1
|
Nemet M, Vasilić M, Ergelašev S, Kuhajda I, Ergelašev I. Intrapleural Fibrinolytic Therapy With Alteplase for the Management of Multiloculated Malignant Pleural Effusion: A Case Series. Cureus 2022; 14:e27549. [PMID: 36059301 PMCID: PMC9428410 DOI: 10.7759/cureus.27549] [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] [Accepted: 08/01/2022] [Indexed: 11/12/2022] Open
Abstract
Malignant pleural effusion refers to the presence of fluid in the pleural space due to an underlying malignancy. Malignant pleural effusion is sometimes accompanied by the formation of fibrous adhesions resulting in a multiloculated effusion. This diminishes the efficacy of drainage and makes successful pleurodesis impossible, leaving the patients with severe shortness of breath. In the process of freeing the pleural space from fluid-filled loculations, intrapleural application of fibrinolytic is being investigated as a possible therapeutic approach. Here, we report four cases of adult patients hospitalized for malignant pleural effusions who were treated with intrapleural fibrinolytic therapy at the Institute for Pulmonary Diseases of Vojvodina, Republic of Serbia.
Collapse
|
2
|
Saxena K, Maturu VN. A Comparative Study of the Safety and Efficacy of Intrapleural Fibrinolysis With Streptokinase and Urokinase in the Management of Loculated Pleural Effusions. Cureus 2022; 14:e26271. [PMID: 35898352 PMCID: PMC9308892 DOI: 10.7759/cureus.26271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2022] [Indexed: 11/05/2022] Open
|
3
|
Goel R, Singh GV, Shadrach BJ, Deokar K, Kumar S, Rajput KS. Efficacy and safety of intrapleural streptokinase in tubercular empyema thoracis - old wine in new wineskin. Trop Doct 2021; 52:23-26. [PMID: 34870518 DOI: 10.1177/00494755211050193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Tubercular empyema thoracis continues to be one of the leading causes of morbidity in low-income countries. Despite antitubercular therapy (ATT) and thoracostomy, empyema drainage is hampered by multiple septations, loculations, debris, and blood clots leading to complications. In a comparative experimental study to estimate the efficacy and safety of intrapleural streptokinase (IPSTK) in tubercular empyema, 30 cases of chronic multiloculated tubercular empyema were compared by radiological improvement by chest radiography, duration and volume of fluid drained, and degree of dyspnoea according to the modified Borg scale, depending on whether streptokinase was used or not. The former scored on all counts; we therefore conclude that intrapleural streptokinase is a safe, efficacious intervention in tubercular empyema. It decreases morbidity and reduces the need for surgery.
Collapse
Affiliation(s)
- Rishabh Goel
- Department of Tuberculosis & Chest Diseases, 30036Sarojini Naidu Medical College, Agra
| | - Gajendra Vikram Singh
- Associate Professor, Department of Tuberculosis & Chest Diseases, 30036Sarojini Naidu Medical College, Agra
| | - Benhur Joel Shadrach
- Department of Tuberculosis & Chest Diseases, 30036Sarojini Naidu Medical College, Agra
| | - Kunal Deokar
- Attending Consultant, Department of Pulmonary Medicine, Sapphire Hospital, Mumbai
| | - Santosh Kumar
- Professor and Head, Department of Tuberculosis & Chest Diseases, 30036Sarojini Naidu Medical College, Agra
| | - Karamvir Singh Rajput
- Department of Tuberculosis & Chest Diseases, 30036Sarojini Naidu Medical College, Agra
| |
Collapse
|
4
|
The Inflammatory Cytokine Profile of Patients with Malignant Pleural Effusion Treated with Pleurodesis. J Clin Med 2020; 9:jcm9124010. [PMID: 33322487 PMCID: PMC7763363 DOI: 10.3390/jcm9124010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 11/30/2020] [Accepted: 12/09/2020] [Indexed: 12/27/2022] Open
Abstract
