Intrapleural therapy

Chemical pleurodesis - a review of mechanisms involved in pleural space obliteration

Chemical pleurodesis is a therapeutic procedure applied to create the symphysis between the parietal and visceral pleura by intrapleural administration of various chemical agents (e.g. talk, tetracycline, iodopovidone, etc.). The two major clinical conditions treated with chemical pleurodesis are recurrent pleural effusion (PE) and recurrent spontaneous pneumothorax. Although the history of chemical pleurodesis began over a century ago, detailed data on the mechanisms of action of sclerosing agents are highly incomplete. The following article aims to present the state of knowledge on this subject.It is believed that mesothelial cells are the main structural axis of pleurodesis. In response to sclerosing agents they secrete a variety of mediators including chemokines such as interleukin 8 (IL-8) and monocyte chemoattractant protein (MCP-1), as well as growth factors - vascular endothelial growth factor (VEGF), platelet-derived growth factor (PDGF), basic fibroblast growth factor (bFGF) and transforming growth factor- β (TGF-β). Numerous data suggest that intact mesothelial cells and the above cytokines play a crucial role in the initiation and maintenance of different pathways of pleural inflammation and pleural space obliteration.It seems that the process of pleurodesis is largely nonspecific to the sclerosant and involves the same ultimate pathways including activation of pleural cells, coagulation cascade, fibrin chain formation, fibroblast proliferation and production of collagen and extracellular matrix components. Of these processes, the coagulation cascade with decreased fibrinolytic activity and increased fibrinogenesis probably plays a pivotal role, at least during the early response to sclerosant administration.A better understanding of various pathways involved in pleurodesis may be a prerequisite for more effective and safe use of various sclerosants and for the development of new, perhaps more personalized therapeutic approaches.

Outcomes of bevacizumab combined with chemotherapy in lung adenocarcinoma-induced malignant pleural effusion

BACKGROUND

VEGF is critical in the pathogenesis of malignant pleural effusion (MPE). To understand the clinical benefits of antiangiogenic agents, the efficacy of chemotherapy containing bevacizmab was investigated in patients with lung adenocarcinoma-induced MPE.

METHODS

The data of lung adenocarcinoma patients with MPE treated with bevacizumab plus chemotherapy on day 1, every three weeks, for ≤ 6 cycles was retrospectively collected. Patients who achieved a response or stable disease were administered bevacizumab as maintenance therapy until progression. The primary outcomes of the study were MPE response rate (RR), MPE control rate, and pleural progression-free survival (PPFS), while the secondary outcomes were PFS, overall survival (OS), changes to the lung volume and thoracic cage, and safety profiles.

RESULTS

A total of 21 cases were collected, and all were evaluable for response, including 15 chemotherapy-naïve patients and 6 who experienced relapse. The median cycle of treatments was 7 (1-42) and 5 (2-6) for bevacizumab and chemotherapy, respectively. The MPE RR reached 81.0%. The MPE control rate at 6, 12, 24, 48, and 96 weeks were 95.2%, 90.0%, 89.5%, 73.7%, and 43.8%, respectively. Median PPFS was significantly longer than PFS (22.2 vs. 7.8 months; P = 0.044), and median OS was 25.8 months. Nineteen (90.5%) patients experienced lung re-expansion after treatment. Only one (4.8%) patient suffered thoracic volume decrease during treatment and the follow-up period. No unexpected adverse events were observed.

CONCLUSIONS

Bevacizumab combined with chemotherapy demonstrated efficacious, persistence, and safety in controlling lung cancer-induced MPE, indicating a potential superior therapeutic option.

Ultrasound-guided intrapleural positioning of pleural catheters: influence on immediate lung expansion and pleurodesis in patients with recurrent malignant pleural effusion

Objective:

To evaluate the role of intrapleural positioning of a pleural catheter in early lung expansion and pleurodesis success in patients with recurrent malignant pleural effusion (RMPE).

Methods:

This was a retrospective study nested into a larger prospective cohort study including patients with RMPE recruited from a tertiary university teaching hospital between June of 2009 and September of 2014. The patients underwent pleural catheter insertion followed by bedside pleurodesis. Chest CT scans were performed twice: immediately before pleurodesis (iCT) and 30 days after pleurodesis (CT30). Catheter positioning was categorized based on iCT scans as posterolateral, anterior, fissural, and subpulmonary. We used the pleural volume on iCT scans to estimate early lung expansion and the difference between the pleural volumes on CT30 and iCT scans to evaluate radiological success of pleurodesis. Clinical pleurodesis success was defined as no need for any other pleural procedure.

Results:

Of the 131 eligible patients from the original study, 85 were included in this nested study (64 women; mean age: 60.74 years). Catheter tip positioning was subpulmonary in 35 patients (41%), anterior in 23 (27%), posterolateral in 17 (20%), and fissural in 10 (12%). No significant differences were found among the groups regarding early lung expansion (median residual pleural cavity = 377 mL; interquartile range: 171-722 mL; p = 0.645), radiological success of pleurodesis (median volume = 33 mL; interquartile range: −225 to 257 mL; p = 0.923), and clinical success of pleurodesis (85.8%; p = 0.676).

