183 (50%) male. Of the 183 procedures, 105 (57%) were local anesthetic thoracoscopies (LAT), 12 (7%) were CT scan guided, and 66 (36%) were ultrasound guided. Successful molecular marker analysis was associated with mode of biopsy, with LAT having the highst yield and ultrasound-guided biopsy the lowest (LAT vs CT scan guided vs ultrasound guided: LAT yield, 95%; CT scan guided, 86%; and ultrasound guided, 77% [P = .004]). Biopsy technique and size of biopsy sample were independently associated with successful molecular marker analysis. LAT had an adjusted OR for successful diagnosis of 30.16 (95% CI, 3.15-288.56; P = .003) and biopsy sample size an OR of 1.18 (95% CI, 1.02-1.37) per millimeter increase in tissue sample size (P < .03). INTERPRETATION Although previous studies have shown comparable overall diagnostic yields, in the modern era of targeted therapies, this study found that LAT offers far superior results to image-guided techniques at achieving molecular profiling and remains the optimal diagnostic tool.
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Affiliation(s)
- Anand Sundaralingam
- Oxford Pleural Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Oxford Centre for Respiratory Medicine, and Department of Radiology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - Avinash Aujayeb
- Respiratory Department, Northumbria Healthcare NHS Trust, Newcastle, UK
| | - Baki Akca
- Karl Landsteiner Institute for Lung Research and Pulmonary Oncology, Klinik Ottakring, Vienna, Austria
| | - Clare Tiedeman
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, NSW, Australia
| | - Vineeth George
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, NSW, Australia
| | - Michael Carling
- Respiratory Department, Northumbria Healthcare NHS Trust, Newcastle, UK
| | - Jennifer Brown
- Department of Histopathology, Nuffield Orthopaedic Centre, Oxford, UK
| | - Radhika Banka
- PD Hinduja National Hospital and Medical Research Centre
| | - Dinesh Addala
- Oxford Pleural Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Oxford Centre for Respiratory Medicine, and Department of Radiology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Eihab O Bedawi
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Rob J Hallifax
- Oxford Pleural Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Beenish Iqbal
- Oxford Pleural Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Poppy Denniston
- Oxford Pleural Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Maria T Tsakok
- Oxford Centre for Respiratory Medicine, and Department of Radiology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Nikolaos I Kanellakis
- Nuffield Department of Medicine, Chinese Academy of Medical Sciences (CAMS) Oxford Institute (COI), University of Oxford, Oxford, UK; Nuffield Department of Medicine, Laboratory of Pleural and Lung Cancer Translational Research, University of Oxford, Oxford, UK; Nuffield Department of Medicine, and the National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Florian Vafai-Tabrizi
- Karl Landsteiner Institute for Lung Research and Pulmonary Oncology, Klinik Ottakring, Vienna, Austria
| | - Michael Bergman
- Karl Landsteiner Institute for Lung Research and Pulmonary Oncology, Klinik Ottakring, Vienna, Austria
| | - Georg-Christian Funk
- Karl Landsteiner Institute for Lung Research and Pulmonary Oncology, Klinik Ottakring, Vienna, Austria
| | - Rachel E Benamore
- Oxford Centre for Respiratory Medicine, and Department of Radiology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - John M Wrightson
- Oxford Pleural Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Najib M Rahman
- Oxford Pleural Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK; Nuffield Department of Medicine, Chinese Academy of Medical Sciences (CAMS) Oxford Institute (COI), University of Oxford, Oxford, UK; Nuffield Department of Medicine, Laboratory of Pleural and Lung Cancer Translational Research, University of Oxford, Oxford, UK; Nuffield Department of Medicine, and the National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
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Moutard N, Richard P, de Blay F, Kessler R, Ohana M. Échogénicité des pleurésies : facteur prédictif d’amélioration de la dyspnée ? Étude pilote concernant les pleurésies métastatiques. Rev Mal Respir 2022; 39:805-813. [DOI: 10.1016/j.rmr.2022.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 09/28/2022] [Indexed: 11/18/2022]
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Recuero Díaz JL, Figueroa Almánzar S, Gálvez Muñoz C, Lázaro Sierra J, López Porras M, Márquez Medina D, Nabal Vicuña M, Sánchez Moreno L, González Cantalejo M, Porcel JM. Recommendations of the Spanish Society of Thoracic Surgery for the management of malignant pleural effusion. Cir Esp 2022; 100:673-683. [PMID: 35667609 DOI: 10.1016/j.cireng.2022.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 05/04/2022] [Indexed: 06/15/2023]
Abstract
This article summarizes the clinical guidelines for the diagnosis and treatment of malignant pleural effusion (MPE) sponsored by the Spanish Society of Thoracic Surgery (SECT). Ten clinical controversies were elaborated under the methodology of PICO (Patient, Intervention, Comparison, Outcome) questions and the quality of the evidence and grading of the strength of the recommendations was based on the GRADE system. Immunocytochemical and molecular analyses of pleural fluid may avoid further invasive diagnostic procedures. Currently, the definitive control of MPE can be achieved either by pleurodesis (talc poudrage or slurry) or the insertion of a indwelling pleural catheter (IPC). It is likely that the combination of both techniques (i.e., thoracoscopy with talc poudrage and insertion of a IPC, or instillation of talc slurry through a IPC) will have a predominant role in the future therapeutic management.
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Affiliation(s)
- José Luis Recuero Díaz
- Servicio de Cirugía Torácica, Hospital Universitario Miguel Servet, Zaragoza, Spain; Instituto de Investigación Sanitaria (IIS) de Aragón, Zaragoza, Spain.
| | | | - Carlos Gálvez Muñoz
- Servicio de Cirugía Torácica, Hospital Universitario de Alicante, Alicante, Spain
| | - Javier Lázaro Sierra
- Instituto de Investigación Sanitaria (IIS) de Aragón, Zaragoza, Spain; Servicio de Neumología, Hospital Royo Villanova, Zaragoza, Spain
| | - Marta López Porras
- Servicio de Cirugía Torácica, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Diego Márquez Medina
- Instituto de Investigación Sanitaria (IIS) de Aragón, Zaragoza, Spain; Servicio de Oncología Médica, Hospital Universitario Miguel Servet, Zaragoza, Spain; Universidad de Zaragoza, Zaragoza, Spain
| | - María Nabal Vicuña
- Cuidados Paliativos, Hospital Universitario Arnau de Vilanova, Lleida, Spain
| | - Laura Sánchez Moreno
- Servicio de Cirugía Torácica, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Mar González Cantalejo
- Servicio de Información Biomédica y Biblioteca, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - José M Porcel
- Unidad de Medicina Pleural, Servicio de Medicina Interna, Hospital Universitario Arnau de Vilanova, Lleida, Spain; Institut de Recerca Biomèdica de Lleida Fundació Dr. Pifarré (IRBLleida), Lleida, Spain; Universitat de Lleida, Lleida. Spain
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Li D, Jackson K, Panchal R, Aujayeb A. Local Anaesthetic Thoracoscopy for Pleural Effusion-A Narrative Review. Healthcare (Basel) 2022; 10:1978. [PMID: 36292425 PMCID: PMC9601808 DOI: 10.3390/healthcare10101978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 10/06/2022] [Accepted: 10/07/2022] [Indexed: 11/04/2022] Open
Abstract
The incidence of pleural disease is increasing, and interventions are crucial in this subspecialist area of respiratory medicine. One of the cornerstones of pleural effusion investigation and management is medical, which is also known as local anaesthetic thoracoscopy. This allows fluid drainage, biopsy for diagnosis and preventative measures for further fluid potential build-up. This article summarises the evidence around this procedure through a narrative review of the available evidence.