Patients with malignant pleural effusion (MPE) who underwent successful pleurodesis survive longer than those for whom it fails. We hypothesize that the therapy-induced inflammatory responses inhibit the cancer progression, and thereby lead to a longer survival. Thirty-three consecutive patients with MPE that were eligible for bleomycin pleurodesis between September 2015 and December 2017 were recruited prospectively. Nineteen patients (57.6%) achieved fully or partially successful pleurodesis, while 14 patients either failed or survived less than 30 days after pleurodesis. Two patients without successful pleurodesis were excluded because of missing data. Interleukin (IL)-1 beta, IL-6, IL-10, transforming growth factor beta, tumor necrosis factor alpha (TNF-α), and vascular endothelial growth factor in the pleural fluid were measured before, and after 3 and 24 h of pleurodesis. Their pleurodesis outcome and survival were monitored and analyzed. Patients who underwent successful pleurodesis had a longer survival rate. Patients without successful pleurodesis had significantly higher TNF-α and IL-10 levels in their pleural fluid than in the successful patients before pleurodesis. Following pleurodesis, there was a significant increment of IL-10 in the first three hours in the successful patients. In contrast, significant increments of TNF-α and IL-10 were found in the unsuccessful patients between 3 and 24 h after pleurodesis. The ability to produce specific cytokines in the pleural space following pleurodesis may be decisive for the patient’s outcome and survival. Serial measurement of cytokines can help allocate the patients to adequate treatment strategies. Further study of the underlying mechanism may shed light on cytokine therapies as novel approaches.
Collapse
|
5
|
Hsu LH, Feng AC, Soong TC, Ko JS, Chu NM, Lin YF, Kao SH. Clinical outcomes of chemical pleurodesis using a minocycline. Ther Adv Respir Dis 2019; 13:1753466619841231. [PMID: 30945619 PMCID: PMC6454655 DOI: 10.1177/1753466619841231] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Background: Pleurodesis is often used to prevent the re-accumulation of a malignant
pleural effusion (MPE). Intrapleural urokinase (IPUK) therapy facilitates
lung re-expansion for patients with loculated MPE or a trapped lung that
allows subsequent pleurodesis. MPE management has been traditionally
regarded as a symptomatic treatment. We tried to evaluate their impact on
patient survival. Methods: There were 314 consecutive patients with symptomatic MPE that underwent
minocycline pleurodesis with (n = 109) and without
(n = 205) the antecedent IPUK therapy between September
2005 and August 2015, who were recruited for the pleurodesis outcome and
survival analysis. Results: The rate of successful pleurodesis was similar between the simple pleurodesis
group and the IPUK therapy group followed by the pleurodesis group (69.0%
versus 70.5%; p = 0.804). The patients
who succeeded pleurodesis had a longer survival rate than those who failed
in either the simple pleurodesis group (median, 414 versus
100 days; p < 0.001) or the IPUK therapy followed by
pleurodesis group (259 versus 102 days; p
< 0.001). The survival differences remained when the lung and breast
cancer patients were studied separately. Conclusion: Successful pleurodesis translated into a better survival rate that promotes
performing pleurodesis on lung re-expansion. The apparent shorter survival
of the patients with loculated MPE or trapped lung, and those that did not
respond to the IPUK therapy, lowered the probability of the survival benefit
through the simple physical barrier by the fibrin formation to prevent the
tumor spreading. The successfully induced inflammatory response by
minocycline is supposed to prohibit the tumor invasion and metastasis.
Further studies are warranted to clarify the mechanism and provide
opportunities to develop novel therapeutic strategies.
