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Castaldo N, Fantin A, Palou-schwartzbaum M, Viterale G, Crisafulli E, Sartori G, Aujayeb A, Patrucco F, Patruno V. Exploring the efficacy and advancements of medical pleurodesis: a comprehensive review of current research. Breathe (Sheff) 2024; 20:240002. [PMID: 39193457 PMCID: PMC11348907 DOI: 10.1183/20734735.0002-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 06/24/2024] [Indexed: 08/29/2024] Open
Abstract
This narrative review aims to provide an overview of medical pleurodesis techniques, and their indications and potential adverse effects. Pleurodesis is a procedure performed with the aim of obliterating the pleural space. It has indications in the management of both malignant and benign pleural effusions and pneumothorax. Various nonsurgical techniques exist to perform pleurodesis. The scope of this work is to review the different nonsurgical techniques and their indications. This narrative review was performed checking scientific databases for medical literature, focusing especially on the data derived from randomised controlled trials. Pleurodesis is an effective method to manage pleural effusions and pneumothorax, and minimally invasive techniques are now frequently used with good results. Further research is needed to assess the efficacy of new treatments and the possibility of using different techniques in association.
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Affiliation(s)
- Nadia Castaldo
- Department of Pulmonology, S. Maria della Misericordia University Hospital, Udine, Italy
| | - Alberto Fantin
- Department of Pulmonology, S. Maria della Misericordia University Hospital, Udine, Italy
| | - Michelangelo Palou-schwartzbaum
- Department of Medicine, Respiratory Medicine Unit, University of Verona and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Giovanni Viterale
- Department of Medicine, Respiratory Medicine Unit, University of Verona and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Ernesto Crisafulli
- Department of Medicine, Respiratory Medicine Unit, University of Verona and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Giulia Sartori
- Department of Medicine, Respiratory Medicine Unit, University of Verona and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Avinash Aujayeb
- Department of Respiratory Medicine, Northumbria Healthcare NHS Trust, Cramlington, UK
| | - Filippo Patrucco
- Respiratory Diseases Unit, Medical Department, AOU Maggiore della Carità di Novara, Novara, Italy
- Translational Medicine Department, University of Eastern Piedmont, Novara, Italy
| | - Vincenzo Patruno
- Department of Pulmonology, S. Maria della Misericordia University Hospital, Udine, Italy
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Kolokotroni SM, Lamprinos D, Goutas N, Kapetanakis EI, Kontzoglou K, Perrea D, Tomos P. Platelet-Rich Plasma for Pleurodesis: An Experimental Study in Rabbits. Medicina (B Aires) 2022; 58:medicina58121842. [PMID: 36557044 PMCID: PMC9785005 DOI: 10.3390/medicina58121842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 12/07/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022] Open
Abstract
Background and Objectives: This study was designed to evaluate platelet-rich plasma (PRP) as a method of pleurodesis in a rabbit model. Pleurodesis with PRP was compared against the gold-standard use of talc. The secondary evaluation assessed the ideal time for achieving pleurodesis. Materials and Methods: 25 healthy New Zealand white rabbits were assigned to three groups, as follows: 12 animals in the first and second groups, as well as one animal with no intervention in the final group, which was used as a control. The talc pleurodesis group (baseline) underwent pleurodesis with sterile talc, which is the gold-standard sclerosing agent used for pleurodesis. The PRP group underwent pleurodesis using autologous PRP. The last group had one rabbit with no intervention. A total of 12 rabbits (n = 6 for the talc pleurodesis group and n = 6 for the PRP group) were sacrificed 3 days (72 h) after the intervention, and 12 rabbits (n = 6 for the talc pleurodesis group and n = 6 for the PRP group) were sacrificed 6 days (144 h) after the intervention. In both the talc and PRP group, FBC and CRP were measured before the intervention and in 3 or 6 days afterwards, respectively. The pleura and the lungs were evaluated histopathologically. Results: Macroscopically, there were no statistically significant differences between the two groups. In terms of microscopic findings, there were no statistically significant differences in inflammatory reactions provoked in the visceral and parietal pleura between the PRP and talc. In addition, with talc pleurodesis, a foreign-body reaction was observed in about 50% of the cases, which was not observed with PRP. In terms of inflammation between 3 and 6 days, there were no statistically significant differences with PRP, there was only a statistically significant difference between 3 and 6 days regarding the parietal pleura in the talc group. Conclusions: The instillation of autologous PRP in the pleural cavity shows promise in achieving pleurodesis. The efficacy of PRP as a pleurodesis agent should be examined further.
