1
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Wong T, Fuld AD, Feller-Kopman DJ. Malignant Pleural Effusions in the Era of Immunotherapy and Antiangiogenic Therapy. Semin Respir Crit Care Med 2023. [PMID: 37308114 DOI: 10.1055/s-0043-1769092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Malignant pleural effusions (MPE) have historically been associated with a poor prognosis, and patients often require a series of invasive procedures and hospitalizations that significantly reduce quality of life at the terminus of life. However, advances in the management of MPE have coincided with the era of immunotherapies, and to a lesser extent, antiangiogenic therapies for the treatment of lung cancer. Landmark studies have shown these drugs to improve overall survival and progression-free survival in patients with lung cancer, but a paucity of phase III trial data exists for the impact of immune checkpoint inhibitors (ICI) on lung cancers associated with MPE. This review will focus on the leading studies investigating the impact of ICI and antiangiogenic therapies in patients with lung cancer and MPE. The diagnostic and prognostic values of vascular endothelial growth factor and endostatin expression levels in malignancy will also be discussed. These advancements are changing the paradigm of MPE management from palliation to treatment for the first time since 1767 when MPE was first reported. The future holds the promise of durable response and extended survival in patients with MPE.
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Affiliation(s)
- Terrence Wong
- Department of Medicine, Geisel School of Medicine, Dartmouth, Hanover, New Hampshire
- Division of Pulmonary and Critical Care Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Alexander D Fuld
- Department of Medicine and Medical Education, Geisel School of Medicine, Dartmouth, Hanover, New Hampshire
- Department of Medical Oncology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - David J Feller-Kopman
- Department of Medicine, Geisel School of Medicine, Dartmouth, Hanover, New Hampshire
- Division of Pulmonary and Critical Care Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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2
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Qureshi M, Thapa B, Muruganandan S. A Narrative Review-Management of Malignant Pleural Effusion Related to Malignant Pleural Mesothelioma. Heart Lung Circ 2023; 32:587-595. [PMID: 36925448 DOI: 10.1016/j.hlc.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 01/29/2023] [Accepted: 02/08/2023] [Indexed: 03/17/2023]
Abstract
Malignant pleural mesothelioma (MPM) is an aggressive, almost universally fatal cancer with limited therapeutic options. Despite efforts, a real breakthrough in treatment and outcomes has been elusive. Pleural effusion with significant breathlessness and pain is the most typical presentation of individuals with MPM. Although thoracentesis provides relief of breathlessness, most such pleural effusions recur rapidly, and a definitive procedure is often required to prevent a recurrence. Unfortunately, the optimal treatment modality for individuals with recurrent MPM-related effusion is unclear, and considerable variation exists in practice. In addition, non-expandable lung is common in pleural effusions due to MPM and makes effective palliation of symptoms more difficult. This review delves into the latest advances in the available management options (both surgical and non-surgical) for dealing with pleural effusion and non-expandable lung related to MPM. We discuss factors that determine the choice of definitive procedures that need to be tailored to the individual patient.
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Affiliation(s)
- Maryum Qureshi
- Department of Thoracic Surgery, Northern Hospital, Melbourne, Vic, Australia.
| | - Bibhusal Thapa
- Department of Thoracic Surgery, Northern Hospital, Melbourne, Vic, Australia
| | - Sanjeevan Muruganandan
- Department of Respiratory Medicine, Northern Hospital, Melbourne, Vic, Australia; School of Medicine, Health Sciences, Dentistry, University of Melbourne, Vic, Australia
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3
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Jacobs B, Sheikh G, Youness HA, Keddissi JI, Abdo T. Diagnosis and Management of Malignant Pleural Effusion: A Decade in Review. Diagnostics (Basel) 2022; 12:1016. [PMID: 35454064 PMCID: PMC9030780 DOI: 10.3390/diagnostics12041016] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 04/12/2022] [Accepted: 04/12/2022] [Indexed: 02/04/2023] Open
Abstract
Malignant pleural effusion (MPE) is a common complication of thoracic and extrathoracic malignancies and is associated with high mortality. Treatment is mainly palliative, with symptomatic management achieved via effusion drainage and pleurodesis. Pleurodesis may be hastened by administering a sclerosing agent through a thoracostomy tube, thoracoscopy, or an indwelling pleural catheter (IPC). Over the last decade, several randomized controlled studies shaped the current management of MPE in favor of an outpatient-based approach with a notable increase in IPC usage. Patient preferences remain essential in choosing optimal therapy, especially when the lung is expandable. In this article, we reviewed the last 10 to 15 years of MPE literature with a particular focus on the diagnosis and evolving management.
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Affiliation(s)
| | | | | | | | - Tony Abdo
- Section of Pulmonary, Critical Care and Sleep Medicine, The University of Oklahoma Health Sciences Center and The Oklahoma City VA Health Care System, Oklahoma City, OK 73104, USA; (B.J.); (G.S.); (H.A.Y.); (J.I.K.)
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4
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Abstract
Malignant pleural effusions have a significant burden on patients and the health care system. Diagnosis is typically via thoracentesis, although other times more invasive procedures are required. Management centers around relief of dyspnea and patient quality of life and can be done via serial thoracentesis, indwelling pleural catheter, or pleurodesis. This article focuses on the diagnosis and management of malignant pleural effusion.