Collapse
Affiliation(s)
- Li-Han Hsu
- PhD Program in Medical Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei.,Division of Pulmonary and Critical Care Medicine, Sun Yat-Sen Cancer Center, Taipei.,Department of Medicine, National Yang-Ming University Medical School, Taipei
| | - An-Chen Feng
- Department of Research, Sun Yat-Sen Cancer Center, Taipei
| | - Thomas C Soong
- Department of Radiology, Sun Yat-Sen Cancer Center, Taipei
| | - Jen-Sheng Ko
- Department of Pathology, Sun Yat-Sen Cancer Center, Taipei
| | - Nei-Min Chu
- Department of Medical Oncology, Sun Yat-Sen Cancer Center, Taipei
| | - Yung-Feng Lin
- PhD Program in Medical Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei.,School of Medical Laboratory Science and Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei
| | - Shu-Huei Kao
- PhD Program in Medical Biotechnology, College of Medical Science and Technology, Taipei Medical University; School of Medical Laboratory Science and Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei 110
| |
Collapse
|
6
|
Bibby AC, Dorn P, Psallidas I, Porcel JM, Janssen J, Froudarakis M, Subotic D, Astoul P, Licht P, Schmid R, Scherpereel A, Rahman NM, Maskell NA, Cardillo G. ERS/EACTS statement on the management of malignant pleural effusions. Eur J Cardiothorac Surg 2019; 55:116-132. [PMID: 30060030 DOI: 10.1093/ejcts/ezy258] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Accepted: 03/28/2018] [Indexed: 12/26/2022] Open
Abstract
Malignant pleural effusions (MPE) are a common pathology, treated by respiratory physicians and thoracic surgeons alike. In recent years, several well-designed randomized clinical trials have been published that have changed the landscape of MPE management. The European Respiratory Society (ERS) and the European Association for Cardio-Thoracic Surgery (EACTS) established a multidisciplinary collaboration of clinicians with expertise in the management of MPE with the aim of producing a comprehensive review of the scientific literature. Six areas of interest were identified, including the optimum management of symptomatic MPE, management of trapped lung in MPE, management of loculated MPE, prognostic factors in MPE, whether there is a role for oncological therapies prior to intervention for MPE and whether a histological diagnosis is always required in MPE. The literature revealed that talc pleurodesis and indwelling pleural catheters effectively manage the symptoms of MPE. There was limited evidence regarding the management of trapped lung or loculated MPE. The LENT score was identified as a validated tool for predicting survival in MPE, with Brims' prognostic score demonstrating utility in mesothelioma prognostication. There was no evidence to support the use of oncological therapies as an alternative to MPE drainage, and the literature supported the use of tissue biopsy as the gold standard for diagnosis and treatment planning.Management options for malignant pleural effusions have advanced over the past decade, with high-quality randomized trial evidence informing practice in many areas. However, uncertainties remain and further research is required http://ow.ly/rNt730jOxOS.
Collapse
Affiliation(s)
- Anna C Bibby
- Academic Respiratory Unit, University of Bristol Medical School Translational Health Sciences, Bristol, UK
- North Bristol Lung Centre, North Bristol NHS Trust, Bristol, UK
| | - Patrick Dorn
- Division of Thoracic Surgery, University Hospital Bern, Bern, Switzerland
| | | | - Jose M Porcel
- Pleural Medicine Unit, Arnau de Vilanova University Hospital, IRB Lleida, Lleida, Spain
| | - Julius Janssen
- Department of Pulmonary Diseases, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Marios Froudarakis
- Department of Respiratory Medicine, Medical School of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - Dragan Subotic
- Clinic for Thoracic Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Phillippe Astoul
- Department of Thoracic Oncology, Pleural Diseases and Interventional Pulmonology, Hospital North Aix-Marseille University, Marseille, France
| | - Peter Licht
- Department of Cardiothoracic Surgery, Odense University Hospital, Odense, Denmark
| | - Ralph Schmid
- Division of Thoracic Surgery, University Hospital Bern, Bern, Switzerland
| | - Arnaud Scherpereel
- Pulmonary and Thoracic Oncology Department, Hospital of the University (CHU) of Lille, Lille, France
| | - Najib M Rahman
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- Oxford Centre for Respiratory Medicine, University Hospitals, NHS Foundation Trust, Oxford, UK
| | - Nick A Maskell
- Academic Respiratory Unit, University of Bristol Medical School Translational Health Sciences, Bristol, UK
- North Bristol Lung Centre, North Bristol NHS Trust, Bristol, UK
- Task force chairperson
| | - Giuseppe Cardillo
- Task force chairperson
- Department of Thoracic Surgery, Carlo Forlanini Hospital, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| |
Collapse
|
7
|
Schembri F, Ferguson JS. Is There a TIME and Place for Thrombolytics in Malignant Pleural Effusions? Am J Respir Crit Care Med 2019; 197:422-423. [PMID: 29072846 DOI: 10.1164/rccm.201710-2044ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Frank Schembri
- 1 The Pulmonary Center Boston University School of Medicine Boston, Massachusetts and
| | - J Scott Ferguson
- 2 Division of Pulmonary and Critical Care University of Wisconsin School of Medicine and Public Health Madison, Wisconsin
| |
Collapse
|
8
|
Herrero Huertas J, López González FJ, García Alfonso L, Enríquez Rodríguez AI. Ambulatory Fibrinolysis in the Management of Septated Malignant Effusions. Arch Bronconeumol 2019; 55:594-596. [PMID: 31133356 DOI: 10.1016/j.arbres.2019.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 04/08/2019] [Accepted: 04/09/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Julia Herrero Huertas
- Servicio de Neumología, Hospital Universitario Central de Asturias, Oviedo, Asturias, España.
