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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: 19] [Impact Index Per Article: 6.3] [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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Noro R, Kobayashi K, Usuki J, Yomota M, Nishitsuji M, Shimokawa T, Ando M, Hino M, Hagiwara K, Miyanaga A, Seike M, Kubota K, Gemma A. Bevacizumab plus chemotherapy in nonsquamous non-small cell lung cancer patients with malignant pleural effusion uncontrolled by tube drainage or pleurodesis: A phase II study North East Japan Study group trial NEJ013B. Thorac Cancer 2020; 11:1876-1884. [PMID: 32421226 PMCID: PMC7327672 DOI: 10.1111/1759-7714.13472] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 04/18/2020] [Accepted: 04/19/2020] [Indexed: 12/26/2022] Open
Abstract
Background Pleurodesis is the standard of care for non‐small cell lung cancer (NSCLC) patients with symptomatic malignant pleural effusion (MPE). However, there is no standard management for MPE uncontrolled by pleurodesis. Most patients with unsuccessful MPE control are unable to receive effective chemotherapy. Vascular endothelial growth factor (VEGF) plays an important role in the pathogenesis of MPE. This multicenter, phase II study investigated the effects of bevacizumab plus chemotherapy in nonsquamous NSCLC patients with unsuccessful management of MPE. Methods Nonsquamous NSCLC patients with MPE following unsuccessful tube drainage or pleurodesis received bevacizumab (15 mg/kg) plus chemotherapy every three weeks. The primary endpoint was pleural effusion control rate (PECR), defined as the percentage of patients without reaccumulation of MPE at eight weeks. Secondary endpoints included pleural progression‐free survival (PPFS), safety, and quality of life (QoL). Results A total of 20 patients (median age: 69 years; 14 males; 20 adenocarcinomas; six epidermal growth factor receptor mutations) were enrolled in nine centers. The PECR was 80% and the primary end point was met. The PPFS and the overall survival (OS) were 16.6 months and 19.6 months, respectively. Patients with high levels of VEGF in the MPE had shorter PPFS (P = 0.010) and OS (P = 0.002). Toxicities of grade ≥ 3 included neutropenia (50%), thrombocytopenia (10%), proteinuria (10%), and hypertension (2%). The cognitive QoL score improved after treatment. Conclusions Bevacizumab plus chemotherapy is highly effective with acceptable toxicities in nonsquamous NSCLC patients with uncontrolled MPE, and should be considered as a standard therapy in this setting. Key points Significant findings of the study Bevacizumab plus chemotherapy is highly effective with acceptable toxicities in nonsquamous NSCLC patients with uncontrolled MPE. What this study adds Bevacizumab plus chemotherapy should be considered as a standard treatment option for patients with uncontrolled MPE. Clinical trial registration UMIN000006868 was a phase II study of efficacy of bevacizumab plus chemotherapy for the management of malignant pleural effusion (MPE) in nonsquamous non‐small cell lung cancer patients with MPE unsuccessfully controlled by tube drainage or pleurodesis (North East Japan Study Group Trial NEJ‐013B) (http://umin.sc.jp/ctr/).
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Affiliation(s)
- Rintaro Noro
- Department of Pulmonary Medicine and Oncology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Kunihiko Kobayashi
- Department of Respiratory medicine, Saitama Medical University International Medical Center, Saitama, Japan
| | - Jiro Usuki
- Department of Pulmonary Medicine, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Makiko Yomota
- Department of Thoracic Oncology and Respiratory Medicine, Tokyo Metropolitan Cancer and Infectious disease Center Komagome Hospital, Tokyo, Japan
| | - Masaru Nishitsuji
- Department of Respiratory Medicine, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Tsuneo Shimokawa
- Department of Respiratory Medicine and Medical Oncology, Yokohama Municipal Citizen's Hospital, Yokohama, Japan
| | - Masahiro Ando
- Department of Internal Medicine, Jizankai Medical Foundation Tsuboi Cancer Center Hospital, Fukushima, Japan
| | - Mitsunori Hino
- Department of Pulmonary Medicine, Nippon Medical School Chiba Hokuso Hospital, Chiba, Japan
| | - Koichi Hagiwara
- Division of Pulmonary Medicine, Jichi Medical University, Tochigi, Japan
| | - Akihiko Miyanaga
- Department of Pulmonary Medicine and Oncology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Masahiro Seike
- Department of Pulmonary Medicine and Oncology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Kaoru Kubota
- Department of Pulmonary Medicine and Oncology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Akihiko Gemma
- Department of Pulmonary Medicine and Oncology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
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Dipper A, Jones HE, Bhatnagar R, Preston NJ, Maskell N, Clive AO. Interventions for the management of malignant pleural effusions: a network meta-analysis. Cochrane Database Syst Rev 2020; 4:CD010529. [PMID: 32315458 PMCID: PMC7173736 DOI: 10.1002/14651858.cd010529.pub3] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Malignant pleural effusion (MPE) is a common problem for people with cancer and usually associated with considerable breathlessness. A number of treatment options are available to manage the uncontrolled accumulation of pleural fluid, including administration of a pleurodesis agent (via a chest tube or thoracoscopy) or placement of an indwelling pleural catheter (IPC). This is an update of a review published in Issue 5, 2016, which replaced the original, published in 2004. OBJECTIVES To ascertain the optimal management strategy for adults with malignant pleural effusion in terms of pleurodesis success and to quantify differences in patient-reported outcomes and adverse effects between interventions. SEARCH METHODS We searched CENTRAL, MEDLINE (Ovid), Embase (Ovid) and three other databases to June 2019. We screened reference lists from other relevant publications and searched trial registries. SELECTION CRITERIA We included randomised controlled trials of intrapleural interventions for adults with symptomatic MPE, comparing types of sclerosant, mode of administration and IPC use. