Diagnosis and management of malignant pleural effusion

The Diagnosis of Malignant Pleural Effusion Using Tumor-Marker Combinations: A Cost-Effectiveness Analysis Based on a Stacking Model

PURPOSE

By incorporating the cost of multiple tumor-marker tests, this work aims to comprehensively evaluate the financial burden of patients and the accuracy of machine learning models in diagnosing malignant pleural effusion (MPE) using tumor-marker combinations.

METHODS

Carcinoembryonic antigen (CEA), carbohydrate antigen (CA)19-9, CA125, and CA15-3 were collected from pleural effusion (PE) and peripheral blood (PB) of 319 patients with pleural effusion. A stacked ensemble (stacking) model based on five machine learning models was utilized to evaluate the diagnostic accuracy of tumor markers. We evaluated the discriminatory accuracy of various tumor-marker combinations using the area under the curve (AUC), sensitivity, and specificity. To evaluate the cost-effectiveness of different tumor-marker combinations, a comprehensive score (C-score) with a tuning parameter w was proposed.

RESULTS

In most scenarios, the stacking model outperformed the five individual machine learning models in terms of AUC. Among the eight tumor markers, the CEA in PE (PE.CEA) showed the best AUC of 0.902. Among all tumor-marker combinations, the PE.CA19-9 + PE.CA15-3 + PE.CEA + PB.CEA combination (C9 combination) achieved the highest AUC of 0.946. When w puts more weight on the cost, the highest C-score was achieved with the single PE.CEA marker. As w puts over 0.8 weight on AUC, the C-score favored diagnostic models with more expensive tumor-marker combinations. Specifically, when w was set to 0.99, the C9 combination achieved the best C-score.

CONCLUSION

The stacking diagnostic model using PE.CEA is a relatively accurate and affordable choice in diagnosing MPE for patients without medical insurance or in a low economic level. The stacking model using the combination PE.CA19-9 + PE.CA15-3 + PE.CEA + PB.CEA is the most accurate diagnostic model and the best choice for patients without an economic burden. From a cost-effectiveness perspective, the stacking diagnostic model with PE.CA19-9 + PE.CA15-3 + PE.CEA combination is particularly recommended, as it gains the best trade-off between the low cost and high effectiveness.

Randomized phase II trial of three intrapleural therapy regimens for the management of malignant pleural effusion in previously untreated non-small cell lung cancer: JCOG 9515

To evaluate the efficacy and toxicity of three intrapleural therapy regimens consisting of bleomycin (BLM), OK-432 (a pulverized product of heat-killed Streptococcus pyogenes) or cisplatin plus etoposide (PE) for the management of malignant pleural effusion (MPE) in previously untreated non-small cell lung cancer. Eligible patients were randomized to the BLM arm: BLM 1mg/kg (maximum 60mg/body), the OK-432 arm: OK-432 0.2 Klinische Einheit units (KE)/kg (maximum 10KE/body), or the PE arm: cisplatin (80mg/m(2)) and etoposide (80mg/m(2)). Pleural response was evaluated every 4 weeks according to the study-specific criteria. All responders received systemic chemotherapy consisting of PE every 3-4 weeks for two or more courses. Pleural progression-free survival (PPFS) was defined as the time from randomization to the first observation of pleural progression or death due to any cause. The primary endpoint was the 4-week PPFS rate. Of 105 patients enrolled, 102 were assessed for response. The 4-week PPFS rate for the BLM arm was 68.6%, 75.8% for the OK-432 arm, and 70.6% for PE arm. Median survival time (MST) for the BLM arm was 32.1 weeks, 48.1 weeks for the OK-432 arm, and 45.7 weeks for the PE arm. However, the outcomes did not differ significantly between groups. Toxicity was tolerable in all arms except for one treatment-related death due to interstitial pneumonia induced by BLM. We will select intrapleural treatment using OK-432 in the management of MPE in NSCLC for further investigation because it had the highest 4-week PPFS rate.