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Affiliation(s)
- Christopher M Kapp
- Department of Medicine, Division of Pulmonary, Critical Care, Sleep and Allergy Medicine, University of Illinois at Chicago, 840 South Wood Street, Room 920-N, Chicago, IL 60612, USA.
| | - Hans J Lee
- Section of Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
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5
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Plaksin SA, Farshatova LI. [Causes of resistant pleural effusions and efficiency of chemical pleurodesis in these patients]. Khirurgiia (Mosk) 2021:24-30. [PMID: 34270190 DOI: 10.17116/hirurgia202107124] [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
OBJECTIVE To study the causes of resistant pleural effusions and efficiency of chemical pleurodesis with Betadin, Iodopyrone and concentrated glucose solution in these patients. MATERIAL AND METHODS Resistant pleuritis with daily exudation over 300 ml lasting ≥6 days occurred in 206 (48%) out of 424 cases of pleural effusions. Twenty-seven patients underwent chemical pleurodesis with Betadine, 15 patients - mixture of Iodopyrone with concentrated glucose solution. Solutions were injected via pleural drainage. RESULTS In multivariate analysis, the risk factors of complicated pleuritis were air leakage, prolonged drainage period, age over 60 years, fluid output volume during thoracoscopy and higher Charlson index. Pleurodesis with a mixture of Betadine 10% 10 ml and glucose 40% 40 ml suppressed exudation in 92.6% of cases. Pleurodesis with a mixture of Iodopyron and glucose solution in the same quantities was effective in 93.4% of cases. If exudation continued, pleurodesis was repeated after 3 days. VAS score of pain syndrome following Iodopyrone injection was 3.0±1.8, in case of Betadine - 3.4±0.3. No significant hemodynamic changes were noted. In case of malignant pleural effusions and low functional parameters after fluid evacuation, favorable effect was obtained after pleurodesis with a mixture of povidone-iodine with glucose through the same catheter and subsequent removal of drainage tube. CONCLUSION Resistant pleural effusions with daily exudation over 300 ml for more than 6 days are characterized by advanced risk of infectious and inflammatory complications due to air leakage and duration of drainage. Pleurodesis with mixtures of Betadine or iodopyrone and 40% glucose solution is effective for resistant pleural effusions.
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Affiliation(s)
- S A Plaksin
- Vagner Perm State Medical University, Perm, Russia
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6
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Indwelling Pleural Catheter Drainage Strategy for Malignant Effusion: A Cost-Effectiveness Analysis. Ann Am Thorac Soc 2021; 17:746-753. [PMID: 32125880 DOI: 10.1513/annalsats.201908-615oc] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Rationale: The likelihood of achieving pleurodesis after indwelling pleural catheter (IPC) placement for malignant pleural effusion varies with the specific drainage strategy used: symptom-guided drainage, daily drainage, or talc instillation through the IPC (IPC + talc). The relative cost-effectiveness of one strategy over the other is unknown.Objectives: We performed a decision tree model-based analysis to ascertain the cost-effectiveness of each IPC drainage strategy from a healthcare system perspective.Methods: We developed a decision tree model using theoretical event probability data derived from three randomized clinical trials and used 2019 Medicare reimbursement data for cost estimation. The primary outcome was incremental cost-effectiveness ratio (ICER) over an analytical horizon of 6 months with a willingness-to-pay threshold of $100,000/quality-adjusted life-year (QALY). Monte Carlo probabilistic sensitivity analysis and one-way sensitivity analyses were conducted to measure the uncertainty surrounding base case estimates.Results: IPC + talc was a cost-effective alternative to symptom-guided drainage, with an ICER of $59,729/QALY. Monte Carlo probabilistic sensitivity analysis revealed that this strategy was favored in 54% of simulations. However, symptom-guided drainage was cost effective for pleurodesis rates >20% and for life expectancy <4 months. Daily drainage was not cost effective in any scenario, including for patients with nonexpandable lung, in whom it had an ICER of $2,474,612/QALY over symptom-guided drainage.Conclusions: For patients with malignant pleural effusion and an expandable lung, IPC + talc may be cost effective relative to symptom-guided drainage, although considerable uncertainty exists around this estimation. Daily IPC drainage is not a cost-effective strategy under any circumstance.
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7
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Botana-Rial M, Ramos-Hernández C, Lojo-Rodríguez I, Represas-Represas C, Ruano-Raviña A, Leiro-Fernández V, Fernández-Villar A. Cost Effectiveness of Malignant Pleural Effusion with Indwelling Catheter: Systematic Review. J Palliat Med 2020; 24:1206-1212. [PMID: 33395352 DOI: 10.1089/jpm.2020.0695] [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: 11/12/2022] Open
Abstract
Background: The current cost of treatment of malignant pleural effusion (MPE) with an indwelling pleural catheter (IPC) is unclear. Objective: We propose a review of the scientific evidence on the cost and effectiveness of this therapeutic option. Methods: Systematic review of the literature on the cost and effectiveness of the treatment of MPE by IPC, according to the PRISMA methodology and quality according to the scientific guidelines. Results: A total of 4 articles, 152 patients, and 159 IPCs were included. The use of IPC was associated with improvement in symptoms and quality of life. The most common complications were infections (empyema in 20.9% of patients and cellulitis in 17.3%); 9% of cases were hospitalized due to complications, and <2% required subsequent procedures. The average cost of IPC (set/drainage bottles) ranged from €2,025.6 to €1,200.5 if it was placed on an outpatient basis, €1,100 if survival was <6 weeks, and €4,028 in patients with mesothelioma. Complications increased the cost, and taking into account follow-up visits, additional tests, and days of admission for complications, the cost was >€5,000. Compared with pleurodesis, the cost of IPC was significantly lower when patient survival was <14 weeks, but not when survival was longer or home care was required. Conclusions: The use of IPC is associated with good control of MPE and seldom requires many subsequent procedures; however, it is also associated with a certain rate of complications, which may increase costs. However, ambulatory management may help reduce costs, which are directly related to the type of tumor, the duration of survival, and the need for specialized treatment.