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Affiliation(s)
- Styliani Maria Kolokotroni
- Department of Cardiothoracic Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Coventry CV2 2DX, UK
- Laboratory of Experimental Surgery and Surgical Research “N. S. Christeas”, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
- Correspondence:
| | | | - Nikolaos Goutas
- Department of Forensic Medicine and Toxicology, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Emmanouil I. Kapetanakis
- Department of Thoracic Surgery, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Konstantinos Kontzoglou
- Laboratory of Experimental Surgery and Surgical Research “N. S. Christeas”, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
- Second Department of Propedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Despoina Perrea
- Laboratory of Experimental Surgery and Surgical Research “N. S. Christeas”, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Periklis Tomos
- Department of Thoracic Surgery, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece
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Désage AL, Mismetti V, Jacob M, Pointel S, Perquis MP, Morfin M, Guezara S, Langrand A, Galor C, Trouillon T, Diaz A, Karpathiou G, Froudarakis M. Place du pneumologue interventionnel dans la gestion des pleurésies métastatiques. Rev Mal Respir 2022; 39:778-790. [DOI: 10.1016/j.rmr.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 09/14/2022] [Indexed: 11/09/2022]
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4
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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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Karpathiou G, Péoc’h M, Sundaralingam A, Rahman N, Froudarakis ME. Inflammation of the Pleural Cavity: A Review on Pathogenesis, Diagnosis and Implications in Tumor Pathophysiology. Cancers (Basel) 2022; 14:1415. [PMID: 35326567 PMCID: PMC8946533 DOI: 10.3390/cancers14061415] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/08/2022] [Accepted: 03/08/2022] [Indexed: 12/12/2022] Open
Abstract
Pleural effusions are a common respiratory condition with many etiologies. Nonmalignant etiologies explain most pleural effusions and despite being nonmalignant, they can be associated with poor survival; thus, it is important to understand their pathophysiology. Furthermore, diagnosing a benign pleural pathology always harbors the uncertainty of a false-negative diagnosis for physicians and pathologists, especially for the group of non-specific pleuritis. This review aims to present the role of the inflammation in the development of benign pleural effusions, with a special interest in their pathophysiology and their association with malignancy.
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Affiliation(s)
- Georgia Karpathiou
- Pathology Department, University Hospital of Saint-Etienne, 42055 Saint-Etienne, France;
| | - Michel Péoc’h
- Pathology Department, University Hospital of Saint-Etienne, 42055 Saint-Etienne, France;
| | - Anand Sundaralingam
- Oxford Centre for Respiratory Medicine, Nuffield Department of Medicine, University of Oxford, Oxford OX3 7LE, UK; (A.S.); (N.R.)
| | - Najib Rahman
- Oxford Centre for Respiratory Medicine, Nuffield Department of Medicine, University of Oxford, Oxford OX3 7LE, UK; (A.S.); (N.R.)
