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Ost DE, Goldblatt C, Jung M, Weiss M, Xu S, Taneja A, Erdal E. The Clinical and Economic Implications of Different Treatment Pathways for Patients With Rapidly Recurrent Malignant Pleural Effusion. Chest 2024:S0012-3692(24)00684-6. [PMID: 38838953 DOI: 10.1016/j.chest.2024.04.036] [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: 11/06/2023] [Revised: 03/14/2024] [Accepted: 04/24/2024] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND Malignant pleural effusion (MPE) is a common cancer complication. Clinical and economic implications of different recurrent MPE treatment pathways have not been evaluated fully. RESEARCH QUESTION What clinical outcomes, complications, health care resource use, and costs are associated with various rapidly recurrent MPE treatment pathways? STUDY DESIGN AND METHODS This retrospective cohort study using Surveillance, Epidemiology and End Results Medicare data (2011-2015) included patients 66 to 90 years of age with rapidly recurrent MPE. Rapid recurrence was defined as receipt of a second pleural procedure within 14 days of the first thoracentesis, including nondefinitive repeated thoracentesis or a definitive treatment option including chest tube, indwelling pleural catheter (IPC), or thoracoscopy. RESULTS Among 8,378 patients with MPE, 3,090 patients (36.9%) had rapidly recurrent MPE (mean ± SD age, 75.9 ± 6.6 years; 45.6% male; primary cancer, 62.9% lung and 37.1% other). Second pleural procedures were nondefinitive thoracentesis (62.3%), chest tube (17.1%), IPC (13.2%), or thoracoscopy (7.4%). A third pleural procedure was required more frequently if the second pleural procedure was nondefinitive thoracentesis vs chest tube placement, IPC placement, or thoracoscopy (70.3% vs 44.1% vs 17.9% vs 14.4%, respectively). The mean number of subsequent pleural procedures over the patient's lifetime varied significantly among the procedures (1.74, 0.82, 0.31, and 0.22 procedures for patients receiving thoracentesis, chest tube, IPC, and thoracoscopy, respectively; P < .05). Average total costs after the second pleural procedure to death adjusted for age at primary cancer diagnosis, race, year of second pleural procedure, Charlson comorbidity index, cancer stage at primary diagnosis, and time from primary cancer diagnosis to diagnostic thoracentesis were lower with IPC ($37,443; P < .0001) or chest tube placement ($40,627; P = .004) vs thoracentesis ($47,711). Patients receiving thoracoscopy ($45,386; P = .5) incurred similar costs as patients receiving thoracentesis. INTERPRETATION Early definitive treatment was associated with fewer subsequent procedures and lower costs in patients with rapidly recurrent MPE.
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Affiliation(s)
- David E Ost
- MD Anderson Cancer Center, University of Texas, Houston, TX.
| | | | - Molly Jung
- Becton, Dickinson, and Company, Franklin Lakes, NJ
| | - Mia Weiss
- Becton, Dickinson, and Company, Franklin Lakes, NJ
| | - Shibei Xu
- Becton, Dickinson, and Company, Franklin Lakes, NJ
| | | | - Erik Erdal
- Becton, Dickinson, and Company, Franklin Lakes, NJ
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Kwok C, Thavorn K, Amjadi K, Aaron SD, Kendzerska T. Resource Use and Costs of Indwelling Pleural Catheters versus Pleurodesis for Malignant Pleural Effusions: A Population-based Study. Ann Am Thorac Soc 2024; 21:940-948. [PMID: 38381853 DOI: 10.1513/annalsats.202304-333oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 02/20/2024] [Indexed: 02/23/2024] Open
Abstract
Rationale: Malignant pleural effusions (MPEs) are associated with significant health service use and healthcare costs, but the current evidence is limited. Objectives: To compare 12-month post-procedure: 1) health service utilization; and 2) healthcare costs after indwelling pleural catheter (IPC) insertion with at-home drainage performed by home care nursing services, versus in-hospital chemical pleurodesis. Methods: We performed a retrospective population-based study on a cohort of adults with MPEs who underwent IPC insertion or chemical pleurodesis between January 1, 2015 and December 31, 2019 using provincial health administrative data (Ontario, Canada). Patients were followed from the procedure date until death or until 12 months after the procedure. Inverse probability of treatment weighting was performed to adjust for imbalances in baseline characteristics. Differences in length of stay, readmissions, emergency department visits, home care visits, and healthcare costs were estimated using weighted regression analysis. Results: Of 5,752 included individuals, 4,432 (77%) underwent IPC insertion and 1,320 (23%) had pleurodesis. In the weighted sample, individuals who received an IPC had fewer inpatient days (12.4 d vs. 16 d; standardized mean difference, 0.229) but a higher proportion of subsequent admissions for empyema (2.7% vs. 1.1%; P = 0.0002) than those undergoing pleurodesis. Individuals with IPCs received more hours of nursing home care (41 h vs. 21.1 h; standardized mean difference, 0.671) but overall had lower average healthcare costs ($40,179 vs. $46,640 per patient; standardized mean difference, 0.177) than those receiving pleurodesis. Conclusions: IPCs with home nursing drainage are associated with reduced health resource use compared with pleurodesis in adults with MPEs, even after controlling for important baseline and clinical characteristics. Given that both procedures have similar health outcomes, our findings support the ongoing promotion of IPCs to increase outpatient management of patients with MPEs.
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Affiliation(s)
- Chanel Kwok
- Department of Medicine, Faculty of Medicine, and
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- ICES Ottawa, Ottawa, Ontario, Canada; and
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Kednapa Thavorn
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- ICES Ottawa, Ottawa, Ontario, Canada; and
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Kayvan Amjadi
- Department of Medicine, Faculty of Medicine, and
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Shawn D Aaron
- Department of Medicine, Faculty of Medicine, and
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Tetyana Kendzerska
- Department of Medicine, Faculty of Medicine, and
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- ICES Ottawa, Ottawa, Ontario, Canada; and
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Zhang X, Wang X, Wen Y, Chen S, Zhou C, Wu F. Single-cell transcriptomics reveal metastatic CLDN4+ cancer cells underlying the recurrence of malignant pleural effusion in patients with advanced non-small-cell lung cancer. Clin Transl Med 2024; 14:e1649. [PMID: 38629624 PMCID: PMC11022306 DOI: 10.1002/ctm2.1649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 02/29/2024] [Accepted: 03/17/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Recurrent malignant pleural effusion (MPE) resulting from non-small-cell lung cancer (NSCLC) is easily refractory to conventional therapeutics and lacks predictive markers. The cellular or genetic signatures of recurrent MPE still remain largely uncertain. METHODS 16 NSCLC patients with pleural effusions were recruited, followed by corresponding treatments based on primary tumours. Non-recurrent or recurrent MPE was determined after 3-6 weeks of treatments. The status of MPE was verified by computer tomography (CT) and cytopathology, and the baseline pleural fluids were collected for single-cell RNA sequencing (scRNA-seq). Samples were then integrated and profiled. Cellular communications and trajectories were inferred by bioinformatic algorithms. Comparative analysis was conducted and the results were further validated by quantitative polymerase chain reaction (qPCR) in a larger MPE cohort from the authors' centre (n = 64). RESULTS The scRNA-seq revealed that 33 590 cells were annotated as 7 major cell types and further characterized into 14 cell clusters precisely. The cell cluster C1, classified as Epithelial Cell Adhesion Molecule (EpCAM)+ metastatic cancer cell and correlated with activation of tight junction and adherence junction, was significantly enriched in the recurrent MPE group, in which Claudin-4 (CLDN4) was identified. The subset cell cluster C3 of C1, which was enriched in recurrent MPE and demonstrated a phenotype of ameboidal-type cell migration, also showed a markedly higher expression of CLDN4. Meanwhile, the expression of CLDN4 was positively correlated with E74 Like ETS Transcription Factor 3 (ELF3), EpCAM and Tumour Associated Calcium Signal Transducer 2 (TACSTD2), independent of driver-gene status. CLDN4 was also found to be associated with the expression of Hypoxia Inducible Factor 1 Subunit Alpha (HIF1A) and Vascular Endothelial Growth Factor A (VEGFA), and the cell cluster C1 was the major mediator in cellular communication of VEGFA signalling. In the extensive MPE cohort, a notably increased expression of CLDN4 in cells from pleural effusion among patients diagnosed with recurrent MPE was observed, compared with the non-recurrent group, which was also associated with a trend towards worse overall survival (OS). CONCLUSIONS CLDN4 could be considered as a predictive marker of recurrent MPE among patients with advanced NSCLC. Further validation for its clinical value in cohorts with larger sample size and in-depth mechanism studies on its biological function are warranted. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Xiaoshen Zhang
- School of MedicineTongji UniversityShanghaiChina
- Department of Medical OncologyShanghai Pulmonary Hospital, Tongji University School of MedicineShanghaiChina
| | - Xuanhe Wang
- School of MedicineTongji UniversityShanghaiChina
- Department of Medical OncologyShanghai Pulmonary Hospital, Tongji University School of MedicineShanghaiChina
| | - Yaokai Wen
- School of MedicineTongji UniversityShanghaiChina
- Department of Medical OncologyShanghai Pulmonary Hospital, Tongji University School of MedicineShanghaiChina
| | - Shen Chen
- Department of Medical OncologyShanghai Pulmonary Hospital, Tongji University School of MedicineShanghaiChina
| | - Caicun Zhou
- Department of Medical OncologyShanghai Pulmonary Hospital, Tongji University School of MedicineShanghaiChina
| | - Fengying Wu
- Department of Medical OncologyShanghai Pulmonary Hospital, Tongji University School of MedicineShanghaiChina
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Alexander M, Ishisaka Y, Miyakawa L, Rothman A. Assessing Factors That May Impact Physician-based Decisions for Placing Indwelling Pleural Catheters. J Bronchology Interv Pulmonol 2024; 31:39-48. [PMID: 37185887 DOI: 10.1097/lbr.0000000000000926] [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: 09/20/2022] [Accepted: 03/27/2023] [Indexed: 05/17/2023]
Abstract
INTRODUCTION Malignant pleural effusion is a common finding in patients with advanced cancer and is a frequent cause of dyspnea. Current guidelines indicate thoracentesis for symptomatic patients, while indwelling pleural catheters (IPC) are recommended for patients who develop pleural fluid re-accumulation. IPC maintenance, however, requires a significant level of financial and social support. This study aims to analyze potential influencing factors that may play a role in the decision for placing IPCs in patients with recurrent malignant pleural effusions. METHODS This study retrospectively collected baseline sociodemographic and laboratory data in patients who underwent thoracentesis for malignant pleural effusion from August 2016 to October 2021, and selected patients who presented with re-accumulation of pleural fluid within 30 days or had a pulmonary physician's note documenting that IPC is a potential management option. Of these selected patients (IPC candidates), we stratified patients who underwent IPC placement and those who did not, and performed statistical analysis between these 2 groups. RESULTS One hundred seventy-six patients who underwent thoracentesis were regarded as IPC candidates. Almost all baseline sociodemographic characteristics, including ethnicity ( P =0.637), sex ( P =0.655), and marital status ( P =0.773) were similar between the 2 groups, but significantly higher ECOG scores ( P =0.049) were noted in the IPC group. No statistically significant differences were noted in age, body mass index, platelet, PTT, international normalized ratio, creatinine, white blood cell, red blood cells, fluid protein, or fluid lactate dehydrogenase. Fluid albumin ( P =0.057) and serum neutrophil:lymphocyte ratio ( P =0.003) were significantly higher in patients without IPC placement. CONCLUSION This study did not recognize any baseline sociodemographic factors that may contribute to the decision to place IPCs.