| | | | - Lucía García Alfonso
- Servicio de Neumología, Complexo Hospitalario Universitario A Coruña, A Coruña, España
| | | |
Collapse
|
9
|
Intrapleural Urokinase Directly Under Medical Thoracoscopy for the Diagnosis of Malignant Pleural Mesothelioma With Severe Multiloculated Pleural Effusions. J Bronchology Interv Pulmonol 2019; 26:e26-e27. [PMID: 30908399 DOI: 10.1097/lbr.0000000000000576] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
10
|
Abstract
Purpose of Review We review recent studies of patients with septated malignant pleural effusions, to understand what the clinical implications for patients are and what evidence-based methods should be used to manage these effusions. Recent Findings Fibrinolytics improve effusion size assessed radiologically in patients with a chest drain inserted for septated malignant pleural effusions but this does not translate into an improvement in breathlessness relief or pleurodesis success. Fibrinolytics have also been used in patients with septated effusions associated with indwelling pleural catheters, but dyspnoea relief has not been assessed in this population. Patients with septated effusions or extensive adhesions appear to have a worse prognosis. Summary Patients with septated malignant pleural effusions have a poor prognosis and do not gain clinical benefit from fibrinolytics via chest drain. The role of fibrinolytics for septated effusions associated with indwelling pleural catheters requires further study.
Collapse
Affiliation(s)
- Radhika Banka
- 1Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, Norfolk, UK
| | - Dayle Terrington
- 1Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, Norfolk, UK.,2University of East Anglia, Norwich, Norfolk, UK
| | - Eleanor K Mishra
- 1Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, Norfolk, UK.,2University of East Anglia, Norwich, Norfolk, UK
| |
Collapse
|
11
|
Komissarov AA, Rahman N, Lee YCG, Florova G, Shetty S, Idell R, Ikebe M, Das K, Tucker TA, Idell S. Fibrin turnover and pleural organization: bench to bedside. Am J Physiol Lung Cell Mol Physiol 2018; 314:L757-L768. [PMID: 29345198 DOI: 10.1152/ajplung.00501.2017] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Recent studies have shed new light on the role of the fibrinolytic system in the pathogenesis of pleural organization, including the mechanisms by which the system regulates mesenchymal transition of mesothelial cells and how that process affects outcomes of pleural injury. The key contribution of plasminogen activator inhibitor-1 to the outcomes of pleural injury is now better understood as is its role in the regulation of intrapleural fibrinolytic therapy. In addition, the mechanisms by which fibrinolysins are processed after intrapleural administration have now been elucidated, informing new candidate diagnostics and therapeutics for pleural loculation and failed drainage. The emergence of new potential interventional targets offers the potential for the development of new and more effective therapeutic candidates.
