Effect of an indwelling pleural catheter vs chest tube and talc pleurodesis for relieving dyspnea in patients with malignant pleural effusion: the TIME2 randomized controlled trial

Setting up a Pleural Disease Service

Pleural disease incidence is continuing to rise internationally and management is becoming increasingly complex. There are now many more options for patients, with access to thoracic ultrasound, image-guided biopsies, indwelling pleural catheters, and local-anesthetic pleuroscopy (thoracoscopy). Safety reports have also highlighted the need for specialist operator knowledge and skill. Consequently, the development of a specialized pleural service can manage patients entirely as an outpatient, limit the number of procedures, and improve patient safety, it also fosters opportunities to enhance specialist procedural skills, engage in clinical research, and reduce the costs of care.

Indwelling Pleural Catheters

Recurrent, symptomatic pleural effusions are common and can contribute to significant morbidity in affected patients. Various management options are available and indwelling pleural catheter placement is becoming more commonplace and is the preferred option in certain clinical scenarios. The body of literature pertaining to indwelling pleural catheter use has grown substantially over the last decade and the purpose of this review is to summarize the best available evidence.

Ambulatory Thoracoscopic Pleurodesis Combined With Indwelling Pleural Catheter in Malignant Pleural Effusion

Background and Objective: Malignant pleural effusion (MPE) often results in debilitating symptoms. Relief of dyspnoea and improvement in quality of life can be achieved with either talc pleurodesis or insertion of an indwelling tunneled pleural catheter (IPC). The former requires a lengthy hospital stay and the latter is associated with lower pleurodesis rates. In response to limited hospital bed capacity, we developed a pragmatic approach in managing MPE by combining thoracoscopic talc poudrage and insertion of IPC into a single day case procedure. We present data on the safety and efficacy of this approach.

Methods: Patients who had undergone the abovementioned procedure between 2017 and 2020 were analyzed. Demographic data, hospital length of stay (LOS), histological diagnosis, rates of pleurodesis success and procedural related complications were collated. Patients were followed-up for 6 months.

Results: Forty-five patients underwent the procedure. Mean age was 68.5 ± 10.4 years and 56% were male. Histological diagnosis was achieved in all cases. 86.7% of patients were discharged on the day of the procedure. Median LOS was 0 (IQR 0–0) days. Successful pleurodesis was attained in 77.8% at 6-month follow-up. No procedure related deaths or IPC related infections were recorded.

Conclusion: Ambulatory thoracoscopic poudrage and IPC insertion is a safe and effective option in the management of MPE. All patients received a definitive pleural intervention with 77.8% pleurodesis success at 6-months and majority of them discharged on the same day. Future randomized trials are required to confirm these findings.

Is Systemic Anticancer Therapy Associated With Higher Rates of Malignant Pleural Effusion Control in People With Pharmacologically Sensitive Tumors?: A Retrospective Analysis of Prospectively Collected Data

BACKGROUND

Malignant pleural effusions (MPEs) often cause symptoms, and guidelines recommend early definitive intervention. However, observational data suggest that systemic anticancer treatment (SACT) may control MPE caused by certain pharmacologically sensitive tumors.

RESEARCH QUESTION

Is SACT associated with higher rates of MPE resolution in people with pharmacologically sensitive tumors?

STUDY DESIGN AND METHODS

This was a retrospective analysis of prospectively collected data from an observational cohort study of people diagnosed with MPE from lung, breast, ovarian, and hematologic malignancy between May 11, 2008, and August 6, 2017. MPE resolution (defined as radiologic resolution with removal of drain or catheter and cessation of interventions) was compared in pharmacologically sensitive (high-grade lymphoma, small cell or target-mutation-positive lung cancer, and hormone-receptor-positive breast or ovarian cancer) and nonsensitive (remainder of cohort) tumors, with and without SACT. Secondary outcomes included time to resolution, 3-month resolution rates, and total pleural interventions.

RESULTS

Of 280 patients, 127 had sensitive and 153 had nonsensitive tumors. One hundred seventy-one received SACT, and 109 did not. More patients with sensitive tumors achieved MPE resolution than those with nonsensitive tumors (53/127 [41.7%] vs 42/153 [27.5%]; P = .01), and this occurred predominantly after receipt of SACT. However, hematologic malignancies were overrepresented in the sensitive group, with high rates of SACT use and MPE resolution. After adjustment for this and other confounders, no relationship was found among pharmacologic sensitivity, SACT, and MPE resolution (adjusted OR, 1.4; 95% CI, 0.5-4.1). The strongest predictor of MPE resolution was administration of chemical pleurodesis (adjusted OR, 6.2; 95% CI, 3.3-11.7). In sensitive tumors, MPE resolution occurred without chemical pleurodesis in 14 of 52 patients (26.9%; 95% CI, 15.6%-41.1%) after SACT and in 5 of 22 patients (22.7%; 95% CI, 8.2%-47.2%) without SACT.

INTERPRETATION

In this observational study, SACT was not associated independently on MPE resolution in pharmacologically sensitive tumors. Randomized trials are required, but with current data, patients with symptomatic MPE should receive early definitive pleural intervention regardless of underlying tumor or intended treatment.

Modern day management of a unilateral pleural effusion

Over 50 systemic conditions may affect the pleura and, thus, unilateral pleural effusions may present for a variety of reasons. Investigating the cause is essential to providing appropriate management. Various pleural interventions are available in current practice, but have varying diagnostic sensitivity. It is, therefore, vital to consider the intervention with the highest diagnostic yield appropriate to the particular clinical situation. The diagnostic pathway in unilateral pleural effusion is increasingly outpatient based, avoiding hospitalisation, which is particularly relevant with the recent COVID-19 pandemic.

Role of thoracic ultrasonography in pleurodesis pathways for malignant pleural effusions (SIMPLE): an open-label, randomised controlled trial

BACKGROUND

Pleurodesis is done as an in-patient procedure to control symptomatic recurrent malignant pleural effusion (MPE) and has a success rate of 75-80%. Thoracic ultrasonography has been shown in a small study to predict pleurodesis success early by demonstrating cessation of lung sliding (a normal sign seen in healthy patients, lung sliding indicates normal movement of the lung inside the thorax). We aimed to investigate whether the use of thoracic ultrasonography in pleurodesis pathways could shorten hospital stay in patients with MPE undergoing pleurodesis.

METHODS

The Efficacy of Sonographic and Biological Pleurodesis Indicators of Malignant Pleural Effusion (SIMPLE) trial was an open-label, randomised controlled trial done in ten respiratory centres in the UK and one respiratory centre in the Netherlands. Adult patients (aged ≥18 years) with confirmed MPE who required talc pleurodesis via either a chest tube or as poudrage during medical thorascopy were eligible. Patients were randomly assigned (1:1) to thoracic ultrasonography-guided care or standard care via an online platform using a minimisation algorithm. In the intervention group, daily thoracic ultrasonography examination for lung sliding in nine regions was done to derive an adherence score: present (1 point), questionable (2 points), or absent (3 points), with a lowest possible score of 9 (preserved sliding) and a highest possible score of 27 (complete absence of sliding); the chest tube was removed if the score was more than 20. In the standard care group, tube removal was based on daily output volume (per British Thoracic Society Guidelines). The primary outcome was length of hospital stay, and secondary outcomes were pleurodesis failure at 3 months, time to tube removal, all-cause mortality, symptoms and quality-of-life scores, and cost-effectiveness of thoracic ultrasonography-guided care. All outcomes were assessed in the modified intention-to-treat population (patients with missing data excluded), and a non-inferiority analysis of pleurodesis failure was done in the per-protocol population. This trial was registered with ISRCTN, ISRCTN16441661.