| | - Marios E. Froudarakis
- Pneumonology and Thoracic Oncology Department, University Hospital of Saint-Etienne, 42055 Saint-Etienne, France;
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Marazioti A, Krontira AC, Behrend SJ, Giotopoulou GA, Ntaliarda G, Blanquart C, Bayram H, Iliopoulou M, Vreka M, Trassl L, Pepe MAA, Hackl CM, Klotz LV, Weiss SAI, Koch I, Lindner M, Hatz RA, Behr J, Wagner DE, Papadaki H, Antimisiaris SG, Jean D, Deshayes S, Grégoire M, Kayalar Ö, Mortazavi D, Dilege Ş, Tanju S, Erus S, Yavuz Ö, Bulutay P, Fırat P, Psallidas I, Spella M, Giopanou I, Lilis I, Lamort A, Stathopoulos GT. KRAS signaling in malignant pleural mesothelioma. EMBO Mol Med 2022; 14:e13631. [PMID: 34898002 PMCID: PMC8819314 DOI: 10.15252/emmm.202013631] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 10/28/2021] [Accepted: 11/15/2021] [Indexed: 12/20/2022] Open
Abstract
Malignant pleural mesothelioma (MPM) arises from mesothelial cells lining the pleural cavity of asbestos-exposed individuals and rapidly leads to death. MPM harbors loss-of-function mutations in BAP1, NF2, CDKN2A, and TP53, but isolated deletion of these genes alone in mice does not cause MPM and mouse models of the disease are sparse. Here, we show that a proportion of human MPM harbor point mutations, copy number alterations, and overexpression of KRAS with or without TP53 changes. These are likely pathogenic, since ectopic expression of mutant KRASG12D in the pleural mesothelium of conditional mice causes epithelioid MPM and cooperates with TP53 deletion to drive a more aggressive disease form with biphasic features and pleural effusions. Murine MPM cell lines derived from these tumors carry the initiating KRASG12D lesions, secondary Bap1 alterations, and human MPM-like gene expression profiles. Moreover, they are transplantable and actionable by KRAS inhibition. Our results indicate that KRAS alterations alone or in accomplice with TP53 alterations likely play an important and underestimated role in a proportion of patients with MPM, which warrants further exploration.
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7
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Addala DN, Kanellakis NI, Bedawi EO, Dong T, Rahman NM. Malignant pleural effusion: Updates in diagnosis, management and current challenges. Front Oncol 2022; 12:1053574. [PMID: 36465336 PMCID: PMC9712949 DOI: 10.3389/fonc.2022.1053574] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 10/27/2022] [Indexed: 11/19/2022] Open
Abstract
Malignant pleural effusion (MPE) is a common condition which often causes significant symptoms to patients and costs to healthcare systems. Over the past decade, the management of MPE has progressed enormously with large scale, randomised trials answering key questions regarding optimal diagnostic strategies and effective management strategies. Despite a number of management options, including talc pleurodesis, indwelling pleural catheters and combinations of the two, treatment for MPE remains symptom directed and centered around drainage strategy. The future goals for providing improved care for patients lies in changing the treatment paradigm from a generic pathway to personalised care, based on probability of malignancy type and survival. This article reviews the current evidence base, new discoveries and future directions in the diagnosis and management of MPE.