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Affiliation(s)
- Dana Li
- Institute for Lung Health, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK
| | - Karl Jackson
- Respiratory Department, Northumbria Health Care NHS Foundation Trust, Care of Gail Hewitt, Newcastle NE23 6NZ, UK
| | - Rakesh Panchal
- Institute for Lung Health, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK
| | - Avinash Aujayeb
- Respiratory Department, Northumbria Health Care NHS Foundation Trust, Care of Gail Hewitt, Newcastle NE23 6NZ, UK
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75
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Yang H, Zhang Y, Wei D, Chen W, Zhang S, He L, Liao H, Tang Q, Liu J. Utility of high-frequency B-mode and contrast-enhanced ultrasound for the differential diagnosis of benign and malignant pleural diseases: a prospective study. J Thorac Dis 2022; 14:3695-3705. [PMID: 36389309 PMCID: PMC9641343 DOI: 10.21037/jtd-22-636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 09/23/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Pleural disease is a prevalent condition. As precision therapy advances, noninvasive imaging modalities play even more important roles in the evaluation of pleural diseases. This study investigated the diagnostic capabilities of high-frequency B-mode ultrasound (US) and contrast-enhanced US (CEUS) in terms of differentiating between benign and malignant pleural diseases. METHODS Patients with unexplained thickened pleurae were prospectively analyzed via transthoracic US. High-frequency B-mode US was used to derive the pleural thickness, morphology, and echogenicity. We analyzed the high-frequency CEUS data including the enhancement mode and time intensity curve (TIC). The cause of pleural thickening was confirmed by pleural biopsy and follow-up after the biopsy. We analyzed the differences in various ultrasonic features between the malignant and benign groups. Moreover, we plotted receiver operator curves (ROCs) and obtained the area under the curves, sensitivities, and specificities of all significant continuous variables. Multivariate logistic regression was used to assess the combined usefulness of multiple US indicators in terms of predicting malignant pleurae. RESULTS Thirty malignant and twenty benign thickened pleurae were finally diagnosed via pleural biopsy and at least six months of follow-up. The pleural morphology and enhancement modes significantly differed between the two groups (all P<0.05). The thickness derived from B-mode US and CEUS were significantly thicker in the malignant group (both P<0.05). Arrival time (AT) and the time to peak (TTP) of TIC were significantly shorter in the malignant group, whereas peak intensity and the area under the TIC were significantly higher in the malignant group (all P<0.05). The area under the ROC for pleural thickness derived from B-mode US was 0.819; pleural thickness derived from CEUS was 0.848; AT was 0.804; TTP was 0.750; peak intensity was 0.745; the area under the TIC was 0.743; and the combined various B-mode and CEUS parameter was 0.975. CONCLUSIONS Pleural thickness, morphology, enhancement mode, and the TIC of high-frequency US aided the differentiation of benign from malignant pleural diseases. Combined analysis of US indicators further improved the diagnostic capability.
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Affiliation(s)
- Hongwei Yang
- Department of Ultrasound, First Affiliated Hospital of Jinan University, Guangzhou, China;,Department of Ultrasound, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yuxin Zhang
- Department of Ultrasound, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Dongjun Wei
- Department of Ultrasound, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Wuxi Chen
- Department of Ultrasound, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Shiyu Zhang
- Department of Ultrasound, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Liantu He
- Department of Ultrasound, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Haixing Liao
- Department of Ultrasound, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Qing Tang
- Department of Ultrasound, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jianhua Liu
- Department of Medical Ultrasound, Guangzhou First People’s Hospital, School of Medicine, South China University of Technology, Guangzhou, China
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76
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Trovisco R, Freitas C, Serino M, Ferreira P, Martins B, Coelho D, Melo N, Fernandes G, Magalhães A, Bastos HN. Predictors of lung entrapment in malignant pleural effusion. Pulmonology 2022:S2531-0437(22)00199-4. [PMID: 36180353 DOI: 10.1016/j.pulmoe.2022.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 07/25/2022] [Accepted: 08/03/2022] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Malignant pleural effusion (MPE) is a common complication in advanced stages of malignancy and is associated with poor prognosis. Non-expandable lung (NEL) often occurs and its presence influences the MPE approach. Our main objective was to assess risk factors for malignant NEL. METHODS Patients diagnosed with pathologically confirmed MPE between January 2012 and December 2018 in our institution were retrospectively analyzed. Demographic and clinical data of patients were reviewed and compared according to the presence or absence of NEL. A univariate and multivariate binary logistic regression analysis were used to determine predictors of the development of NEL. RESULTS Of 365 patients included, 68 (18.6%) had NEL. After multivariate analysis, we found that loculated MPE (OR 8.63, 95%CI 4.30-17.33, p<0.001), complete hemithorax opacification (OR 2.81, 95%CI 1.17-6.76, p<0.021), lung cancer (OR 2.09, 95%CI 1.01-4.31, p=0.047) and higher effusion-serum LDH ratio (OR 1.09, 95%CI 1.00-1.17, p=0.039) were independent predictors of malignant NEL. There were no significant differences compared with expandable lung group regarding time from primary malignancy diagnosis to MPE diagnosis (3.0, IQR 0.0-75.8 vs 2.0, IQR 0.0-75.5 weeks, p=0.942) or MPE symptoms onset to MPE diagnosis (4.0, IQR 1.0-9.0 vs 3.0, IQR 1.0-9.0 weeks, p=0.497). Patients with NEL had a higher number of therapeutic pleural drainages (3.0, IQR 2.0-6.0 vs 2.0, IQR 1.0-3.0; p<0.001) and longer hospital stay (32.5, IQR 15.5-46.3 vs 21.0, IQR 11.0-36.0, p=0.007), measured in hospitalization days until the end of life, than patients with expandable lung. The rate of recurrence of pleural effusion was not significantly different between groups (p=0.291). Overall survival (OS) was 3.0 (95%CI, 2.3-3.7) months, regardless of lung expandability (p=0.923). CONCLUSION Loculated MPE, complete hemithorax opacification, lung cancer and a higher effusion-serum LDH ratio were found to be independent predictors for NEL. These patients underwent thoracocenteses more frequently and had longer hospitalization days, although without significant impact in the OS.