FINDINGS

Between Dec 31, 2015, and Dec 17, 2019, 778 patients were assessed for eligibility and 313 participants (165 [53%] male) were recruited and randomly assigned to thoracic ultrasonography-guided care (n=159) or standard care (n=154). In the modified intention-to-treat population, the median length of hospital stay was significantly shorter in the intervention group (2 days [IQR 2-4]) than in the standard care group (3 days [2-5]; difference 1 day [95% CI 1-1]; p<0·0001). In the per-protocol analysis, thoracic ultrasonography-guided care was non-inferior to standard care in terms of pleurodesis failure at 3 months, which occurred in 27 (29·7%) of 91 patients in the intervention group versus 34 (31·2%) of 109 patients in the standard care group (risk difference -1·5% [95% CI -10·2% to 7·2%]; non-inferiority margin 15%). Mean time to chest tube removal in the intervention group was 2·4 days (SD 2·5) versus 3·1 days (2·0) in the standard care group (mean difference -0·72 days [95% CI -1·22 to -0·21]; p=0·0057). There were no significant between-group differences in all-cause mortality, symptom scores, or quality-of-life scores, except on the EQ-5D visual analogue scale, which was significantly lower in the standard care group at 3 months. Although costs were similar between the groups, thoracic ultrasonography-guided care was cost-effective compared with standard care.

INTERPRETATION

Thoracic ultrasonography-guided care for pleurodesis in patients with MPE results in shorter hospital stay (compared with the British Thoracic Society recommendation for pleurodesis) without reducing the success rate of the procedure at 3 months. The data support consideration of standard use of thoracic ultrasonography in patients undergoing MPE-related pleurodesis.

FUNDING

Marie Curie Cancer Care Committee.

Overview of Interventional Pulmonology for Radiologists

Interventional pulmonology is a growing field specializing in minimally invasive procedures of the mediastinum, lungs, airways, and pleura. These procedures have both diagnostic and therapeutic indications and are performed for benign and malignant diseases. Endobronchial US has been combined with transbronchial needle aspiration to extend tissue sampling beyond the airways and into the lungs and mediastinum. Recent innovations extending the peripheral access of bronchoscopy include electromagnetic navigational bronchoscopy and thinner bronchoscopes. An important indication for therapeutic bronchoscopy is the relief of central airway obstruction, which may be severe and life threatening. Techniques for restoring patency of the central airways include mechanical debulking and multiple modalities for ablation, stent placement, and balloon bronchoplasty. Bronchoscopic lung volume reduction improves quality of life in certain patients with severe emphysema and is an important less invasive alternative to lung volume reduction surgery. Bronchial thermoplasty is likewise a nonpharmacologic treatment in patients with severe uncontrolled asthma. Many of these procedures have unique selection criteria that require precise evaluations at preprocedure imaging. Postprocedure imaging is also essential in determining outcome success and the presence of complications. Radiologists should be familiar with these procedures as well as the relevant imaging features in both planning and later surveillance. Evolving techniques that may become more widely available in the near future include robotic-assisted bronchoscopy, bronchoscopic transparenchymal nodule access, transbronchial cryobiopsy, ablation of early-stage cancers, and endobronchial intratumoral chemotherapy. An invited commentary by Wayne et al is available online. ^©RSNA, 2021.

Epidemiology and Clinical Aspects of Malignant Pleural Mesothelioma

Mesothelioma is a cancer predominantly of the pleural cavity. There is a clear association of exposure to asbestos with a dose dependent risk of mesothelioma. The incidence of mesothelioma in different countries reflect the historical patterns of commercial asbestos utilisation in the last century and predominant occupational exposures mean that mesothelioma is mostly seen in males. Modern imaging techniques and advances in immunohistochemical staining have contributed to an improved diagnosis of mesothelioma. There have also been recent advances in immune checkpoint inhibition, however, mesothelioma remains very challenging to manage, especially considering its limited response to conventional systemic anticancer therapy and that no cure exists. Palliative interventions and support remain paramount with a median survival of 9-12 months after diagnosis. The epidemiology and diagnosis of mesothelioma has been debated over previous decades, due to a number of factors, such as the long latent period following asbestos exposure and disease occurrence, the different potencies of the various forms of asbestos used commercially, the occurrence of mesothelioma in the peritoneal cavity and its heterogeneous pathological and cytological appearances. This review will describe the contemporary knowledge on the epidemiology of mesothelioma and provide an overview of the best clinical practice including diagnostic approaches and management.

Association between Tunneled Pleural Catheter Use and Infection in Patients Immunosuppressed from Antineoplastic Therapy. A Multicenter Study

Rationale: Patients with malignant or paramalignant pleural effusions (MPEs or PMPEs) may have tunneled pleural catheter (TPC) management withheld because of infection concerns from immunosuppression associated with antineoplastic therapy.Objectives: To determine the rate of infections related to TPC use and to determine the relationship to antineoplastic therapy, immune system competency, and overall survival (OS).Methods: We performed an international, multiinstitutional study of patients with MPEs or PMPEs undergoing TPC management from 2008 to 2016. Patients were stratified by whether or not they underwent antineoplastic therapy and/or whether or not they were immunocompromised. Cumulative incidence functions and multivariable competing risk regression analyses were performed to identify independent predictors of TPC-related infection. Kaplan-Meier method and multivariable Cox proportional hazards modeling were performed to examine for independent effects on OS.Results: A total of 1,408 TPCs were placed in 1,318 patients. Patients had a high frequency of overlap between antineoplastic therapy and an immunocompromised state (75-83%). No difference in the overall (6-7%), deep pleural (3-5%), or superficial (3-4%) TPC-related infection rates between subsets of patients stratified by antineoplastic therapy or immune status was observed. The median time to infection was 41 (interquartile range, 19-87) days after TPC insertion. Multivariable competing risk analyses demonstrated that longer TPC duration was associated with a higher risk of TPC-related infection (subdistribution hazard ratio, 1.03; 95% confidence interval [CI], 1.00-1.06; P = 0.028). Cox proportional hazards analysis showed antineoplastic therapy was associated with better OS (hazard ratio, 0.84; 95% CI, 0.73-0.97; P = 0.015).Conclusions: The risk of TPC-related infection does not appear to be increased by antineoplastic therapy use or an immunocompromised state. The overall rates of infection are low and comparable with those of immunocompetent patients with no relevant antineoplastic therapy. These results support TPC palliation for MPE or PMPEs regardless of plans for antineoplastic therapy.

The Impact of Thoracentesis On Postprocedure Pulse Oximetry

BACKGROUND

Although thoracentesis can offer considerable symptomatic relief to the patient, its physiologic impact on oxygen saturation has not been well established in the literature. This study aimed to evaluate the impact of thoracentesis on postprocedure pulse oximetry (SpO2) in an inpatient population.

METHODS

A retrospective study of patients undergoing thoracentesis from January 2012 to November 2017 was performed. Inclusion criteria were age above 18 and thoracentesis performed in an inpatient setting. Records were reviewed for patient demographics, procedure reports, and laboratory values. SpO2 and FiO2 values were collected before and 6 and 24 hours postprocedure. Multivariable linear regression models were used to evaluate for changes in SpO2 and SpO2/FiO2. Analyses were adjusted for age, sex, serum hemoglobin, effusion etiology, volume removed, nonexpandable lung physiology and procedural complications and FiO2.

RESULTS

A total of 502 patients were included. The mean (SD) age was 60 (14) years, and 53.4% of the patients were male. The most common cause of pleural effusion was malignant effusion (37%). The median (interquartile range) volume of fluid removed was 1400 (1000 to 2000) mL and nonexpandable lung physiology was noted in 35%. There was no significant within-subject difference in 24 hours postprocedure SpO2 compared with preprocedure SpO2. In multivariable analysis, there was a small increase in 24-hour postprocedure SpO2 [β=0.31, 95% confidence interval (0.22, 0.41), P<0.01] and a similar small increase in 24-hour postprocedure SpO2/FiO2 [β=0.84, 95% confidence interval: (0.68, 1.01), P<0.01).