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Affiliation(s)
| | | | - Lina Miyakawa
- Department of Pulmonary & Critical Care Medicine, Mount Sinai Beth Israel
| | - Adam Rothman
- Department of Pulmonary & Critical Care Medicine, Mount Sinai Morningside-West, New York, NY
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Efteev LA, Esakov YS, Blinova EV, Bazylyuk AV, Blinov KD. [Treatment of malignant effusion]. Khirurgiia (Mosk) 2024:141-147. [PMID: 39008708 DOI: 10.17116/hirurgia2024071141] [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] [Indexed: 07/17/2024]
Abstract
Malignant effusion complicates more than 15% of all cancers in delayed stages of progression. The most common causes of metastatic pleuritis are lung cancer, breast cancer, ovarian cancer, lymphoproliferative diseases or dissemination of gastrointestinal tumors. Malignant effusion is associated with negative prognosis for overall survival regardless of etiology of tumor, significantly complicates the course of the underlying disease, impairs life quality and complicates treatment. Despite various methods for pleural cavity obliteration in recurrent metastatic pleuritis, there is still no a uniform approach to choosing the optimal treatment strategy. We analyzed the main methods of conservative and surgical treatment of recurrent metastatic pleuritic regarding efficacy, risk of recurrence and reproducibility.
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Affiliation(s)
- L A Efteev
- Clinical Oncological Hospital N. 1, Moscow, Russia
| | - Yu S Esakov
- Clinical Oncological Hospital N. 1, Moscow, Russia
| | - E V Blinova
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - A V Bazylyuk
- Clinical Oncological Hospital N. 1, Moscow, Russia
| | - K D Blinov
- Sechenov First Moscow State Medical University, Moscow, Russia
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Wen KZ, Brereton CJ, Douglas EM, Samuel SRN, Jones AC. Pleural procedures: an audit of practice and complications in a regional Australian teaching hospital. Intern Med J 2024; 54:172-177. [PMID: 37255366 DOI: 10.1111/imj.16147] [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: 03/31/2023] [Accepted: 05/13/2023] [Indexed: 06/01/2023]
Abstract
BACKGROUND Pleural procedures are essential for the investigation and management of pleural disease and can be associated with significant morbidity and mortality. There is a lack of pleural procedure complication data in the Australian and New Zealand region. AIMS To review pleural procedure practices at Wollongong Hospital with an emphasis on the assessment of complications, use of thoracic ultrasound (TUS), pathology results and comparison of findings with international data. METHODS Retrospective analysis of medical records was performed on pleural procedures identified through respiratory specialist trainee logbooks at Wollongong Hospital from January 2018 to December 2021. Comparison of complication rates was made to the British Thoracic Society 2011 a national pleural audit. RESULTS One hundred and twenty-one pleural procedures were identified. There were 71 chest drains, 49 thoracocentesis and one indwelling pleural catheter (IPC) insertion. Ninety-seven per cent of procedures were performed for pleural effusions and 3% for pneumothorax. This audit demonstrated a complication rate (excluding pain) of 16.9% for chest drains and 4.1% for thoracocentesis. This gave an overall complication event rate of 10.8% (excluding pain) for pleural procedures. There was no major bleeding, organ puncture, pleural space infection or death. Bedside TUS was used in 99% of procedures. CONCLUSION Complication rates for pleural procedures performed by respiratory specialist trainees at Wollongong Hospital are comparable with international outcomes. This audit provides data for comparison on pleural procedure complication rates in Australia. Future studies are required to determine complication rates with IPCs.
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Affiliation(s)
- Kevin Z Wen
- Department of Respiratory and Sleep Medicine, Wollongong Hospital, Sydney, New South Wales, Australia
| | - Christopher J Brereton
- Department of Respiratory and Sleep Medicine, Wollongong Hospital, Sydney, New South Wales, Australia
- Faculty of Science, Medicine and Health, University of Wollongong, Sydney, New South Wales, Australia
| | - Eric M Douglas
- Department of Respiratory and Sleep Medicine, Wollongong Hospital, Sydney, New South Wales, Australia
| | - Sameh R N Samuel
- Department of Respiratory and Sleep Medicine, Wollongong Hospital, Sydney, New South Wales, Australia
- Faculty of Science, Medicine and Health, University of Wollongong, Sydney, New South Wales, Australia
| | - Andrew C Jones
- Department of Respiratory and Sleep Medicine, Wollongong Hospital, Sydney, New South Wales, Australia
- Faculty of Science, Medicine and Health, University of Wollongong, Sydney, New South Wales, Australia
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Shaw JA, Louw EH, Koegelenberg CF. A practical approach to the diagnosis and management of malignant pleural effusions in resource-constrained settings. Breathe (Sheff) 2023; 19:230140. [PMID: 38125800 PMCID: PMC10729815 DOI: 10.1183/20734735.0140-2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/03/2023] [Indexed: 12/23/2023] Open
Abstract
No pleural intervention in a patient with confirmed malignant pleural effusion (MPE) prolongs life, but even the recommended interventions for diagnosis and palliation can be costly and therefore unavailable in large parts of the world. However, there is good evidence to guide clinicians working in low- and middle-income countries on the most cost-effective and clinically effective strategies for the diagnosis and management of MPE. Transthoracic ultrasound-guided closed pleural biopsy is a safe method of pleural biopsy with a diagnostic yield approaching that of thoracoscopy. With the use of pleural fluid cytology and ultrasound-guided biopsy, ≥90% of cases can be diagnosed. Cases with an associated mass lesion are best suited to an ultrasound-guided fine needle aspiration with/without core needle biopsy. Those with diffuse pleural thickening and/or nodularity should have an Abrams needle (<1 cm thickening) or core needle (≥1 cm thickening) biopsy of the area of interest. Those with insignificant pleural thickening should have an ultrasound-guided Abrams needle biopsy close to the diaphragm. The goals of management are to alleviate dyspnoea, prevent re-accumulation of the pleural effusion and minimise re-admissions to hospital. As the most cost-effective strategy, we suggest early use of indwelling pleural catheters with daily drainage for 14 days, followed by talc pleurodesis if the lung expands. The insertion of an intercostal drain with talc slurry is an alternative strategy which is noninferior to thoracoscopy with talc poudrage. Educational aims To provide clinicians practising in resource-constrained settings with a practical evidence-based approach to the diagnosis and management of malignant pleural effusions.To explain how to perform an ultrasound-guided closed pleural biopsy.To explain the cost-effective use of indwelling pleural catheters.