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data on study design, characteristics, outcome measures, potential effect modifiers and risk of bias. The primary outcome was pleurodesis failure rate. Secondary outcomes were adverse events, patient-reported breathlessness control, quality of life, cost, mortality, survival, duration of inpatient stay and patient acceptability. We performed network meta-analyses of primary outcome data and secondary outcomes with enough data. We also performed pair-wise meta-analyses of direct comparison data. If we deemed interventions not jointly randomisable, or we found insufficient available data, we reported results by narrative synthesis. For the primary outcome, we performed sensitivity analyses to explore potential causes of heterogeneity and to evaluate pleurodesis agents administered via a chest tube only. We assessed the certainty of the evidence using GRADE. MAIN RESULTS We identified 80 randomised trials (18 new), including 5507 participants. We found all except three studies at high or unclear risk of bias for at least one domain. Due to the nature of the interventions, most studies were unblinded. Pleurodesis failure rate We included 55 studies of 21 interventions in the primary network meta-analysis. We estimated the rank of each intervention's effectiveness. Talc slurry (ranked 6, 95% credible interval (Cr-I) 3 to 10) is an effective pleurodesis agent (moderate certainty for comparison with placebo) and may result in fewer pleurodesis failures than bleomycin and doxycycline (bleomycin versus talc slurry: odds ratio (OR) 2.24, 95% Cr-I 1.10 to 4.68; low certainty; ranked 11, 95% Cr-I 7 to 15; doxycycline versus talc slurry: OR 2.51, 95% Cr-I 0.81 to 8.40; low certainty; ranked 12, 95% Cr-I 5 to 18). There is little evidence of a difference between the pleurodesis failure rate of talc poudrage and talc slurry (OR 0.50, 95% Cr-I 0.21 to 1.02; moderate certainty). Evidence for any difference was further reduced when restricting analysis to studies at low risk of bias (defined as maximum one high risk domain in the risk of bias assessment) (pleurodesis failure talc poudrage versus talc slurry: OR 0.78, 95% Cr-I 0.16 to 2.08). IPCs without daily drainage are probably less effective at obtaining a definitive pleurodesis (cessation of pleural fluid drainage facilitating IPC removal) than talc slurry (OR 7.60, 95% Cr-I 2.96 to 20.47; rank = 18/21, 95% Cr-I 13 to 21; moderate certainty). Daily IPC drainage or instillation of talc slurry via IPC are likely to reduce pleurodesis failure rates. Adverse effects Adverse effects were inconsistently reported. We performed network meta-analyses for the risk of procedure-related fever and pain. The evidence for risk of developing fever was of low certainty, but suggested there may be little difference between interventions relative to talc slurry (talc poudrage: OR 0.89, 95% Cr-I 0.11 to 6.67; bleomycin: OR 2.33, 95% Cr-I 0.45 to 12.50; IPCs: OR 0.41, 95% Cr-I 0.00 to 50.00; doxycycline: OR 0.85, 95% Cr-I 0.05 to 14.29). Evidence also suggested there may be little difference between interventions in the risk of developing procedure-related pain, relative to talc slurry (talc poudrage: OR 1.26, 95% Cr-I 0.45 to 6.04; very-low certainty; bleomycin: OR 2.85, 95% Cr-I 0.78 to 11.53; low certainty; IPCs: OR 1.30, 95% Cr-I 0.29 to 5.87; low certainty; doxycycline: OR 3.35, 95% Cr-I 0.64 to 19.72; low certainty). Patient-reported control of breathlessness Pair-wise meta-analysis suggests there is likely no difference in breathlessness control, relative to talc slurry, of talc poudrage ((mean difference (MD) 4.00 mm, 95% CI -6.26 to 14.26) on a 100 mm visual analogue scale for breathlessness; studies = 1; participants = 184; moderate certainty) and IPCs without daily drainage (MD -6.12 mm, 95% CI -16.32 to 4.08; studies = 2; participants = 160; low certainty). Overall mortality There may be little difference between interventions when compared to talc slurry (bleomycin and IPC without daily drainage; low certainty) but evidence is uncertain for talc poudrage and doxycycline. Patient acceptability Pair-wise meta-analysis demonstrated that IPCs probably result in a reduced risk of requiring a repeat invasive pleural intervention (OR 0.25, 95% Cr-I 0.13 to 0.48; moderate certainty) relative to talc slurry. There is likely little difference in the risk of repeat invasive pleural intervention with talc poudrage relative to talc slurry (OR 0.96, 95% CI 0.59 to 1.56; moderate certainty). AUTHORS' CONCLUSIONS Based on the available evidence, talc poudrage and talc slurry are effective methods for achieving a pleurodesis, with lower failure rates than a number of other commonly used interventions. IPCs provide an alternative approach; whilst associated with inferior definitive pleurodesis rates, comparable control of breathlessness can probably be achieved, with a lower risk of requiring repeat invasive pleural intervention. Local availability, global experience of agents and adverse events (which may not be identified in randomised trials) and patient preference must be considered when selecting an intervention. Further research is required to delineate the roles of different treatments according to patient characteristics, such as presence of trapped lung. Greater attention to patient-centred outcomes, including breathlessness, quality of life and patient preference is essential to inform clinical decision-making. Careful consideration to minimise the risk of bias and standardise outcome measures is essential for future trial design.
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Affiliation(s)
| | - Hayley E Jones
- University of BristolPopulation Health Sciences, Bristol Medical SchoolCanynge Hall39 Whatley RoadBristolUKBS8 2PS
| | | | - Nancy J Preston
- Lancaster UniversityInternational Observatory on End of Life CareFurness CollegeLancasterUKLA1 4YG
| | - Nick Maskell
- University of BristolAcademic Respiratory UnitBristolUK
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Hassan M, Gadallah M, Mercer RM, Harriss E, Rahman NM. Predictors of outcome of pleurodesis in patients with malignant pleural effusion: a systematic review and meta-analysis. Expert Rev Respir Med 2020; 14:645-654. [PMID: 32213100 DOI: 10.1080/17476348.2020.1746647] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Objectives: Pleurodesis is an important management option to palliate breathlessness in patients with malignant pleural effusion (MPE). This systematic review aimed to examine available literature for studies investigating factors that predict pleurodesis outcome.Methods: The healthcare databases advanced search (HDAS) Medline and Embase in addition to Cochrane Database of Systematic Reviews were searched on for publications reporting on pleurodesis for MPE in English language. All study types reporting previously unpublished data on predictors of pleurodesis success were included. Thirty-four studies involving 4626 patients were included in the systematic review.Results: The most common pleurodesis agent used was talc which was used in 27 studies. Meta-analyses demonstrated that the strongest predictors of pleurodesis success were higher pleural fluid pH, smaller volume of effusion pre-pleurodesis and full lung re-expansion post effusion drainage. Shorter duration of tube drainage, higher pleural fluid glucose, lower LDH, and lower pleural tumor burden all seem to favor pleurodesis success, but with considerable statistical heterogeneity between studies. Available data do not suggest that chest tube size affects pleurodesis outcome.Conclusion: Overall, available results are difficult to interpret due to evidence quality. Prospective studies are needed to further explore these factors.Protocol registration: CRD42018115874 (Prospero database of systematic reviews).