CONCLUSION

Among inpatients undergoing thoracentesis, there is no clinically significant change in SpO2 or SpO2/FiO2 at 24-hours post-procedure compared to pre-procedural SpO2 or SpO2/FiO2.

Predicting Survival for Patients with Malignant Pleural Effusion: Development of the CONCH Prognostic Model

BACKGROUND

Malignant pleural effusion (MPE) is a frequent complication of advanced malignancies that leads to a poor quality of life and limits treatment options.

OBJECTIVE

The objective of this study was to identify biomarkers of survival in patients with MPE, which will greatly facilitate the clinical management of this complication.

METHODS

This retrospective study recruited patients who had been pathologically diagnosed with MPE, regardless of the type of primary cancer, at Beijing Chao-Yang Hospital over 158 months. Demographic, clinical, hematological, and pleural fluid data were collected and analyzed as potential predictors of survival, and a new predictive model was developed based on Cox and logistic regression analyses.

RESULTS

In our alternative prognostic model (n = 281), four routinely detected variables, namely, carcinoembryonic antigen (CEA) level, monocyte count, N-terminal pro B-type natriuretic peptide (NT-pro-BNP) level, and pleural effusion chloride level on admission, were identified as predictors (the CONCH prognostic score). Patients were divided into three prognosis subgroups based on risk stratification, with median survival periods of 17, 11, and 5 months, respectively. In comparison with the low-risk group, patients in the medium- and high-risk groups showed significantly poorer survival (medium-risk group: hazard ratio [HR], 1.586; 95% confidence interval [CI], 1.047-2.402; P = 0.029; high-risk group: HR, 4.389; 95% CI, 2.432-7.921; P < 0.001).

CONCLUSION

Four routinely detected variables were used to develop the CONCH scoring system, which was confirmed to be an accurate prognostic score for patients with MPE. This system can guide the selection of interventions and management for MPE.

Breast and Lung Effusion Survival Score Models: Improving Survival Prediction in Patients With Malignant Pleural Effusion and Metastasis

BACKGROUND

Evidence-based guidelines recommend management strategies for malignant pleural effusions (MPEs) based on life expectancy. Existent risk-prediction rules do not provide precise individualized survival estimates.

RESEARCH QUESTION

Can a newly developed continuous risk-prediction survival model for patients with MPE and known metastatic disease provide precise survival estimates?

STUDY DESIGN AND METHODS

Single-center retrospective cohort study of patients with proven malignancy, pleural effusion, and known metastatic disease undergoing thoracentesis from 2014 through 2017. The outcome was time from thoracentesis to death. Risk factors were identified using Cox proportional hazards models. Effect-measure modification (EMM) was tested using the Mantel-Cox test and was addressed by using disease-specific models (DSMs) or interaction terms. Three DSMs and a combined model using interactions were generated. Discrimination was evaluated using Harrell's C-statistic. Calibration was assessed by observed-minus-predicted probability graphs at specific time points. Models were validated using patients treated from 2010 through 2013. Using LENT (pleural fluid lactate dehydrogenase, Eastern Cooperative Oncology Group performance score, neutrophil-to-lymphocyte ratio and tumor type) variables, we generated both discrete (LENT-D) and continuous (LENT-C) models, assessing discrete vs continuous predictors' performances.

RESULTS

The development and validation cohort included 562 and 727 patients, respectively. The Mantel-Cox test demonstrated interactions between cancer type and neutrophil to lymphocyte ratio (P < .0001), pleural fluid lactate dehydrogenase (P = .029), and bilateral effusion (P = .002). DSMs for lung, breast, and hematologic malignancies showed C-statistics of 0.72, 0.72, and 0.62, respectively; the combined model's C-statistics was 0.67. LENT-D (C-statistic, 0.60) and LENT-C (C-statistic, 0.65) models underperformed.

INTERPRETATION

EMM is present between cancer type and other predictors; thus, DSMs outperformed the models that failed to account for this. Discrete risk-prediction models lacked enough precision to be useful for individual-level predictions.

Complications of thoracoscopic talc insufflation for the treatment of malignant pleural effusions: a meta-analysis

Background

Talc pleurodesis is an effective treatment for malignant pleural effusions (MPEs). This study was designed to estimate complication rates of thoracoscopic talc insufflation.

Methods

Literature search was conducted in electronic databases and studies were selected if they reported complication rates of thoracoscopic talc insufflation in cancer patients with MPEs. Meta-analyses of proportions were performed to obtain incidence rates of complications.

Results

Twenty-six studies (4482 patients; age 62.9 years [95% confidence interval (CI): 61.5, 64.4]; 50% [95% CI: 43, 58] females) were included. Intraoperative, perioperative, 30-day, and 90-day mortality rates were 0% [95% CI: 0, 1], 2% [95% CI: 0, 4], 7% [95% CI: 3, 13] and 21% [95% CI: 5, 43] respectively. Incidence rates [95% CI] of various complications were: pain (20% [1, 2]), fever (14% [3, 4]), dyspnea (13% [5, 6]), pneumothorax (6% [7, 8]) pneumonia (4% [0, 12]), emphysema (3% [3, 7]), prolonged air leakage (3% [0, 7]), prolonged drainage (3% [9, 10]), thromboembolism (3% [9, 11]), lung injury (2% [7, 12]), respiratory insufficiency (2% [0, 5]), re-expansion pulmonary edema (1% [0, 3]), empyema (1% [0, 2]), respiratory failure (0% [0, 1]), and acute respiratory distress syndrome (ARDS; 0% [0, 1].

Conclusions

Whereas pain and fever were the most frequent complications of thoracoscopic talc insufflation, the incidence of ARDS was low. Pneumothorax, pneumonia, emphysema, prolonged air leakage, pulmonary embolism, arrythmia, re-expansion pulmonary edema, and empyema are important complications of thoracoscopic talc insufflation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-021-01475-1.

Primary human mesothelial cell culture in the evaluation of the inflammatory response to different sclerosing agents used for pleurodesis

The mechanisms of chemical pleurodesis are still not fully explained. We aimed to evaluate the feasibility of using primary biopsy‐derived human mesothelial cells to establish an in vitro culture and to assess the response of pleural mesothelial cells to different sclerosing agents. Talc, povidone‐iodine, doxycycline, and TGF‐β were used at different doses to stimulate pleural mesothelial cells. After 6 and 24 h, mRNA expression of interleukin (IL)‐1β, IL‐6, IL‐8, TGF‐β, MCP‐1, IL‐17A, and MMP9 was measured in cultured cells, and the protein level of IL‐1β, IL‐6, and IL‐8 was measured in the culture supernatant. The most pronounced response was observed after talc exposure. It was expressed as an increase in IL‐1β concentration in culture supernatant after 24 h of higher talc dose stimulation compared to 6 h of stimulation (17.14 pg/ml [11.96–33.32 pg/ml] vs. 1.84 pg/ml [1.81–1.90 pg/ml], p = 0.02). We showed that culture pleural mesothelial cells isolated from pleura biopsy specimens is feasible. Inflammatory responses of mesothelial cells to different sclerosants were highly variable with no consistent pattern of mesothelium reaction neither in terms of different sclerosing agents nor in the time of the most significant reaction. We demonstrated that pro‐inflammatory mesothelial response includes an increase in IL‐1β mRNA expression and protein production. This may suggest the role of IL‐1β in the formation and maintenance of the inflammatory response during pleurodesis.

Malignant Pleural Effusions-A Window Into Local Anti-Tumor T Cell Immunity?