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Affiliation(s)
- Dinesh Narayan Addala
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.,Oxford Pleural Unit, Oxford University Hospitals, Oxford, United Kingdom
| | - Nikolaos I Kanellakis
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.,Oxford Biomedical Research Centre, National Institute for Health Research, Oxford, United Kingdom.,Nuffield Department of Medicine, Medical Sciences Division, Chinese Academy of Medical Science Oxford Institute, University of Oxford, Oxford, United Kingdom
| | - Eihab O Bedawi
- Oxford Pleural Unit, Oxford University Hospitals, Oxford, United Kingdom.,Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Tao Dong
- Nuffield Department of Medicine, Medical Sciences Division, Chinese Academy of Medical Science Oxford Institute, University of Oxford, Oxford, United Kingdom.,Medical Research Council (MRC) Human Immunology Unit, Radcliffe Department of Medicine, Medical Research Council (MRC) Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.,Oxford Pleural Unit, Oxford University Hospitals, Oxford, United Kingdom.,Oxford Biomedical Research Centre, National Institute for Health Research, Oxford, United Kingdom.,Nuffield Department of Medicine, Medical Sciences Division, Chinese Academy of Medical Science Oxford Institute, University of Oxford, Oxford, United Kingdom
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8
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Muruganandan S, Duong V. Malignant Pleural Effusion in Malignant Pleural Mesothelioma: An Innocent Bystander? Chest 2021; 160:1602-1603. [PMID: 34743845 DOI: 10.1016/j.chest.2021.06.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 06/30/2021] [Accepted: 06/30/2021] [Indexed: 11/25/2022] Open
Affiliation(s)
| | - Victor Duong
- Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, VIC, Australia
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A multidirectional two-tube method for chemical pleurodesis could improve distribution of the sclerosing agent within the pleural cavity - A pilot study. Ann Med Surg (Lond) 2021; 68:102697. [PMID: 34408869 PMCID: PMC8361043 DOI: 10.1016/j.amsu.2021.102697] [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] [Received: 05/30/2021] [Revised: 08/05/2021] [Accepted: 08/07/2021] [Indexed: 01/15/2023] Open
Abstract
Introduction Malignant pleural effusion (MPE) affects approximately 200,000 people in the United States per annum. Chemical pleurodesis is a recommended first line treatment in the management of MPE, however, success rates as low as 43% has been reported. A bedside chemical pleurodesis can cost up to $11,224 and an estimated inpatient annual expenditure of more than $5 billion in the US alone. This study aims to assess the distribution of the talc slurry within the pleural space using human cadaveric models and to determine the force required to push the talc slurry though a 14 Fr chest tube. Materials and methods The force required to administer the talc slurry through a 14 Fr chest tube was tested using a Zwick/Roelle Z005 mechanical tester, using a porcine thoracic biomodel. Talc slurry distribution within the pleural cavity was assessed by direct visualisation following administration to the human cadaveric models using single and multidirectional two-tube methods. Results Maximum force required to push the talc slurry through a 14 Fr chest tube was 11.36 N ± 2.79 N. Distribution of the talc slurry within the pleural cavity was found to be poor with a single tube method. Multidirectional two-tube method of administration showed more even distribution. Conclusion The experimental multidirectional two-tube method results in wider distribution of the talc slurry within the pleural cavity and could further improve success rate of the talc pleurodesis. Yearly, there are over 150,000 new cases of MPE in the US alone. Success rate of talc pleurodesis as low as 43% has been reported. Doctor's hand grip strength does not affect the talc distribution within the pleural cavity. Bedside multidirectional two-tube method may improve the success rate of talc slurry pleurodesis.
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10
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The Association Between Pleural Fluid Exposure and Survival in Pleural Mesothelioma. Chest 2021; 160:1925-1933. [PMID: 34119515 DOI: 10.1016/j.chest.2021.05.063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 05/18/2021] [Accepted: 05/21/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Most patients with malignant pleural mesothelioma (MPM) seek treatment with malignant pleural effusion (MPE). In vitro evidence suggests that MPE may not be a simple bystander of malignancy, but rather potentially has biological properties that improve cancer cell survival and promote cancer progression. If this is the case, MPE management may need to shift from current symptomatic strategies to aggressive fluid removal to impact survival. RESEARCH QUESTION Is there an association between pleural fluid exposure and survival in MPM? STUDY DESIGN AND METHODS Data from 761 patients who received a diagnosis of MPM between 2008 and 2018 were collected from patient medical records in three UK pleural units. Data included factors previously identified as influencing prognosis in MPM. Medical imaging was reviewed for presence, size, and duration of pleural effusion. Time-dependent covariate analysis of pleural fluid exposure and survival (model included weight loss, serum albumin, hemoglobin, MPM subtype, performance status, chemotherapy, and age) and multivariate Cox regression analysis of pleurodesis and survival were conducted. RESULTS Median overall survival was 278 days (interquartile range, 127-505 days; 95% CI, 253-301 days). Pleural fluid exposure duration showed no association with survival (hazard ratio, 1.0; 95% CI, 1.0-1.0). Median survival was 473, 378, and 258 days with complete, partial, and no pleurodesis (P = .008). INTERPRETATION Pleurodesis success seems to be associated with improved survival; however, it is unclear whether duration of MPM exposure to pleural fluid is associated with survival within the limitations of this retrospective study. Future prospective studies are required to assess this potentially important mechanism.