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Affiliation(s)
- Jane A. Shaw
- Division of Pulmonology, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Biomedical Research Institute, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Elizabeth H. Louw
- Division of Pulmonology, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Coenraad F.N. Koegelenberg
- Division of Pulmonology, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
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Siefen AC, Eilers L, Baltin CT, Kron F. Cost Comparison of Treatment Alternatives for Pleural Effusion and Ascites from a Payer Perspective: Are There Cost Savings from Indwelling Catheters? J Palliat Med 2023; 26:1510-1520. [PMID: 37352428 PMCID: PMC10658739 DOI: 10.1089/jpm.2022.0592] [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] [Accepted: 05/15/2023] [Indexed: 06/25/2023] Open
Abstract
Background: The presence of pleural effusions and ascites in patients is often considered a marker of illness severity and a poor prognostic indicator. This study aims to compare inpatient and outpatient costs of alternative invasive treatments for ascites and pleural effusions. Methods: The retrospective single-institution study included inpatient cases treated for pleural effusion (J90 and J91) or ascites (R18) at the University Hospital Cologne (UHC) in Germany between January 01, 2020, and December 31, 2021. Costs for punctures and indwelling catheter systems (ICSs) as well as pleurodesis were analyzed in different comparator treatment pathways. Real-world data from the UHC tertiary care center were based on diagnosis-related group fees from 2020 to 2021. A simulation of outpatient expenses was carried out to compare inpatient and outpatient costs for each pathway from a payer perspective. Results: A total of 4323 cases (3396 pleural effusions and 1302 ascites) were analyzed. For ascites, inpatient implantation with home care drainage was found to be the most expensive option, with total costs of €1,918.58 per procedure, whereas outpatient puncture was the least expensive option at €60.02. For pleural effusions, the most expensive treatment pathway was pleurodesis at €8,867.84 compared with the least costly option of outpatient puncture resulting in total costs per procedure of €70.03. A break-even analysis showed that outpatient puncture remains the most inexpensive treatment option, and the ICS comprises a cost-saving potential. Longevity of several months with the use of ICSs results in both enhanced quality of life for patients and increased cost savings.
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Affiliation(s)
| | - Leonie Eilers
- VITIS Healthcare Group, Cologne, Germany
- KCM KompetenzCentrum für Medizinoekonomie, FOM University of Applied Sciences, Essen, Germany
| | - Christoph T. Baltin
- VITIS Healthcare Group, Cologne, Germany
- KCM KompetenzCentrum für Medizinoekonomie, FOM University of Applied Sciences, Essen, Germany
- Department of Orthopedics and Trauma Surgery, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Florian Kron
- VITIS Healthcare Group, Cologne, Germany
- Department I of Internal Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
- Faculty of Medicine and University Hospital Cologne, Centre for Integrated Oncology (CIO ABCD), University of Cologne, Cologne, Germany
- KCM KompetenzCentrum für Medizinoekonomie, FOM University of Applied Sciences, Essen, Germany
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Cloyes RR, Josan E, Pastis N, Ma J, Palettas M, Peng J, Vasko-Wood S, Mohrman C, Ghattas C, Presley C, Revelo A, Pannu J. Reducing hospital admissions in patients with malignant pleural effusion: a quality improvement study. BMJ Open Qual 2023; 12:e002197. [PMID: 37751941 PMCID: PMC10533796 DOI: 10.1136/bmjoq-2022-002197] [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: 11/18/2022] [Accepted: 09/07/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND Malignant pleural effusions (MPE) can cause severe dyspnoea leading to greater than 125 000 hospitalisations per year and cost greater than US$5 billion per year in the USA. Timely insertion of tunnelled pleural catheters (TPCs) is associated with fewer inpatient days and emergency department visits. We conducted a quality improvement study to reduce hospital admissions of patients with MPE. METHODS Key stakeholders were surveyed, including thoracic and breast oncology teams, general pulmonary and interventional pulmonology (IP) to help identify the underlying causes and solutions. Our preintervention group consisted of 51 patients who underwent TPC placement by our IP service. In our first intervention, we reviewed referrals for MPE with the scheduling team and triaged them based on urgency. In the second intervention, we added a follow-up phone call 1 week after the initial thoracentesis performed by IP to assess for the recurrence of symptoms. RESULTS Demographic and clinical characteristics were summarised across the three groups. We evaluated the rate ratio (RR) of admissions in the intervention groups with the multivariable Poisson regression and adjusted for race, gender and cancer. Compared with the preintervention group, intervention I showed trends towards a 41% lower hospital admission rate (RR 0.59 (0.33-1.07), p=0.11). Compared with the preintervention group, intervention II showed trends towards a 40% lower hospital admission rate (RR 0.6 (0.36-0.99), p=0.07). The results did not reach statistical significance. Exploratory comparisons in readmission rates between interventions I and II showed no difference (RR 0.89 (0.43-1.79), p=0.75). CONCLUSIONS Both interventions showed trends toward fewer hospital readmissions although they were not statistically significant. Larger-size prospective studies would be needed to demonstrate the continued effectiveness of these interventions.
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Affiliation(s)
- Rebecca R Cloyes
- Pulmonary, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Enambir Josan
- Pulmonary, The University of Tennessee Medical Center, Knoxville, Tennessee, USA
| | - Nicholas Pastis
- Pulmonary, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Jianing Ma
- Biostatistics, The Ohio State University, Columbus, Ohio, USA
| | | | - Jing Peng
- Biostatistics, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Susan Vasko-Wood
- The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Chelsea Mohrman
- The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Christian Ghattas
- The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Carolyn Presley
- The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Alberto Revelo
- The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Jasleen Pannu
- The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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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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11
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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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12
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Vakil E, Taghizadeh N, Tremblay A. The Global Burden of Pleural Diseases. Semin Respir Crit Care Med 2023. [PMID: 37263289 DOI: 10.1055/s-0043-1769614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Pleural diseases include a spectrum of disorders broadly categorized into pneumothorax and pleural effusion. They often cause pain, breathlessness, cough, and reduced quality of life. The global burden of diseases reflects regional differences in conditions and exposures associated with pleural disease, such as smoking, pneumonia, tuberculosis, asbestos, cancer, and organ failure. Disease burden in high-income countries is overrepresented given the availability of data and disease burden in lower-income countries is likely underestimated. In the United States, in 2016, there were 42,215 treat-and-discharge visits to the emergency room for pleural diseases and an additional 361,270 hospitalizations, resulting in a national cost of $10.1 billion.
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Affiliation(s)
- Erik Vakil
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Niloofar Taghizadeh
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary and Emergency Strategic Clinical Network, Alberta Health Services, Calgary, Alberta, Canada
| | - Alain Tremblay
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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13
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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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14
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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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15
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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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16
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Yan M, Tjong M, Chan WC, Darling G, Delibasic V, Davis LE, Doherty M, Hallet J, Kidane B, Mahar A, Mittmann N, Parmar A, Tan V, Tan H, Wright FC, Coburn NG, Louie AV. Dyspnea in patients with stage IV non-small cell lung cancer: a population-based analysis of disease burden and patterns of care. J Thorac Dis 2023; 15:494-506. [PMID: 36910044 PMCID: PMC9992624 DOI: 10.21037/jtd-22-919] [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: 07/03/2022] [Accepted: 12/09/2022] [Indexed: 02/23/2023]
Abstract
Background Patients with metastatic non-small cell lung cancer (NSCLC) experience significant morbidity with dyspnea being a common symptom with a prevalence of 70%. The objective of this study was to determine factors associated with a moderate-to-severe dyspnea score based on the Edmonton Symptom Assessment System (ESAS), as well as resultant patterns of intervention and factors correlated to intervention receipt. Methods Using health services administrative data, we conducted a population-based study of all patients diagnosed with metastatic NSCLC treated from January 2007 to September 2018 in the province of Ontario. The primary outcomes of interest are the prevalence of moderate-to-severe dyspnea scores, and the receipt of dyspnea-directed intervention. Differences in baseline characteristic between moderate-to-severe dyspnea and low dyspnea score cohorts were assessed by comparative statistics. Predictors of intervention receipt for patients with moderate-to-severe dyspnea scores were estimated using multivariable modified Poisson regression. Results The initial study cohort included 13,159 patients diagnosed with metastatic NSCLC and of these, 9,434 (71.7%) reported a moderate-to-severe dyspnea score. Compared to patients who did not report moderate-to-severe dyspnea scores, those who reported a moderate-to-severe dyspnea score were more likely to complete a greater number of ESAS surveys, be male, have a higher Elixhauser comorbidity index (ECI) score, and receive subsequent systemic therapy after diagnosis. Most patients with a moderate-to-severe dyspnea score received intervention (96%), of which the most common were palliative care management (87%), thoracic radiotherapy (56%) and thoracentesis (37%). Multivariable regression identified older patients to be less likely to undergo pleurodesis. Thoracentesis was less common for patients living in rural and non-major urban areas, lower income areas, and earlier year of diagnosis. Receipt of thoracic radiotherapy was less common for older patients, females, those with ECI ≥4, patients living in major urban areas, and those with later year of diagnosis. Finally, palliative care referrals were less frequent for patients with ECI ≥4, age 60-69, residence outside of major urban areas, earlier year of diagnosis, and lower income areas. Conclusions Dyspnea is a prevalent symptom amongst patients with metastatic NSCLC. Subpopulations of patients with moderate-to-severe dyspnea scores were in which inequities may exist in access to care that require further attention and evaluation.