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Affiliation(s)
- Maribel Botana-Rial
- Pulmonary Department, Hospital Álvaro Cunqueiro, Vigo, Spain.,PneumoVigoI+I Research Group, Sanitary Research Institute Galicia Sur (IIS Galicia Sur), Vigo, Spain
| | - Cristina Ramos-Hernández
- Pulmonary Department, Hospital Álvaro Cunqueiro, Vigo, Spain.,PneumoVigoI+I Research Group, Sanitary Research Institute Galicia Sur (IIS Galicia Sur), Vigo, Spain
| | - Irene Lojo-Rodríguez
- Pulmonary Department, Hospital Álvaro Cunqueiro, Vigo, Spain.,PneumoVigoI+I Research Group, Sanitary Research Institute Galicia Sur (IIS Galicia Sur), Vigo, Spain
| | - Cristina Represas-Represas
- Pulmonary Department, Hospital Álvaro Cunqueiro, Vigo, Spain.,PneumoVigoI+I Research Group, Sanitary Research Institute Galicia Sur (IIS Galicia Sur), Vigo, Spain
| | - Alberto Ruano-Raviña
- Deparment of Preventive Medicine and Public Health, University of Santiago de Compostela, Santiago de Compostela, Spain.,Consortium for Biomedical Research in Epidemiologic and Public Health (CIBER en Epidemiologia y Salúd Pública-CIBERESP), Madrid, Spain
| | - Virginia Leiro-Fernández
- Pulmonary Department, Hospital Álvaro Cunqueiro, Vigo, Spain.,PneumoVigoI+I Research Group, Sanitary Research Institute Galicia Sur (IIS Galicia Sur), Vigo, Spain
| | - Alberto Fernández-Villar
- Pulmonary Department, Hospital Álvaro Cunqueiro, Vigo, Spain.,PneumoVigoI+I Research Group, Sanitary Research Institute Galicia Sur (IIS Galicia Sur), Vigo, Spain
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8
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Aboudara M, Roller L, Lentz R, Rickman OB, Gillaspie EA, Maldonado F. A Survey-Based Study of Patient-Centered Costs Associated With Indwelling Pleural Catheters. Am J Hosp Palliat Care 2020; 38:361-365. [PMID: 32869650 DOI: 10.1177/1049909120954810] [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: 11/15/2022] Open
Abstract
INTRODUCTION Indwelling pleural catheters (IPC) are effective at palliating benign and malignant pleural effusions (MPE). They have also been found to be cost effective from a third-party payor perspective. Little is known of the impact IPCs have on patient-centered quality of life outcomes such as financial burden and patient and caregiver burden. We performed a cross-sectional survey study evaluating the impact of IPCs on multiple patient and caregiver quality of life metrics. METHODS Patients ≥ 18 years old with an IPC in place for 2 months were eligible. Twenty patients were recruited over a 10-month period. Patients completed the CDC-Health Related Quality of Life (HRQOL)-4 and a HRQOL-financial questionnaire. The primary objective was to describe the socio-economic impact of IPCs. Demographic and IPC specific data were collected. Descriptive statistics were used. RESULTS The mean (SD) age was 64.3 (0.70). The indication was MPE in 19/20. All patients had medical insurance. Medicare or Medicaid (CMS) comprised 10/20 of payors. The median (IQR) copay for private insurers was $238.45 (72-875); 11/20 had additional costs related to the IPC; 4/20 had significant life changes after the IPC; 17/20 received assistance from a non-paid caregiver; 6/20 patients could not do activities because of the IPC and this negatively impacted QOL in 3/6 of those patients. CONCLUSION Patients with IPCs may experience negative life consequences, incur additional medical expenses, and require assistance from a non-paid caregiver. Activities may be negatively impacted by IPC. Discussion of alternative means of symptom palliation and pleurodesis would be beneficial.
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Affiliation(s)
- Matthew Aboudara
- 14414St. Luke's Health System, Division of Pulmonary and Critical Care, University of Missouri at Kansas City School of Medicine, Kansas City, MO, USA
| | - Lance Roller
- Division of Allergy, Pulmonary and Critical Care Medicine, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Rob Lentz
- Division of Allergy, Pulmonary and Critical Care Medicine, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Thoracic Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Otis B Rickman
- Division of Allergy, Pulmonary and Critical Care Medicine, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Thoracic Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Erin A Gillaspie
- Department of Thoracic Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Fabien Maldonado
- Division of Allergy, Pulmonary and Critical Care Medicine, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Thoracic Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
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9
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Abstract
The field of interventional pulmonology has grown rapidly since first being defined as a subspecialty of pulmonary and critical care medicine in 2001. The interventional pulmonologist has expertise in minimally invasive diagnostic and therapeutic procedures involving airways, lungs, and pleura. In this review, we describe recent advances in the field as well as up-and-coming developments, chiefly from the perspective of medical practice in the United States. Recent advances include standardization of formalized training, new tools for the diagnosis and potential treatment of peripheral lung nodules (including but not limited to robotic bronchoscopy), increasingly well-defined bronchoscopic approaches to management of obstructive lung diseases, and minimally invasive techniques for maximizing patient-centered outcomes for those with malignant pleural effusion.
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10
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Abstract
Malignant pleural effusion frequently complicates both solid and hematologic malignancies and is associated with high morbidity, mortality, and health care costs. Although no pleura-specific therapy is known to impact survival, both pleurodesis and indwelling pleural catheter (IPC) placement can significantly alleviate symptoms and improve quality of life. The optimal choice of therapy in terms of efficacy and particularly cost-effectiveness depends on patient preferences and individual characteristics, including lung expansion and life expectancy. Attempting chemical pleurodesis through an IPC in the outpatient setting appears to be a particularly promising approach in the absence of a nonexpandable lung.