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11
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Bedawi EO, Guinde J, Rahman NM, Astoul P. Advances in pleural infection and malignancy. Eur Respir Rev 2021; 30:200002. [PMID: 33650525 PMCID: PMC9488125 DOI: 10.1183/16000617.0002-2020] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 06/12/2020] [Indexed: 02/03/2023] Open
Abstract
Pleural infection and malignancy are among the most common causes of pleural disease and form the mainstay of pleural practice. There has been significant research and increase in scientific understanding in these areas in the past decade. With regard to pleural infection, the rising incidence remains worrying. An increased awareness allowing earlier diagnosis, earlier escalation of therapy and the use of validated risk stratification measures may improve outcomes. In pleural malignancy, research has enabled clinicians to streamline patient pathways with focus on reducing time to diagnosis, definitive management of malignant pleural effusion and achieving these with the minimum number of pleural interventions. Trials comparing treatment modalities of malignant pleural effusion continue to highlight the importance of patient choice in clinical decision-making. This article aims to summarise some of the most recent literature informing current practice in these two areas.
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Affiliation(s)
- Eihab O Bedawi
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals, Oxford, UK
| | - Julien Guinde
- Dept of Thoracic Oncology, Pleural Diseases and Interventional Pulmonology, North University Hospital, Marseille, France
| | - Najiib M Rahman
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals, Oxford, UK
- NIHR Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Philippe Astoul
- Dept of Thoracic Oncology, Pleural Diseases and Interventional Pulmonology, North University Hospital, Marseille, France
- Aix-Marseille University, Marseille, France
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12
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Survival and pleurodesis outcome in patients with malignant pleural effusion – a systematic review. Pleura Peritoneum 2021. [DOI: 10.1515/pap-2020-0147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Malignant pleural effusion (MPE) is a common condition that presents with progressive breathlessness. Long term solutions are often required due to recurrence of effusion after simple drainage. Pleurodesis is one of the main options resorted to for long term control of MPE. There is data to suggest there may be a survival benefit for patients with MPE who achieve successful pleurodesis. A systematic review was carried out to explore this correlation and results suggest that there could be a survival difference according to pleurodesis outcome in patients with MPE. Fifteen studies (reported in 13 papers) were included; 13 (86.6%) of the studies showed survival difference in favour of pleurodesis success. The median [interquartile range] difference in survival between the two groups among the different studies was five [3.5–5.8] months. Most of the included studies suffered moderate to severe risk of bias and, thus, large prospective studies of patients undergoing pleurodesis are required to ascertain this effect.
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13
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Hassan M, Harriss E, Mercer RM, Rahman NM. Survival and pleurodesis outcome in patients with malignant pleural effusion - a systematic review. Pleura Peritoneum 2021; 6:1-5. [PMID: 34222645 PMCID: PMC8223802 DOI: 10.1515/pp-2020-0147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 12/27/2020] [Indexed: 01/21/2023] Open
Abstract
Malignant pleural effusion (MPE) is a common condition that presents with progressive breathlessness. Long term solutions are often required due to recurrence of effusion after simple drainage. Pleurodesis is one of the main options resorted to for long term control of MPE. There is data to suggest there may be a survival benefit for patients with MPE who achieve successful pleurodesis. A systematic review was carried out to explore this correlation and results suggest that there could be a survival difference according to pleurodesis outcome in patients with MPE. Fifteen studies (reported in 13 papers) were included; 13 (86.6%) of the studies showed survival difference in favour of pleurodesis success. The median [interquartile range] difference in survival between the two groups among the different studies was five [3.5–5.8] months. Most of the included studies suffered moderate to severe risk of bias and, thus, large prospective studies of patients undergoing pleurodesis are required to ascertain this effect.