The success of immunotherapy that targets inhibitory T cell receptors for the treatment of multiple cancers has seen the anti-tumor immune response re-emerge as a promising biomarker of response to therapy. Longitudinal characterization of T cells in the tumor microenvironment (TME) helps us understand how to promote effective anti-tumor immunity. However, serial analyses at the tumor site are rarely feasible in clinical practice. Malignant pleural effusions (MPE) associated with thoracic cancers are an abnormal accumulation of fluid in the pleural space that is routinely drained for patient symptom control. This fluid contains tumor cells and immune cells, including lymphocytes, macrophages and dendritic cells, providing a window into the local tumor microenvironment. Recurrent MPE is common, and provides an opportunity for longitudinal analysis of the tumor site in a clinical setting. Here, we review the phenotype of MPE-derived T cells, comparing them to tumor and blood T cells. We discuss the benefits and limitations of their use as potential dynamic biomarkers of response to therapy.

Avoid the Trap: Nonexpanding Lung

Nonexpanding lung is a mechanical complication in which part of the lung is unable to expand to the chest wall, preventing apposition of the visceral and parietal pleura. This can result from various visceral pleural disease processes, including malignant pleural effusion and empyema. Nonexpanding lung can be referred to as trapped lung or lung entrapment, both with distinct clinical features and management strategies. Early evaluation of pleural effusions is important to address underlying causes of pleural inflammation and to prevent the progression from lung entrapment to trapped lung. Some patients with trapped lung will not experience symptomatic relief with pleural fluid removal. Therefore, misrecognition of trapped lung can result in patients undergoing unnecessary procedures with significant cost and morbidity. We reviewed the current understanding of nonexpanding lung, which included causes, common presentations, preventative strategies, and recommendations for clinical care.

Tract metastasis in patients with long-term pleural catheter-computed tomography diagnosis and longitudinal assessment

OBJECTIVES

Long-term indwelling pleural catheters (IPC), used for the management of malignant pleural mesothelioma (MPM), may lead to catheter tract metastasis (CTM). While computed tomography (CT) is valuable for diagnosis, no studies have assessed CT manifestations of CTM. Our goal is to describe the incidence, CT appearances, and temporal evolution of CTM in MPM.

METHODS

A retrospective review of CT of 90 consecutive patients with MPM and IPC. In patients with CTM, a longitudinal assessment was performed for CT appearance at diagnosis and over time, interval from insertion to diagnosis and rate of progression.

RESULTS

The incidence of CTM was 26% (23/90), in 22 men (54-83 years, mean 73 years). CTM manifested with focal lesion (3 to 60 mm, mean 25 mm) in the subcutaneous tissue at the insertion site. Abnormalities of sub-adjacent skin and fat stranding were present in 16/24 (66%) and 11/24 (46%), respectively, enlargement of chest wall musculature in 11/24 (46%), and dilated subcutaneous vessels in 4/24 (17%) patients. On follow-up, 53% had enlargement of focal lesion. The average rate of progression was 3.5 mm/month, compared to 0.79 mm/month for pleural thickening (p = 0.03). The time between IPC insertion and CTM diagnosis varied from 58 to 1375 days (median 408 days); 83% occurred after IPC removal. Reporting radiologists described focal abnormality at the insertion site in only 9/23 (39%) patients.

CONCLUSIONS

CTM is commonly overlooked and underreported by radiologists. CT invariably demonstrates focal subcutaneous lesion in the procedure tract, most commonly after IPC removal. Ancillary findings, notably serratus or latissimus dorsi muscle enlargement, are novel finding that can assist in CT detection and diagnosis.

KEY POINTS

• Catheter tract metastasis (CTM), resulting from indwelling pleural catheter to manage malignant pleural mesothelioma, invariably manifested on CT as a focal subcutaneous lesion at the site of insertion, more commonly after catheter removal. • Ipsilateral muscle enlargement is a newly described CT finding that can assist in the detection and diagnosis. • Catheter tract metastasis was commonly overlooked by radiologists, reported in only 39% of cases.

Pleural Drainage Strategy After IPC Placement: A Focused Clinical Review

The first indwelling pleural catheter (IPC) received Federal Drug Administration approval in 1997, nearly 40 years after John Chambers first described instillation of talc into the pleural space for palliation of malignant pleural effusions. Since then IPCs have revolutionized the management of malignant pleural effusions, providing an effective means of controlling dyspnea in the end stages of life without the pain and prolonged hospital stays long associated with chemical sclerosing agents. While palliation of symptoms is the primary purpose of IPCs, development of pleurodesis in the outpatient setting is often an important secondary goal. Historically, decisions regarding IPC drainage frequency have been largely arbitrary and only recently has the evidence started to emerge regarding the effects of specific drainage strategies on both symptom control and pleurodesis development. This focused clinical review explores the current literature regarding IPC drainage strategies as well as novel methods designed to improve the efficacy of IPCs in a thorough and systematic manner. In addition, this review provides an in-depth analysis and synthesis of the data focusing on key considerations needed to develop patient-centered and cost-effective strategies for the use of IPCs in malignancy.

Video-assisted thoracoscopic surgery pleurectomy: a suitable alternative for treating malignant pleural effusions

Background

Malignant pleural effusions (MPEs) are common manifestations of metastatic cancers and are associated with a dismal prognosis. Talc pleurodesis has been proven to be effective in the management of MPEs, however, class-action lawsuits linking talc to ovarian adenocarcinoma have rendered it unavailable at many institutions. As a result, surgeons have resorted to less effective chemical pleurodesis as an alternative to indwelling pleural drainage catheters. Given the absence of talc, we explored the effectiveness of video-assisted thoracoscopic surgery (VATS) partial pleurectomy (VPP) for treating MPEs.

Methods

We performed a retrospective review of patients with MPEs managed after talc became unavailable at our institution. Between 2016 and 2018, we identified five patients who refused pleural drainage catheters and underwent VPP. Symptoms at presentation included fatigue, dyspnea, and pleuritic chest pain. All had unilateral MPEs (left n=3, right n=2). VPP included removal of parietal surfaces of the pleura other than the pleura overlying the subclavian vessels, the mediastinum, and the lung viscera.

Results

There were no significant perioperative adverse events and post-operative pain was well controlled. Chest tubes were removed between post-operative day (POD) 3 and 7. Follow-up time ranged from four to 36 weeks. All patients had symptomatic relief and radiographic evidence of improved MPEs. No patients required re-interventions. One patient expired six months after surgery while the remaining four were alive at last follow-up.

Conclusions

VPP offers an effective alternative to chemical pleurodesis for managing MPEs in patients who prefer to avoid pleural drainage catheters.

Advances in pleural infection and malignancy

Pleural infection and malignancy are among the most common causes of pleural disease and form the mainstay of pleural practice. There has been significant research and increase in scientific understanding in these areas in the past decade. With regard to pleural infection, the rising incidence remains worrying. An increased awareness allowing earlier diagnosis, earlier escalation of therapy and the use of validated risk stratification measures may improve outcomes. In pleural malignancy, research has enabled clinicians to streamline patient pathways with focus on reducing time to diagnosis, definitive management of malignant pleural effusion and achieving these with the minimum number of pleural interventions. Trials comparing treatment modalities of malignant pleural effusion continue to highlight the importance of patient choice in clinical decision-making. This article aims to summarise some of the most recent literature informing current practice in these two areas.

Study protocol of a phase 1 clinical trial establishing the safety of intrapleural administration of liposomal curcumin: curcumin as a palliative treatment for malignant pleural effusion (IPAL-MPE)

INTRODUCTION

This is a phase 1, open-label, single-centre, uncontrolled, dose-escalation study to evaluate the feasibility, tolerability and pharmacokinetic profiles of a single dose of liposomal curcumin, administered via an existing tunnelled indwelling pleural catheter (TIPC) directly to the tumour site in individuals with diagnoses of malignant pleural effusion. Primarily, we aim to determine a maximum tolerated dose of liposomal curcumin administered via this method.