Collapse
Affiliation(s)
- Andrey A Komissarov
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler , Tyler, Texas
| | - Najib Rahman
- Oxford Pleural Unit and Oxford Respiratory Trials Unit, University of Oxford, Churchill Hospital; and National Institute of Health Research Biomedical Research Centre , Oxford , United Kingdom
| | - Y C Gary Lee
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital; Pleural Medicine Unit, Institute for Respiratory Health , Perth ; School of Medicine and Pharmacology, University of Western Australia , Perth , Australia
| | - Galina Florova
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler , Tyler, Texas
| | - Sreerama Shetty
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler , Tyler, Texas
| | - Richard Idell
- Department of Behavioral Health, Child and Adolescent Psychiatry, The University of Texas Health Science Center at Tyler , Tyler, Texas
| | - Mitsuo Ikebe
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler , Tyler, Texas
| | - Kumuda Das
- Department of Translational and Vascular Biology, The University of Texas Health Science Center at Tyler , Tyler, Texas
| | - Torry A Tucker
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler , Tyler, Texas
| | - Steven Idell
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler , Tyler, Texas
| |
Collapse
|
12
|
Intrapleural Fibrinolytic Therapy for Residual Coagulated Hemothorax After Lung Surgery. World J Surg 2016; 40:1121-8. [PMID: 26711639 DOI: 10.1007/s00268-015-3378-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Many studies have described the use of intrapleural fibrinolytics for the treatment of complex pleural processes and traumatic hemothorax, but data are scarce regarding their use for hemothorax after lung surgery. OBJECTIVE To evaluate the utility of intrapleural fibrinolytic therapy with urokinase for residual coagulated hemothorax (blood clot accumulation in the pleural cavity) after lung surgery. METHODS From July 2009 to November 2013, 46 patients (33 males; mean age, 56.9 ± 10.7 years) were treated with intrapleural urokinase (250,000 IU per dose) for residual hemothorax after lung surgery. Complete response was defined as clinical improvement with complete drainage of the retained collection shown by chest X-ray, and partial response as substantial resolution with minimal residual opacity (<25 % of the thorax). Follow-up was at least 30 days. RESULTS The procedure was successful in 42 patients (91.3 %), with complete response observed in 35/46 patients (76.1 %) and partial response in 7/46 (15.2 %). These 42 patients did not require re-intervention for fluid accumulation in the pleural cavity. Treatment failed in 4 patients (8.7 %): one developed bronchopleural fistula that later resolved spontaneously and three (6.5 %) required thoracoscopic drainage for pleural cavity fluid accumulation and lung collapse. No patient required thoracotomy for total decortication. Intrapleural urokinase administration was not associated with serious adverse events, including bleeding complications or allergic reactions. CONCLUSIONS Intrapleural fibrinolytic agents should be considered a useful therapeutic option for the treatment of postoperative residual hemothorax. This method appears to be safe and effective in >90 % of patients with postoperative hemothorax.
Collapse
|
13
|
Hsu LH, Hsu PC, Liao TL, Feng AC, Chu NM, Kao SH. Pleural fluid osteopontin, vascular endothelial growth factor, and urokinase-type plasminogen activator levels as predictors of pleurodesis outcome and prognosticators in patients with malignant pleural effusion: a prospective cohort study. BMC Cancer 2016; 16:463. [PMID: 27411914 PMCID: PMC4944509 DOI: 10.1186/s12885-016-2529-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Accepted: 07/06/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Rapidly growing cancer cells secrete growth-promoting polypeptides and have increased proteolytic activity, contributing to tumor progression and metastasis. Their presentation in malignant pleural effusion (MPE) and their predictive value for the outcome of pleurodesis and survival were studied. METHODS Between February 2011 and March 2012, MPE samples were prospectively collected from 61 patients. Twenty-five patients with non-malignant pleural effusion in the same period were included as controls. Pleural fluid osteopontin (OPN), vascular endothelial growth factor (VEGF), and urokinase-type plasminogen activator (uPA) concentrations were measured. RESULTS Patients with MPE had higher pleural fluid OPN, VEGF, and uPA concentrations than those with non-malignant pleural effusion, but only differences in VEGF were statistically significant (p = 0.045). Patients with distant metastases had significantly elevated pleural fluid VEGF concentrations than those without (p = 0.004). Pleural fluid OPN, VEGF, and uPA concentrations were positively correlated in most patients. However, there was no significant difference in pleural fluid OPN, VEGF, and uPA concentrations between patients with successful pleurodesis and those without. There was also no significant difference in cancer-specific survival between sub-groups with higher and lower pleural fluid OPN, VEGF, or uPA concentrations. Patients with successful pleurodesis had significantly longer cancer-specific survival than those without (p = 0.015). CONCLUSIONS Pleural fluid OPN, VEGF, and uPA concentrations are elevated in MPE but are not satisfactory predictors of pleurodesis outcome or survival. Patients with higher pleural fluid VEGF concentration have higher risk of distant metastasis. Evaluating the benefits of therapy targeting the VEGF pathway in these patients warrants further studies.