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Affiliation(s)
- Majid Shafiq
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - David Feller-Kopman
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, 1800 Orleans Street, Suite 7-125, Baltimore, MD 21287, USA.
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11
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Shafiq M, Ma X, Taghizadeh N, Kharrazi H, Feller-Kopman DJ, Tremblay A, Yarmus LB. Healthcare Costs and Utilization among Patients Hospitalized for Malignant Pleural Effusion. Respiration 2020; 99:257-263. [PMID: 32155630 DOI: 10.1159/000506210] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 01/25/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Malignant pleural effusion (MPE) poses a considerable healthcare burden, but little is known about trends in directly attributable hospital utilization. OBJECTIVE We aimed to study national trends in healthcare utilization and outcomes among hospitalized MPE patients. METHODS We analyzed adult hospitalizations attributable to MPE using the Healthcare Cost and Utilization Project - National Inpatient Sample (HCUP-NIS) databases from 2004, 2009, and 2014. Cases were included if MPE was coded as the principal admission diagnosis or if unspecified pleural effusion was coded as the principal admission diagnosis in the setting of metastatic cancer. Annual hospitalizations were estimated for the entire US hospital population using discharge weights. Length of stay (LOS), hospital charges, and hospital mortality were also estimated. RESULTS We analyzed 92,034 hospital discharges spanning a decade (2004-2014). Yearly hospitalizations steadily decreased from 38,865 to 23,965 during this time frame, the mean LOS decreased from 7.7 to 6.3 days, and the adjusted hospital mortality decreased from 7.9 to 4.5% (p = 0.00 for all trend analyses). The number of pleurodesis procedures also decreased over time (p = 0.00). The mean inflation-adjusted charge per hospitalization rose from USD 41,252 to USD 56,951, but fewer hospitalizations drove the total annual charges down from USD 1.51 billion to USD 1.37 billion (p = 0.00 for both analyses). CONCLUSIONS The burden of hospital-based resource utilization associated with MPE has decreased over time, with a reduction in attributable hospitalizations by one third in the span of 1 decade. Correspondingly, the number of inpatient pleurodesis procedures has decreased during this time frame.
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Affiliation(s)
- Majid Shafiq
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA,
| | - Xiaomeng Ma
- Center for Population Health IT, Department of Health Policy Management, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Hadi Kharrazi
- Center for Population Health IT, Department of Health Policy Management, Johns Hopkins University, Baltimore, Maryland, USA
| | - David J Feller-Kopman
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Alain Tremblay
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Lonny B Yarmus
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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12
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Efforts to Limit Publication Bias and Improve Quality in the Journal: Introduction of Double-Blind Peer Review. J Bronchology Interv Pulmonol 2020; 26:143-147. [PMID: 31233467 DOI: 10.1097/lbr.0000000000000600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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13
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Shi XY, Yi FS, Wang Z, Qiao X, Zhai K. Prognostic value of a new score using serum alkaline phosphatase and pleural effusion lactate dehydrogenase for patients with malignant pleural effusion. Thorac Cancer 2019; 11:320-328. [PMID: 31837116 PMCID: PMC6996981 DOI: 10.1111/1759-7714.13262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 11/06/2019] [Accepted: 11/07/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The objective of our study was to analyze the prognostic value of the combination of serum ALP and pleural effusion LDH (AL score) for malignant pleural effusion (MPE) patients. METHODS This study includes retrospective, descriptive and observational research from 1 June 2006 to 1 December 2017, which aimed to identify prognostic factors related to MPE patients. We analyzed the association of various clinical features, routinely tested markers from peripheral blood and MPE at diagnosis and overall survival (OS). All MPE patients were assigned to three groups according to their AL score. The impact of the AL score and other prognostic factors were evaluated with multivariable regression. RESULTS According to their AL score, 193 patients were assigned to three groups with 25 in group 0 (sALP < 65 U/L and pLDH < 155 U/L), 121 in group 1 (sALP > 65 U/L or pLDH > 155 U/L) and 47 (sALP > 65 U/L and pLDH > 155 U/L) in group 2. For groups 0, 1 and 2, median survival times (MST) were 23, 15 and 7 months, respectively. Among the three groups, MST, serum albumin level, C reactive protein, erythrocyte sedimentation rate, the ratios of platelet-to-lymphocyte, neutrophil-to-lymphocyte showed significant differences. The counts of neutrophils, monocytes, platelets and AL score (0 vs. 1, P = 0.038, hazard ratio [HR]: 1.858, 95% confidence interval [CI]: [1.034, 3.339]; 0 vs. 2, P = 0.001, HR: 2.993, 95% CI: [1.556, 5.531]) were independent prognostic indicators for OS of MPE patients. CONCLUSION AL score is a promising indicator which can be used to predict the prognosis of MPE patients. It can assist physicians in the selection of patients for appropriate palliative treatment. KEY POINTS To our knowledge, this paper is the first study that combined two enzymes (sALP and pLDH) from serum and pleural effusion and studied the prognostic value for MPE patients. It has been proved to be a promising indicator to assist physicians select patients for appropriate palliative treatment.
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Affiliation(s)
- Xin-Yu Shi
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Feng-Shuang Yi
- Department of Medical Research Center, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Zheng Wang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Xin Qiao
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Kan Zhai
- Department of Medical Research Center, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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14
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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.