METHODS AND ANALYSIS

We will use a 3+3 expanded cohort for predefined dose-escalation levels or until a predefined number of dose-limiting toxicities are reached. Participants will be administered a single dose of liposomal curcumin (LipoCurc, SignPath Pharma) via their existing TIPC as a sequential enrolling case series with the following dose cohorts: 100, 200 and 300 mg/m². Primary endpoints are determination of the maximum tolerated dose within the predetermined dose range, and determination of the feasibility of intrapleural administration of liposomal curcumin via an existing TIPC. Secondary endpoints include determination of the safety and tolerability of intrapleural administration of liposomal curcumin, median overall survival, effects on quality of life and on feelings of breathlessness, and the pharmacokinetics and concentrations of curcumin from the plasma and the pleural fluid. Important inclusion criteria include age ≥18 years, an existing TIPC, a pleural biopsy or pleural fluid cytology-proven diagnosis of malignant pleural effusion and for whom no antitumour therapy of proven benefit is available or has been previously declined, eastern cooperative group performance status <2.

ETHICS AND DISSEMINATION

The study protocol has been approved by the Southern Adelaide Local Health Network Human Research Ethics Committee (HREC) (approval number: HREC/20/SAC/11). Study results will be published in peer-reviewed journals, and presented at conferences, in field of medical oncology and respiratory medicine.

TRIAL REGISTRATION NUMBER

ACTRN12620001216909.

PROTOCOL VERSION NUMBER

V.1.0.

Indwelling Pleural Catheter Drainage Strategy for Malignant Effusion: A Cost-Effectiveness Analysis

Rationale: The likelihood of achieving pleurodesis after indwelling pleural catheter (IPC) placement for malignant pleural effusion varies with the specific drainage strategy used: symptom-guided drainage, daily drainage, or talc instillation through the IPC (IPC + talc). The relative cost-effectiveness of one strategy over the other is unknown.Objectives: We performed a decision tree model-based analysis to ascertain the cost-effectiveness of each IPC drainage strategy from a healthcare system perspective.Methods: We developed a decision tree model using theoretical event probability data derived from three randomized clinical trials and used 2019 Medicare reimbursement data for cost estimation. The primary outcome was incremental cost-effectiveness ratio (ICER) over an analytical horizon of 6 months with a willingness-to-pay threshold of $100,000/quality-adjusted life-year (QALY). Monte Carlo probabilistic sensitivity analysis and one-way sensitivity analyses were conducted to measure the uncertainty surrounding base case estimates.Results: IPC + talc was a cost-effective alternative to symptom-guided drainage, with an ICER of $59,729/QALY. Monte Carlo probabilistic sensitivity analysis revealed that this strategy was favored in 54% of simulations. However, symptom-guided drainage was cost effective for pleurodesis rates >20% and for life expectancy <4 months. Daily drainage was not cost effective in any scenario, including for patients with nonexpandable lung, in whom it had an ICER of $2,474,612/QALY over symptom-guided drainage.Conclusions: For patients with malignant pleural effusion and an expandable lung, IPC + talc may be cost effective relative to symptom-guided drainage, although considerable uncertainty exists around this estimation. Daily IPC drainage is not a cost-effective strategy under any circumstance.

Breathlessness Predicts Survival in Patients With Malignant Pleural Effusions: Meta-analysis of Individual Patient Data From Five Randomized Controlled Trials

BACKGROUND

Patients with malignant pleural effusions (MPEs) experience breathlessness and poor survival. Breathlessness is associated with poor survival in other conditions.

RESEARCH QUESTION

Is breathlessness, measured using a visual analog scale for dyspnea (VASD), associated with survival in patients with MPE?

STUDY DESIGN AND METHODS

Individual patient data from five randomized controlled trials of 553 patients undergoing interventions for MPE were analyzed. VASD was recorded at baseline and daily after intervention. Patients were followed up until death or end of trial. Univariate and multivariable Cox regression were used to identify factors associated with survival.

RESULTS

Baseline VASD was significantly associated with worse survival, with a hazard ratio of 1.10 (95% CI, 1.06-1.15) for a 10-mm increase in VASD. On multivariable regression, it remained a significant predictor of survival. Mean 7-day VASD and mean total VASD were also predictors of survival (mean 7-day VASD: hazard ratio [HR], 1.26 [95% CI, 1.19-1.34]; total VASD: HR, 1.25 [95% CI, 1.15-1.37]). Other predictors of survival were serum C-reactive protein level and tumor type. Previous treatment with chemotherapy, performance status, pleural fluid lactate dehydrogenase, serum albumin, hemoglobin, serum neutrophil:lymphocyte ratio, and size of effusion were associated with survival on univariate but not multivariable analysis.

INTERPRETATION

Breathlessness, measured using VASD at baseline and postprocedure, is a predictor of survival in patients with MPE.

Update on biology and management of mesothelioma

Malignant pleural mesothelioma is an aggressive, incurable cancer that is usually caused by asbestos exposure several decades before symptoms arise. Despite widespread prohibition of asbestos production and supply, its incidence continues to increase. It is heterogeneous in its presentation and behaviour, and diagnosis can be notoriously difficult. Identification of actionable gene mutations has proven challenging and current treatment options are largely ineffective, with a median survival of 10-12 months.However, the past few years have witnessed major advances in our understanding of the biology and pathogenesis of mesothelioma. This has also revealed the limitations of existing diagnostic algorithms and identified new treatment targets.Recent clinical trials have re-examined the role of surgery, provided new options for the management of associated pleural effusions and heralded the addition of targeted therapies. The increasing complexity of mesothelioma management, along with a desperate need for further research, means that a multidisciplinary team framework is essential for the delivery of contemporary mesothelioma care.This review provides a synthesised overview of the current state of knowledge and an update on the latest research in the field.

Advancement of Biomaterial-Based Postoperative Adhesion Barriers

Postoperative peritoneal adhesion (PPA) is a prevalent incidence that generally happens during the healing process of traumatized tissues. It causes multiple severe complications such as intestinal obstruction, chronic abdominal pain, and female infertility. To prevent PPA, several antiadhesion materials and drug delivery systems composed of biomaterials are used clinically, and clinical antiadhesive is one of the important applications nowadays. In addition to several commercially available materials, like film, spray, injectable hydrogel, powder, or solution type have been energetically studied based on natural and synthetic biomaterials such as alginate, hyaluronan, cellulose, starch, chondroitin sulfate, polyethylene glycol, polylactic acid, etc. Moreover, many kinds of animal adhesion models, such as cecum abrasion models and unitary horn models, are developed to evaluate new materials' efficacy. A new animal adhesion model based on hepatectomy and conventional animal adhesion models is recently developed and a new adhesion barrier by this new model is also developed. In summary, many kinds of materials and animal models are studied; thus, it is quite important to overview this field's current progress. Here, PPA is reviewed in terms of the species of biomaterials and animal models and several problems to be solved to develop better antiadhesion materials in the future are discussed.