Locoregional immunotherapy of malignant effusion from colorectal cancer using the streptococcal preparation OK-432 plus interleukin-2: induction of autologous tumor-reactive CD4+ Th1 killer lymphocytes

In total, 16 patients with cytologically proven malignant effusion from colorectal cancer were treated by locoregional administration of the streptococcal preparation OK-432 alone or OK-432 plus the T-cell growth factor interleukin (IL)-2, and the action mechanism of the treatment was studied. A positive clinical response, showing a cytologic disappearance of cancer cells and decrease of effusion, was observed in nine of 11 (82%) patients treated with OK-432 alone and in all five patients treated with OK-432 plus IL-2. Flow cytometric analysis revealed that OK-432 plus IL-2 locally induced acute inflammation-like responses, including serial cellular infiltrations of granulocyte migration within a matter of hours, and activation of macrophages and T lymphocyte involvement within the following days, and that a predominant expansion of CD3+CD4+ lymphocytes (CD: cluster of differentiation) was induced by in vitro stimulation with IL-2 of locoregional cells after the OK-432 administration (OK/IL-2AK cells). The OK/IL-2AK cells produced tumour necrosis factor-α and interferon-γ, but these cells did not produce IL-4 and IL-6. The OK/IL-2AK cells expressed potent killing activity against autologous tumour cells. This activity was abrogated by treatment of the lymphocytes with anti-CD3, -CD4, -TCRαβ antibody, and by the treatment of target cells with anti-human leukocyte antigen (HLA)-DR antibody. The OK/IL-2AK cells expressed Fas-L gene, and flow cytometric analysis demonstrated HLA-DR expression in approximately 75% of CEA+ or cytokeratin+ effusion cells. TCRVβ gene analysis of the OK/IL-2AK cells showed an oligoclonal usage of TCRβ20, which was also involved in the cytotoxic mechanism of the OK/IL-2AK cells. Single-strand conformational polymorphism analysis demonstrated the clonotypes for the TCRVβ20 gene, and the CDR3s of the gene were sequenced. The clonotypic PCR using the TCRVβ20-CDR3 sequences could detect the CDR3-identical TCRs in effusion lymphocytes from the other patients. Taken together, it is suggested that locoregional administration of OK-432 plus IL-2 is highly effective for the management of malignant effusion from colorectal cancer. OK-432 plus IL-2 induces autologous tumour-reactive CD4+ Th1 killer lymphocytes, which recognise tumour antigen(s) presented with HLA class II molecules on effusion tumour cells by means of preferential usage of TCRVβ20. The clonotypic PCR using the TCRVβ20-CDR3 sequences may be informative for treating malignant effusion from colorectal cancer using OK-432 plus IL-2.

Managing dyspnea and cough

Dyspnea, like pain, is a subjective experience that incorporates physical elements and affective components. Management of breathlessness in patients with cancer requires expertise that includes an understanding and assessment of the multidimensional components of the symptom, knowledge of the pathophysiologic mechanisms and clinical syndromes that are common in cancer, and familiarity with the indications and limitations of the available therapeutic approaches. Relief of breathlessness should be the goal of treatment at all stages of cancer. Good control of dyspnea will improve the patient's quality of life.

Pleurodesis with iodized talc for malignant effusions using pigtail catheters

OBJECTIVE

To assess the efficacy of using an iodized talc slurry as a sclerosing agent instilled into the pleural space via a 12-French pigtail catheter for controlling malignant pleural effusions.

DESIGN

A prospective study in which patients were followed until their death.

SETTING

A university-affiliated tertiary-care teaching hospital.

PATIENTS

Medical oncology patients admitted with symptomatic malignant pleural effusions were considered for iodized talc pleurodesis.

MAIN OUTCOME MEASURES

The control of pleural effusion. Treatment failure was defined as any reaccumulation of fluid in the pleural space.

RESULTS

Fifteen patients were treated for a total of 17 instillations. The median follow-up on all patients until death was 6 months (range 1-20). The most frequent adverse effect in the study group was pleuritic chest pain (60%). The probability of control of effusion, as determined by the method of Kaplan-Meier, was 81% (SEM 9.7%). The cost of preparing 5 g of iodized talc was $4.32 (US).