Collapse
Affiliation(s)
- Li-Han Hsu
- Ph.D. for Medical Biotechnology Program, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University Medical School, Taipei, Taiwan.,Division of Pulmonary and Critical Care Medicine, Sun Yat-Sen Cancer Center, Taipei, Taiwan
| | - Pei-Chi Hsu
- School of Medical Laboratory Science and Biotechnology, College of Medical Science and Technology, Taipei Medical University, 250 Wu-Hsing Street, Taipei, 110, Taiwan
| | - Tien-Ling Liao
- School of Medical Laboratory Science and Biotechnology, College of Medical Science and Technology, Taipei Medical University, 250 Wu-Hsing Street, Taipei, 110, Taiwan
| | - An-Chen Feng
- Department of Research, Sun Yat-Sen Cancer Center, Taipei, Taiwan
| | - Nei-Min Chu
- Department of Medical Oncology, Sun Yat-Sen Cancer Center, Taipei, Taiwan
| | - Shu-Huei Kao
- Ph.D. for Medical Biotechnology Program, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan. .,School of Medical Laboratory Science and Biotechnology, College of Medical Science and Technology, Taipei Medical University, 250 Wu-Hsing Street, Taipei, 110, Taiwan.
| |
Collapse
|
14
|
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.
Collapse
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
| | | |
Collapse
|
15
|
Thomas R, Piccolo F, Miller D, MacEachern PR, Chee AC, Huseini T, Yarmus L, Bhatnagar R, Lee HJ, Feller-Kopman D, Maskell NA, Tremblay A, Lee YCG. Intrapleural Fibrinolysis for the Treatment of Indwelling Pleural Catheter-Related Symptomatic Loculations: A Multicenter Observational Study. Chest 2015; 148:746-751. [PMID: 25742001 DOI: 10.1378/chest.14-2401] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Indwelling pleural catheters (IPCs) are an effective option in the management of malignant pleural effusion. Up to 14% of patients with IPCs develop symptomatic pleural loculations causing ineffective fluid drainage and breathlessness. To our knowledge, this is the first study to describe intrapleural fibrinolytic therapy for IPC-related symptomatic loculations. METHODS All patients who received intrapleural fibrinolytic therapy for symptomatic loculations between January 1, 2002, and June 30, 2014, in four established IPC centers were retrospectively included. Patient outcomes, treatment effectiveness, and adverse events were recorded. RESULTS Sixty-six patients (mean age, 64.7 ± 14.2 years; 52% women) were included. Lung cancer (31.3%) and malignant pleural mesothelioma (20.3%) were the most common malignancies. Fibrinolytic instillation was performed in outpatient (61%) and inpatient settings. Tissue-plasminogen activator (n = 52), urokinase (n = 12), and streptokinase (n = 2) were used. The majority (69.7%) received only one fibrinolytic dose (range, one to six). Pleural fluid drainage increased in 93% of patients, and dyspnea improved in 83% following therapy. The median cumulative pleural fluid volume drained at 24 h posttreatment was 500 mL (interquartile range 300-1,034 mL). The area of opacity caused by pleural effusion on chest radiograph decreased from (mean, SD) 52% (14%) to 31% (21%) of the hemithorax (n = 13; P = .001). There were two cases of nonfatal pleural bleed (3%). CONCLUSIONS Intrapleural fibrinolytic therapy can improve pleural fluid drainage and symptoms in selected patients with IPC and symptomatic loculation, but it carries a small risk of pleural bleeding. There is significant heterogeneity in its use currently, and further studies are needed to determine patient selection and optimal dosing regimen and to define its safety profile.