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Affiliation(s)
- Maged Hassan
- Chest Diseases Department, Alexandria Faculty of Medicine, Alexandria, Egypt
| | - Mohamed Gadallah
- Chest Diseases Department, Alexandria Faculty of Medicine, Alexandria, Egypt
| | - Rachel M Mercer
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Elinor Harriss
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Najib M Rahman
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
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5
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Conway FM, Garner JL, Orton CM, Srikanthan K, Kemp SV, Shah PL. Contemporary Concise Review 2018: Lung cancer and pleural disease. Respirology 2019; 24:475-483. [PMID: 30772946 DOI: 10.1111/resp.13499] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 01/23/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Francesca M Conway
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College, London, UK
| | - Justin L Garner
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College, London, UK
| | - Christopher M Orton
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College, London, UK
| | - Karthi Srikanthan
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College, London, UK
| | - Samuel V Kemp
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College, London, UK
| | - Pallav L Shah
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College, London, UK
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6
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Thoracic Ultrasound as an Early Predictor of Pleurodesis Success in Malignant Pleural Effusion. Chest 2018; 154:1115-1120. [DOI: 10.1016/j.chest.2018.08.1031] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 07/07/2018] [Accepted: 08/01/2018] [Indexed: 11/22/2022] Open
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Saka H, Oki M, Kitagawa C, Kogure Y, Kojima Y, Saito AM, Ishida A, Miyazawa T, Takeda K, Nakagawa K, Sasada S, Negoro S. Sterilized talc pleurodesis for malignant pleural effusions: a Phase II study for investigational new drug application in Japan. Jpn J Clin Oncol 2018. [PMID: 29528450 DOI: 10.1093/jjco/hyy020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Malignant pleural effusion is a commonly seen complication of malignancies such as lung and breast cancers. In Western countries, talc is frequently used as a standard therapeutic agent (pleurodesis agent) with the aim of alleviating symptoms including dyspnea and chest pain. Talc is not recognized as a pleurodesis agent in Japan. The aim of this study was to verify the efficacy and safety of sterilized talc (NPC-05) for the introduction of talc in Japan. Methods The study was a single-arm, open-label, investigator-initiated trial conducted jointly at six institutions. The subjects were 30 patients with malignant pleural effusions. A solution of 4 g NPC-05 suspended in 50 ml physiological saline was instilled into the pleural space to perform pleurodesis. Results The efficacy of NPC-05 for pleural adhesion 30 days after pleurodesis was 83.3% (25/30 cases). Amelioration of dyspnea and pain (chest pain) was seen. Commonly seen adverse effects were increased C-reactive protein (CRP) and fever. Nearly all adverse events were phenomena previously reported as adverse effects of talc. No acute respiratory distress syndrome (ARDS) or other serious side effects occurred. Conclusion The efficacy and safety of NPC-05 for malignant pleural effusion in Japanese patients was verified, and the clinical outcomes with talc were confirmed to be the same as previously reported in other countries. There is thought to be a high level of need for this agent in the treatment of malignant pleural effusion in Japan.
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Affiliation(s)
- Hideo Saka
- Department of Respiratory Medicine, National Hospital Organization Nagoya Medical Center, Aichi
| | - Masahide Oki
- Department of Respiratory Medicine, National Hospital Organization Nagoya Medical Center, Aichi
| | - Chiyoe Kitagawa
- Department of Respiratory Medicine, National Hospital Organization Nagoya Medical Center, Aichi
| | - Yoshihito Kogure
- Department of Respiratory Medicine, National Hospital Organization Nagoya Medical Center, Aichi
| | - Yuki Kojima
- Department of Respiratory Medicine, National Hospital Organization Nagoya Medical Center, Aichi
| | - Akiko M Saito
- Clinical Research Center, National Hospital Organization, Nagoya Medical Center, Aichi
| | - Atsuko Ishida
- Department of Respiratory/Infectious Diseases, St. Marianna University School of Medicine Hospital, Kanagawa
| | - Teruomi Miyazawa
- Department of Respiratory/Infectious Diseases, St. Marianna University School of Medicine Hospital, Kanagawa
| | - Koji Takeda
- Department of Medical Oncology, Osaka City General Hospital, Osaka
| | | | - Shinji Sasada
- Department of Respiratory Medicine, Tokyo Saiseikai Central Hospital, Tokyo
| | - Shunichi Negoro
- Department of Medical Oncology, Hyogo Cancer Center, Hyogo, Japan
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Ferreiro L, San José E, Gude F, Valdés L. Análisis del líquido y elastancia pleurales como predictores de respuesta a la pleurodesis en los derrames pleurales malignos. Arch Bronconeumol 2018; 54:163-165. [DOI: 10.1016/j.arbres.2017.07.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 07/22/2017] [Accepted: 07/29/2017] [Indexed: 12/13/2022]
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Mercer RM, Hassan M, Rahman NM. The role of pleurodesis in respiratory diseases. Expert Rev Respir Med 2018; 12:323-334. [DOI: 10.1080/17476348.2018.1445971] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Rachel M. Mercer
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Maged Hassan
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
- Chest Diseases Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Najib M. Rahman
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
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Abstract
Malignant pleural effusion is a common complication of cancer and denotes a poor prognosis. It usually presents with dyspnea and a unilateral large pleural effusion. Thoracic computed tomography scans and ultrasound are helpful in distinguishing malignant from benign effusions. Pleural fluid cytology is diagnostic in about 60% of cases. In cytology-negative disease, pleural biopsies are helpful. Current management is palliative. Previously, first-line treatment for recurrent symptomatic malignant pleural effusion was chest drain insertion and talc pleurodesis, with indwelling pleural catheter insertion reserved for patients with trapped lung or failed talc pleurodesis. However, catheter insertion is an increasingly acceptable first-line treatment.
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Affiliation(s)
- Rachelle Asciak
- Respiratory Medicine, Oxford University Hospitals, Churchill Hospital, Old Road, Headington, Oxford OX3 7LE, Great Britain
| | - Najib M Rahman
- Respiratory Medicine, Oxford University Hospitals, Churchill Hospital, Old Road, Headington, Oxford OX3 7LE, Great Britain.
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Psallidas I, Piotrowska HEG, Yousuf A, Kanellakis NI, Kagithala G, Mohammed S, Clifton L, Corcoran JP, Russell N, Dobson M, Miller RF, Rahman NM. Efficacy of sonographic and biological pleurodesis indicators of malignant pleural effusion (SIMPLE): protocol of a randomised controlled trial. BMJ Open Respir Res 2017; 4:e000225. [PMID: 29225889 PMCID: PMC5708313 DOI: 10.1136/bmjresp-2017-000225] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Revised: 10/06/2017] [Indexed: 01/11/2023] Open
Abstract
Introduction Malignant pleural effusion (MPE) is common and currently in UK there are an estimated 50 000 new cases of MPE per year. Talc pleurodesis remains one of the most popular methods for fluid control. The value of thoracic ultrasound (TUS) imaging, before and after pleurodesis, in improving the quality and efficacy of care for patients with MPE remains unknown. Additionally, biomarkers of successful pleurodesis including measurement of pleural fluid proteins have not been validated in prospective studies.The SIMPLE trial is an appropriately powered, multicentre, randomised controlled trial designed to assess 'by the patient bedside' use of TUS imaging and pleural fluid analysis in improving management of MPE. Methods and analysis 262 participants with a confirmed MPE requiring intervention will be recruited from hospitals in UK and The Netherlands. Participants will be randomised (1:1) to undergo either chest drain insertion followed by instillation of sterile talc, or medical thoracoscopy and simultaneous poudrage. The allocated procedure will be done while the patient is hospitalised, and within 3 days of randomisation. Following hospital discharge, participants will be followed up at 1, 3 and 12 months. The primary outcome measure is the length of hospital stay during initial hospitalisation. Ethics and dissemination The trial has received ethical approval from the South Central-Oxford C Research Ethics Committee (Reference number 15/SC/0600). The Trial Steering Committee includes an independent chair and members, and a patient representative. The trial results will be published in a peer-reviewed journal and presented at international conferences. Trial registration number ISRCTN: 16441661.