Conclusions:

Our results suggest that the position of the tip of the pleural catheter influences neither early lung expansion nor bedside pleurodesis success in patients with RMPE.

Precision-guided, Personalized Intrapleural Fibrinolytic Therapy for Empyema and Complicated Parapneumonic Pleural Effusions: The Case for the Fibrinolytic Potential

Complicated pleural effusions and empyema with loculation and failed drainage are common clinical problems. In adults, intrapleural fibrinolytic therapy is commonly used with variable results and therapy remains empiric. Despite the intrapleural use of various plasminogen activators; fibrinolysins, for about sixty years, there is no clear consensus about which agent is most effective. Emerging evidence demonstrates that intrapleural administration of plasminogen activators is subject to rapid inhibition by plasminogen activator inhibitor-1 and that processing of fibrinolysins is importantly influenced by other factors including the levels and quality of pleural fluid DNA. Current therapy for loculation that accompanies pleural infections also includes surgery, which is invasive and for which patient selection can be problematic. Most of the clinical literature published to date has used flat dosing of intrapleural fibrinolytic therapy in all subjects but little is known about how that strategy influences the processing of the administered fibrinolysin or how this influences outcomes. We developed a new test of pleural fluids ex vivo, which is called the Fibrinolytic Potential or FP, in which a dose of a fibrinolysin is added to pleural fluids ex vivo after which the fibrinolytic activity is measured and normalized to baseline levels. Testing in preclinical and clinical empyema fluids reveals a wide range of responses, indicating that individual patients will likely respond differently to flat dosing of fibrinolysins. The test remains under development but is envisioned as a guide for dosing of these agents, representing a novel candidate approach to personalization of intrapleural fibrinolytic therapy.

Predictors of talc slurry pleurodesis success in patients with malignant pleural effusions

INTRODUCTION

Malignant pleural effusions are an important burden of malignant disease. Slurry talc pleurodesis remains one of the most common and effective therapeutic options.

AIM

Investigate the predictive factors related with the efficacy of this technique in malignant pleural effusions.

METHODS

Retrospective analysis of all pleurodesis performed during a 10-year period in a Pulmonology Unit. All demographic and clinical data were collected, including the histologic tumoral type and the biochemical, microbiological and cytological fluid features. Efficacy was defined as the lack of recurrence of pleural effusion. It was used Kaplan-Meyer analysis to estimate overall survival.

RESULTS

From a total of 202 patients submitted to pleurodesis (47% men; mean age 66.9±12.02 years). Light's criteria identified 86.6% as exudates. We found 85.1% survival at 30-day post-pleurodesis, which means the therapy used has significant success. A logistic regression model applied explained that variance in post-pleurodesis events was mostly due to age and gender rather than pleural biochemical factors (X²₍₅₎=44.648, p<0.001, R² 28.3%).

CONCLUSION

This study suggests that clinical evaluation of biochemical values, bacteriological results and malignant tumor diagnosis may not be enough to predict post-pleurodesis relapse with high accuracy. Furthermore, we observed, in ten years of pleurodesis performed in our Hospital, that pleurodesis is an effective life prolonging therapy for patients that fit the criteria for this intervention.

Role of Neutrophil Extracellular Traps in Asthma and Chronic Obstructive Pulmonary Disease

Objective:

Asthma and chronic obstructive pulmonary disease (COPD) are representative chronic inflammatory airway diseases responsible for a considerable burden of disease. In this article, we reviewed the relationship between neutrophil extracellular traps (NETs) and chronic inflammatory airway diseases.

Data Sources:

Articles published up to January 1, 2017, were selected from the PubMed, Ovid Medline, Embase databases, with the keywords of “asthma” or “pulmonary disease, chronic obstructive”, “neutrophils” and “extracellular traps.”

Study Selection:

Articles were obtained and reviewed to analyze the role of NETs in asthma and COPD.

Results:

NETs are composed of extracellular DNA, histones, and granular proteins, which are released from activated neutrophils. Multiple studies have indicated that there are a large amount of NETs in the airways of asthmatics and COPD patients. NETs can engulf and kill invading pathogens in the host. However, disordered regulation of NET formation has shown to be involved in the development of asthma and COPD. An overabundance of NETs in the airways or lung tissue could cause varying degrees of damage to lung tissues by inducing the death of human epithelial and endothelial cells, and thus resulting in impairing pulmonary function and accelerating the progress of the disease.

Conclusions:

Excessive NETs accumulate in the airways of asthmatics and COPD patients. Although NETs play an essential role in the innate immune system against infection, excessive components of NETs can cause lung tissue damage and accelerate disease progression in asthmatics and COPD patients. These findings suggest that administration of NETs could be a novel approach to treat asthma and COPD. Mechanism studies, clinical practice, and strategies to regulate neutrophil activation or directly interrupt NET function in asthmatics and COPD patients are desperately needed.