Cost Effectiveness of Malignant Pleural Effusion with Indwelling Catheter: Systematic Review

Background: The current cost of treatment of malignant pleural effusion (MPE) with an indwelling pleural catheter (IPC) is unclear. Objective: We propose a review of the scientific evidence on the cost and effectiveness of this therapeutic option. Methods: Systematic review of the literature on the cost and effectiveness of the treatment of MPE by IPC, according to the PRISMA methodology and quality according to the scientific guidelines. Results: A total of 4 articles, 152 patients, and 159 IPCs were included. The use of IPC was associated with improvement in symptoms and quality of life. The most common complications were infections (empyema in 20.9% of patients and cellulitis in 17.3%); 9% of cases were hospitalized due to complications, and <2% required subsequent procedures. The average cost of IPC (set/drainage bottles) ranged from €2,025.6 to €1,200.5 if it was placed on an outpatient basis, €1,100 if survival was <6 weeks, and €4,028 in patients with mesothelioma. Complications increased the cost, and taking into account follow-up visits, additional tests, and days of admission for complications, the cost was >€5,000. Compared with pleurodesis, the cost of IPC was significantly lower when patient survival was <14 weeks, but not when survival was longer or home care was required. Conclusions: The use of IPC is associated with good control of MPE and seldom requires many subsequent procedures; however, it is also associated with a certain rate of complications, which may increase costs. However, ambulatory management may help reduce costs, which are directly related to the type of tumor, the duration of survival, and the need for specialized treatment.

Minimal clinically important difference for chest discomfort in patients undergoing pleural interventions

RATIONALE

Therapeutic thoracentesis is among the most frequently performed medical procedures. Chest discomfort is a common complication and has been associated with increasingly negative pleural pressure as fluid is withdrawn in the setting of non-expendable lung. Visual analogue scales (VASs) are commonly employed to measure changes in discomfort and dyspnoea related to pleural interventions. The minimal clinically important difference (MCID), defined as the smallest change in VAS score associated with patient report of significant change in a symptom, is required to interpret the results of studies using VAS scores and is used in clinical trial power calculations. The MCID for chest discomfort in patients undergoing pleural interventions has not been determined.

METHODS

Prospectively collected data from two recent randomised trials of therapeutic thoracentesis were used for this investigation. Adult patients with symptomatic pleural effusions referred for therapeutic thoracentesis were enrolled across ten US academic medical centres. Patients were asked to rate their level of chest discomfort on 100 mm VAS before, during and following thoracentesis. Patients then completed a 7-point Likert scale indicating the significance of any change in chest discomfort from preprocedure to postprocedure. The mean difference between discomfort 5 min postprocedure and discomfort just prior to the start of pleural fluid drainage was categorised by Likert scale response.

RESULTS

Data from a total of 262 thoracenteses were included in the analysis. Thirty-four of 262 patients experienced a 'small but significant increase' or a 'large or moderate increase' in discomfort following thoracentesis. The mean increase in VAS score in those reporting a 'small but significant increase' in chest discomfort (n=23) was 16 mm (SD 22.44, 95% CI 6.87 to 25.21).

CONCLUSIONS

The MCID for thoracentesis-related chest discomfort measured by 100 mm VAS is 16 mm. This MCID specific to discomfort resulting from pleural fluid interventions can inform the design and analysis of future pleural intervention studies.

Talc pleurodesis in malignant pleural effusion: a systematic review and meta-analysis

OBJECTIVE

Malignant pleural effusion is a severe and common complication in patients with primary or metastatic malignancies of the pleura. Although talc pleurodesis is widely used for managing malignant pleural effusions, there is still controversy in the literature regarding its superiority compared to other approaches. We conducted this meta-analysis to further investigate its efficacy compared to alternative interventions.

METHODS

We systematically reviewed the PubMed, Cochrane, and Scopus databases to identify studies that fulfilled our inclusion criteria. Study quality was evaluated using validated tools and the pooled Risk Ratio (RR) and confidence interval (CI) were calculated. We performed sensitivity analyses based on the meta-analysis method and type of study.

RESULTS

Twenty-four studies were included in the current systematic review meta-analysis. Talc pleurodesis was associated with statistically significant higher successful pleurodesis rates when compared with all controls [RR (95% CI) 1.15 (1.00, 1.31); P_z = 0.04], only chemical controls [RR (95% CI) 1.26 (1.13, 1.40); P_z < 0.0001], and bleomycin [RR (95% CI) 1.22 (1.05, 1.42); P_z = 0.008]. The comparison between talc pleurodesis and controls at the > 1-month follow-up time point favored talc pleurodesis [RR (95% CI): 1.62 (1.15, 2.27); P_z = 0.005]. Finally, talc poudrage was associated with a statistically significant higher successful pleurodesis rate when compared with all controls. Sensitivity analyses verified the robustness of our results.

CONCLUSION

Talc pleurodesis is an effective MPE management approach presenting borderline statistically significant superiority compared to control methods especially compared to bleomycin as well as when pleurodesis success is evaluated later than 1 month postoperatively.

Viscum pleurodesis is as effective as talc pleurodesis and tends to have less adverse effect

PURPOSE

Many patients diagnosed with advanced cancer have malignant pleural effusion that does not respond to chemotherapy or radiation therapy. These patients often have respiratory symptoms, especially dyspnea. In order to relieve these symptoms, various procedures including chemical pleurodesis have been performed. Although talc is the most widely used and effective sclerosing agent, there it has various adverse effects. The objective of this study was to determine whether Viscum (ABNOVA Viscum® Fraxini Injection, manufactured by ABNOVA GmbH, Germany) could be used as an agent to replace talc in clinical practice.

METHODS

Data of 56 patients with malignant pleural effusion who received chemical pleurodesis after tube thoracostomy from January 2003 to December 2017 were retrospectively reviewed to analyze clinical course and response after pleurodesis with each agent.

RESULTS

After pleurodesis, changes in numeric rating scale (NRS) was 1.4 ± 1.6 in the talc group and 0.5 ± 1.5 in the Viscum group (p = 0.108). Changes in white blood cell counts after pleurodesis were 4154.8 ± 6710.7 in the talc group and 3487.3 ± 6067.7 in the Viscum group (p = 0.702). Changes in C-reactive protein (CRP) were 9.03 ± 6.86 in the talc group and 6.3 ± 7.5 in the Viscum group (p = 0.366). The success rate of pleurodesis was 93.3% in the talc group and 96% in the Viscum group (p = 0.225).

CONCLUSION

Viscum pleurodesis showed comparable treatment results with talc pleurodesis while its adverse effects such as chest pain and fever tended to be relatively weak.

Oncolytic herpesvirus therapy for mesothelioma - A phase I/IIa trial of intrapleural administration of HSV1716

OBJECTIVES

Malignant Pleural Mesothelioma (MPM) remains a major oncological challenge with limited therapeutic options. HSV1716 is a replication restricted oncolytic herpes simplex virus with anti-tumor effects in multiple cell lines including MPM. Intrapleural treatment appeals because MPM is typically multifocal but confined to the pleura, and distant metastases are uncommon. We assessed the safety and possible efficacy of intrapleural HSV1716 for inoperable MPM.

MATERIALS AND METHODS

Patients with MPM received 1 × 10⁷iu HSV1716 injected via an indwelling intrapleural catheter (IPC) on one, two or four occasions a week apart. The primary endpoint was the safety and tolerability of HSV1716. Secondary endpoints were assessment of HSV1716 replication, detection of immune response and evaluation of tumor response.

RESULTS

Of thirteen patients enrolled, five had received previous pemetrexed-cisplatin chemotherapy, and eight were chemotherapy naïve. Three patients were enrolled to receive one dose, three patients to two doses and seven patients to four doses. The treatment was well-tolerated with few virus-related adverse events and no dose limiting toxicities. Twelve patients were evaluable for response, as one patient withdrew early after a catheter fracture. There was evidence of viral replication/persistence in pleural fluid in seven of the twelve patients. Induction of Th1 cytokine responses to HSV1716 treatment occurred in eight patients and four patients developed novel anti-tumor IgG. No objective responses were observed but disease stabilization was reported in 50 % of patients at 8 weeks.

CONCLUSIONS

Intrapleural HSV1716 was well-tolerated and demonstrated an anti-tumor immune response in MPM patients. These results provide a rationale for further studies with this agent in MPM and in combination with other therapies.