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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
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15
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Epelbaum O, Rahman NM. Contemporary approach to the patient with malignant pleural effusion complicating lung cancer. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:352. [PMID: 31516898 DOI: 10.21037/atm.2019.03.61] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Malignant pleural effusion (MPE) occurring in the patient with lung cancer can have profound prognostic and management implications. If clinically relevant, such an effusion first needs to be confirmed as malignant and then, in the majority of lung cancer patients, it will require a pleural intervention to relieve symptoms related to fluid accumulation. The field of pleural diseases in general, and pleural malignancy in particular, has undergone dynamic changes in recent years as the evidence base informing practice has grown by leaps and bounds. Both the diagnosis and management of MPE are dynamically changing disciplines in thoracic medicine. As commonly happens, emerging data have generated just as many questions as they have answered. The aim of the present review is to summarize the current knowledge about MPE resulting from lung cancer in a manner that is accessible to clinicians across medical specialties.
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Affiliation(s)
- Oleg Epelbaum
- Division of Pulmonary, Critical Care and Sleep Medicine, Westchester Medical Center, Valhalla, NY, USA
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Respiratory Trials Unit, Oxford University, Oxford, UK
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16
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Abstract
Pleural effusions are a common clinical problem for the primary care physician. Over the past 10 years, there has been a paradigm shift in the field due to emergence of new evidence, which includes the ubiquitous use of thoracic ultrasound, the reemergence of pleuroscopy as a diagnostic and therapeutic modality, the widespread use of indwelling pleural catheters for malignant pleural effusions, and the evidence-based approach to management of complex parapneumonic effusions. This review focuses on these advancements with an emphasis on practical clinical application.
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Affiliation(s)
- Matthew Aboudara
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, The Vanderbilt Clinic, 1301 Medical Center Drive, B-817 The Vanderbilt Clinic, Nashville, TN 37232-5735, USA
| | - Fabien Maldonado
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, The Vanderbilt Clinic, 1301 Medical Center Drive, B-817 The Vanderbilt Clinic, Nashville, TN 37232-5735, USA.
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17
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Rakesh HR, Gelzinis TA. The Updated ATS/STS/STR Clinical Practice Guidelines on the Management of Malignant Pleural Effusions: What Is New in 2018? J Cardiothorac Vasc Anesth 2019; 33:1181-1186. [DOI: 10.1053/j.jvca.2018.11.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Indexed: 12/16/2022]
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18
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Mazzocchi A, Devarasetty M, Herberg S, Petty WJ, Marini F, Miller L, Kucera G, Dukes DK, Ruiz J, Skardal A, Soker S. Pleural Effusion Aspirate for use in 3D Lung Cancer Modeling and Chemotherapy Screening. ACS Biomater Sci Eng 2019; 5:1937-1943. [PMID: 31723594 DOI: 10.1021/acsbiomaterials.8b01356] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Lung cancer is the leading cause of cancer-related death worldwide yet in vitro disease models have been limited to traditional 2D culture utilizing cancer cell lines. In contrast, recently developed 3D models (organoids) have been adopted by researchers to improve the physiological relevance of laboratory study. We have hypothesized that 3D hydrogel-based models will allow for improved disease replication and characterization over standard 2D culture using cells taken directly from patients. Here, we have leveraged the use of 3D hydrogel-based models to create lung cancer organoids using a unique cell source, pleural effusion aspirate, from multiple lung cancer patients. With these 3D models, we have characterized the cell populations comprising the pleural effusion aspirate and have tracked phenotypic changes that develop during short-term in vitro culture. We found that isolated, patient cells placed directly into organoids created anatomically relevant structures and exhibited lung cancer specific behaviors. On the other hand, cells first grown in plastic dishes and then cultured in 3D did not create similar structures. Further, we have been able to compare chemotherapeutic response of patient cells between 2D and 3D cell culture systems. Our results show that cells in 2D culture were more sensitive to treatment when compared with 3D organoids. Collectively, we have been able to utilize tumor cells from pleural effusion fluid of lung cancer patients to create organoids that display in vivo like anatomy and drug response and thus could serve as more accurate disease models for study of tumor progression and drug development.
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Affiliation(s)
- Andrea Mazzocchi
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, 391 Technology Way, Winston-Salem, NC, 27101, USA.,Virginia Tech-Wake Forest School of Biomedical Engineering and Sciences, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Mahesh Devarasetty
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, 391 Technology Way, Winston-Salem, NC, 27101, USA
| | - Samuel Herberg
- Current address: SUNY Upstate Medical University, 505 Irving Avenue, Syracuse, NY 13210
| | - William J Petty
- Department of Cancer Biology, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA.,Comprehensive Cancer Center at Wake Forest Baptist Medical, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Frank Marini
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, 391 Technology Way, Winston-Salem, NC, 27101, USA.,Department of Cancer Biology, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Lance Miller
- Department of Cancer Biology, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA.,Comprehensive Cancer Center at Wake Forest Baptist Medical, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Gregory Kucera
- Department of Cancer Biology, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA.,Comprehensive Cancer Center at Wake Forest Baptist Medical, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - David K Dukes
- Current address: Alabama College of Osteopathic Medicine, 445 Health Sciences Blvd, Dothan, AL 36303, USA
| | - Jimmy Ruiz
- Department of Cancer Biology, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA.,Comprehensive Cancer Center at Wake Forest Baptist Medical, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Aleksander Skardal