Ultrasound in the management of pleural disease

INTRODUCTION

Pleural disease encompasses a large range of conditions, is a common presentation to the acute medical take and often requires comprehensive investigation and treatment. Ultrasound is well recognised as a useful investigative tool in pleural disease especially in the field of pleural effusion, pleural thickening and interventional procedures. Thoracic ultrasound (TUS) has gained widespread use by physicians as evidence has shown a reduced rate of complications when performing pleural procedures with ultrasound guidance. Areas covered: This article will review studies assessing the role of TUS in the management of pleural disease and examine ongoing research into how TUS could advance our knowledge and understanding over the next decade. Expert commentary: Physician lead thoracic ultrasound has become commonplace over the last decade, and now represents a minimum standard of safety in conducting the majority of 'bedside' pleural procedures. The current evidence points to important diagnostic and procedural roles of the use of bedside thoracic ultrasound. In the future, research developments are likely to lead to the use of thoracic ultrasound in prognostication, targeted treatment and understanding pathogenesis in pleural disease.

Important prognostic factors for survival in patients with malignant pleural effusion

BACKGROUND

The approach to palliative treatment of malignant pleural effusion (MPE) should be individualized because these patients generally have poor survival. Our study aimed to develop a model to identify prognostic factors or survival time in patients diagnosed with MPE.

METHODS

This is a retrospective, descriptive, observational study to identify prognostic factors related to MPE in patients with a confirmed cancer diagnosis. Cox regression analysis was used to determine significant potential prognostic factors with respect to survival time. Survival time was defined as the time from pathological diagnosis to death.

RESULTS

One hundred and sixty-five patients were included; 77 were men (47%) and 88 were women (53%). The median age was 60 years, and all of the patients were pathologically proven to have MPE. Non-small-cell lung cancer (36.0%), breast carcinoma (26%), and lymphoma (13.0%) were the most frequently diagnosed tumors. The median overall survival of patients from the initial diagnosis was 5 months (range: 1.0-96.0 months). Kaplan-Meier univariate analysis showed that survival was significantly related to the following prognostic factors: ECOG PS (hazard ratio [HR] 10.0, 95% confidence interval [95% CI] 5.96 to 18.50, p < 0.0001), primary cancer site (HR 1.99, 95% CI 1.23 to 3.22, p < 0.01), positive pleural cytology (HR 1.25, 95% CI 0.88 to 1.78, p = 0.04), and positive histology (HR 1.33, 95% CI 0.97 to 1.81, p = 0.04). Other potential independent diagnostic factors that were examined did not affect survival. Cox regression analysis showed that only the ECOG PS was highly predictive of survival (HR 73.58, 95% CI 23.44 to 230.95, p < 0.0001).

CONCLUSIONS

ECOG PS is an independent predictor of survival in patients with MPE at initial diagnosis. This prognostic factor can help physicians select patients for appropriate palliative treatment of this syndrome.

Lung cancer coexisting with ipsilateral pleural effusion

SUMMARY 

Invasion beyond the elastic layer of the visceral pleura and/or diffuse pleural metastatic spread affects negatively survival in lung cancer. Presence of pleural effusion is also associated with poor prognosis, and image techniques can be of great help for diagnosis. When pleural fluid cytology is negative, thoracoscopy is advisable before attempting tumor resection, in order to detect unsuspected pleural metastases. If widespread pleural malignancy is confirmed, chemical pleurodesis using graded talc (with particles larger than 20 µm in diameter) is the best option, unless the lung is unable to re-expand. In this case, or when a previous pleurodesis has failed, or there is a short life expectancy, placement of a indwelling pleural catheter is the treatment of choice.

NET balancing: a problem in inflammatory lung diseases

Neutrophil extracellular traps (NETs) are beneficial antimicrobial defense structures that can help fight against invading pathogens in the host. However, recent studies reveal that NETs exert adverse effects in a number of diseases including those of the lung. Many inflammatory lung diseases are characterized with a massive influx of neutrophils into the airways. Neutrophils contribute to the pathology of these diseases. To date, NETs have been identified in the lungs of cystic fibrosis (CF), acute lung injury (ALI), allergic asthma, and lungs infected with bacteria, virus, or fungi. These microbes and several host factors can stimulate NET formation, or NETosis. Different forms of NETosis have been identified and are dependent on varying types of stimuli. All of these pathways however appear to result in the formation of NETs that contain DNA, modified extracellular histones, proteases, and cytotoxic enzymes. Some of the NET components are immunogenic and damaging to host tissue. Innate immune collectins, such as pulmonary surfactant protein D (SP-D), bind NETs, and enhance the clearance of dying cells and DNA by alveolar macrophages. In many inflammatory lung diseases, bronchoalveolar SP-D levels are altered and its deficiency results in the accumulation of DNA in the lungs. Some of the other therapeutic molecules under consideration for treating NET-related diseases include DNases, antiproteases, myeloperoxidase (MPO) inhibitors, peptidylarginine deiminase-4 inhibitors, and anti-histone antibodies. NETs could provide important biological advantage for the host to fight against certain microbial infections. However, too much of a good thing can be a bad thing. Maintaining the right balance of NET formation and reducing the amount of NETs that accumulate in tissues are essential for harnessing the power of NETs with minimal damage to the hosts.