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Affiliation(s)
- Ioannis Psallidas
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Nuffield Department of Medicine, Laboratory of Pleural and Lung Cancer Translational Research, University of Oxford, Oxford, UK.,Oxford Respiratory Trials Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK.,National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Hania E G Piotrowska
- Oxford Respiratory Trials Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Ahmed Yousuf
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Oxford Respiratory Trials Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Nikolaos I Kanellakis
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Nuffield Department of Medicine, Laboratory of Pleural and Lung Cancer Translational Research, University of Oxford, Oxford, UK.,Oxford Respiratory Trials Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK.,National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Gayathri Kagithala
- Oxford Respiratory Trials Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Seid Mohammed
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Lei Clifton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - John P Corcoran
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Oxford Respiratory Trials Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Nicky Russell
- Oxford Respiratory Trials Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Melissa Dobson
- Oxford Respiratory Trials Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Robert F Miller
- Institute of Global Health, University College London, London, UK.,Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Nuffield Department of Medicine, Laboratory of Pleural and Lung Cancer Translational Research, University of Oxford, Oxford, UK.,Oxford Respiratory Trials Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK.,National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
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12
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Abstract
Malignant pleural effusion (MPE) is common in clinical practice, and despite the existence of studies to guide clinical decisions, it often poses diagnostic and therapeutic dilemmas. Once it is diagnosed, median survival does not usually exceed 6 months. The management of these patients focuses on symptom relief since no treatments have been shown to increase survival to date. Conversely, poor management can shorten survival. The approach must be multidisciplinary and allow for individualized care. Initial diagnostic procedures should be minimally invasive and, according to the results and other factors, procedures of increasing complexity will be selecting. Likewise, the treatment of MPEs should be individualized according to factors such as type of tumor, patient functional status, means available, benefits of each procedure, or life expectancy. Currently, treatment seems to tend toward less interventional approaches, in which patients can be managed on an outpatient basis, thus minimizing both the discomfort that more aggressive approaches involve and the costs of care associated with this disease. This article reviews the pleural procedures employed in the management of MPEs with special emphasis on the indication for each one, its usefulness, benefits, and complications.
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Affiliation(s)
- Lucía Ferreiro
- Department of Pulmonology, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain; Interdisciplinary Research Group in Pulmonology, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Juan Suárez-Antelo
- Department of Pulmonology, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Luis Valdés
- Department of Pulmonology, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain; Interdisciplinary Research Group in Pulmonology, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
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13
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Usui K, Sugawara S, Nishitsuji M, Fujita Y, Inoue A, Mouri A, Watanabe H, Sakai H, Kinoshita I, Ohhara Y, Maemondo M, Kagamu H, Hagiwara K, Kobayashi K. A phase II study of bevacizumab with carboplatin-pemetrexed in non-squamous non-small cell lung carcinoma patients with malignant pleural effusions: North East Japan Study Group Trial NEJ013A. Lung Cancer 2016; 99:131-6. [DOI: 10.1016/j.lungcan.2016.07.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 06/01/2016] [Accepted: 07/03/2016] [Indexed: 10/21/2022]
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Clive AO, Jones HE, Bhatnagar R, Preston NJ, Maskell N. Interventions for the management of malignant pleural effusions: a network meta-analysis. Cochrane Database Syst Rev 2016; 2016:CD010529. [PMID: 27155783 PMCID: PMC6450218 DOI: 10.1002/14651858.cd010529.pub2] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Malignant pleural effusion (MPE) is a common problem for people with cancer as a result of malignant infiltration of the pleura. It is usually associated with considerable breathlessness. A number of treatment options are available to manage the uncontrolled accumulation of pleural fluid including administration of a pleurodesis agent (either via a chest tube or at thoracoscopy) or indwelling pleural catheter insertion. OBJECTIVES To ascertain the optimal management strategy for adults with malignant pleural effusion in terms of pleurodesis success. Additionally, to quantify differences in patient-reported outcomes and adverse effects between management strategies. SEARCH METHODS We searched The Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Ovid EMBASE; EBSCO CINAHL; SCI-EXPANDED and SSCI (ISI Web of Science) to April 2015. SELECTION CRITERIA We included randomised controlled trials of intrapleural interventions for adults with symptomatic MPE in the review. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data on study design, study characteristics, outcome measures, potential effect modifiers and risk of bias.The primary outcome measure was pleurodesis failure rate. Secondary outcome measures were adverse effects and complications, patient-reported control of breathlessness, quality of life, cost, mortality, duration of inpatient stay and patient acceptability.We performed network meta-analysis with random effects to analyse the primary outcome data and those secondary outcomes with enough data. We also performed pair-wise random-effects meta-analyses of direct comparison data. If interventions were not deemed jointly randomisable, or insufficient data were available, we reported the results by narrative synthesis. We performed sensitivity analyses to explore heterogeneity and to evaluate only those pleurodesis agents administered via a chest tube at the bedside. MAIN RESULTS Of the 1888 records identified, 62 randomised trials, including a total of 3428 patients, were eligible for inclusion. All studies were at high or uncertain risk of bias for at least one domain.Network meta-analysis evaluating the rate of pleurodesis failure, suggested talc poudrage to be a highly effective method (ranked second of 16 (95% credible interval (Cr-I) 1 to 5)) and provided evidence that it resulted in fewer pleurodesis failures than eight other methods. The estimated ranks of other commonly used agents were: talc slurry (fourth; 95% Cr-I 2 to 8), mepacrine (fourth; 95% Cr-I 1 to 10), iodine (fifth; 95% Cr-I 1 to 12), bleomycin (eighth; 95% Cr-I 5 to 11) and doxycyline (tenth; 95% Cr-I 4 to 15). The estimates were imprecise as evidenced by the wide credible intervals and both high statistical and clinical heterogeneity.Most of the secondary outcomes, including adverse events, were inconsistently reported by the included studies and the methods used to describe them varied widely. Hence the majority of the secondary outcomes were reported descriptively in this review. We obtained sufficient data to perform network meta-analysis for the most commonly reported adverse events: pain, fever and mortality. The fever network was imprecise and showed substantial heterogeneity, but suggested placebo caused the least fever (ranked first of 11 (95% Cr-I 1 to 7)) and mepacrine and Corynebacterium parvum (C. parvum) appeared to be associated with the most fever (ranked tenth (95% Cr-I 6 to 11) and eleventh (95% Cr-I 7 to 11) respectively). No differences between interventions were revealed by the network meta-analysis of the pain data. The only potential difference in mortality identified in the mortality network was that those receiving tetracycline appeared to have a longer survival than those receiving mitoxantrone (OR 0.16 (95% Confidence Interval (CI) 0.03 to 0.72)). Indwelling pleural catheters were examined in two randomised studies, both of which reported improved breathlessness when compared to talc slurry pleurodesis, despite lower pleurodesis success rates.The risk of bias in a number of the included studies was substantial, for example the vast majority of studies were unblinded, and the methods used for sequence generation and allocation concealment were often unclear. Overall, however, the risk of bias for all studies was moderate. We have not reported the GRADE quality of evidence for the outcomes, as the role of GRADE is not well established in the context of Network Meta-analysis (NMA). AUTHORS' CONCLUSIONS Based on the available evidence, talc poudrage is a more effective pleurodesis method in MPE than a number of other frequently used methods, including tetracycline and bleomycin. However further data are required to definitively confirm whether it is more effective than certain other commonly used interventions such as talc slurry and doxycycline, particularly in view of the high statistical and clinical heterogeneity within the network and the high risk of bias of many of the included studies. Based on the strength of the evidence from both direct and indirect comparisons of randomised data of sclerosants administered at the bedside, there is no evidence to suggest large differences between the other highly effective methods (talc slurry, mepacrine, iodine and C. parvum). However, local availability, global experience of these agents and their adverse events, which may not be identified in randomised trials, must also be considered when selecting a sclerosant. Further research is required to delineate the roles of different treatments according to patient characteristics (e.g. according to their prognosis or presence of trapped lung) and to explore patient-centred outcomes, such as breathlessness and quality of life, in more detail. Careful consideration to minimise the risk of bias and standardise outcome measures is essential for future trial design.