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Affiliation(s)
- Michael Yan
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Michael Tjong
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Wing C Chan
- Institute for Clinical Evaluative Sciences (ICES), Toronto, ON, Canada
| | - Gail Darling
- Division of Thoracic Surgery, University of Toronto, Toronto, ON, Canada
| | - Victoria Delibasic
- Department of Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Laura E Davis
- Department of Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Mark Doherty
- Department of Oncology, St. Vincent's Hospital Group, Dublin, Ireland.,Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Julie Hallet
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Biniam Kidane
- Division of Thoracic Surgery, University of Manitoba, Winnipeg, Canada
| | - Alyson Mahar
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Nicole Mittmann
- Canadian Agency for Drugs and Technology in Health, Ottawa, Canada
| | - Ambica Parmar
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Vivian Tan
- Department of Radiation Oncology, University of Western Ontario, London, Canada
| | - Hendrick Tan
- Department of Radiation Oncology, Fiona Stanley Hospital, Perth, Australia
| | - Frances C Wright
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Natalie G Coburn
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Alexander V Louie
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
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17
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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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18
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Yang L, Wang Y. Malignant pleural effusion diagnosis and therapy. Open Life Sci 2023; 18:20220575. [PMID: 36874629 PMCID: PMC9975958 DOI: 10.1515/biol-2022-0575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 01/09/2023] [Accepted: 01/22/2023] [Indexed: 03/06/2023] Open
Abstract
Malignant pleural effusion (MPE) is a serious complication of advanced tumor, with relatively high morbidity and mortality rates, and can severely affect the quality of life and survival of patients. The mechanisms of MPE development are not well defined, but much research has been conducted to gain a deeper understanding of this process. In recent decades, although great progress has been made in the management of MPE, the diagnosis and treatment of MPE are still major challenges for clinicians. In this article, we provide a review of the research advances in the mechanisms of MPE development, diagnosis and treatment approaches. We aim to offer clinicians an overview of the latest evidence on the management of MPE, which should be individualized to provide comprehensive interventions for patients in accordance with their wishes, health status, prognosis and other factors.
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Affiliation(s)
- Liangliang Yang
- Department of Thoracic Surgery, China-Japan Union Hospital of Jilin University, No. 126 Xiantai Street, Erdao District, Changchun 130033, China
| | - Yue Wang
- Department of Thoracic Surgery, China-Japan Union Hospital of Jilin University, No. 126 Xiantai Street, Erdao District, Changchun 130033, China
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19
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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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20
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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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21
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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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22
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Abstract
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.
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Affiliation(s)
- Audra J Schwalk
- Division of Pulmonary and Critical Care, The University of Texas Southwestern Medical Center, Professional Office Building II, 5939 Harry Hines Boulevard, Dallas, TX 75390, USA.
| | - David E Ost
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Unit 1462, 1515 Holcombe Boulevard, Houston, TX 77030, USA
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23
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Psallidas I, Hassan M, Yousuf A, Duncan T, Khan SL, Blyth KG, Evison M, Corcoran JP, Barnes S, Reddy R, Bonta PI, Bhatnagar R, Kagithala G, Dobson M, Knight R, Dutton SJ, Luengo-Fernandez R, Hedley E, Piotrowska H, Brown L, Asa'ari KAM, Mercer RM, Asciak R, Bedawi EO, Hallifax RJ, Slade M, Benamore R, Edey A, Miller RF, Maskell NA, Rahman NM. Role of thoracic ultrasonography in pleurodesis pathways for malignant pleural effusions (SIMPLE): an open-label, randomised controlled trial. THE LANCET RESPIRATORY MEDICINE 2021; 10:139-148. [PMID: 34634246 DOI: 10.1016/s2213-2600(21)00353-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 06/30/2021] [Accepted: 07/13/2021] [Indexed: 01/24/2023]
Abstract
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.
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Affiliation(s)
- Ioannis Psallidas
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Maged Hassan
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK; Chest Diseases Department, Alexandria University Faculty of Medicine, Alexandria, Egypt.
| | - Ahmed Yousuf
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Tracy Duncan
- Department of Respiratory Medicine, North Manchester General Hospital, Manchester, UK
| | - Shahul Leyakathali Khan
- Department of Respiratory Medicine, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Kevin G Blyth
- Institute of Cancer Sciences, University of Glasgow and Glasgow Pleural Disease Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Matthew Evison
- North West Lung Centre, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - John P Corcoran
- Interventional Pulmonology Unit, Chest Clinic, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Simon Barnes
- Department of Respiratory Medicine, Somerset NHS Foundation Trust, Taunton, UK
| | - Raja Reddy
- Department of Respiratory Medicine, Kettering General Hospital, Kettering, UK
| | - Peter I Bonta
- Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Rahul Bhatnagar
- Academic Respiratory Unit, University of Bristol, Bristol, UK
| | | | - Melissa Dobson
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Ruth Knight
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Susan J Dutton
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Ramon Luengo-Fernandez
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Emma Hedley
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Hania Piotrowska
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Louise Brown
- Department of Respiratory Medicine, North Manchester General Hospital, Manchester, UK
| | - Kamal Abi Musa Asa'ari
- Department of Respiratory Medicine, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Rachel M Mercer
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Rachelle Asciak
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Eihab O Bedawi
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Rob J Hallifax
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Mark Slade
- Department of Respiratory Medicine, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - Rachel Benamore
- Department of Thoracic Imaging, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Anthony Edey
- Department of Imaging, North Bristol NHS Trust, Bristol, UK
| | - Robert F Miller
- Institute for Global Health, University College London, London, UK
| | - Nick A Maskell
- Academic Respiratory Unit, University of Bristol, Bristol, UK
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK; Oxford NIHR Biomedical Research Centre, Oxford, UK
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Garrison GW, Cho JL, Deng JC, Camac E, Oh S, Sundar K, Baptiste JV, Cheng GS, De Cardenas J, Fitzgerald C, Garfield J, Ha NT, Holden VK, O’Corragain O, Patel S, Wayne MT, McSparron JI, Wang T, Çoruh B, Hayes MM, Guzman E, Channick CL. ATS Core Curriculum 2021. Adult Pulmonary Medicine: Thoracic Oncology. ATS Sch 2021; 2:468-483. [PMID: 34667994 PMCID: PMC8518653 DOI: 10.34197/ats-scholar.2021-0032re] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 05/25/2021] [Indexed: 11/18/2022] Open
Abstract
The American Thoracic Society Core Curriculum updates clinicians annually in adult and pediatric pulmonary disease, medical critical care, and sleep medicine at the annual international conference. The 2021 Pulmonary Core Curriculum focuses on lung cancer and include risks and prevention, screening, nodules, therapeutics and associated pulmonary toxicities, and malignant pleural effusions. Although tobacco smoking remains the primary risk factor for developing lung cancer, exposure to other environmental and occupational substances, including asbestos, radon, and burned biomass, contribute to the global burden of disease. Randomized studies have demonstrated that routine screening of high-risk smokers with low-dose chest computed tomography results in detection at an earlier stage and reduction in lung cancer mortality. On the basis of these trials and other lung cancer risk tools, screening recommendations have been developed. When evaluating lung nodules, clinical and radiographic features are used to estimate the probability of cancer. Management guidelines take into account the nodule size and cancer risk estimates to provide recommendations at evaluation. Newer lung cancer therapies, including immune checkpoint inhibitors and molecular therapies, cause pulmonary toxicity more frequently than conventional chemotherapy. Treatment-related toxicity should be suspected in patients receiving these medications who present with respiratory symptoms. Evaluation is aimed at excluding other etiologies, and treatment is based on the severity of symptoms. Malignant pleural effusions can be debilitating. The diagnosis is made by using simple pleural drainage and/or pleural biopsies. Management depends on the clinical scenario and the patient's preferences and includes the use of serial thoracentesis, a tunneled pleural catheter, or pleurodesis.
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Affiliation(s)
- Garth W. Garrison
- Divison of Pulmonary Disease and Critical Care Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont
| | - Josalyn L. Cho
- Division of Pulmonary, Critical Care and Occupational Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Jane C. Deng
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | - Erin Camac
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Scott Oh
- Division of Pulmonary, Critical Care Medicine, Clinical Immunology, and Allergy, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Krishna Sundar
- Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah, Salt Lake City, Utah
| | - Janelle V. Baptiste
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center–Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Guang-Shing Cheng
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Jose De Cardenas
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
- Section of Thoracic Surgery, Department of Surgery, School of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Codi Fitzgerald
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Jamie Garfield
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Ngoc-Tram Ha
- Division of Pulmonary and Critical Care Medicine, School of Medicine, University of Maryland, Baltimore, Maryland; and
| | - Van K. Holden
- Division of Pulmonary and Critical Care Medicine, School of Medicine, University of Maryland, Baltimore, Maryland; and
| | - Oisin O’Corragain
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Sahil Patel
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center–Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Max T. Wayne
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | - Jakob I. McSparron
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | - Tisha Wang
- Division of Pulmonary, Critical Care Medicine, Clinical Immunology, and Allergy, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Başak Çoruh
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Margaret M. Hayes
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center–Harvard Medical School, Harvard University, Boston, Massachusetts
| | | | - Colleen L. Channick
- Division of Pulmonary, Critical Care Medicine, Clinical Immunology, and Allergy, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
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25
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Association between Tunneled Pleural Catheter Use and Infection in Patients Immunosuppressed from Antineoplastic Therapy. A Multicenter Study. Ann Am Thorac Soc 2021; 18:606-612. [PMID: 33026887 DOI: 10.1513/annalsats.202007-886oc] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
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.