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, 391 Technology Way, Winston-Salem, NC, 27101, USA.,Virginia Tech-Wake Forest School of Biomedical Engineering and Sciences, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA.,Department of Cancer Biology, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA.,Comprehensive Cancer Center at Wake Forest Baptist Medical, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Shay Soker
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, 391 Technology Way, Winston-Salem, NC, 27101, USA.,Virginia Tech-Wake Forest School of Biomedical Engineering and Sciences, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA.,Department of Cancer Biology, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA.,Comprehensive Cancer Center at Wake Forest Baptist Medical, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
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19
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Grosu HB, Molina S, Casal R, Song J, Li L, Diaz-Mendoza J, Reddy C, Yarmus L, Schiavo D, Simoff M, Johnstun J, Raid AA, Feller-Kopman D, Lee H, Sahetya S, Foley F, Maldonado F, Tian X, Noor L, Miller R, Mudambi L, Saettele T, Vial-Rodriguez M, Eapen GA, Ost DE. Risk factors for pleural effusion recurrence in patients with malignancy. Respirology 2019; 24:76-82. [PMID: 29966171 PMCID: PMC7315912 DOI: 10.1111/resp.13362] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Revised: 04/09/2018] [Accepted: 06/07/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVE The main purpose of treatment in patients with malignant pleural effusion (MPE) is symptom palliation. Currently, patients undergo repeat thoracenteses prior to receiving a definitive procedure as clinicians are not aware of the risk factors associated with fluid recurrence. The primary objective of this study was to identify risk factors associated with recurrent symptomatic MPE. METHODS Retrospective multicentre cohort study of patients who underwent first thoracentesis was performed. The primary outcome was time to fluid recurrence requiring intervention in patients with evidence of metastatic disease. We used a cause-specific hazard model to identify risk factors associated with fluid recurrence. We also developed a predictive model, utilizing Fine-Gray subdistribution hazard model, and externally validated the model. RESULTS A total of 988 patients with diagnosed metastatic disease were included. Cumulative incidence of recurrence was high with 30% of patients recurring by day 15. On multivariate analysis, size of the effusion on chest X-ray (up to the top of the cardiac silhouette (hazard ratio (HR): 1.84, 95% CI: 1.21-2.80, P = 0.004) and above the cardiac silhouette (HR: 2.22, 95% CI: 1.43-3.46, P = 0.0004)), larger amount of pleural fluid drained (HR: 1.06, 95% CI: 1.04-1.07, P < 0.0001) and higher pleural fluid LDH (HR: 1.008, 95% CI: 1.004-1.011, P < 0.0001) were associated with increased hazard of recurrence. Negative cytology (HR: 0.52, 95% CI: 0.43-0.64, P < 0.0001) was associated with decreased hazard of recurrence. The model had low prediction accuracy. CONCLUSION Pleural effusion size, amount of pleural fluid drained, LDH and pleural fluid cytology were found to be risk factors for recurrence.
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Affiliation(s)
- Horiana B Grosu
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sofia Molina
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- School of Medicine and Health Sciences TecSalud, Monterrey, Mexico
| | - Roberto Casal
- Pulmonary Department, Michael DeBakey VA Medical Center, Baylor College of Medicine, Houston, TX, USA
| | - Juhee Song
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Liang Li
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Chakravarthy Reddy
- Pulmonary Department, University of Utah Health Care, Salt Lake City, UT, USA
| | - Lonny Yarmus
- Pulmonary Department, Johns Hopkins University, Baltimore, MD, USA
| | - Dante Schiavo
- Pulmonary Department, Mayo Clinic, Rochester, MN, USA
| | - Michael Simoff
- Pulmonary Department, Henry Ford Hospital, Detroit, MI, USA
| | - Jared Johnstun
- Pulmonary Department, University of Utah Health Care, Salt Lake City, UT, USA
| | - Abu-Awwad Raid
- Pulmonary Department, Michael DeBakey VA Medical Center, Baylor College of Medicine, Houston, TX, USA
| | | | - Hans Lee
- Pulmonary Department, Johns Hopkins University, Baltimore, MD, USA
| | - Sarina Sahetya
- Pulmonary Department, Johns Hopkins University, Baltimore, MD, USA
| | - Finbar Foley
- Pulmonary Department, Mayo Clinic, Rochester, MN, USA
| | | | - Xin Tian
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Laila Noor
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Russell Miller
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lakshmi Mudambi
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Timothy Saettele
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Macarena Vial-Rodriguez
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gerogie A Eapen
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David E Ost
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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20
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Outcomes of a Clinical Pathway for Pleural Disease Management: "Pleural Pathway". Pulm Med 2018; 2018:2035248. [PMID: 29805807 PMCID: PMC5899858 DOI: 10.1155/2018/2035248] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 01/25/2018] [Accepted: 01/30/2018] [Indexed: 11/17/2022] Open
Abstract
Background and Objectives Clinical pathways are evidence based multidisciplinary team approaches to optimize patient care. Pleural diseases are common and accounted for 3.4 billion US $ in 2014 US inpatient aggregate charges (HCUPnet data). An institutional clinical pathway ("pleural pathway") was implemented in conjunction with a dedicated pleural service. Design, implementation, and outcomes of the pleural pathway (from August 1, 2014, to July 31, 2015) in comparison to a previous era (from August 1, 2013, to July 31, 2014) are described. Methods Tuality Healthcare is a 215-bed community healthcare system in Hillsboro, OR, USA. With the objective of standardizing pleural disease care, locally adapted British Thoracic Society guidelines and a centralized pleural service were implemented in the "pathway" era. System-wide consensus regarding institutional guidelines for care of pleural disease was achieved. Preimplementation activities included training, acquisition of ultrasound equipment, and system-wide education. An audit database was set up with the intent of prospective audits. An administrative database was used for harvesting outcomes data and comparing them with the "prior to pathway" era. Results 54 unique consults were performed. A total of 55 ultrasound examinations and 60 pleural procedures were performed. All-cause inpatient pleural admissions were lower in the "pathway" era (n = 9) compared to the "prior to pathway" era (n = 17). Gains in average case charges (21,737$ versus 18,818.2$/case) and average length of stay (3.65 versus 2.78 days/case) were seen in the "pathway" era. Conclusion A "pleural pathway" and a centralized pleural service are associated with reduction in case charges, inpatient admissions, and length of stay for pleural conditions.