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Affiliation(s)
- Amelia O Clive
- University of BristolAcademic Respiratory UnitSouthmead RoadBristolUKBS10 5NB
| | - Hayley E Jones
- University of BristolSchool of Social and Community MedicineCanynge Hall39 Whatley RoadBristolUKBS8 2PS
| | - Rahul Bhatnagar
- University of BristolAcademic Respiratory UnitSouthmead RoadBristolUKBS10 5NB
| | - Nancy J Preston
- Lancaster UniversityInternational Observatory on End of Life CareFurness CollegeLancasterUKLA1 4YG
| | - Nick Maskell
- University of BristolAcademic Respiratory UnitSouthmead RoadBristolUKBS10 5NB
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Rial MB, Lamela IP, Fernández VL, Arca JA, Delgado MN, Pombo CV, Hernández CR, Fernández-Villar A. Management of malignant pleural effusion by an indwelling pleural catheter: A cost-efficiency analysis. Ann Thorac Med 2015; 10:181-4. [PMID: 26229560 PMCID: PMC4518348 DOI: 10.4103/1817-1737.160837] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 04/30/2015] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND For patients that are expected to survive for longer, the risk of complications combined with the need for more vacuum drainage bottles have become barriers to the placement of indwelling pleural catheter (IPC), since these could increase costs. OBJETIVES The objective of the current article is to determine the cost and efficiency of treating malignant pleural effusion (MPE) with IPC in Spanish hospitals. METHODS We compared the cost associated with the use of IPC per outpatient and per inpatient. We analyzed the number of consultations, length of hospital stay, and outcome of the procedure. RESULTS Fifty-five patients were recruited. Spontaneous pleurodesis was achieved in 34.4% of the cases. Post-catheterization complications were observed in 7.2%. Supplementary procedures were unnecessary and 87.7% of the patients reported improved dyspnea. In 64.9% of the cases, the IPCs were inserted during hospitalization with a median hospitalization time of 4 days (1-7.5). There were differences in the number of visits with more consultations being observed in the outpatient group. There was no difference in the number of vacuum drainage bottles used. The complications supposed a cost increase of €1045.6 per outpatient and €432.54 per inpatient. The overall average cost of treatment per outpatient was €3310.2 and €5450.3 per inpatient. CONCLUSIONS The treatment with IPC was effective, safe, without need of any more procedures and led to improved dyspnea in more than 85% of the patients. The cost is lower in the outpatient group, although complications represent an increased cost in both groups.
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Affiliation(s)
- Maribel Botana Rial
- Department of Pneumology, Bronchopleural Unit, Respiratory and Infectious Disease Research Group, Bio-medical Research Institute of Vigo (IBIV), Complexo Hospitalario Universitario de Vigo (CHUVI), Vigo, Spain
| | - Isaura Parente Lamela
- Department of Pneumology, Bronchopleural Unit, Complexo Hospitalario Universitario de Ourense (CHOU), Ourense, Spain
| | - Virginia Leiro Fernández
- Department of Pneumology, Bronchopleural Unit, Respiratory and Infectious Disease Research Group, Bio-medical Research Institute of Vigo (IBIV), Complexo Hospitalario Universitario de Vigo (CHUVI), Vigo, Spain
| | - José Abal Arca
- Department of Pneumology, Bronchopleural Unit, Complexo Hospitalario Universitario de Ourense (CHOU), Ourense, Spain
| | - Manuel Núñez Delgado
- Department of Pneumology, Bronchopleural Unit, Respiratory and Infectious Disease Research Group, Bio-medical Research Institute of Vigo (IBIV), Complexo Hospitalario Universitario de Vigo (CHUVI), Vigo, Spain
| | - Carlos Vilariño Pombo
- Department of Pneumology, Bronchopleural Unit, Respiratory and Infectious Disease Research Group, Bio-medical Research Institute of Vigo (IBIV), Complexo Hospitalario Universitario de Vigo (CHUVI), Vigo, Spain
| | - Cristina Ramos Hernández
- Department of Pneumology, Bronchopleural Unit, Respiratory and Infectious Disease Research Group, Bio-medical Research Institute of Vigo (IBIV), Complexo Hospitalario Universitario de Vigo (CHUVI), Vigo, Spain
| | - Alberto Fernández-Villar
- Department of Pneumology, Bronchopleural Unit, Respiratory and Infectious Disease Research Group, Bio-medical Research Institute of Vigo (IBIV), Complexo Hospitalario Universitario de Vigo (CHUVI), Vigo, Spain
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16
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Sweatt AJ, Sung A. Interventional pulmonologist perspective: treatment of malignant pleural effusion. Curr Treat Options Oncol 2015; 15:625-43. [PMID: 25240411 DOI: 10.1007/s11864-014-0312-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OPINION STATEMENT The management of known malignant pleural effusions focuses around the initial thoracentesis and subsequent objective and subjective findings. A completely reexpanded lung after fluid removal and with symptomatic improvement predicts successful pleurodesis. Pleurodesis method depends on center expertise as well as patient preference. Medical thoracoscopy does not require the operating room setting and is performed on the spontaneously breathing patient with similar success rate to surgical thoracoscopy in the appropriately selected patients. However, it is not widely available. Talc insufflation is preferred for even distribution of sprayed particles to pleural surfaces. Most often, patients can be discharged home within 24 to 48 hours after continuous chest tube suction. Indwelling pleural catheter has become popular given the ease of insertion and patient centered home drainage. Coordinated care with good patient and family education and support is paramount to maximizing the beneficial potential of the catheter. Complications are minimal, and catheters are easily removed if patients can no longer benefit from drainage, or if pleurodesis has occurred. In the setting of trapped lung as a result of visceral pleura encasement from tumor, indwelling catheter can still be useful if the patient improves with thoracentesis. However, if no subjective improvement is seen after thoracentesis for trapped lung, then no procedure is recommended and other modes of palliation should be sought.
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Affiliation(s)
- Andrew J Sweatt
- Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, CA, USA,
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17
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Madani A, Ferri L, Seely A. Pleural Disorders. POCKET MANUAL OF GENERAL THORACIC SURGERY 2015. [PMCID: PMC7123486 DOI: 10.1007/978-3-319-17497-6_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
This chapter provides an overview of both benign and malignant pleural disorders, starting with the relevant anatomy and physiology. The focus is on the management of pneumothoraces and pleural effusions—conditions that are commonly encountered on a general thoracic surgery service. The pleural cavity is lined by parietal and visceral pleura, which are smooth membranes that are continuous with one another at the hilum and pulmonary ligaments.
Parietal Pleura: innermost chest wall layer, divided into cervical, costal, mediastinal and diaphragmatic pleura.