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Affiliation(s)
- Maged Hassan
- Chest Diseases Department, Alexandria Faculty of Medicine, Alexandria, Egypt
| | - Elinor Harriss
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Rachel M Mercer
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Najib M Rahman
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
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14
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Asciak R, George V, Rahman NM. Update on biology and management of mesothelioma. Eur Respir Rev 2021; 30:30/159/200226. [PMID: 33472960 DOI: 10.1183/16000617.0226-2020] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 10/27/2020] [Indexed: 12/23/2022] Open
Abstract
Malignant pleural mesothelioma is an aggressive, incurable cancer that is usually caused by asbestos exposure several decades before symptoms arise. Despite widespread prohibition of asbestos production and supply, its incidence continues to increase. It is heterogeneous in its presentation and behaviour, and diagnosis can be notoriously difficult. Identification of actionable gene mutations has proven challenging and current treatment options are largely ineffective, with a median survival of 10-12 months.However, the past few years have witnessed major advances in our understanding of the biology and pathogenesis of mesothelioma. This has also revealed the limitations of existing diagnostic algorithms and identified new treatment targets.Recent clinical trials have re-examined the role of surgery, provided new options for the management of associated pleural effusions and heralded the addition of targeted therapies. The increasing complexity of mesothelioma management, along with a desperate need for further research, means that a multidisciplinary team framework is essential for the delivery of contemporary mesothelioma care.This review provides a synthesised overview of the current state of knowledge and an update on the latest research in the field.
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Affiliation(s)
- Rachelle Asciak
- Oxford Centre for Respiratory Medicine, University Hospitals NHS Foundation Trust, Oxford, UK .,Mater Dei Hospital, Msida, Malta
| | - Vineeth George
- Oxford Centre for Respiratory Medicine, University Hospitals NHS Foundation Trust, Oxford, UK
| | - Najiib M Rahman
- Oxford Centre for Respiratory Medicine, University Hospitals NHS Foundation Trust, Oxford, UK
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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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Ferreiro L, Suárez-Antelo J, Valdés L. Malignant Pleural Effusion Management. Arch Bronconeumol 2020; 57:7-8. [PMID: 32624211 DOI: 10.1016/j.arbres.2020.05.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 05/27/2020] [Accepted: 05/28/2020] [Indexed: 01/08/2023]
Affiliation(s)
- Lucía Ferreiro
- Hospital Clínico Universitario de Santiago, Grupo Interdisciplinar de Investigación en Neumología, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, España; Hospital Clínico Universitario de Santiago, Santiago de Compostela, España.
| | - Juan Suárez-Antelo
- Hospital Clínico Universitario de Santiago, Grupo Interdisciplinar de Investigación en Neumología, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, España
| | - Luis Valdés
- Hospital Clínico Universitario de Santiago, Grupo Interdisciplinar de Investigación en Neumología, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, España; Hospital Clínico Universitario de Santiago, Santiago de Compostela, España
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Abbott DM, Bortolotto C, Benvenuti S, Lancia A, Filippi AR, Stella GM. Malignant Pleural Mesothelioma: Genetic and Microenviromental Heterogeneity as an Unexpected Reading Frame and Therapeutic Challenge. Cancers (Basel) 2020; 12:cancers12051186. [PMID: 32392897 PMCID: PMC7281319 DOI: 10.3390/cancers12051186] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 05/02/2020] [Accepted: 05/04/2020] [Indexed: 12/18/2022] Open
Abstract
Mesothelioma is a malignancy of serosal membranes including the peritoneum, pleura, pericardium and the tunica vaginalis of the testes. Malignant mesothelioma (MM) is a rare disease with a global incidence in countries like Italy of about 1.15 per 100,000 inhabitants. Malignant Pleural Mesothelioma (MPM) is the most common form of mesothelioma, accounting for approximately 80% of disease. Although rare in the global population, mesothelioma is linked to industrial pollutants and mineral fiber exposure, with approximately 80% of cases linked to asbestos. Due to the persistent asbestos exposure in many countries, a worldwide progressive increase in MPM incidence is expected for the current and coming years. The tumor grows in a loco-regional pattern, spreading from the parietal to the visceral pleura and invading the surrounding structures that induce the clinical picture of pleural effusion, pain and dyspnea. Distant spreading and metastasis are rarely observed, and most patients die from the burden of the primary tumor. Currently, there are no effective treatments for MPM, and the prognosis is invariably poor. Some studies average the prognosis to be roughly one-year after diagnosis. The uniquely poor mutational landscape which characterizes MPM appears to derive from a selective pressure operated by the environment; thus, inflammation and immune response emerge as key players in driving MPM progression and represent promising therapeutic targets. Here we recapitulate current knowledge on MPM with focus on the emerging network between genetic asset and inflammatory microenvironment which characterize the disease as amenable target for novel therapeutic approaches.