Collapse
Affiliation(s)
- Rajesh Thomas
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia; School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia; Lung Institute of Western Australia, Perth, WA, Australia
| | - Francesco Piccolo
- Department of Internal Medicine, Swan District Hospital, Perth, WA, Australia
| | - Daniel Miller
- Division of Respiratory Medicine and Southern Alberta Cancer Research Institute, University of Calgary, Calgary, AB, Canada
| | - Paul R MacEachern
- Division of Respiratory Medicine and Southern Alberta Cancer Research Institute, University of Calgary, Calgary, AB, Canada
| | - Alex C Chee
- Division of Respiratory Medicine and Southern Alberta Cancer Research Institute, University of Calgary, Calgary, AB, Canada
| | - Taha Huseini
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Lonny Yarmus
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Rahul Bhatnagar
- Academic Respiratory Unit, University of Bristol, Bristol, England
| | - Hans J Lee
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - David Feller-Kopman
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Nick A Maskell
- Academic Respiratory Unit, University of Bristol, Bristol, England
| | - Alain Tremblay
- Division of Respiratory Medicine and Southern Alberta Cancer Research Institute, University of Calgary, Calgary, AB, Canada
| | - Y C Gary Lee
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia; School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia; Lung Institute of Western Australia, Perth, WA, Australia.
| |
Collapse
|
16
|
Kriegel I, Daniel C, Falcou MC, Marcou A, de Bosschère L, Benarab S, Livartowski A, Estève M. Use of a Subcutaneous Implantable Pleural Port in the Management of Recurrent Malignant Pleurisy: Five-Year Experience Based on 168 Subcutaneous Implantable Pleural Ports. J Palliat Med 2011; 14:829-34. [DOI: 10.1089/jpm.2010.0539] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Irène Kriegel
- Département d'anesthésie-réanimation-Douleur, Institut Curie, Paris, France
| | | | | | - Aurore Marcou
- Département d'anesthésie-réanimation-Douleur, Institut Curie, Paris, France
| | | | - Smina Benarab
- Département d'anesthésie-réanimation-Douleur, Institut Curie, Paris, France
| | | | - Marc Estève
- Département d'anesthésie-réanimation-Douleur, Institut Curie, Paris, France
| |
Collapse
|
17
|
Okur E, Baysungur V, Tezel C, Ergene G, Okur HK, Halezeroglu S. Streptokinase for malignant pleural effusions: a randomized controlled study. Asian Cardiovasc Thorac Ann 2011; 19:238-43. [DOI: 10.1177/0218492311410874] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Effective palliative treatment in malignant pleural effusion can only be carried out when the lung is fully expanded after drainage of effusion. We investigated the efficacy of intrapleural fibrinolytics for lysing fibrin deposits and improving lung reexpansion in patients with malignant pleural effusion. We randomly allocated 47 patients with malignant pleural effusion into 2 groups: a fibrinolytic group of 24 were given 3 cycles of 250,000 U intrapleural streptokinase; the control group of 23 received pleural drainage only. Pleurodesis with 5 mg of talc slurry was performed in all patients who had lung reexpansion after drainage. Patient characteristics, pleural drainage, lung expansion assessed by chest radiography, and pleurodesis outcomes were compared between the 2 groups. Patient characteristics were similar in both groups. Lung reexpansion was adequate for performing talc pleurodesis in 96% of patients in the fibrinolytic group and 74% in the control group. In the fibrinolytic group, the mean volume of daily pleural drainage before streptokinase administration was 425 mL, and it increased significantly to 737 mL after streptokinase infusion. Intrapleural administration of streptokinase is advisable for patients with malignant pleural effusion.