Predicting the survival in patients with malignant pleural effusion undergoing indwelling pleural catheter insertion

CONTEXT

Malignant pleural effusion (MPE) is a common comorbid condition in advanced malignancies with variable survival.

AIMS

The aim of this study was to predict the survival in patients with MPE undergoing indwelling pleural catheter (IPC) insertion.

SETTINGS AND DESIGN

This was a cross-sectional study conducted at Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan.

METHODS

One hundred and ten patients with MPE who underwent IPC insertion from January 2011 to December 2019 were reviewed. Kaplan-Meier method was used to determine the overall survival (OS) of the patient's cohort with respect to LENT score.

STATISTICAL ANALYSIS USED

The IBM SPSS version 20 was used for statistical analysis.

RESULTS

We retrospectively reviewed 110 patients who underwent IPC insertion for MPE, with a mean age of 49 ± 15 years. 76 (69.1%) patients were females, of which majority 59 (53.6%) had a primary diagnosis of breast cancer. The LENT score was used for risk stratification, and Kaplan-Meier survival curves were used to predict the OS. The proportion of patients with low-risk LENT score had 91%, 58%, and 29% survival, the moderate-risk group had 76%, 52%, and 14% survival, and in the high-risk group, 61%, 15%, and 0% patients survived at 1, 3, and 6 months, respectively. In addition, there was a statistically significant survival difference (P = 0.05) in patients who received chemotherapy pre- and post-IPC insertion.

CONCLUSIONS

LENT score seems to be an easy and attainable tool, capable of predicting the survival of the patients with MPE quite accurately. It can be helpful in palliating the symptoms of patients with advanced malignancies by modifying the treatment strategies.

AABIP Evidence-informed Guidelines and Expert Panel Report for the Management of Indwelling Pleural Catheters

BACKGROUND

While the efficacy of Indwelling pleural catheters for palliation of malignant pleural effusions is supported by relatively robust evidence, there is less clarity surrounding the postinsertion management.

METHODS

The Trustworthy Consensus-Based Statement approach was utilized to develop unbiased, scientifically valid guidance for the management of patients with malignant effusions treated with indwelling pleural catheters. A comprehensive electronic database search of PubMed was performed based on a priori crafted PICO questions (Population/Intervention/Comparator/Outcomes paradigm). Manual searches of the literature were performed to identify additional relevant literature. Dual screenings at the title, abstract, and full-text levels were performed. Identified studies were then assessed for quality based on a combination of validated tools. Appropriateness for data pooling and formation of evidence-based recommendations was assessed using predetermined criteria. All panel members participated in development of the final recommendations utilizing the modified Delphi technique.

RESULTS

A total of 7 studies were identified for formal quality assessment, all of which were deemed to have a high risk of bias. There was insufficient evidence to allow for data pooling and formation of any evidence-based recommendations. Panel consensus resulted in 11 ungraded consensus-based recommendations.

CONCLUSION

This manuscript was developed to provide clinicians with guidance on the management of patients with indwelling pleural catheters placed for palliation of malignant pleural effusions. Through a systematic and rigorous process, management suggestions were developed based on the best available evidence with augmentation by expert opinion when necessary. In addition, these guidelines highlight important gaps in knowledge which require further study.

Malignant Pleural Effusion: Diagnosis and Management

Symptomatic malignant pleural effusion is a common clinical problem. This condition is associated with very high mortality, with life expectancy ranging from 3 to 12 months. Studies are contributing evidence on an increasing number of therapeutic options (therapeutic thoracentesis, thoracoscopic pleurodesis or thoracic drainage, indwelling pleural catheter, surgery, or a combination of these therapies). Despite the availability of therapies, the management of malignant pleural effusion is challenging and is mainly focused on the relief of symptoms. The therapy to be administered needs to be designed on a case-by-case basis considering patient's preferences, life expectancy, tumour type, presence of a trapped lung, resources available, and experience of the treating team. At present, the management of malignant pleural effusion has evolved towards less invasive approaches based on ambulatory care. This approach spares the patient the discomfort caused by more invasive interventions and reduces the economic burden of the disease. A review was performed of the diagnosis and the different approaches to the management of malignant pleural effusion, with special emphasis on their indications, usefulness, cost-effectiveness, and complications. Further research is needed to shed light on the current matters of controversy and help establish a standardized, more effective management of this clinical problem.

Thoracic ultrasound as a predictor of pleurodesis success at the time of indwelling pleural catheter removal

BACKGROUND AND OBJECTIVE

IPC in patients with MPE are removed within 3 months in 30-58% of cases, usually due to decreased pleural fluid output as a result of pleurodesis. Disease control can also account for the lack of fluid output, potentially explaining why 4-14% of patients undergo repeat pleural intervention for fluid re-accumulation (at the time of disease recurrence or progression). The aim of our pilot study is to determine the accuracy of thoracic ultrasound (TUS) in predicting pleurodesis success in patients with MPE at the time of IPC removal.

METHODS

This is a single-centre, prospective observational cohort study that enrolled consecutive patients with confirmed MPE treated with IPC at the time of IPC removal. TUS was performed to calculate a PAS. Patients were followed up for a minimum of 3 months. Failure was defined as pleural fluid recurrence within 3 months.

RESULTS

Twenty-seven patients were screened and 25 were included in the final analysis. Pleurodesis success was observed in 88% (n = 22) and failure in 12% (n = 3) of patients. The mean PAS was higher in patients with pleurodesis success (22.0 vs 9.3, P = 0.01). A PAS greater than 10 predicted pleurodesis success with a sensitivity of 100% and specificity of 86%.

CONCLUSION

This pilot study suggests that TUS at the time of IPC removal accurately identifies patients who have achieved pleurodesis and therefore will not have re-accumulation of pleural effusion or require an ipsilateral pleural intervention for at least 3 months post-IPC removal.

Pleural effusions and pneumothorax: Beyond simple plumbing: Expert opinions on knowledge gaps and essential next steps

Pleural diseases affect millions of people worldwide. Pleural infection, malignant pleural diseases and pneumothorax are common clinical challenges. A large number of recent clinical trials have provided an evidence-based platform to evaluate conventional and novel methods to drain pleural effusions/air which reduce morbidity and unnecessary interventions. These successes have generated significant enthusiasm and raised the profile of pleural medicine as a new subspecialty. The ultimate goal of pleural research is to prevent/stop development of pleural effusions/pneumothorax. Current research studies mainly focus on the technical aspects of pleural drainage. Significant knowledge gaps exist in many aspects such as understanding of the pathobiology of the underlying pleural diseases, pharmacokinetics of pleural drug delivery, etc. Answers to these important questions are needed to move the field forward. This article collates opinions of leading experts in the field in highlighting major knowledge gaps in common pleural diseases to provoke thinking beyond pleural drainage. Recognizing the key barriers will help prioritize future research in the quest to ultimately cure (rather than just drain) these pleural conditions.

A Survey-Based Study of Patient-Centered Costs Associated With Indwelling Pleural Catheters

INTRODUCTION

Indwelling pleural catheters (IPC) are effective at palliating benign and malignant pleural effusions (MPE). They have also been found to be cost effective from a third-party payor perspective. Little is known of the impact IPCs have on patient-centered quality of life outcomes such as financial burden and patient and caregiver burden. We performed a cross-sectional survey study evaluating the impact of IPCs on multiple patient and caregiver quality of life metrics.

METHODS

Patients ≥ 18 years old with an IPC in place for 2 months were eligible. Twenty patients were recruited over a 10-month period. Patients completed the CDC-Health Related Quality of Life (HRQOL)-4 and a HRQOL-financial questionnaire. The primary objective was to describe the socio-economic impact of IPCs. Demographic and IPC specific data were collected. Descriptive statistics were used.