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Affiliation(s)
- R Trovisco
- Faculty of Medicine, University of Porto, Alameda Prof. Hernani Monteiro, 4200-319 Porto, Portugal
| | - C Freitas
- Faculty of Medicine, University of Porto, Alameda Prof. Hernani Monteiro, 4200-319 Porto, Portugal; Department of Pulmonology, Centro Hospitalar e Universitário São João, Porto, Portugal
| | - M Serino
- Department of Pulmonology, Centro Hospitalar e Universitário São João, Porto, Portugal
| | - P Ferreira
- Department of Pulmonology, Centro Hospitalar e Universitário São João, Porto, Portugal
| | - B Martins
- Department of Pulmonology, Centro Hospitalar e Universitário São João, Porto, Portugal
| | - D Coelho
- Faculty of Medicine, University of Porto, Alameda Prof. Hernani Monteiro, 4200-319 Porto, Portugal; Department of Pulmonology, Centro Hospitalar e Universitário São João, Porto, Portugal
| | - N Melo
- Department of Pulmonology, Centro Hospitalar e Universitário São João, Porto, Portugal
| | - G Fernandes
- Faculty of Medicine, University of Porto, Alameda Prof. Hernani Monteiro, 4200-319 Porto, Portugal; Department of Pulmonology, Centro Hospitalar e Universitário São João, Porto, Portugal
| | - A Magalhães
- Department of Pulmonology, Centro Hospitalar e Universitário São João, Porto, Portugal
| | - H N Bastos
- Faculty of Medicine, University of Porto, Alameda Prof. Hernani Monteiro, 4200-319 Porto, Portugal; Department of Pulmonology, Centro Hospitalar e Universitário São João, Porto, Portugal; Institute for Research and Innovation in Health, University of Porto, Rua Alfredo Allen, 208, 4200-136 Porto, Portugal.
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Pippard B, Bhatnagar M, McNeill L, Donnelly M, Frew K, Aujayeb A. Hepatic Hydrothorax: A Narrative Review. Pulm Ther 2022; 8:241-254. [PMID: 35751800 PMCID: PMC9458779 DOI: 10.1007/s41030-022-00195-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 06/01/2022] [Indexed: 12/10/2022] Open
Abstract
Hepatic hydrothorax (HH) represents a distinct clinical entity within the broader classification of pleural effusion that is associated with significant morbidity and mortality. The median survival of patients with cirrhosis who develop HH is 8-12 months. The diagnosis is typically made in the context of advanced liver disease and ascites, in the absence of underlying cardio-pulmonary pathology. A multi-disciplinary approach to management, involving respiratory physicians, hepatologists, and palliative care specialists is crucial to ensuring optimal patient-centered care. However, the majority of accepted therapeutic options are based on expert opinion rather than large, adequately powered randomized controlled trials. In this narrative review, we discuss the epidemiology, pathophysiology, clinical characteristics, and management of HH, highlighting the use of salt restriction and diuretic therapy, porto-systemic shunts, and liver transplantation. We include specific sections focusing on the role of pleural interventions and palliative care, respectively.
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Affiliation(s)
- Benjamin Pippard
- Department of Respiratory Medicine, South Tyneside and Sunderland NHS Foundation Trust, Sunderland, UK
| | - Malvika Bhatnagar
- Department of Respiratory Medicine, South Tyneside and Sunderland NHS Foundation Trust, Sunderland, UK
| | - Lisa McNeill
- Department of Hepatology, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Mhairi Donnelly
- Department of Hepatology, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Katie Frew
- Department of Palliative Medicine, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Avinash Aujayeb
- Department of Respiratory Medicine, Northumbria Healthcare NHS Foundation Trust, North Shields, Northumbria Way, Northumberland, Cramlington, NE23 6NZ, UK.
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78
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Lester M, Maldonado F, Rickman OB, Roller LJ, Avasarala SK, Katsis JM, Lentz RJ. Association between terminal pleural elastance and radiographic lung re-expansion after therapeutic thoracentesis in patients with symptomatic pleural effusion: a post-hoc analysis of a randomised trial. BMJ Open 2022; 12:e053606. [PMID: 35820740 PMCID: PMC9277390 DOI: 10.1136/bmjopen-2021-053606] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Recurrent symptomatic effusions can be durably managed with pleurodesis or placement of indwelling pleural catheters. Recent pleurodesis trials have largely relied on lung re-expansion on post-thoracentesis radiograph as an inclusion criterion rather than pleural elastance as determined by manometry, which is an important predictor of successful pleurodesis. We investigated the association between lung re-expansion on post-pleural drainage chest imaging and pleural physiology, with particular attention to pleural elastance over the final 200 mL aspirated. DESIGN Post-hoc analysis of a recent randomised trial. SETTING AND PARTICIPANTS Post-results analysis of 61 subjects at least 18 years old with symptomatic pleural effusions estimated to be at least of 0.5 L in volume allocated to manometry-guided therapeutic thoracentesis in a recent randomised trial conducted at two major university hospitals in the USA. PRIMARY OUTCOME MEASURES The primary outcome was concordance of radiographic with normal terminal pleural elastance over the final 200 mL aspirated. We label this terminal elastance 'visceral pleural recoil', or the tendency of the maximally expanded lung to withdraw from the chest wall. RESULTS Post-thoracentesis chest radiograph and thoracic ultrasound indicated successful lung re-expansion in 69% and 56% of cases, respectively. Despite successful radiographic lung re-expansion, visceral pleural recoil was abnormal in 71% of subjects expandable by radiograph and 77% expandable by ultrasound. The sensitivity and positive predictive value of radiographic lung re-expansion for normal visceral pleural recoil were 44% and 24%, respectively. CONCLUSION Radiographic lung re-expansion by post-thoracentesis chest radiograph or thoracic ultrasound is a poor surrogate for normal terminal pleural elastance. Clinical management of patients with recurrent symptomatic pleural effusions guided by manometry rather than post-thoracentesis imaging might produce better outcomes, which should be investigated by future clinical trials. TRIAL REGISTRATION NUMBER NCT02677883; Post-results.