Collapse
Affiliation(s)
- Erdal Okur
- Department of Thoracic Surgery, Acibadem University Medical School, Istanbul, Turkey
| | - Volkan Baysungur
- Department of Thoracic Surgery, Sureyyapasa Chest Diseases and Thoracic Surgery Teaching Hospital, Istanbul, Turkey
| | - Cagatay Tezel
- Department of Thoracic Surgery, Sureyyapasa Chest Diseases and Thoracic Surgery Teaching Hospital, Istanbul, Turkey
| | - Gokhan Ergene
- Department of Thoracic Surgery, Sureyyapasa Chest Diseases and Thoracic Surgery Teaching Hospital, Istanbul, Turkey
| | - Hacer Kuzu Okur
- Department of Respiratory Disease, Sureyyapasa Chest Diseases and Thoracic Surgery Teaching Hospital, Istanbul, Turkey
| | - Semih Halezeroglu
- Department of Thoracic Surgery, Acibadem University Medical School, Istanbul, Turkey
| |
Collapse
|
18
|
Mishra EK, Davies RJO. Advances in the investigation and treatment of pleural effusions. Expert Rev Respir Med 2010; 4:123-33. [PMID: 20387298 DOI: 10.1586/ers.09.67] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Pleural effusions present a challenge for both diagnosis and treatment. They are a commonly presenting problem of a wide range of local and systemic potentially life threatening diseases and cause significant breathlessness. Significant advances have been made in the last 5 years in the diagnostic pathway and management options. This article reviews recent developments in the investigation of pleural effusions, particularly in pleural fluid analysis, biomarkers, imaging and pleural biopsy, and in the treatment of pleural infection and both malignant and benign effusions, including the use of indwelling pleural catheters. Although significant recent advances have been made in the management of pleural effusions, there the need still remains for further research if we are to reduce the morbidity and mortality caused by pleural effusions.
Collapse
Affiliation(s)
- Eleanor K Mishra
- Oxford Respiratory Trials Unit, Nuffield Department of Medicine, University of Oxford, Churchill Hospital, Old Road, Headington, Oxford, OX3 7LJ, UK.
| | | |
Collapse
|
19
|
Goralski JL, Bromberg PA, Haithcock B. Intrapleural hemorrhage after administration of tPA: a case report and review of the literature. Ther Adv Respir Dis 2010; 3:295-300. [PMID: 19934281 DOI: 10.1177/1753465809350748] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Intrapleural fibrinolytic enzymes have been used for over 60 years in the treatment of complicated pleural effusions to lyse loculations and promote resolution. Despite this extensive history of use, however, little is known about complications that may arise with the use of this therapy. Here we discuss a patient with chronic renal failure on hemodialysis who developed an intrapleural hemorrhage after the administration of intrapleural tPA to treat a complicated parapneumonic effusion. A review of the literature examines the efficacy and safety of this therapy, focusing on bleeding complications. Specific attention is paid to patients who have underlying coagulopathies or who are receiving anticoagulation. DATA SOURCES A review of the literature, as indexed in PubMed, was undertaken using the following search terms in combination: tPA, pleural effusion, complications of thrombolytics, and intrapleural hemorrhage. The search was inclusive of patients under the age of 18, but was limited by English language and human subjects. STUDY SELECTION/DATA EXTRACTION All relevant articles identified during the search were reviewed. Those studies that reported on bleeding complications, or lack thereof, were included in this review. Limitations of each article are noted in the text. CONCLUSIONS Multiple studies, including a 2000 ACP consensus statement and a 2008 Cochrane review, indicate the need for further investigations to evaluate the safety and efficacy of intrapleural thrombolytics for the treatment of complicated pleural effusions and empyemas. Limited studies specifically address bleeding complications, especially in subpopulations of patients receiving concurrent anticoagulant therapy.
Collapse
Affiliation(s)
- Jennifer L Goralski
- University of North Carolina at Chapel Hill, Division of Pulmonary and Critical Care Medicine, Chapel Hill, NC, USA.
| | | | | |
Collapse
|