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26
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Mummadi SR, Stoller JK, Lopez R, Kailasam K, Gillespie C, Hahn PY. Epidemiology of Adult Pleural Disease in the United States. Chest 2021; 160:1534-1551. [PMID: 34023322 DOI: 10.1016/j.chest.2021.05.026] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 04/27/2021] [Accepted: 05/10/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Comprehensive US epidemiologic data for adult pleural disease are not available. RESEARCH QUESTION What are the epidemiologic measures related to adult pleural disease in the United States? STUDY DESIGN AND METHODS Retrospective cohort study using Healthcare Utilization Project databases (2007-2016). Adults (≥ 18 years of age) with malignant pleural mesothelioma, malignant pleural effusion, nonmalignant pleural effusion, empyema, primary and secondary spontaneous pneumothorax, iatrogenic pneumothorax, and pleural TB were studied. RESULTS In 2016, ED treat-and-discharge (T&D) visits totaled 42,215, accounting for charges of $286.7 million. In 2016, a total of 361,270 hospitalizations occurred, resulting in national costs of $10.1 billion. A total of 64,174 readmissions contributed $1.16 billion in additional national costs. Nonmalignant pleural effusion constituted 85.5% of ED T&D visits, 63.5% of hospitalizations, and 66.3% of 30-day readmissions. Contemporary sex distribution (male to female ratio) in primary spontaneous pneumothorax (2.1:1) differs from older estimates (6.2:1). Decadal analyses of annual hospitalization rates/100,000 adult population (2007 vs 2016) showed a significant (P < .001) decrease for malignant pleural mesothelioma (1.3 vs 1.09, respectively), malignant pleural effusion (33.4 vs 31.9, respectively), iatrogenic pneumothorax (17.9 vs 13.9, respectively), and pleural TB (0.20 vs 0.09, respectively) and an increase for empyema (8.1 vs 11.1, respectively) and nonmalignant pleural effusion (78.1 vs 100.1, respectively). Empyema hospitalizations have high costs per case ($38,591) and length of stay (13.8 days). The mean proportion of readmissions attributed to a pleural cause varied widely: malignant pleural mesothelioma, 49%; malignant pleural effusion, 45%; nonmalignant pleural effusion, 31%; empyema, 27%; primary spontaneous pneumothorax, 27%; secondary spontaneous pneumothorax, 27%; and iatrogenic pneumothorax, 20%. INTERPRETATION Significant epidemiologic trends and changes in various pleural disease were observed. The analysis identifies multiple opportunities for improvement in management of pleural disease.
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Affiliation(s)
| | - James K Stoller
- Education Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Rocio Lopez
- Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Karthik Kailasam
- Community Care Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Colin Gillespie
- Respiratory Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Peter Y Hahn
- Department of Pulmonary and Critical Care, Metro Health-University of Michigan Health, Wyoming, MI
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Tajarernmuang P, Gonzalez AV, Valenti D, Beaudoin S. Overuse of small chest drains for pleural effusions: a retrospective practice review. Int J Health Care Qual Assur 2021; ahead-of-print. [PMID: 33909374 DOI: 10.1108/ijhcqa-11-2020-0231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE Small-bore drains (≤ 16 Fr) are used in many centers to manage all pleural effusions. The goal of this study was to determine the proportion of avoidable chest drains and associated complications when a strategy of routine chest drain insertion is in place. DESIGN/METHODOLOGY/APPROACH We retrospectively reviewed consecutive pleural procedures performed in the Radiology Department of the McGill University Health Centre over one year (August 2015-July 2016). Drain insertion was the default drainage strategy. An interdisciplinary workgroup established criteria for drain insertion, namely: pneumothorax, pleural infection (confirmed/highly suspected), massive effusion (more than 2/3 of hemithorax with severe dyspnea /hypoxemia), effusions in ventilated patients and hemothorax. Drains inserted without any of these criteria were deemed potentially avoidable. FINDINGS A total of 288 procedures performed in 205 patients were reviewed: 249 (86.5%) drain insertions and 39 (13.5%) thoracenteses. Out of 249 chest drains, 113 (45.4%) were placed in the absence of drain insertion criteria and were deemed potentially avoidable. Of those, 33.6% were inserted for malignant effusions (without subsequent pleurodesis) and 34.5% for transudative effusions (median drainage duration of 2 and 4 days, respectively). Major complications were seen in 21.5% of all procedures. Pneumothorax requiring intervention (2.1%), bleeding (0.7%) and organ puncture or drain misplacement (2%) only occurred with drain insertion. Narcotics were prescribed more frequently following drain insertion vs. thoracentesis (27.1% vs. 9.1%, p = 0.03). ORIGINALITY/VALUE Routine use of chest drains for pleural effusions leads to avoidable drain insertions in a large proportion of cases and causes unnecessary harms.
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Affiliation(s)
- Pattraporn Tajarernmuang
- Division of Pulmonary, Critical Care, and Allergy, Department of Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Anne V Gonzalez
- Respiratory Division, Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - David Valenti
- Radiology Department, McGill University Health Centre, Montreal, Canada
| | - Stéphane Beaudoin
- Respiratory Division, Department of Medicine, McGill University Health Centre, Montreal, Canada
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28
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Gillett D, Mitchell MA, Dhaliwal I. Avoid the Trap: Nonexpanding Lung. Chest 2021; 160:1131-1136. [PMID: 33895128 DOI: 10.1016/j.chest.2021.04.025] [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: 01/05/2021] [Revised: 03/15/2021] [Accepted: 04/18/2021] [Indexed: 10/21/2022] Open
Abstract
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.
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Affiliation(s)
- Dan Gillett
- Division of Respirology, Western University, London, ON, Canada.
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29
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The Inflammatory Cytokine Profile of Patients with Malignant Pleural Effusion Treated with Pleurodesis. J Clin Med 2020; 9:jcm9124010. [PMID: 33322487 PMCID: PMC7763363 DOI: 10.3390/jcm9124010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 11/30/2020] [Accepted: 12/09/2020] [Indexed: 12/27/2022] Open
Abstract
Patients with malignant pleural effusion (MPE) who underwent successful pleurodesis survive longer than those for whom it fails. We hypothesize that the therapy-induced inflammatory responses inhibit the cancer progression, and thereby lead to a longer survival. Thirty-three consecutive patients with MPE that were eligible for bleomycin pleurodesis between September 2015 and December 2017 were recruited prospectively. Nineteen patients (57.6%) achieved fully or partially successful pleurodesis, while 14 patients either failed or survived less than 30 days after pleurodesis. Two patients without successful pleurodesis were excluded because of missing data. Interleukin (IL)-1 beta, IL-6, IL-10, transforming growth factor beta, tumor necrosis factor alpha (TNF-α), and vascular endothelial growth factor in the pleural fluid were measured before, and after 3 and 24 h of pleurodesis. Their pleurodesis outcome and survival were monitored and analyzed. Patients who underwent successful pleurodesis had a longer survival rate. Patients without successful pleurodesis had significantly higher TNF-α and IL-10 levels in their pleural fluid than in the successful patients before pleurodesis. Following pleurodesis, there was a significant increment of IL-10 in the first three hours in the successful patients. In contrast, significant increments of TNF-α and IL-10 were found in the unsuccessful patients between 3 and 24 h after pleurodesis. The ability to produce specific cytokines in the pleural space following pleurodesis may be decisive for the patient’s outcome and survival. Serial measurement of cytokines can help allocate the patients to adequate treatment strategies. Further study of the underlying mechanism may shed light on cytokine therapies as novel approaches.