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21
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Gilbert CR, Akulian JA, Gorden JA. The Impact of the ASAP Trial: Maybe We Shouldn’t Act So Quickly. Am J Respir Crit Care Med 2018; 197:142-143. [DOI: 10.1164/rccm.201705-0956le] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Jason A. Akulian
- University of North Carolina School of MedicineChapel Hill, North Carolina
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22
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Desai NR, Lee HJ. Diagnosis and management of malignant pleural effusions: state of the art in 2017. J Thorac Dis 2017; 9:S1111-S1122. [PMID: 29214068 DOI: 10.21037/jtd.2017.07.79] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Malignant pleural effusion (MPE) is a known complication of both thoracic and extra thoracic malignancies. The presence of MPE regardless of the primary site translates into advanced stage disease. Diagnosis and management of MPE with the goals of palliation and improving quality of life poses a challenge for chest physicians. Recently, multiple studies have made attempts to answer questions regarding optimal management in various clinical scenarios. We will review the current evidence and available options for the management of MPE.
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Affiliation(s)
| | - Hans J Lee
- Section of Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, USA
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23
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24
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Penz E, Watt KN, Hergott CA, Rahman NM, Psallidas I. Management of malignant pleural effusion: challenges and solutions. Cancer Manag Res 2017; 9:229-241. [PMID: 28694705 PMCID: PMC5491570 DOI: 10.2147/cmar.s95663] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Malignant pleural effusion (MPE) is a sign of advanced cancer and is associated with significant symptom burden and mortality. To date, management has been palliative in nature with a focus on draining the pleural space, with therapies aimed at preventing recurrence or providing intermittent drainage through indwelling catheters. Given that patients with MPEs are heterogeneous with respect to their cancer type and response to systemic therapy, functional status, and pleural milieu, response to MPE therapy is also heterogeneous and difficult to predict. Furthermore, the impact of therapies on important patient outcomes has only recently been evaluated consistently in clinical trials and cohort studies. In this review, we examine patient outcomes that have been studied to date, address the question of which are most important for managing patients, and review the literature related to the expected value for money (cost-effectiveness) of indwelling pleural catheters relative to traditionally recommended approaches.
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Affiliation(s)
- Erika Penz
- Division of Respirology, Department of Medicine, University of Saskatchewan, Saskatoon, SK
| | - Kristina N Watt
- Division of Respirology, Department of Medicine, University of Saskatchewan, Saskatoon, SK
| | - Christopher A Hergott
- Division of Respirology, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Respiratory Trials Unit, Oxford University, Oxford, UK
| | - Ioannis Psallidas
- Oxford Centre for Respiratory Medicine, Respiratory Trials Unit, Oxford University, Oxford, UK
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25
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Wichmann AB, Adang EM, Stalmeier PF, Kristanti S, Van den Block L, Vernooij-Dassen MJ, Engels Y. The use of Quality-Adjusted Life Years in cost-effectiveness analyses in palliative care: Mapping the debate through an integrative review. Palliat Med 2017; 31:306-322. [PMID: 28190374 PMCID: PMC5405846 DOI: 10.1177/0269216316689652] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND In cost-effectiveness analyses in healthcare, Quality-Adjusted Life Years are often used as outcome measure of effectiveness. However, there is an ongoing debate concerning the appropriateness of its use for decision-making in palliative care. AIM To systematically map pros and cons of using the Quality-Adjusted Life Year to inform decisions on resource allocation among palliative care interventions, as brought forward in the debate, and to discuss the Quality-Adjusted Life Year's value for palliative care. DESIGN The integrative review method of Whittemore and Knafl was followed. Theoretical arguments and empirical findings were mapped. DATA SOURCES A literature search was conducted in PubMed, EMBASE, and CINAHL, in which MeSH (Medical Subject Headings) terms were Palliative Care, Cost-Benefit Analysis, Quality of Life, and Quality-Adjusted Life Years. FINDINGS Three themes regarding the pros and cons were identified: (1) restrictions in life years gained, (2) conceptualization of quality of life and its measurement, including suggestions to adapt this, and (3) valuation and additivity of time, referring to changing valuation of time. The debate is recognized in empirical studies, but alternatives not yet applied. CONCLUSION The Quality-Adjusted Life Year might be more valuable for palliative care if specific issues are taken into account. Despite restrictions in life years gained, Quality-Adjusted Life Years can be achieved in palliative care. However, in measuring quality of life, we recommend to-in addition to the EQ-5D- make use of quality of life or capability instruments specifically for palliative care. Also, we suggest exploring the possibility of integrating valuation of time in a non-linear way in the Quality-Adjusted Life Year.
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Affiliation(s)
- Anne B Wichmann
- 1 IQ healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Eddy Mm Adang
- 2 Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Peep Fm Stalmeier
- 2 Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sinta Kristanti
- 1 IQ healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lieve Van den Block
- 3 End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Myrra Jfj Vernooij-Dassen
- 1 IQ healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Yvonne Engels
- 4 Department of Anesthesiology, Pain and Palliative Care, Radboud University Medical Center, Nijmegen, The Netherlands
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26
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Management of Malignant Pleural Effusion with ASEPT® Pleural Catheter: Quality of Life, Feasibility, and Patient Satisfaction. Can Respir J 2016; 2016:4273480. [PMID: 28074083 PMCID: PMC5198149 DOI: 10.1155/2016/4273480] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 11/09/2016] [Indexed: 11/17/2022] Open
Abstract
Objective. The PleurX® IPC system has been used extensively in the past. Over time, management of MPE with the PleurX system can be costly. The new ASEPT pleural catheter, through advantages in design, may ultimately show cost savings. The primary outcome of this study was to evaluate safety and efficacy of the ASEPT system. Method. This single centre, prospective study enrolled 50 patients with MPE, who were followed for as long as they were alive with a catheter. Quality of Life (QoL) was assessed before, at 2 weeks, and 6 weeks after ASEPT catheter insertion using the EORTC QLQ-C30 and LC13 questionnaires. Ease of catheter use and complications were reported by physician and community nurses. Results. 50 patients with MPE with a mean age of 64.5 ± 1.9, BDI of 2.8 ± 0.9, and ECOG score of 3.0 ± 0.7 were recruited. No immediate or long-term complications were reported during the study period. Compared to precatheter insertion, global health status (-18, p < 0.001), QLQ-C30 dyspnea (-39, p < 0.00001), and LC13 dyspnea (-11, p < 0.0005) significantly improved at 2 and 6 weeks after intervention. Provider surveys indicated favourable ease of use. Conclusion. The new ASEPT catheter offers a safe and effective option for the management of MPE.