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Affiliation(s)
- Michael Lester
- Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Fabien Maldonado
- Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
- Department of Thoracic Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Otis B Rickman
- Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
- Department of Thoracic Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Lance J Roller
- Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Sameer K Avasarala
- Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - James M Katsis
- Department of Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Robert J Lentz
- Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
- Department of Thoracic Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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79
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Baltaji S, Shojaee S. Indwelling Pleural Catheters for Refractory Hepatic Hydrothorax? A Call for Prospective Studies and Randomized Controlled Trials. J Bronchology Interv Pulmonol 2022; 29:161-163. [PMID: 35730776 DOI: 10.1097/lbr.0000000000000851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Stephanie Baltaji
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Allegheny Health Network, Pittsburg, PA
| | - Samira Shojaee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University Health System, Richmond, VA
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Recuero Díaz JL, Figueroa Almánzar S, Gálvez Muñoz C, Lázaro Sierra J, López Porras M, Márquez Medina D, Nabal Vicuña M, Sánchez Moreno L, González Cantalejo M, M. Porcel J. Recomendaciones de la Sociedad Española de Cirugía Torácica para el manejo del derrame pleural maligno. Cir Esp 2022. [DOI: 10.1016/j.ciresp.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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81
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Markowiak T, Ried M, Großer C, Hofmann HS, Hillejan L, Hecker E, Semik M, Lesser T, Kugler C, Seifert S, Scheubel R. Postoperative outcome after palliative treatment of malignant pleural effusion. Thorac Cancer 2022; 13:2158-2163. [PMID: 35748347 PMCID: PMC9346186 DOI: 10.1111/1759-7714.14534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 05/23/2022] [Accepted: 05/25/2022] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND The objective of this nationwide, registry-based study was to compare the two most frequently used procedures for the palliative treatment of a malignant pleural effusion (MPE) and to evaluate differentiated indications for these two procedures. METHODS This was a retrospective observational study based on data of the "PLEURATUMOR" registry of the German Society for Thoracic Surgery. Patients who were documented in the period from January 2015 to November 2021 and had video-assisted thoracic surgery (VATS) talc pleurodesis or implantation of an indwelling pleural catheter (IPC) were included. RESULTS A total of 543 patients were evaluated. The majority suffered from secondary pleural carcinomatosis (n = 402; 74%). VATS talc pleurodesis (n = 361; 66.5%) was performed about twice as often as IPC implantation (n = 182; 33.5%). The duration of surgery was significantly shorter in IPC-patients with 30 min compared to VATS talc pleurodesis (38 min; p = 0.000). Postoperative complication rate was 11.8% overall and slightly higher after VATS talc pleurodesis (n = 49; 13.6%) than after IPC implantation (n = 15; 8.2%). After VATS talc pleurodesis patients were hospitalized significantly longer compared to the IPC group (6 vs. 3.5 days; p = 0.000). There was no significant difference in postoperative wound infections between the groups (p = 0.10). The 30-day mortality was 7.9% (n = 41). CONCLUSION The implantation of an IPC can significantly shorten the duration of surgery and the hospital stay. For this reason, the procedure should be matched with the patient's expectations preoperatively and the use of an IPC should be considered not only in the case of a trapped lung.
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Affiliation(s)
- Till Markowiak
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Michael Ried
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Christian Großer
- Department of Thoracic Surgery, Hospital Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Hans-Stefan Hofmann
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany.,Department of Thoracic Surgery, Hospital Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Ludger Hillejan
- Department of Thoracic Surgery, Niels-Stensen-Kliniken, Ostercappeln, Germany
| | - Erich Hecker
- Department of Thoracic Surgery, Thoraxzentrum Ruhrgebiet, Academic Hospital, University Duisburg-Essen, Herne, Germany
| | - Michael Semik
- Department of Thoracic Surgery, Ibbenbueren General Hospital, Ibbenbueren, Germany
| | - Thomas Lesser
- Department of Thoracic and Vascular Surgery, Lung Cancer Center DKG, SRH Wald-Klinikum Gera, Gera, Germany
| | | | - Sven Seifert
- Department of Thorax, Vascular and Endovascular Surgery, Chemnitz Hospital, Chemnitz, Germany
| | - Robert Scheubel
- Clinic of Thoracic Surgery, Waldburg-Zeil Clinic, Wangen im Allgäu, Germany
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82
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The intrapleural administration with thymic peptides in malignant pleural effusion: A clustered systematic review and meta-analysis. Int Immunopharmacol 2022; 107:108688. [DOI: 10.1016/j.intimp.2022.108688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 02/27/2022] [Accepted: 03/06/2022] [Indexed: 11/24/2022]
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83
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Trivedi SB, Niemeyer M. Treating Recurrent Pleural Disease: A Review of Indications and Technique for Chemical Pleurodesis for the Interventional Radiologist. Semin Intervent Radiol 2022; 39:275-284. [PMID: 36062225 PMCID: PMC9433148 DOI: 10.1055/s-0042-1754349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Pleural space diseases such as recurrent pleural effusion and pneumothorax inflict a significant symptomatic burden on patients. Guidelines and studies are available to guide best practices in the setting of refractory effusions, mostly in the setting of malignancy, and recurrent pneumothorax. Less data is available to guide management of refractory transudative effusions. Recurrent pleural effusions can be treated with tunneled pleural catheters or catheter-based pleurodesis. While refractory transudative effusions can benefit from tunneled pleural catheter, this is an area of ongoing research. Regarding recurrent pneumothorax, video-assisted thoracoscopic surgery (VATS) pleurodesis using mechanical or laser/argon beam coagulation is the most effective means of preventing recurrence. Catheter based pleurodesis, a less invasive means of administering chemical sclerosant via percutaneous thoracostomy tube, is only used when surgery is not an option. However, both approaches induce inflammation of the pleural space, resulting in adherence of the parietal and visceral pleura to prevent fluid or air re-accumulation. This article will discuss catheter based chemical pleurodesis geared toward the interventional radiologist, including a review of disease processes and indications, technique, and strategies to mitigate complications as well as a literature review comparing percutaneous chemical pleurodesis to other therapies.
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Affiliation(s)
- Surbhi B. Trivedi
- Department of Radiology, University of Illinois Hospital and Health Sciences System, Chicago, Illinois
| | - Matthew Niemeyer
- Department of Radiology, University of Illinois Hospital and Health Sciences System, Chicago, Illinois
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84
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Guinde J, Dutau H, Astoul P. Management of Malignant Pleural Effusion: Where Are We Now? Semin Respir Crit Care Med 2022; 43:559-569. [PMID: 35613947 DOI: 10.1055/s-0042-1748185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Pleural malignancies are among the most common causes of pleural disease and form the basis of our daily pleural practice. There has been significant research and increase in both diagnostic and therapeutic management of malignant pleural diseases in the last decade. Good-quality data have led to a paradigm shift in the management options of pleural malignancies, and indwelling pleural catheter is now recommended and widely used as first-line intervention. Several trials compared different treatment modalities for pleural malignancies and continue to emphasize the need to reduce hospital length of stay and unnecessary pleural intervention, and the importance of patient choice in clinical decision making. This practical review aims to summarize the current knowledge for the management of pleural malignancies, and the understanding of the steps that we still have to climb to optimize management and reduce morbidity.