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30
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Wilshire CL, Chang SC, Gilbert CR, Akulian JA, AlSarraj MK, Asciak R, Bevill BT, Davidson KR, Delgado A, Grosu HB, Herth FJF, Lee HJ, Lewis JE, Maldonado F, Ost DE, Pastis NJ, Rahman NM, Reddy CB, Roller LJ, Sanchez TM, Shojaee S, Steer H, Thiboutot J, Wahidi MM, Wright AN, Yarmus LB, Gorden JA. Temporal Trends in Tunneled Pleural Catheter Utilization in Patients With Malignancy: A Multicenter Review. Chest 2020; 159:2483-2487. [PMID: 33307064 DOI: 10.1016/j.chest.2020.10.095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 10/06/2020] [Accepted: 10/24/2020] [Indexed: 10/22/2022] Open
Affiliation(s)
- Candice L Wilshire
- Division of Thoracic Surgery and Interventional Pulmonology, Swedish Cancer Institute, Seattle, WA
| | - Shu-Ching Chang
- Medical Data Research Center, Providence St. Joseph Health, Portland, OR
| | - Christopher R Gilbert
- Division of Thoracic Surgery and Interventional Pulmonology, Swedish Cancer Institute, Seattle, WA
| | - Jason A Akulian
- Division of Pulmonary and Critical Care, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Mohammed K AlSarraj
- Division of Pulmonary, Allergy and Critical Care Medicine, Duke University, Durham, NC
| | - Rachelle Asciak
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Benjamin T Bevill
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, Charleston, SC
| | - Kevin R Davidson
- Division of Pulmonary, Allergy and Critical Care Medicine, Duke University, Durham, NC
| | - Ashley Delgado
- Division of Pulmonary and Critical Care, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Horiana B Grosu
- Department of Pulmonary Medicine, MD Anderson Cancer Center, Houston, TX
| | - Felix J F Herth
- Department of Internal Medicine, Pulmonology, and Critical Care Medicine, Thoraxklinik Universitatsklinikum Heidelberg, Heidelberg, Germany
| | - Hans J Lee
- Division of Pulmonary/Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Justin E Lewis
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, Charleston, SC
| | - Fabien Maldonado
- Division of Allergy, Pulmonary and Critical Care, Vanderbilt University, Nashville, TN
| | - David E Ost
- Department of Pulmonary Medicine, MD Anderson Cancer Center, Houston, TX
| | - Nicholas J Pastis
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, Charleston, SC
| | - Najib M Rahman
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Chakravarthy B Reddy
- Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT
| | - Lance J Roller
- Division of Allergy, Pulmonary and Critical Care, Vanderbilt University, Nashville, TN
| | - Trinidad M Sanchez
- Division of Pulmonary Disease and Critical Care Medicine, Virginia Commonwealth University, Richmond, VA
| | - Samira Shojaee
- Division of Pulmonary Disease and Critical Care Medicine, Virginia Commonwealth University, Richmond, VA
| | - Henry Steer
- Department of Respiratory Medicine, Gloucestershire Royal Hospital, Gloucester, UK
| | - Jeffrey Thiboutot
- Division of Pulmonary/Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Momen M Wahidi
- Division of Pulmonary, Allergy and Critical Care Medicine, Duke University, Durham, NC
| | - Amber N Wright
- Division of Pulmonary and Critical Care, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Lonny B Yarmus
- Division of Pulmonary/Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jed A Gorden
- Division of Thoracic Surgery and Interventional Pulmonology, Swedish Cancer Institute, Seattle, WA.
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31
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Schwalk AJ, Ost DE, Saltijeral SN, De La Garza H, Casal RF, Jimenez CA, Eapen GA, Lewis J, Rinsurongkawong W, Rinsurongkawong V, Lee J, Elamin Y, Zhang J, Roth JA, Swisher S, Heymach JV, Grosu HB. Risk Factors for and Time to Recurrence of Symptomatic Malignant Pleural Effusion in Patients With Metastatic Non-Small Cell Lung Cancer with EGFR or ALK Mutations. Chest 2020; 159:1256-1264. [PMID: 33217413 DOI: 10.1016/j.chest.2020.10.081] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 09/21/2020] [Accepted: 10/29/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The main goal of management in patients with non-small cell lung cancer (NSCLC) and malignant pleural effusion (MPE) is palliation. Patients with MPE and actionable mutations, because their disease is expected to respond quickly and markedly to targeted therapy, are less likely than those without actionable mutations to receive definitive MPE management. Whether such management is indicated in these patients is unclear. RESEARCH QUESTIONS What is the time to ipsilateral MPE recurrence requiring intervention in patients with metastatic NSCLC by mutation status? What are the risk factors for MPE recurrence? STUDY DESIGN AND METHODS Retrospective cohort study of consecutive patients who underwent initial thoracentesis for MPE. We used a Fine-Gray subdistribution hazard model to calculate the time to ipsilateral MPE recurrence requiring intervention within 100 days of initial thoracentesis and to identify variables associated with time to pleural fluid recurrence. RESULTS A total of 396 patients, comprising 295 (74.5%) without and 101 (25.5%) with actionable mutations, were included. Most patients with actionable mutations (90%) were receiving targeted treatment within 30 days of initial thoracentesis. On univariate analysis, patients with actionable mutations showed a significantly higher hazard of MPE recurrence. On multivariate analysis, this difference was not significant. Larger pleural effusion size on chest radiography (P < .001), higher pleural fluid lactate dehydrogenase (P < .001), and positive cytologic examination results (P = .008) were associated with an increased hazard of recurrence. INTERPRETATION Our findings indicate that patients with actionable mutations have a similar risk of MPE recurrence when compared with patients without mutations and would benefit from a similar definitive management approach to MPE.
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Affiliation(s)
- Audra J Schwalk
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - David E Ost
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | - Roberto F Casal
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Carlos A Jimenez
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Georgie A Eapen
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jeff Lewis
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Waree Rinsurongkawong
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Jack Lee
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Yasir Elamin
- Department of Thoracic Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jianjun Zhang
- Department of Thoracic Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jack A Roth
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Stephen Swisher
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - John V Heymach
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Horiana B Grosu
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
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32
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Mytinger A, Taylor T, Gershman E, Shojaee S. Pleural Disease Management: Manometry-guided Thoracentesis, Optimal Drainage Regimen of Indwelling Pleural Catheters, and Talc Poudrage versus Slurry for Malignant Pleural Effusion. Am J Respir Crit Care Med 2020; 202:448-450. [PMID: 32421351 DOI: 10.1164/rccm.202003-0599rr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Andrea Mytinger
- Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University Health System, Richmond, Virginia
| | - Trevor Taylor
- Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University Health System, Richmond, Virginia
| | - Evgeni Gershman
- Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University Health System, Richmond, Virginia
| | - Samira Shojaee
- Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University Health System, Richmond, Virginia
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33
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Malignant Pleural Effusion: Diagnosis and Management. Can Respir J 2020; 2020:2950751. [PMID: 33273991 PMCID: PMC7695997 DOI: 10.1155/2020/2950751] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/05/2020] [Accepted: 09/11/2020] [Indexed: 12/11/2022] Open
Abstract
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.
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Wang L, Deng H, Chen X, Li C, Yi F, Wei Y, Zhang W. Talc pleurodesis versus indwelling pleural catheter among patients with malignant pleural effusion: a meta-analysis of randomized controlled trials. World J Surg Oncol 2020; 18:184. [PMID: 32703255 PMCID: PMC7379784 DOI: 10.1186/s12957-020-01940-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 06/29/2020] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Li Wang
- Department of Thoracic Surgery, The Second Affiliated Hospital of Nanchang University, No. 1, Minde Rd, Nanchang, 330006, People's Republic of China
- Department of Respiratory and Critical Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
- Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
| | - Huan Deng
- Department of Thoracic Surgery, The Second Affiliated Hospital of Nanchang University, No. 1, Minde Rd, Nanchang, 330006, People's Republic of China
| | - Xinling Chen
- Department of Respiratory and Critical Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
- Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
| | - Can Li
- Department of Respiratory and Critical Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
- Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
| | - Fengming Yi
- Department of Oncology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Yiping Wei
- Department of Thoracic Surgery, The Second Affiliated Hospital of Nanchang University, No. 1, Minde Rd, Nanchang, 330006, People's Republic of China.
| | - Wenxiong Zhang
- Department of Thoracic Surgery, The Second Affiliated Hospital of Nanchang University, No. 1, Minde Rd, Nanchang, 330006, People's Republic of China.
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Banka R, George V, Rahman NM. Multidisciplinary approaches to the management of malignant pleural effusions: a guide for the clinician. Expert Rev Respir Med 2020; 14:1009-1018. [PMID: 32634337 DOI: 10.1080/17476348.2020.1793672] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Malignant pleural effusion (MPE) is a complication of advanced cancer, associated with significant mortality and morbidity. This entity is commonly treated by respiratory physicians, oncologists, and thoracic surgeons. There have been various randomized clinical trials assessing the relative merits of chest drain pleurodesis, indwelling pleural catheters, treatment of septated MPEs, the use of thoracoscopy and pleurodesis and pleurodesis through IPCs in the past decade which have addressed some key areas in the management of MPEs, with an increasing focus on patient related outcome. AREAS COVERED In this review, we examine and review the literature for management strategies for MPEs and discuss future directions. A detailed search of scientific literature and clinical trial registries published in the past two decades was undertaken. EXPERT OPINION Tremendous progress has been made in management of MPE in the past decade and current strategy involves patient preference along with local expertise that is available.
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Affiliation(s)
- Radhika Banka
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust , Oxford, UK
| | - Vineeth George
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust , Oxford, UK
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust , Oxford, UK.,University of Oxford Respiratory Trials Unit, Churchill Hospital , Oxford, UK.,NIHR Oxford Biomedical Research Centre, University of Oxford , Oxford, UK
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Management of Indwelling Tunneled Pleural Catheters: A Modified Delphi Consensus Statement. Chest 2020; 158:2221-2228. [PMID: 32561437 DOI: 10.1016/j.chest.2020.05.594] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 04/04/2020] [Accepted: 05/17/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The management of recurrent pleural effusions remains a challenging issue for clinicians. Advances in management have led to increased use of indwelling tunneled pleural catheters (IPC) because of their effectiveness and ease of outpatient placement. However, with the increase in IPC placement there have also been increasing reports of complications, including infections. Currently there is minimal guidance in IPC-related management issues after placement. RESEARCH QUESTION Our objective was to formulate clinical consensus statements related to perioperative and long-term IPC catheter management based on a modified Delphi process from experts in pleural disease management. STUDY DESIGN AND METHODS Expert panel members used a modified Delphi process to reach consensus on common perioperative and long-term management options related to IPC use. Members were identified from multiple countries, specialties, and practice settings. A series of meetings and anonymous online surveys were completed. Responses were used to formulate consensus statements among panel experts, using a modified Delphi process. Consensus was defined a priori as greater than 80% agreement among panel constituents. RESULTS A total of 25 physicians participated in this project. The following topics were addressed during the process: definition of an IPC infection, management of IPC-related infectious complications, interventions to prevent IPC infections, IPC-related obstruction/malfunction management, assessment of IPC removal, and instructions regarding IPC management by patients and caregivers. Strong consensus was obtained on 36 statements. No consensus was obtained on 29 statements. INTERPRETATION The management of recurrent pleural disease with IPC remains complex and challenging. This statement offers statements for care in numerous areas related to IPC management based on expert consensus and identifies areas that lack consensus. Further studies related to long-term management of IPC are warranted.