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27
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Krochmal R, Reddy C, Yarmus L, Desai NR, Feller-Kopman D, Lee HJ. Patient evaluation for rapid pleurodesis of malignant pleural effusions. J Thorac Dis 2016; 8:2538-2543. [PMID: 27747006 DOI: 10.21037/jtd.2016.08.55] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Malignant pleural effusions (MPEs) represent advanced stage disease with potentially significant patient discomfort due to dyspnea. Palliative management options include repetitive thoracenteses, placement of a tunneled pleural catheter (TPC), chemical pleurodesis, or some combination of these procedures. The rapid pleurodesis procedure combines thoracoscopic talc pleurodesis and insertion of a TPC at the same time with the goals of reducing both the length of hospitalization and the duration of catheter use. The rapid pleurodesis procedure has previously been described to achieve both of these goals in a pilot study of 30 patients with fully expandable lungs. Both symptoms of dyspnea and quality of life improved with few complications. Additional data on procedural effectiveness is needed to optimize patient selection for this procedure. METHODS We performed a retrospective analysis of patients who had undergone rapid pleurodesis protocol at two academic institutions over a 40-month period. Data was collected and analyzed on time to removal of the TPC, chemotherapy, malignancy type, complications, age, and catheter occlusion. RESULTS A total of 29 patients underwent the rapid pleurodesis protocol with a median hospital length of stay of 2 days. Total length of hospitalization was not significantly different between patients with and without primary lung cancer. Median duration of the indwelling TPC was 10 days. Patients with primary lung cancer and those actively or recently undergoing chemotherapy maintained the catheter longer than their counterparts. CONCLUSIONS The rapid pleurodesis protocol should be considered a viable treatment option for select patients with symptomatic recurrent MPEs undergoing chemical pleurodesis.
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Affiliation(s)
- Rebecca Krochmal
- Division of Pulmonary and Critical Care Medicine, University of Maryland Medical Center, Baltimore, USA
| | - Chakravarthy Reddy
- Division of Pulmonary and Critical Care Medicine, University of Utah Health Sciences Center, Salt Lake City, USA
| | - Lonny Yarmus
- Section of Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, USA
| | | | - David Feller-Kopman
- Section of Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, USA
| | - Hans J Lee
- Section of Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, USA
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28
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Bhatnagar R, Corcoran JP, Maldonado F, Feller-Kopman D, Janssen J, Astoul P, Rahman NM. Advanced medical interventions in pleural disease. Eur Respir Rev 2016; 25:199-213. [PMID: 27246597 PMCID: PMC9487240 DOI: 10.1183/16000617.0020-2016] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 03/17/2016] [Indexed: 12/18/2022] Open
Abstract
The burden of a number of pleural diseases continues to increase internationally. Although many pleural procedures have historically been the domain of interventional radiologists or thoracic surgeons, in recent years, there has been a marked expansion in the techniques available to the pulmonologist. This has been due in part to both technological advancements and a greater recognition that pleural disease is an important subspecialty of respiratory medicine. This article summarises the important literature relating to a number of advanced pleural interventions, including medical thoracoscopy, the insertion and use of indwelling pleural catheters, pleural manometry, point-of-care thoracic ultrasound, and image-guided closed pleural biopsy. We also aim to inform the reader regarding the latest updates to more established procedures such as chemical pleurodesis, thoracentesis and the management of chest drains, drawing on contemporary data from recent randomised trials. Finally, we shall look to explore the challenges faced by those practicing pleural medicine, especially relating to training, as well as possible future directions for the use and expansion of advanced medical interventions in pleural disease.
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Affiliation(s)
- Rahul Bhatnagar
- Academic Respiratory Unit, University of Bristol, Bristol, UK These authors contributed equally
| | - John P Corcoran
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, UK These authors contributed equally
| | - Fabien Maldonado
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt-Ingram Cancer Center, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - David Feller-Kopman
- Division of Pulmonary and Critical Care Medicine, John Hopkins University, Baltimore, MD, USA
| | - Julius Janssen
- Department of Pulmonary Diseases, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Philippe Astoul
- Department of Thoracic Oncology, Pleural Diseases and Interventional Pulmonology, Hôpital Nord, Aix-Marseille University, Marseille, France
| | - 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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29
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The Undefined Value of Pleural Interventions in Advanced Heart Failure and Recurrent Pleural Effusions. Ann Am Thorac Soc 2016; 13:447-8. [PMID: 26963358 DOI: 10.1513/annalsats.201512-825le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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30
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Reply: The Undefined Value of Pleural Interventions in Advanced Heart Failure and Recurrent Pleural Effusions. Ann Am Thorac Soc 2016; 13:448-9. [PMID: 26963360 DOI: 10.1513/annalsats.201512-852le] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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