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Affiliation(s)
- Julien Guinde
- Department of Thoracic Oncology, Pleural Diseases, and Interventional Pulmonology, North University Hospital, Marseille, France
| | - Hervé Dutau
- Department of Thoracic Oncology, Pleural Diseases, and Interventional Pulmonology, North University Hospital, Marseille, France
| | - Philippe Astoul
- Department of Thoracic Oncology, Pleural Diseases, and Interventional Pulmonology, North University Hospital, Marseille, France.,Aix-Marseille University, Marseille, France
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85
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Jiang H, Yang XM, Wang CQ, Xu J, Huang J, Feng JH, Chen XF, Chen K, Zhan L, Xiao X, Xiao Z. Intrapleural Perfusion With Staphylococcal Enterotoxin C for Malignant Pleural Effusion: A Clustered Systematic Review and Meta-Analysis. Front Med (Lausanne) 2022; 9:816973. [PMID: 35547209 PMCID: PMC9081816 DOI: 10.3389/fmed.2022.816973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 03/21/2022] [Indexed: 11/21/2022] Open
Abstract
Introduction The staphylococcal enterotoxin C (SEC), a commercially available bio-product from Staphylococcus aureus (S. aureus), has been widely used to control MPE. Objectives We designed and performed a new systematic review (SR) and meta-analysis to clarify the perfusion protocols with SEC, determine their clinical effectiveness and safety, and reveal the indication and optimum usage for achieving the desired responses. Methodology All randomized controlled trials (RCTs) about SEC for MPE were collected from electronic databases (from inception until July 2021), and clustered into multiple logical topics. After evaluating their methodological quality, we pooled the data from each topic using the meta-analysis or descriptive analysis, and summarized the evidence quality using the grading of recommendation assessment, development, and evaluation (GRADE) approach. Results All 114 studies were clustered into SEC perfusion alone or plus chemical agents. The SEC alone showed a better complete response (CR), a lower pleurodesis failure, and adverse drug reactions (ADRs), and a higher fever than cisplatin (DDP) alone. The SEC and chemical agents developed 10 perfusion protocols. Among them, only SEC and DDP perfusion showed a better CR, a lower failure, disease progression and ADRs, and a higher fever than DDP alone. The SEC (100–200 ng per time, one time a week for one to four times) with DDP (30–40 mg, or 50–60 mg each time) significantly improved clinical responses for patients with moderate to large volume, Karnofsky performance status (KPS) scores ≥40, ≥50, or ≥60, and anticipated survival time (AST) ≥2 or 3 months. Most results were moderate to low quality. Conclusion Current pieces of evidence indicate that super-antigen SEC is a pleurodesis agent, which provides an attractive alternative to existing palliative modalities for patients with MPE. Among 10 protocols, the SEC and DDP perfusion is a most commonly used, which shows a significant improvement in clinical responses with low ADRs. These findings also provide a possible indication and optimal usage for SEC and DDP perfusion.
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Affiliation(s)
- Hong Jiang
- Department of General Practice, Affiliated Hospital of Zunyi Medical University, Zunyi, China.,Evidence-Based Medicine Center, MOE Virtual Research Center of Evidence-Based Medicine at Zunyi Medical College, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Xue-Mei Yang
- Department of General Practice, Affiliated Hospital of Zunyi Medical University, Zunyi, China.,Evidence-Based Medicine Center, MOE Virtual Research Center of Evidence-Based Medicine at Zunyi Medical College, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Cheng-Qiong Wang
- Department of General Practice, Affiliated Hospital of Zunyi Medical University, Zunyi, China.,Evidence-Based Medicine Center, MOE Virtual Research Center of Evidence-Based Medicine at Zunyi Medical College, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Jiao Xu
- Department of General Practice, Affiliated Hospital of Zunyi Medical University, Zunyi, China.,Evidence-Based Medicine Center, MOE Virtual Research Center of Evidence-Based Medicine at Zunyi Medical College, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Jun Huang
- Department of Pharmacy, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Ji-Hong Feng
- Department of Oncology, Lishui People's Hospital, Sixth Affiliated Hospital of Wenzhou Medical University, Lishui, China
| | - Xiao-Fan Chen
- Evidence-Based Medicine Research Centre, Jiangxi University of Traditional Chinese Medicine, Nanchang, China
| | - Kai Chen
- Department of Surgery, First Affiliated Hospital of Chongqing Medical and Pharmaceutical College, Chongqing, China
| | - Lin Zhan
- Laboratory Research Center, Guizhou Provincial People's Hospital, Guizhou University, Guiyang, China
| | - Xue Xiao
- Department of General Practice, Affiliated Hospital of Zunyi Medical University, Zunyi, China.,Evidence-Based Medicine Center, MOE Virtual Research Center of Evidence-Based Medicine at Zunyi Medical College, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Zheng Xiao
- Department of General Practice, Affiliated Hospital of Zunyi Medical University, Zunyi, China.,Evidence-Based Medicine Center, MOE Virtual Research Center of Evidence-Based Medicine at Zunyi Medical College, Affiliated Hospital of Zunyi Medical University, Zunyi, China
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86
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Fan X, Liu Y, Liang Z, Wang S, Yang J, Wu A. Diagnostic Value of Six Tumor Markers for Malignant Pleural Effusion in 1,230 Patients: A Single-Center Retrospective Study. Pathol Oncol Res 2022; 28:1610280. [PMID: 35515016 PMCID: PMC9065255 DOI: 10.3389/pore.2022.1610280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 03/15/2022] [Indexed: 11/13/2022]
Abstract
Background: The diagnostic value of tumor markers in pleural effusion (PE) and serum for malignant pleural effusion (MPE) is still in debate. This study aimed to evaluate the diagnostic value of six tumor markers in PE, serum, and the corresponding PE/serum (PE/S) ratio in distinguishing MPE from benign pleural effusion (BPE). Methods: A total of 1,230 patients with PE (452 MPEs and 778 BPEs) were retrospectively included in the study. PE and serum levels of carcinoembryonic antigen (CEA), carbohydrate antigen 15-3 (CA15-3), carbohydrate antigen 125 (CA125), carbohydrate antigen 19-9 (CA19-9), cytokeratin 19 fragment (CYFRA 21-1), and neuron-specific enolase (NSE) were measured. The area under the curve (AUC) was used to assess the single and combined diagnostic values of the six tumor markers for MPE. Results: The levels of the six tumor markers in PE, serum, and PE/S were significantly higher in MPE than that in BPE, except for serum CA125. PE CEA showed the highest AUC [0.890 (0.871–0.907)] at a cut-off value of 3.7 ng/ml compared to any single tumor marker using receiver operating characteristic (ROC) analysis. The specificity, sensitivity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (PLR), and negative likelihood ratio (NLR) of PE CEA were 74.1%, 95.5%, 90.5%, 86.4%, 16.47, and 0.27, respectively. The combination of PE CEA and serum CYFRA21-1 showed the best diagnostic performance with an AUC of 0.934 (sensitivity, 79.9%; specificity, 95.7%, PPV, 90.5; PLR, 17.35) among all two or three combinations. Besides, serum CYFRA21-1 was the best diagnostic tumor marker in distinguishing cytology-negative MPE from BPE at a cut-off value of 3.0 ng/ml. Conclusion: PE CEA was the best diagnostic tumor marker in distinguishing MPE from BPE. Serum CYFRA21-1 was the best diagnostic tumor marker in distinguishing cytology-negative MPE from BPE. The combination of PE CEA and serum CYFRA21-1 could increase the diagnostic performance in distinguishing MPE from BPE and cytology-negative MPE from BPE.