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Affiliation(s)
- David Michael Abbott
- Department of Medical Sciences and Infective Diseases, Unit of Respiratory Diseases, IRCCS Policlinico San Matteo Foundation and University of Pavia Medical School, 27100 Pavia, Italy;
| | - Chandra Bortolotto
- Unit of Radiology, Department of Intensive Medicine, IRCCS Policlinico San Matteo Foundation and University of Pavia Medical School, 27100 Pavia, Italy;
| | - Silvia Benvenuti
- Candiolo Cancer Institute, FPO—IRCCS—Str. Prov.le 142, km. 3,95—10060 Candiolo (TO), Italy;
| | - Andrea Lancia
- Unit of Radiation Therapy, Department of Medical Sciences and Infective Diseases, IRCCS Policlinico San Matteo Foundation and University of Pavia Medical School, 27100 Pavia, Italy; (A.L.); (A.R.F.)
| | - Andrea Riccardo Filippi
- Unit of Radiation Therapy, Department of Medical Sciences and Infective Diseases, IRCCS Policlinico San Matteo Foundation and University of Pavia Medical School, 27100 Pavia, Italy; (A.L.); (A.R.F.)
| | - Giulia Maria Stella
- Department of Medical Sciences and Infective Diseases, Unit of Respiratory Diseases, IRCCS Policlinico San Matteo Foundation and University of Pavia Medical School, 27100 Pavia, Italy;
- Correspondence:
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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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Kermenli T, Azar C. Postoperative survival results of patients with stage I-II malignant pleural mesothelioma in an endemic area. SANAMED 2020. [DOI: 10.24125/sanamed.v15i2.442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Introduction: The accepted treatment option for malignant pleural mesothelioma (MPM) is multimodality treatment including surgery, chemotherapy and radiotherapy. In this study, we aimed to evaluate the results of patients who underwent surgical resection for multimodality treatment due to MPM at our clinic between July 2015 and October 2019. Method: The results of 13 patients who underwent surgical treatment for MPM in our clinic were evaluated retrospectively. Patients' demographic structure, regions where they live, symptom presentation, disease localization, biopsy diagnosis, type of surgical treatment, choice of neoadjuvant or adjuvant chemotherapy, postoperative complications and survival outcomes were evaluated. Results: The mean survival time was 19.6 months. Six patients were still under follow-up. One patient whose postoperative pathology was reported as mixed type had the worst survival with 13 months and the best survival was 32 months in the patient who underwent postoperative hyperthermic chemotherapy with pleural decortication. Four patients died due to local recurrence and general condition disorder, and two patients died after peritonitis carcinomatosis and ascites. Conclusion: Epitheloid type multimodality treatment and intrapleural hyperthermic chemotherapy may be a good choice in patients with the stage I and II malignant mesothelioma without surgical comorbidity
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