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Outpatient talc administration via indwelling pleural catheters for malignant effusions. Curr Opin Pulm Med 2020; 25:380-383. [PMID: 30998600 DOI: 10.1097/mcp.0000000000000587] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
PURPOSE OF REVIEW Malignant pleural effusion is a common cause of breathlessness and signifies advanced disease. Common options for definitive pleural intervention include insertion of an indwelling pleural catheter (IPC) or talc pleurodesis. RECENT FINDINGS Administration of graded talc through an IPC offers an increased chance of pleurodesis compared with IPC drainage alone and is not associated with a significant risk of adverse events. SUMMARY In patients where an ambulatory treatment pathway is preferred, the increased chance of pleurodesis with talc administration via IPC can result in a faster time to device removal and may be associated with better quality of life and symptom scores.
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Agrawal A, Murgu S. Multimodal approach to the management of malignant pleural effusions: role of thoracoscopy with pleurodesis and tunneled indwelling pleural catheters. J Thorac Dis 2020; 12:2803-2811. [PMID: 32642188 PMCID: PMC7330308 DOI: 10.21037/jtd.2020.03.57] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Malignant pleural effusion (MPE) is associated with a median survival of 3–6 months and causes significant symptoms affecting the overall quality of life in patients with advanced malignancies. Despite the high incidence of recurrent MPE, less than 25% of patients undergo a definitive pleural intervention as recommended by guidelines. In this review, we summarize the latest guidelines for management of MPE by various societies and discuss a multimodal approach in these patients using thoracoscopy with pleurodesis using talc insufflation and placement of tunneled indwelling pleural catheters (TIPC). We also address the role of diagnostic thoracoscopy for histologic and molecular diagnosis and outline our approach to patients with known or suspected MPE.
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Affiliation(s)
- Abhinav Agrawal
- Interventional Pulmonology, Section of Pulmonary & Critical Care, The University of Chicago Medicine, Chicago, IL, USA
| | - Septimiu Murgu
- Interventional Pulmonology, Section of Pulmonary & Critical Care, The University of Chicago Medicine, Chicago, IL, USA
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Pan CX, Palathra BC, Leo-To WF. Management of Respiratory Symptoms in Those with Serious Illness. Med Clin North Am 2020; 104:455-470. [PMID: 32312409 DOI: 10.1016/j.mcna.2019.12.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Respiratory symptoms are common in patients living with serious illness, both in cancer and nonmalignant conditions. Common symptoms include dyspnea (breathlessness), cough, malignant pleural effusions, airway secretions, and hemoptysis. Basic management of respiratory symptoms is within the scope of primary palliative care. There are pharmacologic and nonpharmacologic approaches to treating respiratory symptoms. This article provides clinicians with treatment approaches to these burdensome symptoms.
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Affiliation(s)
- Cynthia X Pan
- Division of Palliative Medicine and Geriatrics, Designated Institution Official of Graduate Medical Education, NewYork-Presbyterian Queens, 56-45 Main Street, Flushing, NY 11355, USA; Weill Cornell Medical College, New York, NY, USA.
| | - Brigit C Palathra
- Weill Cornell Medical College, New York, NY, USA; Hospice and Palliative Medicine Fellowship, Division of Palliative Medicine and Geriatrics, NewYork-Presbyterian Queens, 56-45 Main Street, Flushing, NY 11355, USA. https://twitter.com/bpalathra
| | - Wing Fun Leo-To
- NewYork-Presbyterian Queens, 56-45 Main Street, Flushing, NY 11355, USA; Affiliate Clinical Faculty, College of Pharmacy and Health Science, St John's University, Jamaica, NY, USA
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Abstract
Malignant pleural effusion frequently complicates both solid and hematologic malignancies and is associated with high morbidity, mortality, and health care costs. Although no pleura-specific therapy is known to impact survival, both pleurodesis and indwelling pleural catheter (IPC) placement can significantly alleviate symptoms and improve quality of life. The optimal choice of therapy in terms of efficacy and particularly cost-effectiveness depends on patient preferences and individual characteristics, including lung expansion and life expectancy. Attempting chemical pleurodesis through an IPC in the outpatient setting appears to be a particularly promising approach in the absence of a nonexpandable lung.
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Affiliation(s)
- Majid Shafiq
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - David Feller-Kopman
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, 1800 Orleans Street, Suite 7-125, Baltimore, MD 21287, USA.
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Shafiq M, Ma X, Taghizadeh N, Kharrazi H, Feller-Kopman DJ, Tremblay A, Yarmus LB. Healthcare Costs and Utilization among Patients Hospitalized for Malignant Pleural Effusion. Respiration 2020; 99:257-263. [PMID: 32155630 DOI: 10.1159/000506210] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 01/25/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Malignant pleural effusion (MPE) poses a considerable healthcare burden, but little is known about trends in directly attributable hospital utilization. OBJECTIVE We aimed to study national trends in healthcare utilization and outcomes among hospitalized MPE patients. METHODS We analyzed adult hospitalizations attributable to MPE using the Healthcare Cost and Utilization Project - National Inpatient Sample (HCUP-NIS) databases from 2004, 2009, and 2014. Cases were included if MPE was coded as the principal admission diagnosis or if unspecified pleural effusion was coded as the principal admission diagnosis in the setting of metastatic cancer. Annual hospitalizations were estimated for the entire US hospital population using discharge weights. Length of stay (LOS), hospital charges, and hospital mortality were also estimated. RESULTS We analyzed 92,034 hospital discharges spanning a decade (2004-2014). Yearly hospitalizations steadily decreased from 38,865 to 23,965 during this time frame, the mean LOS decreased from 7.7 to 6.3 days, and the adjusted hospital mortality decreased from 7.9 to 4.5% (p = 0.00 for all trend analyses). The number of pleurodesis procedures also decreased over time (p = 0.00). The mean inflation-adjusted charge per hospitalization rose from USD 41,252 to USD 56,951, but fewer hospitalizations drove the total annual charges down from USD 1.51 billion to USD 1.37 billion (p = 0.00 for both analyses). CONCLUSIONS The burden of hospital-based resource utilization associated with MPE has decreased over time, with a reduction in attributable hospitalizations by one third in the span of 1 decade. Correspondingly, the number of inpatient pleurodesis procedures has decreased during this time frame.
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Affiliation(s)
- Majid Shafiq
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA,
| | - Xiaomeng Ma
- Center for Population Health IT, Department of Health Policy Management, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Hadi Kharrazi
- Center for Population Health IT, Department of Health Policy Management, Johns Hopkins University, Baltimore, Maryland, USA
| | - David J Feller-Kopman
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Alain Tremblay
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Lonny B Yarmus
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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Ambulatory Iodopovidone Instillation Via Indwelling Pleural Catheters For Malignant Pleural Effusions. J Bronchology Interv Pulmonol 2020; 26:290-292. [PMID: 31107295 DOI: 10.1097/lbr.0000000000000599] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Malignant pleural effusions' (MPEs) treatment goals focus on optimizing the quality of life and decreasing time spent in health care facilities in this patient population with limited life expectancy. Numerous pleural palliation options and combination of these exist and continue to undergo studies to identify safe, superior and ideally patient-centered care. We report a cohort of 13 patients with symptomatic MPE managed with iodopovidone intrapleural instillation via an indwelling pleural catheter (IPC) in the ambulatory setting. Successful complete pleurodesis was achieved in 10 of 13 (76.9%) patients at a median time of 5 days with IPC removal at a median of 16 days. Two patient obtained partial pleurodesis with IPC removal, 1 required IPC reinsertion due to symptom recurrence. Complications were limited to intraprocedural pain in 4 patients (31%). Iodopovidone pleurodesis via IPC may represent a safe, feasible, and effective ambulatory-based option for pleural palliation in MPE.