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Affiliation(s)
- Xin Fan
- Department of Dermatology, Ningbo First Hospital, Ningbo, China
| | - Yanqing Liu
- Department of Laboratory Medicine, Ningbo First Hospital, Ningbo, China
| | - Zhigang Liang
- Department of Thoracic Surgery, Ningbo First Hospital, Ningbo, China
| | - Shanshan Wang
- Department of Laboratory Medicine, Ningbo First Hospital, Ningbo, China
| | - Jing Yang
- Department of Respiratory and Critical Care, Ningbo First Hospital, Ningbo, China
| | - Aihua Wu
- Department of Laboratory Medicine, Ningbo First Hospital, Ningbo, China
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87
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Update on the diagnosis and management of malignant pleural effusions. Respir Med 2022; 196:106802. [DOI: 10.1016/j.rmed.2022.106802] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 02/25/2022] [Accepted: 03/02/2022] [Indexed: 12/17/2022]
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88
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Porcel JM. Mesotelioma pleural. Med Clin (Barc) 2022; 159:240-247. [DOI: 10.1016/j.medcli.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 03/28/2022] [Accepted: 03/29/2022] [Indexed: 10/18/2022]
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89
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Nikoomanesh K, Phan AT, Sond V, Hasan M. Intrapleural Tissue Plasminogen Activator and Dornase Alfa Administration for a Multiloculated Recurrent Malignant Pleural Effusion: A Case Report. Cureus 2022; 14:e24373. [PMID: 35619869 PMCID: PMC9126429 DOI: 10.7759/cureus.24373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2022] [Indexed: 11/05/2022] Open
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90
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Jacobs B, Sheikh G, Youness HA, Keddissi JI, Abdo T. Diagnosis and Management of Malignant Pleural Effusion: A Decade in Review. Diagnostics (Basel) 2022; 12:1016. [PMID: 35454064 PMCID: PMC9030780 DOI: 10.3390/diagnostics12041016] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 04/12/2022] [Accepted: 04/12/2022] [Indexed: 02/04/2023] Open
Abstract
Malignant pleural effusion (MPE) is a common complication of thoracic and extrathoracic malignancies and is associated with high mortality. Treatment is mainly palliative, with symptomatic management achieved via effusion drainage and pleurodesis. Pleurodesis may be hastened by administering a sclerosing agent through a thoracostomy tube, thoracoscopy, or an indwelling pleural catheter (IPC). Over the last decade, several randomized controlled studies shaped the current management of MPE in favor of an outpatient-based approach with a notable increase in IPC usage. Patient preferences remain essential in choosing optimal therapy, especially when the lung is expandable. In this article, we reviewed the last 10 to 15 years of MPE literature with a particular focus on the diagnosis and evolving management.
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Affiliation(s)
| | | | | | | | - Tony Abdo
- Section of Pulmonary, Critical Care and Sleep Medicine, The University of Oklahoma Health Sciences Center and The Oklahoma City VA Health Care System, Oklahoma City, OK 73104, USA; (B.J.); (G.S.); (H.A.Y.); (J.I.K.)
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91
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Ambulatory Management of a Recurrent Pneumothorax With an Indwelling Tunneled Pleural Catheter. J Bronchology Interv Pulmonol 2022; 29:e15-e18. [DOI: 10.1097/lbr.0000000000000782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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92
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Kosti CN, Vaitsi PC, Pappas AG, Iliopoulou MP, Psarra KK, Magkouta SF, Kalomenidis IT. CSF1/CSF1R signaling mediates malignant pleural effusion formation. JCI Insight 2022; 7:155300. [PMID: 35315360 PMCID: PMC8986064 DOI: 10.1172/jci.insight.155300] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 02/09/2022] [Indexed: 01/01/2023] Open
Abstract
Malignant pleural effusion (MPE) is an incurable common manifestation of many malignancies. Its formation is orchestrated by complex interactions among tumor cells, inflammatory cells, and the vasculature. Tumor-associated macrophages present the dominant inflammatory population of MPE, and M2 macrophage numbers account for dismal prognosis. M2 polarization is known to be triggered by CSF1/CSF1 receptor (CSF1R) signaling. We hypothesized that CSF1R+ M2 macrophages favor MPE formation and could be therapeutically targeted to limit MPE. We generated mice with CSF1R-deficient macrophages and induced lung and colon adenocarcinoma–associated MPE. We also examined the therapeutic potential of a clinically relevant CSF1R inhibitor (BLZ945) in lung and colon adenocarcinoma–induced experimental MPE. We showed that CSF1R+ macrophages promoted pleural fluid accumulation by enhancing vascular permeability, destabilizing tumor vessels, and favoring immune suppression. We also showed that CSF1R inhibition limited MPE in vivo by reducing vascular permeability and neoangiogenesis and impeding tumor progression. This was because apart from macrophages, CSF1R signals in cancer-associated fibroblasts leading to macrophage inflammatory protein 2 secretion triggered the manifestation of suppressive and angiogenic properties in macrophages upon CXCR2 paracrine activation. Pharmacological targeting of the CSF1/CSF1R axis can therefore be a vital strategy for limiting MPE.
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Affiliation(s)
- Chrysavgi N Kosti
- Marianthi Simou Laboratory, 1st Department of Critical Care and Pulmonary Medicine, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Photene C Vaitsi
- Marianthi Simou Laboratory, 1st Department of Critical Care and Pulmonary Medicine, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Apostolos G Pappas
- Marianthi Simou Laboratory, 1st Department of Critical Care and Pulmonary Medicine, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Marianthi P Iliopoulou
- Marianthi Simou Laboratory, 1st Department of Critical Care and Pulmonary Medicine, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Katherina K Psarra
- Department of Immunology - Histocompatibility, Evangelismos Hospital, Athens, Greece
| | - Sophia F Magkouta
- Marianthi Simou Laboratory, 1st Department of Critical Care and Pulmonary Medicine, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioannis T Kalomenidis
- Marianthi Simou Laboratory, 1st Department of Critical Care and Pulmonary Medicine, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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93
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Chian CF, Wu FP, Tsai CL, Peng CK, Shen CH, Perng WC, Hsu SC. Echogenic swirling pattern, carcinoembryonic antigen, and lactate dehydrogenase in the diagnosis of malignant pleural effusion. Sci Rep 2022; 12:4077. [PMID: 35260758 PMCID: PMC8904853 DOI: 10.1038/s41598-022-08188-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 03/01/2022] [Indexed: 12/16/2022] Open
Abstract
The echogenic swirling pattern has a role in predicting malignant pleural effusion (MPE). However, its predictive ability is suboptimal, and its clinical utility remains to be defined. The aim of this study was to assess the diagnostic potential of the echogenic swirling pattern combined with pleural carcinoembryonic antigen (CEA) and routine laboratory tests of pleural effusion in MPE. The 80 consecutive patients with underlying malignancy and pleural effusions were recruited. All patients underwent one diagnostic thoracentesis with a cytologic examination of pleural fluid. Our study showed that the sensitivity of echogenic swirling patterns in MPE diagnosis was 67.7%, specificity was 72.2%, positive predictive value (PPV) was 89.4%, and negative predictive value (NPV) was 39.4%. Both CEA and lactate dehydrogenase (LDH) had acceptable sensitivity (71.0% and 60.7%) and specificity (72.2% and 77.8%). Combining the echogenic swirling pattern, pleural CEA, and pleural LDH, the highest sensitivity (95.2%) with a good PPV (86.8) was reached. In this clinical study, we found that combining the echogenic swirling pattern, pleural CEA, and pleural LDH had a higher sensitivity and a high positive predictive value for the diagnosis of MPE. This combination is a potentially suitable method for MPE screening in cancer patients with pleural effusions.