RESULTS

The mean (SD) age was 64.3 (0.70). The indication was MPE in 19/20. All patients had medical insurance. Medicare or Medicaid (CMS) comprised 10/20 of payors. The median (IQR) copay for private insurers was $238.45 (72-875); 11/20 had additional costs related to the IPC; 4/20 had significant life changes after the IPC; 17/20 received assistance from a non-paid caregiver; 6/20 patients could not do activities because of the IPC and this negatively impacted QOL in 3/6 of those patients.

CONCLUSION

Patients with IPCs may experience negative life consequences, incur additional medical expenses, and require assistance from a non-paid caregiver. Activities may be negatively impacted by IPC. Discussion of alternative means of symptom palliation and pleurodesis would be beneficial.

Indications and clinical outcomes of indwelling pleural catheter placement in patients with malignant pleural effusion in a cancer setting hospital

BACKGROUND

The placement of indwelling pleural catheters (IPC) is an effective outpatient approach for the management of malignant pleural effusions (MPE).

AIMS

The indications and outcome of IPC in patients with MPE. Risk stratifications, prevention and management of IPC-related complications.

METHODS

We retrospectively reviewed the clinical data of patients with MPE who underwent IPC insertion from July 2011 to July 2019. The multivariable logistic regression model was used to identify the independent risk factors associated with IPC infection and the Kaplan-Meier method to determine the overall survival.

RESULTS

A total of 102 patients underwent IPC insertion during the stipulated period and the mean age was 50.49 ± 14.36 years. Seventy-one (69.6%) were females. The indications were Trap Lung in 38 (37.3%), failed talc pleurodesis in 28 (27.5%) and as a primary intervention in 36 (35.3%). The infection rate was 25.5%, of which 65.4% patients had nosocomial infections. Post-IPC overall median survival time was 9.0 ± 2.50 weeks with highest in patients with trap lung (18 ± 1.50 weeks). In multivariable analysis, following variables were identified as a significant independent risk factor for IPC infection: Multiloculated MPE (AOR 2.80; 95%CI (1.00-9.93), 0.04), trap lung (AOR 7.57; 95%CI (1.39-41.25), 0.01), febrile neutropenia (FN) (AOR 28.55; 95%CI (4.23-19.74), 0.001), IPC domiciliary education (AOR 0.18; 95%CI (0.05-0.66), 0.001) and length of hospital stay (AOR 1.16; 95%CI (1.01-1.33), 0.03).

CONCLUSION

IPC insertion is an effective management for MPE with reasonable survival benefits. Infection is the most common complication, of which mostly are nosocomial infections with higher incidence in multiloculated effusions, trap lung, FN and with lack of domiciliary IPC care education.

Using creative co-design to develop a decision support tool for people with malignant pleural effusion

BACKGROUND

Malignant pleural effusion (MPE) is a common, serious problem predominantly seen in metastatic lung and breast cancer and malignant pleural mesothelioma. Recurrence of malignant pleural effusion is common, and symptoms significantly impair people's daily lives. Numerous treatment options exist, yet choosing the most suitable depends on many factors and making decisions can be challenging in pressured, time-sensitive clinical environments. Clinicians identified a need to develop a decision support tool. This paper reports the process of co-producing an initial prototype tool.

METHODS

Creative co-design methods were used. Three pleural teams from three disparate clinical sites in the UK were involved. To overcome the geographical distance between sites and the ill-health of service users, novel distributed methods of creative co-design were used. Local workshops were designed and structured, including video clips of activities. These were run on each site with clinicians, patients and carers. A joint national workshop was then conducted with representatives from all stakeholder groups to consider the findings and outputs from local meetings. The design team worked with participants to develop outputs, including patient timelines and personas. These were used as the basis to develop and test prototype ideas.

RESULTS

Key messages from the workshops informed prototype development. These messages were as follows. Understanding and managing the pleural effusion was the priority for patients, not their overall cancer journey. Preferred methods for receiving information were varied but visual and graphic approaches were favoured. The main influences on people's decisions about their MPE treatment were personal aspects of their lives, for example, how active they are, what support they have at home. The findings informed the development of a first prototype/service visualisation (a video representing a web-based support tool) to help people identify personal priorities and to guide shared treatment decisions.

CONCLUSION

The creative design methods and distributed model used in this project overcame many of the barriers to traditional co-production methods such as power, language and time. They allowed specialist pleural teams and service users to work together to create a patient-facing decision support tool owned by those who will use it and ready for implementation and evaluation.

Indwelling pleural catheter versus talc pleurodesis for malignant pleural effusion: a meta-analysis

Malignant pleural effusion (MPE) results from primary mesothelioma or the spreading of metastatic cancer. Both talc pleurodesis (TP) and indwelling pleural catheter (IPC) improve MPE symptoms. We performed a meta-analysis of randomized controlled trials to compare the efficacy of TP with that of IPC in patients with MPE. PubMed, EMBASE, Cochrane Library, and ClinicalTrials.gov databases were searched for studies published before February 2020. Individual effect sizes were standardized, and a meta-analysis was conducted to calculate a pooled effect size by using random effects models. In total, 4 trials with 500 patients were reviewed. Difference in pleurodesis success rate and change in dyspnea scores at 4 and 6 weeks between MPE patients treated with IPC and those treated with TP for pleurodesis were nonsignificant. The number of hospital inpatient days was significantly lower among patients who were treated with IPC (weight mean difference: 2.19; 95% confidence interval 0.70-3.67) than among those who were treated with TP. No significant difference was shown in adverse event profile between patients treated with IPC and those treated with TP for pleurodesis. In conclusion, both TP and IPC are equally effective in treating patients with MPE. The number of hospitalization days was significantly lower for patients who were treated with IPC, but the magnitude of the difference is of uncertain clinical importance.

Talc pleurodesis versus indwelling pleural catheter among patients with malignant pleural effusion: a meta-analysis of randomized controlled trials

BACKGROUND

Talc pleurodesis (TP) and indwelling pleural catheter (IPC) are used for the management of malignant pleural effusion (MPE). Our meta-analysis was conducted to assess the efficacy and safety of both treatments among patients with MPE.

METHODS

We acquired pertinent randomized controlled trials (RCTs) by searching PubMed, ScienceDirect, the Cochrane Library, Scopus, Ovid Medline, Embase, Web of Science, and Google Scholar. The endpoints included survival, pleurodesis rates, total drainage, further pleural interventions, hospital days, symptoms, quality of life (QoL), and complications.

RESULTS

We included four high-quality RCTs. Both treatments were effective among patients with MPE and no previous pleurodesis, with comparable survival and equivalent relief of breathlessness. Additionally, the TP group had higher pleurodesis rates, less total drainage, and fewer all-grade complications (including catheter blockage and cellulitis). However, patients in the TP group had more pleural procedures and relatively longer hospital stays. Additionally, no apparent difference was detected in QoL.

CONCLUSIONS

TP has better pleurodesis rates, less total drainage, and fewer all-grade complications. However, TP has more pleural procedures and is not feasible for patients with trapped lungs. IPC has fewer further pleural interventions and shorter hospital stays. However, IPC has the nuisance of long-term in situ draining.

Recent Advances in Interventional Pulmonology

The field of interventional pulmonology has grown rapidly since first being defined as a subspecialty of pulmonary and critical care medicine in 2001. The interventional pulmonologist has expertise in minimally invasive diagnostic and therapeutic procedures involving airways, lungs, and pleura. In this review, we describe recent advances in the field as well as up-and-coming developments, chiefly from the perspective of medical practice in the United States. Recent advances include standardization of formalized training, new tools for the diagnosis and potential treatment of peripheral lung nodules (including but not limited to robotic bronchoscopy), increasingly well-defined bronchoscopic approaches to management of obstructive lung diseases, and minimally invasive techniques for maximizing patient-centered outcomes for those with malignant pleural effusion.