CONCLUSIONS

Iodized talc slurry instilled through a small-bore pigtail catheter is a safe, economical, and effective treatment for malignant pleural effusion.

Closed percutaneous pleural brushing: a new method for diagnosis of malignant pleural effusions

Pleural fluid cytology and pleural biopsy are the two most commonly employed diagnostic tests for malignant pleural effusions. Here, we have introduced a new diagnostic method, namely closed percutaneous pleural brushing, and have compared its diagnostic yield with those of pleural fluid cytology and pleural biopsy in patients with suspected malignant pleural effusion. Forty-three consecutive patients with suspected malignant pleural effusion underwent thoracentesis, closed pleural brushing and closed pleural biopsy using Cope's pleural biopsy needle and a cytological brush (BC-10C) which was introduced into the pleural cavity through the cannula of the same needle. All the samples were sent for bacteriological and cytological studies. Patients had a mean follow-up period of 9.28 +/- 1.87 months during which seven cases whose entire studies were non-diagnostic underwent thoracotomy and open pleural biopsy. Thirty-four cases were finally documented to have malignancy. Closed pleural brushing was positive in 31 (91%) of cases. This was superior to that achieved by either pleural fluid cytology (67%) (P = 0.01) or pleural biopsy (58%) (P = 0.002). No pneumothorax or other major complications were encountered with this method. Closed pleural brushing via Cope's needle is a relatively safe, simple and well-tolerated technique with a high diagnostic yield for patients with malignant pleural effusion. It may substitute for other more invasive and more expensive procedures such as thoracoscopy and thoracotomy in this group of patients.

Management of malignant pleural effusions

Malignant pleural effusions (MPEs) represent a common complication of advanced malignancies. However, adequate palliation of this highly symptomatic accompaniment to cancer can be achieved in most patients by adopting the appropriate therapy. Several options are available for the treatment of MPE. Systemic therapy may control the effusion in patients whose underlying malignancy is sensitive to anti-cancer agents. Repeated thoracocentesis can be appropriate for patients with limited life expectancy or slowly recurrent effusions. In the majority of the remaining cases the treatment of choice is pleurodesis with sclerosing agents administered via tube thoracostomy. Controversy still exists as to which drug produces the best results: talc and bleomycin appear to be among the most cost-effective agents. The debate over the best agent to be used for pleurodesis refers to the difficulty in comparing results of studies using different eligibility criteria, response assessment and end-points. This article describes the various treatments which have been reported in the literature to play a role in the management of MPEs. It is also aimed at providing guidelines in allocating patients to appropriate treatments.

Treatment of malignant pleural effusions with a combination of bleomycin and tetracycline. A comparison of bleomycin or tetracycline alone versus a combination of bleomycin and tetracycline

BACKGROUND

Treatment of patients with malignant pleural effusions is mostly palliative. Tetracycline and bleomycin are the two most commonly used agents for the treatment of pleurodesis. In this study, the authors used a combination of the two drugs for this particular purpose.

METHODS

Sixty patients with massive malignant pleural effusions were divided in 3 equal groups in a simple randomized manner. Tetracycline (20 mg/kg [maximum of 2 g] in 50 mL of normal saline) was administered through a chest tube in Group 1. Group 2 received bleomycin (1 U/kg [maximum of 60 U] in 50 mL of normal saline). Group 3 received the above 2 preparations (tetracycline, 20 mg/kg [maximum of 2 g] in 40 mL of normal saline and bleomycin, 1 U/kg [maximum of 60 U] in 30 mL of normal saline) instilled one after the other, while the chest tube was clamped for 5 minutes in the interim. Follow-up examinations were performed at 7 days, 30 days, 60 days, 90 days, and 6 months.

RESULTS

There was no significant difference in the complete response rate of the 3 groups during the first 4 months. At the end of the study, Group 3 had a significantly higher complete response rate (70%) compared with Groups 1 and 2 (35% and 25%, respectively) (P = 0.02).

CONCLUSIONS

The response to use of a combination of bleomycin and tetracycline for the treatment of patients with pleurodesis is superior to that achieved by either of these agents used alone.