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Affiliation(s)
- Chih-Feng Chian
- Division of Pulmonary and Critical Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Fu-Ping Wu
- Hsiao Chung-Cheng Hospital, New Taipei City, Taiwan, ROC
| | - Chen-Liang Tsai
- Division of Pulmonary and Critical Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Chung-Kan Peng
- Division of Pulmonary and Critical Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC.,Hyperbaric Oxygen Therapy Center, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Chih-Hao Shen
- Division of Pulmonary and Critical Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC.,Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Wann-Cherng Perng
- Division of Pulmonary and Critical Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Shih-Chang Hsu
- Emergency Department, Department of Emergency and Critical Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan, ROC. .,Department of Emergency, School of Medicine, College of Medicine, Taipei Medical University, No.250, Wuxing St., 11031, Taipei, Taiwan.
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94
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Yousaf Z, Ata F, Chaudhary H, Krause F, Illigens BMW, Siepmann T. Etiology, pathological characteristics, and clinical management of black pleural effusion: A systematic review. Medicine (Baltimore) 2022; 101:e28130. [PMID: 35212269 PMCID: PMC8878788 DOI: 10.1097/md.0000000000028130] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 11/10/2021] [Accepted: 11/12/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Pleural effusion is characterized by excessive fluid collection in the pleural cavity. Black pleural effusion (BPE) is a rare entity with only limited scientific data. We aimed to review the current literature on black pleural effusion to characterize demographics, etiology, clinical presentation, pathological findings, available treatment strategies, and prognosis of this rare condition. METHODS We performed a systematic review of case reports and series and synthesized data on demographics, manifestations, management, and outcomes of patients with BPE. We searched Cochrane Library, PubMed, SCOPUS, and Google Scholar for any date until January 10, 2021. All studies (n = 31) that reported black pleural effusion in patients were added to the review. Prospective Register of Systematic Reviews registration number: CRD42020213839. Summary and descriptive analysis was performed on Jamovi version 1.2. RESULTS The mean age of 32 patients with BPE was 53 years, with male predominance (69%). The commonest risk factor was smoking (n = 9) followed by alcohol intake (n = 8). Dyspnea was the commonest symptom (n = 24, 75%). Pleural fluid was mostly exudative (n = 21). The commonest associated diagnosis was malignancy (n = 14), with 50% secondary to metastatic melanoma. The commonest intervention was therapeutic thoracocentesis (n = 25, 78%), and the effusion recurred in half of the cases where recurrence was reported (n = 13). In our review, we found the mortality rate to be at 20.8% (n = 20.8%). 58.3% of the patients were successfully treated and discharged home (n = 14). CONCLUSION Although rare, BPE appears to be a relevant symptom as it seems to be frequently associated with modifiable risk factors and underlying malignancy. Our systematic review substantiates a vital research gap as observational research is imperative to characterize BPE further and form a basis for designing tailored diagnostic, preventive, and therapeutic strategies for BPE.
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Affiliation(s)
- Zohaib Yousaf
- Internal Medicine, Hamad Medical Corporation, Doha, Qatar
- Division of Health Care Sciences, Center for Clinical Research and Management Education, Dresden International University, Dresden, Germany
| | - Fateen Ata
- Internal Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Haseeb Chaudhary
- Department of Internal Medicine, Reading Hospital, Tower Health, PA
| | - Florian Krause
- Department of Internal Medicine I, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Ben Min-Woo Illigens
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Timo Siepmann
- Division of Health Care Sciences, Center for Clinical Research and Management Education, Dresden International University, Dresden, Germany
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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95
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Zhang J, Zha T, Zhang N, Sun G. Diagnostic value of periostin in lung cancer-related malignant pleural effusion. J Clin Lab Anal 2022; 36:e24179. [PMID: 35152510 PMCID: PMC8842311 DOI: 10.1002/jcla.24179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 11/22/2021] [Accepted: 12/04/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Periostin (POSTN) is an extracellular matrix protein that is overexpressed in lung cancer and is considered an effective diagnostic and prognostic biomarker for lung cancer. The purpose of this study was to investigate the diagnostic performance of POSTN and to further evaluate the diagnostic value of POSTN combined with carcinoembryonic antigen (CEA) and cancer ratio [CR: serum lactate dehydrogenase (LDH)/pleural effusion adenosine deaminase (PE ADA)] in lung cancer-related malignant PE (MPE). METHODS A total of 108 patients with PE, including 54 with lung cancer and 54 with benign lung disease, were enrolled in this study. The POSTN levels of PE and serum were detected using an enzyme-linked immunosorbent assay. Information on the expression of PE and serum CEA, serum LDH, and PE ADA was collected from medical records. RESULTS The levels of PE POSTN in MPE of patients with lung cancer were significantly higher than those in patients with benign PE (p < 0.0001). The receiver operating characteristic (ROC) curve indicated that the diagnostic sensitivity and specificity of PE POSTN for lung cancer-related MPE were respectively 77.78% and 68.52% when the cutoff value was determined to be 53.45 ng/ml. The ROC curve analysis demonstrated that PE POSTN has a high diagnostic value in MPE associated with lung cancer [area under the curve (AUC) = 0.764], and the combination of PE POSTN, PE CEA, and CR can improve the diagnostic accuracy of lung cancer-related MPE (AUC = 0.948). CONCLUSION POSTN can be used as a potential marker for lung cancer-related MPE diagnosis.
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Affiliation(s)
- Jinjin Zhang
- Department of Respiratory and Critical Care MedicineThe First Affiliated Hospital of Anhui Medical UniversityAnhuiChina
| | - Tongtong Zha
- Department of Respiratory and Critical Care MedicineThe First Affiliated Hospital of Anhui Medical UniversityAnhuiChina
| | - Na Zhang
- Department of Respiratory and Critical Care MedicineThe First Affiliated Hospital of Anhui Medical UniversityAnhuiChina
| | - Gengyun Sun
- Department of Respiratory and Critical Care MedicineThe First Affiliated Hospital of Anhui Medical UniversityAnhuiChina
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96
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Alwakeel AJ, Shieh B, Beaudoin S. Management of Malignant Pleural Effusions-The Effusion Strikes Back: A Teachable Moment. JAMA Intern Med 2022; 182:218-219. [PMID: 34928296 DOI: 10.1001/jamainternmed.2021.6775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Amr J Alwakeel
- Pulmonary Medicine Division, Department of Medicine, King Faisal Specialist Hospital and Research Center (Gen Org), Jeddah, Saudi Arabia.,Respiratory Division, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Benjamin Shieh
- Respiratory Division, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Stéphane Beaudoin
- Respiratory Division, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
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97
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Qiao X, Zhang ZR, Shi XY, Yi FS. Total Protein-Chloride Ratio in Pleural Fluid Independently Predicts Overall Survival in Malignant Pleural Effusion at the First Diagnosis. Front Oncol 2022; 11:777930. [PMID: 35083140 PMCID: PMC8786110 DOI: 10.3389/fonc.2021.777930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 12/10/2021] [Indexed: 11/21/2022] Open
Abstract
Objective Pre-treatment biomarkers to estimate overall survival (OS) for malignant pleural effusion (MPE) are unidentified, especially those in pleural fluid. We evaluated the relationship between OS and total protein–chloride ratio in malignant pleural effusion (PE TPClR). Materials and Methods A retrospective study was undertaken to identify patients from 2006 to 2018 who had pathologically or cytologically confirmed MPE and received no tumor-targeted therapy. We recorded the pre-treatment clinicopathologic characteristics and follow-up status. OS was estimated by the Kaplan–Meier method, and the association between variables and OS was evaluated by Cox proportional hazards models. Results We screened 214 patients who met the eligibility criteria. The optimal cutoff value for the PE TPClR was set at 0.53. The univariate analysis showed that there was a significant correlation between PE TPClR and OS (P < 0.001). The multivariate analysis between OS and the variables selected from the univariate analysis showed that the levels of neutrophil, alkaline phosphatase, neuron-specific enolase, platelets, albumin in peripheral blood, and white blood cells in pleural effusion were also independent predictors of OS. Conclusion In patients with MPE, pre-treatment PE TPClR independently predicts OS. Although further research is necessary to generalize our results, this information will help clinicians and patients to determine the most appropriate treatment for MPE patients.