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Affiliation(s)
| | | | - Andrew Seely
- The Ottawa Hospital – General Campus, University of Ottawa, Ottawa, Ontario Canada
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18
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Thomas R, Francis R, Davies HE, Lee YCG. Interventional therapies for malignant pleural effusions: the present and the future. Respirology 2014; 19:809-22. [PMID: 24947955 DOI: 10.1111/resp.12328] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 05/01/2014] [Accepted: 05/01/2014] [Indexed: 11/29/2022]
Abstract
The approach to management of malignant pleural effusions (MPE) has changed over the past few decades. The key goals of MPE management are to relieve patient symptoms using the least invasive means and in the most cost-effective manner. There is now a realization that patient-reported outcome measures should be the primary goal of MPE treatment, and this now is the focus in most clinical trials. Efforts to minimize patient morbidity are complemented by development of less invasive treatments that have mostly replaced the more aggressive surgical approaches of the past. Therapeutic thoracentesis is simple, effective and generally safe, although its benefits may only be temporary. Pleurodesis is the conventional and for a long time the only definitive therapy available. However, the efficacy and safety of talc pleurodesis has been challenged. Indwelling pleural catheter (IPC) drainage is increasingly accepted worldwide and represents a new concept to improve symptoms without necessarily generating pleural symphysis. Recent studies support the effectiveness of IPC treatment and provide reassurance regarding its safety. An unprecedented number of clinical trials are now underway to improve various aspects of MPE care. However, choosing an optimal intervention for MPE in an individual patient remains a challenge due to our limited understanding of the underlying pathophysiology of breathlessness in MPE and a lack of predictors of survival and pleurodesis outcome. This review provides an overview of common pleural interventional procedures used for MPE management, controversies and limitations of current practice, and areas of research most needed to improve practice in future.
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Affiliation(s)
- Rajesh Thomas
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia; School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia, Australia; Pleural Disease Unit, Lung Institute of Western Australia, Perth, Western Australia, Australia
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19
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Sigurdardottir KR, Oldervoll L, Hjermstad MJ, Kaasa S, Knudsen AK, Løhre ET, Loge JH, Haugen DF. How are palliative care cancer populations characterized in randomized controlled trials? A literature review. J Pain Symptom Manage 2014; 47:906-914.e17. [PMID: 24018205 DOI: 10.1016/j.jpainsymman.2013.06.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 06/05/2013] [Accepted: 06/14/2013] [Indexed: 02/08/2023]
Abstract
CONTEXT The difficulties in defining a palliative care patient accentuate the need to provide stringent descriptions of the patient population in palliative care research. OBJECTIVES To conduct a systematic literature review with the aim of identifying which key variables have been used to describe adult palliative care cancer populations in randomized controlled trials (RCTs). METHODS The data sources used were MEDLINE (1950 to January 25, 2010) and Embase (1980 to January 25, 2010), limited to RCTs in adult cancer patients with incurable disease. Forty-three variables were systematically extracted from the eligible articles. RESULTS The review includes 336 articles reporting RCTs in palliative care cancer patients. Age (98%), gender (90%), cancer diagnosis (89%), performance status (45%), and survival (45%) were the most frequently reported variables. A large number of other variables were much less frequently reported. CONCLUSION A substantial variation exists in how palliative care cancer populations are described in RCTs. Few variables are consistently registered and reported. There is a clear need to standardize the reporting. The results from this work will serve as the basis for an international Delphi process with the aim of reaching consensus on a minimum set of descriptors to characterize a palliative care cancer population.
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Affiliation(s)
- Katrin Ruth Sigurdardottir
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Sunniva Centre for Palliative Care, Haraldsplass Deaconess Hospital, Bergen, Norway; Regional Centre of Excellence for Palliative Care, Western Norway, Haukeland University Hospital, Bergen, Norway.
| | - Line Oldervoll
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Røros Rehabilitation Centre, Røros, Norway
| | - Marianne Jensen Hjermstad
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Regional Centre for Excellence in Palliative Care, South Eastern Norway, Oslo University Hospital, Oslo, Norway
| | - Stein Kaasa
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Department of Oncology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Anne Kari Knudsen
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Department of Oncology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Erik Torbjørn Løhre
- Department of Oncology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Jon Håvard Loge
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; National Resource Centre for Late Effects After Cancer Treatment, Oslo University Hospital, Oslo, Norway
| | - Dagny Faksvåg Haugen
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Regional Centre of Excellence for Palliative Care, Western Norway, Haukeland University Hospital, Bergen, Norway
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Corcoran JP, Hallifax R, Rahman NM. Advances in the management of pleural disease. Expert Rev Respir Med 2013; 7:499-513. [PMID: 24138694 DOI: 10.1586/17476348.2013.838016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Pleural disease affects over 3000 people per million population annually. Consequently, it represents a significant proportion of the respiratory physician's workload and can present to clinicians of all backgrounds in primary and secondary care. Pleural effusions have been reported in association with over 50 different conditions; some related to specific pulmonary pathologies, but many being manifestations of multisystem disease. The burden that conditions such as pleural infection; malignant pleural disease; and pneumothorax impose on patients and health care systems is enormous and growing. As such, a clear understanding of these key conditions is crucial to any physician regardless of the specialty. This article addresses a number of areas relating to pleural disease, providing an overview of the diagnostic and therapeutic advances that have been made in our understanding of pleural pathology in recent years. The directions that future research in this important area of respiratory medicine might take will also be discussed.
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Affiliation(s)
- John P Corcoran
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals, Oxford, OX3 7LE, UK and
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21
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Abstract
Pleural disease is increasingly recognised as an important subspecialty within respiratory medicine, especially as cases of pleural disease continue to rise internationally. Recent advances have seen an expansion in the options available for managing patients with pleural disease, with access to local-anaesthetic thoracoscopy, indwelling pleural catheters and thoracic ultrasound all becoming commonplace. Pleural teams usually consist of a range of practitioners who can optimise the use of specialist services to ensure that patients with all types of pleural disease - who have traditionally needed extended admissions - are managed efficiently, often entirely as outpatients. A pleural service can also provide improved opportunities for enhancing procedural skills, engaging in clinical research, and reducing the costs of care. This article explores the justification for dedicated pleural services and teams, as well as highlighting the various roles of hospital personnel who might be most useful in ensuring their success.
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Affiliation(s)
- Rahul Bhatnagar
- Academic Respiratory Unit (University of Bristol)
- North Bristol Lung Centre, Southmead Hospital
| | - Nick Maskell
- Academic Respiratory Unit (University of Bristol)
- North Bristol Lung Centre, Southmead Hospital
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22
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Boshuizen RC, Onderwater S, Burgers SJA, van den Heuvel MM. The use of indwelling pleural catheters for the management of malignant pleural effusion--direct costs in a Dutch hospital. ACTA ACUST UNITED AC 2013; 86:224-8. [PMID: 23887083 DOI: 10.1159/000351796] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Accepted: 04/29/2013] [Indexed: 12/27/2022]
Abstract
BACKGROUND Indwelling pleural catheters (IPCs) are increasingly used in the treatment of malignant pleural effusion (MPE). In general, these catheters have been reported to manage MPE efficiently. Unfortunately, insurance companies in the Netherlands do not reimburse these catheters in either first-line treatment or following failed talc pleurodesis. OBJECTIVES Investigation of direct costs of IPC placement. METHODS Retrospective analysis of a prospectively collected database. Direct costs for both catheters and vacuum bottles were calculated. Indicators for indirect costs such as adverse events and complications and the need for additional home care for drainage were registered. RESULTS Mean costs for IPC amounted to EUR 2,173 and were different between tumor types - mesothelioma: EUR 4,028, breast: EUR 2,204, lung: EUR 1,146 and other: EUR 1,841; p = 0.017. Four patients were admitted to hospital for treatment of complications. Mean costs for IPC placement was similar when inserted as frontline treatment and after failed pleurodesis. Approximately 75% of patients did not need any help from specialized home care. CONCLUSION Direct costs for IPC placement turn out to be acceptable when compared with estimated hospitalization costs for pleurodesis treatment. Randomized controlled trials have to be performed to compare the cost-effectiveness of IPCs compared to pleurodesis.