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Mitchell MA, Dhaliwal I, Mulpuru S, Amjadi K, Chee A. Early Readmission to Hospital in Patients With Cancer With Malignant Pleural Effusions. Chest 2020; 157:435-445. [DOI: 10.1016/j.chest.2019.09.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 08/13/2019] [Accepted: 09/01/2019] [Indexed: 02/04/2023] Open
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Foote DC, Burke CR, Pandian B, Banks S, Haug KL, Hipp M, Zhao L, Smola B, Roh M, Carrott PW, Lynch WR, Chang AC, Lin J, Reddy RM. Gender Disparity in Referral for Definitive Care of Malignant Pleural Effusions. J Surg Res 2019; 244:409-416. [DOI: 10.1016/j.jss.2019.06.068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 05/23/2019] [Accepted: 06/14/2019] [Indexed: 01/13/2023]
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Ost DE, Niu J, Zhao H, Grosu HB, Giordano SH. Quality Gaps and Comparative Effectiveness in Lung Cancer Staging and Diagnosis. Chest 2019; 157:1322-1345. [PMID: 31610159 DOI: 10.1016/j.chest.2019.09.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 08/28/2019] [Accepted: 09/21/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Guidelines recommend mediastinal sampling first for patients with mediastinal lymphadenopathy with suspected lung cancer. The objective of this study was to describe practice patterns and outcomes of diagnostic strategies in patients with lung cancer. METHODS This study included a retrospective cohort of 15,914 patients with lung cancer with T1-3N1-3M0 disease diagnosed from 2004 to 2013 in the National Cancer Institute's Surveillance, Epidemiology, and End Results or Texas Cancer Registry Medicare-linked databases. Patients who had mediastinal sampling as their first invasive test were classified as guideline consistent; all others were guideline inconsistent. Propensity matching was used to compare the number of tests performed, and multivariable logistic regression was used to compare the incidence of complications. RESULTS Guideline-consistent care increased from 23% to 34% of patients from 2004 to 2013 (P < .001). Use of endobronchial ultrasound-guided transbronchial needle aspiration increased from 0.1% to 25% of all patients (P < .001), and mediastinal sampling increased from 54% to 64% (P < .0001). Guideline-consistent care was associated with fewer thoracotomies (38% vs 71%; P < .001) and CT scan-guided biopsies (10% vs 75%; P < .001) than guideline-inconsistent care but more transbronchial needle aspirations (59% vs 12%; P < .001). Guideline-consistent care was associated with fewer pneumothoraxes (5.1% vs 22%; P < .001), chest tubes (0.9% vs 4.4%; P < .001), hemorrhages (3.5% vs 5.8%; P < .001), and respiratory failure events (2.7% vs 3.7%; P = .047) than guideline-inconsistent care. Bronchoscopic mediastinal sampling was associated with fewer complications than surgical mediastinal sampling. CONCLUSIONS Guideline-consistent care with mediastinal sampling first was associated with fewer tests and complications. Quality gaps decreased with the introduction of endobronchial ultrasound-guided transbronchial needle aspiration but persist. Gaps include failure to sample the mediastinum first, failure to sample the mediastinum at all, and overuse of thoracotomy.
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Affiliation(s)
- David E Ost
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Jiangong Niu
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Hui Zhao
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Horiana B Grosu
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sharon H Giordano
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX
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Epelbaum O, Rahman NM. Contemporary approach to the patient with malignant pleural effusion complicating lung cancer. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:352. [PMID: 31516898 DOI: 10.21037/atm.2019.03.61] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Malignant pleural effusion (MPE) occurring in the patient with lung cancer can have profound prognostic and management implications. If clinically relevant, such an effusion first needs to be confirmed as malignant and then, in the majority of lung cancer patients, it will require a pleural intervention to relieve symptoms related to fluid accumulation. The field of pleural diseases in general, and pleural malignancy in particular, has undergone dynamic changes in recent years as the evidence base informing practice has grown by leaps and bounds. Both the diagnosis and management of MPE are dynamically changing disciplines in thoracic medicine. As commonly happens, emerging data have generated just as many questions as they have answered. The aim of the present review is to summarize the current knowledge about MPE resulting from lung cancer in a manner that is accessible to clinicians across medical specialties.
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Affiliation(s)
- Oleg Epelbaum
- Division of Pulmonary, Critical Care and Sleep Medicine, Westchester Medical Center, Valhalla, NY, USA
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Respiratory Trials Unit, Oxford University, Oxford, UK
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Meriggi F. Malignant Pleural Effusion: Still a Long Way to Go. Rev Recent Clin Trials 2019; 14:24-30. [PMID: 30514193 DOI: 10.2174/1574887114666181204105208] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 11/26/2018] [Accepted: 11/27/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Malignant pleural effusion, which is a common clinical problem in patients with cancer, may be due to both primary thoracic tumours or to a metastatic spread in the chest and constitutes the first sign of disease in approximately 10% of patients. Almost all cancers can potentially produce a pleural effusion. The presence of malignant tumour cells in the pleural fluid is generally indicative of advanced disease and is associated with high morbidity and mortality with reduced therapeutic options. Dyspnoea during mild physical activity or at rest is generally the typical sign of restrictive respiratory failure. METHODS This is a systematic review of all the main articles in the English language on the topic of malignant pleural effusion and reported by the Pubmed database from 1959 to 2018. I reviewed the literature and guidelines with the aims to focus on what is known and on future pathways to follow the diagnosis and treatment of malignant pleural effusions. RESULTS The main goal of palliation of a malignant pleural effusion is a quick improvement in dyspnoea, while thoracentesis under ultrasound guidance is the treatment of choice for patients with a limited life expectancy or who are not candidates for more invasive procedures such as drainage using an indwelling small pleural catheter, chemical pleurodesis with sclerosing agents, pleurectomy or pleuro-peritoneal shunt. CONCLUSION Despite progress in therapeutic options, the prognosis remains severe, and the average survival is 4-9 months from the diagnosis of malignant pleural effusion. Moreover, mortality is higher for patients with malignant pleural effusion compared with those with metastatic cancer but no malignant pleural effusion. Therefore, the prognosis of these patients primarily depends on the underlying disease and the extension of a primary tumour. This review focuses on the most relevant updates in the management of malignant pleural effusion.
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Affiliation(s)
- Fausto Meriggi
- Oncology Department - Poliambulanza Foundation, Brescia, Italy
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Beck TN, Deneka AY, Chai L, Kanach C, Johal P, Alvarez NJ, Boumber Y, Golemis EA, Laub GW. An improved method of delivering a sclerosing agent for the treatment of malignant pleural effusion. BMC Cancer 2019; 19:614. [PMID: 31234819 PMCID: PMC6589887 DOI: 10.1186/s12885-019-5777-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 05/30/2019] [Indexed: 12/26/2022] Open
Abstract
Background Malignant pleural effusion (MPE) is a devastating sequela associated with cancer. Talc pleurodesis is a common treatment strategy for MPE but has been estimated to be unsuccessful in up to 20–50% of patients. Clinical failure of talc pleurodesis is thought to be due to poor dispersion. This monograph reports the development of a foam delivery system designed to more effectively coat the pleural cavity. Methods C57BL/6 mice were injected with Lewis lung carcinoma (LL/2) cells intrapleurally to induce MPE. The mice then received either normal saline (NS) control, foam control (F), talc slurry (TS, 2 mg/g) or talc foam (TF, 2 mg/g). Airspace volume was evaluated by CT, lungs/pleura were collected, and percent fibrosis was determined. Results The TF group had significantly better survival than the TS group (21 vs 13.5 days, p < 0.0001). The average effusion volume was less in the talc groups compared to the control group (140 vs 628 μL, p < 0.001). TF induced significant lung fibrosis (p < 0.01), similar to TS. On CT, TF significantly (p < 0.05) reduced loss of right lung volume (by 30–40%) compared to the control group. This was not seen with TS (p > 0.05). Conclusions This report describes using a novel talc foam delivery system for the treatment of MPE. In the LL/2 model, mice treated with the TF had better survival outcomes and less reduction of lung volume than mice treated with the standard of care TS. These data provide support for translational efforts to move talc foam from animal models into clinical trials.
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Affiliation(s)
- Tim N Beck
- Program in Molecular Therapeutics, Fox Chase Cancer Center, Philadelphia, PA, 19111, USA. .,Digestive Disease & Surgery Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | - Alexander Y Deneka
- Program in Molecular Therapeutics, Fox Chase Cancer Center, Philadelphia, PA, 19111, USA.,Department of Biochemistry, Kazan Federal University, Kazan, Russia
| | - Louis Chai
- Department of Cardiothoracic Surgery, Drexel University College of Medicine, Hahnemann University Hospital, 230 North Broad Street, Philadelphia, PA, 19102, USA
| | - Colin Kanach
- Department of Pathology, Drexel University College of Medicine, Philadelphia, PA, 19129, USA
| | - Priya Johal
- Department of Pathology, Drexel University College of Medicine, Philadelphia, PA, 19129, USA
| | - Nicolas J Alvarez
- Department of Chemical and Biological Engineering, Drexel University, Philadelphia, PA, 19129, USA
| | - Yanis Boumber
- Department of Biochemistry, Kazan Federal University, Kazan, Russia.,Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, PA, 19111, USA
| | - Erica A Golemis
- Program in Molecular Therapeutics, Fox Chase Cancer Center, Philadelphia, PA, 19111, USA
| | - Glenn W Laub
- Department of Cardiothoracic Surgery, Drexel University College of Medicine, Hahnemann University Hospital, 230 North Broad Street, Philadelphia, PA, 19102, USA.
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50
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Rakesh HR, Gelzinis TA. The Updated ATS/STS/STR Clinical Practice Guidelines on the Management of Malignant Pleural Effusions: What Is New in 2018? J Cardiothorac Vasc Anesth 2019; 33:1181-1186. [DOI: 10.1053/j.jvca.2018.11.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Indexed: 12/16/2022]
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