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Affiliation(s)
- Xin Qiao
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Clinical Center for Pleural Diseases, Capital Medical University, Beijing, China
| | - Zhi-Rong Zhang
- Department of Thoracic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Xin-Yu Shi
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Clinical Center for Pleural Diseases, Capital Medical University, Beijing, China
| | - Feng-Shuang Yi
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Clinical Center for Pleural Diseases, Capital Medical University, Beijing, China
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98
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Mohs Z, DeVillers M, Ziegler S, Basson MD, Newman W. Management of Malignant Pleural Effusions in U.S. Veterans: A Retrospective Review. Ann Thorac Cardiovasc Surg 2022; 28:420-428. [PMID: 36328570 PMCID: PMC9763720 DOI: 10.5761/atcs.oa.22-00124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE To compare malignant pleural effusion (MPE) treatment outcomes and complications among patients receiving indwelling pleural catheter (IPC), talc pleurodesis (TPS), or dual therapy. Outcomes were determined by measuring length of stay (LOS) and post-procedure dyspnea scores. Complications were measured by comparing intervention failures and adverse events. METHODS The Veterans Affairs' Corporate Data Warehouse was utilized to retrospectively review the charts of 314 MPE subjects. Dyspnea scores were estimated by researchers and LOS was determined by adding the duration of stay for all admissions post procedure. Complications were recorded through chart review. RESULTS IPC exhibited higher failure rates than the other approaches 1 year post intervention. Pneumonia/chest infection rate and lung entrapment were also more prevalent. There was no significant difference in dyspnea rates. LOS illustrated a significant difference between groups, with talc patients spending a median of 7 days in the hospital immediately post procedure, while IPC and IPC + TPS patients spent a median of 3 and 2 days, respectively. CONCLUSION Patients receiving IPC or combination treatment spend fewer days in the hospital than TPS patients. However, IPC appears to be associated with more adverse events and higher long-term failure rates than other management strategies.
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Affiliation(s)
- Zachary Mohs
- Department of Internal Medicine, UND School of Medicine and Health Sciences, Grand Forks, ND, USA
| | - Megan DeVillers
- Department of Internal Medicine, UND School of Medicine and Health Sciences, Grand Forks, ND, USA
| | - Stephanie Ziegler
- Department of Internal Medicine, UND School of Medicine and Health Sciences, Grand Forks, ND, USA
| | - Marc D. Basson
- Department of Surgery, UND School of Medicine and Health Sciences, Grand Forks, ND, USA,Corresponding author: Marc D. Basson. Department of Surgery, UND School of Medicine and Health Sciences, 1301 N Columbia Rd, Grand Forks, ND 58203, USA
| | - William Newman
- Department of Internal Medicine, UND School of Medicine and Health Sciences, Grand Forks, ND, USA,Department of Internal Medicine, Fargo Veterans Affairs Medical Center, Fargo, ND, USA
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99
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Dipper A, Welch H, Maskell N. Multimodal Approaches Toward Management of Malignant Pleural Effusion: Establishing Treatment Goals is Paramount. Arch Bronconeumol 2022; 58:640-641. [DOI: 10.1016/j.arbres.2021.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 12/16/2021] [Indexed: 11/24/2022]
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100
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D'Ambrosio PD, de Araújo PHXN, Junior ER, Filho MR, Pêgo-Fernandes PM, Terra RM. Risk factors related to pleural empyema after talc slurry pleurodesis. Clinics (Sao Paulo) 2022; 77:100098. [PMID: 36041370 PMCID: PMC9440271 DOI: 10.1016/j.clinsp.2022.100098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 06/29/2022] [Accepted: 08/03/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Empyema is a complication of talc-pleurodesis that may lead to further surgical intervention and death. Therefore, the present study's objective was to identify the risk factors for the development of post-pleurodesis empyema after talc slurry pleurodesis in order to better select patients for this procedure and minimize its morbidity. METHODS Patients with malignant pleural effusion who underwent talc slurry pleurodesis at the present institution from January 2018 to January 2020 were retrospectively analyzed. Post-pleurodesis empyema was defined as pleural infection up to 30 days after pleurodesis. Using Cox regression analysis, significant prognostic factors for the development of empyema were examined. RESULTS Of the 86 patients identified for inclusion in the study, 62 were women (72%). Their mean age was 56.3±12.6 years. The median pleural drainage time was 9 days, and 20 patients (23.3%) developed empyema. In the univariate analysis, both drainage time (p = 0.038) and the use of antibiotics prior to pleurodesis (p < 0.001) were risk factors for pleural empyema. Multivariate analysis also identified the use of antibiotics as an independent risk factor (Odds Ratio [OR] 9.81; 95% Confidence Interval [95% CI] 2.87‒33.54). Although the pulmonary expansion was not associated with empyema in the multivariate analysis, patients with less than 50% pulmonary expansion had a 4.5-times increased risk of empyema (95% CI 0.90‒22.86; p = 0.067), and patients with 50‒70% pulmonary expansion had a 3.8-times increased risk of empyema (95% CI 0.98‒15; p = 0.053) after pleurodesis. CONCLUSION The study suggests that antibiotic therapy prior to talc slurry pleurodesis may increase the risk of developing empyema. Furthermore, pleurodesis should be considered with caution in patients with long-duration chest tube placement and incomplete lung expansion.
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Affiliation(s)
- Paula Duarte D'Ambrosio
- Instituto do Câncer do Estado de São Paulo (ICESP), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
| | - Pedro Henrique Xavier Nabuco de Araújo
- Instituto do Câncer do Estado de São Paulo (ICESP), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Eserval Rocha Junior
- Instituto do Câncer do Estado de São Paulo (ICESP), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Mauro Razuk Filho
- Instituto do Câncer do Estado de São Paulo (ICESP), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Paulo Manuel Pêgo-Fernandes
- Instituto do Coração, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Ricardo Mingarini Terra
- Instituto do Câncer do Estado de São Paulo (ICESP), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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