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Affiliation(s)
- Rogier C Boshuizen
- Department of Thoracic Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
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Fysh ETH, Waterer GW, Kendall PA, Bremner PR, Dina S, Geelhoed E, McCarney K, Morey S, Millward M, Musk AWB, Lee YCG. Indwelling pleural catheters reduce inpatient days over pleurodesis for malignant pleural effusion. Chest 2012; 142:394-400. [PMID: 22406960 DOI: 10.1378/chest.11-2657] [Citation(s) in RCA: 116] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Patients with malignant pleural effusion (MPE) have limited prognoses. They require long-lasting symptom relief with minimal hospitalization. Indwelling pleural catheters (IPCs) and talc pleurodesis are approved treatments for MPE. Establishing the implications of IPC and talc pleurodesis on subsequent hospital stay will influence patient choice of treatment. Therefore, our objective was to compare patients with MPE treated with IPC vs pleurodesis in terms of hospital bed days (from procedure to death or end of follow-up) and safety. METHODS In this prospective, 12-month, multicenter study, patients with MPE were treated with IPC or talc pleurodesis, based on patient choice. Key end points were hospital bed days from procedure to death (total and effusion-related). Complications, including infection and protein depletion, were monitored longitudinally. RESULTS One hundred sixty patients with MPE were recruited, and 65 required definitive fluid control; 34 chose IPCs and 31 pleurodesis. Total hospital bed days (from any causes) were significantly fewer in patients with IPCs (median, 6.5 days; interquartile range [IQR] = 3.75-13.0 vs pleurodesis, mean, 18.0; IQR, 8.0-26.0; P = .002). Effusion-related hospital bed days were significantly fewer with IPCs (median, 3.0 days; IQR, 1.8-8.3 vs pleurodesis, median, 10.0 days; IQR, 6.0-18.0; P < .001). Patients with IPCs spent significantly fewer of their remaining days of life in hospital (8.0% vs 11.2%, P < .001, χ(2) = 28.25). Fewer patients with IPCs required further pleural procedures (13.5% vs 32.3% in pleurodesis group). There was no difference in rates of pleural infection (P = .68) and protein (P = .65) or albumin loss (P = .22). More patients treated with IPC reported immediate (within 7 days) improvements in quality of life and dyspnea. CONCLUSIONS Patients treated with IPCs required significantly fewer days in hospital and fewer additional pleural procedures than those who received pleurodesis. Safety profiles and symptom control were comparable.
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Affiliation(s)
- Edward T H Fysh
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth; Centre for Asthma, Allergy, and Respiratory Research, University of Western Australia, Perth; School of Medicine and Pharmacology, University of Western Australia, Perth
| | - Grant W Waterer
- School of Medicine and Pharmacology, University of Western Australia, Perth; Department of Respiratory Medicine, Royal Perth Hospital, Perth
| | - Peter A Kendall
- School of Medicine and Pharmacology, University of Western Australia, Perth; Department of Respiratory Medicine, Fremantle Hospital, Fremantle, WA, Australia
| | - Peter R Bremner
- Department of Respiratory Medicine, Fremantle Hospital, Fremantle, WA, Australia
| | - Sharifa Dina
- Department of Respiratory Medicine, Fremantle Hospital, Fremantle, WA, Australia
| | | | - Kate McCarney
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth
| | - Sue Morey
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth
| | - Michael Millward
- Department of Medical Oncology, Sir Charles Gairdner Hospital, Perth; School of Medicine and Pharmacology, University of Western Australia, Perth
| | - A W Bill Musk
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth; School of Population Health, University of Western Australia, Perth
| | - Y C Gary Lee
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth; Centre for Asthma, Allergy, and Respiratory Research, University of Western Australia, Perth; School of Medicine and Pharmacology, University of Western Australia, Perth.
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Kitamura K, Kubota K, Ando M, Takahashi S, Nishijima N, Sugano T, Toyokawa M, Miwa K, Kosaihira S, Noro R, Minegishi Y, Seike M, Yoshimura A, Gemma A. Bevacizumab plus chemotherapy for advanced non-squamous non-small-cell lung cancer with malignant pleural effusion. Cancer Chemother Pharmacol 2012. [DOI: 10.1007/s00280-012-2026-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
Numerous intrapleural therapies have been adopted to treat a vast array of pleural diseases. The first intrapleural therapies proposed focused on the use of fibrinolytics and DNase to promote fluid drainage in empyema. Numerous case series and five randomized controlled trials have been published to determine the outcomes of fibrinolytics in empyema treatment. In the largest randomized trial, the use of streptokinase had no reduction in mortality, decortication rates or hospital days compared with placebo in the treatment of empyema. Criticism over study design and patient selection may have potentially affected the outcomes in this study. The development of dyspnoea is common in the setting of malignant pleural effusions. Pleural fluid evacuation followed by pleurodesis is often attempted. Numerous sclerosing agents have been studied, with talc emerging as the most effective agent. Small particle size of talc should be avoided because of increased systemic absorption potentiating toxicity, such as acute lung injury. Over the past several years, the use of chronic indwelling pleural catheters have emerged as the preferred modality in the treating a symptomatic malignant pleural effusion. For patients with malignant-related lung entrapment, pleurodesis often fails due to the presence of visceral pleural restriction; however, chronic indwelling pleural catheters are effective in palliation of dyspnoea. Finally, the use of staphylococcal superantigens has been proposed as a therapeutic model for the treatment of non-small lung cancer. Intrapleural instillation of staphylococcal superantigens increased median survival by 5 months in patients with non-small cell lung cancer with a malignant pleural effusion.
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Affiliation(s)
- J Terrill Huggins
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Medical University of South Carolina, Charleston, South Carolina 29425, USA.
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MACEACHERN PAUL, TREMBLAY ALAIN. Pleural controversy: Pleurodesis versus indwelling pleural catheters for malignant effusions. Respirology 2011; 16:747-54. [DOI: 10.1111/j.1440-1843.2011.01986.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Medford ARL. Theoretical cost benefits of medical thoracoscopy (MT). Respir Med 2010; 104:1075-6. [PMID: 20350801 DOI: 10.1016/j.rmed.2010.03.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2010] [Accepted: 03/08/2010] [Indexed: 02/07/2023]
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Abstract
PURPOSE OF REVIEW The technique and clinical applications of medical thoracoscopy have substantially evolved in the last few decades. The recent development of a semirigid thoracoscope, which is handled similarly to a bronchoscope, has made this procedure more attractive to pulmonologists. We will review the latest data on clinical applications, recently developed techniques, and safety of medical thoracoscopy, focusing mainly on its role in thoracic malignancies. RECENT FINDINGS Recent data confirm the high diagnostic yield of medical thoracoscopy - both with rigid and semirigid instruments - in detecting pleural metastases and determining the origin of pleural effusions. The degree of pleural adhesions found during thoracoscopy has been proposed by some authors as a prognostic factor for survival in patients with malignant pleural effusion. A large prospective multicenter study has established the safety of talc poudrage with large-particle talc, showing no cases of acute respiratory distress syndrome. SUMMARY Medical thoracoscopy is an excellent tool to establish diagnosis in patients with exudative pleural effusion of unclear origin. It is highly valuable in clarifying the origin of pleural effusions in patients with lung cancer, as the presence of a malignant pleural effusion is associated with poor survival and precludes the possibility of treatment with curative intention. Pleurodesis with talc poudrage is efficacious and well tolerated, especially with the use of large-particle talc.
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Abstract
Malignant pleural effusion (MPE) often presents in patients with cancer at an advanced stage and thus carries a poor prognosis. This review updates the current knowledge on the management of MPE, focusing on recent literature about the efficacy and safety of the most common methods, including pleurodesis by either thoracoscopy with talc insufflation or thoracostomy with talc slurry, use of an indwelling pleural catheter, and intrapleural chemotherapy. Talc remains the agent of choice in pleurodesis, although the use of alternative agents continues to be explored. The choice of procedure to achieve pleurodesis depends on careful patient selection based on predictive factors and individual characteristics. Talc pleuro-desis is relatively well tolerated and safe, as is an indwelling pleural catheter, in an appropriate patient population. Because MPE is a common problem in cancer patients, future research with more randomized, prospective designs and innovative interventions is needed.
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Abstract
Malignant pleural effusions (MPEs) complicate the clinical course of patients with a broad array of malignancies, which are most often due to lymphomas or carcinomas of the breast, lung, gastrointestinal tract or ovaries. Patients may present with a MPE as the initial manifestation of a cancer or develop an effusion during the advanced phases of a known malignancy. In either circumstance, the median survival after presentation with a MPE is 4 months. Effusions may result from direct pleural invasion (MPE) or indirect effects (paraneoplastic effusions), such as impairment of fluid efflux from the pleural space by lymphatic obstruction or pleural effects of cancer radiation or drug therapy. Because only 50% of patients with cancer who develop a pleural effusion during their clinical course have a MPE, careful evaluation of the effusion to establish its aetiology is required to direct therapy. Management is palliative with interventions directed towards decreasing the volume of intrapleural fluid and the severity of associated symptoms.
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Predictors of talc pleurodesis outcome in patients with malignant pleural effusions. Lung Cancer 2008; 62:139-44. [PMID: 18403045 DOI: 10.1016/j.lungcan.2008.02.017] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2007] [Revised: 02/18/2008] [Accepted: 02/24/2008] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Chemical pleurodesis is an accepted palliative therapy for patients with recurrent, symptomatic, malignant pleural effusions (MPE). The purpose of the study was to determine the factors that have an effect on successful pleurodesis for MPE. PATIENTS AND INTERVENTIONS Eighty-four consecutive patients with biopsy-proven malignant pleural disease and recurrent, symptomatic MPE were eligible to participate in this study. Five grams of talc mixed in 150ml of normal saline were administered via tube thoracostomy or small-bore catheters after complete drainage of the pleural effusion. RESULTS Seven patients did not return for their 30-day follow-up visit and were excluded from further analysis. Successful pleurodesis was achieved in 63 of 77 eligible patients (81.8%) with MPE. In the univariate analysis, female gender, Karnofsky performance status, pleural fluid pH, cholesterol, and adenosine deaminase level showed a significant association with the probability of success. Multivariate logistic regression analysis showed that pleural fluid pH and ADA levels were independent predictors of talc pleurodesis outcome. CONCLUSION Our results show that pleurodesis using talc as the sclerosing agent is a simple and acceptable procedure with high efficacy for controlling MPE, especially when used in appropriate patients.
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Yoneda KY, Mathur PN, Gasparini S. The evolving role of interventional pulmonary in the interdisciplinary approach to the staging and management of lung cancer. Part III: diagnosis and management of malignant pleural effusions. Clin Lung Cancer 2008; 8:535-47. [PMID: 18186958 DOI: 10.3816/clc.2007.n.040] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The diagnosis and management of a malignant pleural effusion can be one of the most vexing problems faced by physicians and their patients. Lung cancer is the most common primary tumor of origin with a prognosis that is limited, but variable and correlated with performance status (PS). Therefore, with a poor PS and known advanced lung cancer, establishing whether or not an effusion is malignant might not be necessary. Conversely, identifiable subsets of patients will have a much better survival, and establishing a definitive diagnosis could be of critical importance. In the great majority of cases, a diagnosis can be determined by serial thoracenteses with or without closed pleural biopsy. However, thoracoscopy is increasingly being utilized and can expedite the workup by obviating the need for repeated thoracenteses and/or closed pleural biopsy, while in the same setting providing definitive palliative treatment. Although studies comparing diagnostic and treatment strategies are limited, we will present the available data with the intention of providing the practicing oncologist with a practical strategy for the diagnosis and management of malignant pleural effusions due to lung cancer. The interventional pulmonologist can play an important role from diagnosis to palliation, greatly facilitating the care of patients with malignant pleural effusions.
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Affiliation(s)
- Ken Y Yoneda
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of California, Davis Medical Center, Sacramento, CA 95817, USA.
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Abstract
Malignant pleural effusions (MPEs) are an important complication for patients with intrathoracic and extrathoracic malignancies. Median survival after diagnosis of an MPE is 4 months. Patients can present with an MPE as a complication of far-advanced cancer or as the initial manifestation of an underlying malignancy. Common cancer types causing MPEs include lymphomas, mesotheliomas, and carcinomas of the breast, lung, gastrointestinal tract, and ovaries. However, almost all tumor types have been reported to cause MPEs. New imaging modalities assist the evaluation of patients with a suspected MPE; however, positive cytologic or tissue confirmation of malignant cells is necessary to establish a diagnosis. Even in the presence of known malignancy, up to 50% of pleural effusions are benign, underscoring the importance of a firm diagnosis to guide therapy. Rapidly evolving interventional and histopathologic techniques have improved the diagnostic yield of standard cytology and biopsy. Management of an MPE remains palliative; it is critical that the appropriate management approach is chosen on the basis of available expertise and the patient's clinical status. This review summarizes the pathogenesis, diagnosis, and management of MPE. Studies in the English language were identified by searching the MEDLINE database (1980-2007) using the search terms pleura, pleural, malignant, pleurodesis, and thoracoscopy.
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Affiliation(s)
- John E Heffner
- Department of Medicine, Providence Portland Medical Center, Oregon Health and Science University, 5040 NE Hoyt St, Ste 540, Portland, OR 97213, USA.
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