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Scarci M, Caruana E, Bertolaccini L, Bedetti B, Brunelli A, Varela G, Papagiannopoulos K, Kuzdzal J, Massard G, Ruffini E, Falcoz PE, Opitz I, Batirel H, Toker A, Rocco G. Current practices in the management of malignant pleural effusions: a survey among members of the European Society of Thoracic Surgeons. Interact Cardiovasc Thorac Surg 2017; 24:414-417. [PMID: 28040756 DOI: 10.1093/icvts/ivw373] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 09/27/2016] [Indexed: 01/27/2023] Open
Abstract
Objectives Malignant pleural effusion (MPE) commonly complicates advanced malignancy and their exact management is still undefined. We undertook a survey to determine the current practice among members of the European Society of Thoracic Surgeons (ESTS). Methods A cross-sectional survey focused on the current practice of management of MPE was developed by the authors. The questions were outlined after a review of the literature and circulated in an Internet-based survey format. Results Computed tomography (125, 92%) and chest X-ray (106, 78%) are the most common imaging modalities performed in the initial evaluation. Video-assisted thoracoscopic surgery for washout and pleurodesis (93, 68%) was reported as the preferred approach to patients with uncomplicated MPE. Sixty-one (45%) of the responding colleagues routinely use large bore chest tubes for draining malignant effusions. Forty-nine (35%) surgeons would not apply suction to the drainage system, whilst 50 (37%) would use -2 kPa or less. Talc (124, 91%) is the most commonly used sclerosing agent for pleurodesis in the context of malignant pleural effusion. The practice of 76 (56%) of the respondents is not informed by any clinical guidelines, whilst 60 (44%) reported adhering to the 2010 British Thoracic Society Pleural Disease Guideline. Seventy-one (52%) declared that the guidance was in need of updating or revision. Conclusions This survey demonstrates the lacking adoption of the existing clinical guidance in this field, as well as the need for more contemporary guidelines for a better-informed practice. The ESTS Working Group on the management of MPE has been established for this purpose.
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Affiliation(s)
- Marco Scarci
- Department of Thoracic Surgery, University College London Hospitals, London, United Kingdom
| | - Edward Caruana
- Department of Thoracic Surgery, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Luca Bertolaccini
- Department of Thoracic Surgery, Sacro Cuore, Don Calabria Research Hospital, Negrar, Verona, Italy
| | - Benedetta Bedetti
- Department of Thoracic Surgery, University College London Hospitals, London, United Kingdom
| | - Alessandro Brunelli
- Department of Thoracic Surgery, St. James's University Hospital, Leeds, United Kingdom
| | - Gonzalo Varela
- Department of Thoracic Surgery, Salamanca University Hospital, Salamanca, Spain
| | | | - Jaroslaw Kuzdzal
- Department of Thoracic Surgery, Jagiellonian University Collegium Medicum, John Paul II Hospital, Cracow, Poland
| | - Gilbert Massard
- Department of Thoracic Surgery, Strasbourg University Hospital, Strasbourg, France
| | - Enrico Ruffini
- Department of Thoracic Surgery, University of Torino, Torino, Italy
| | | | - Isabelle Opitz
- Division of Thoracic Surgery, Zurich University Hospital, Zurich, Switzerland
| | - Hasan Batirel
- Department of Thoracic Surgery, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Alper Toker
- Department of Thoracic Surgery, Istanbul Medical School, Istanbul University, Istanbul, Turkey
| | - Gaetano Rocco
- Division of Thoracic Surgery, Department of Thoracic Surgical and Medical Oncology, Istituto Nazionale Tumori, Fondazione Pascale, IRCSS, Naples, Italy
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Abstract
The surgeon's role in the treatment of malignant peritoneal disease has expanded over time, stemming from a better understanding of tumor biology. For the majority of patients, carcinomatosis is a terminal process with surgical intervention being reserved for palliation of bowel obstruction or symptomatic ascites. However, for select patients with favorable tumor biologies, aggressive surgical approaches may result in long-term survival. This review describes the patterns of peritoneal tumor dissemination, surgical palliation of malignant bowel obstruction or ascites, and the principles, indications, toxicities, and overall results of cytoreductive surgery with intraperitoneal hyperthermic chemotherapy. On the other hand, long-term survival is rarely expected for malignant pleural disease unless the causal tumor is highly responsive to systemic chemotherapy. There are controversies and considerable geographic variations in the management of malignant pleural effusions. However, less invasive ambulatory palliative treatments for patients so afflicted are gaining popularity.
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Abstract
The management of malignant pleural effusions are a common, and sometimes difficult, therapeutic problem. This article reviews the currently available sclerosing agents and discusses novel agents that show promise for the future. Talc, tetracycline and bleomycin are currently the most widely used agents but none is an ideal sclerosant and certain adverse effects are of concern. Novel agents, particularly transforming growth factor (TGF)-beta(2) and metalloproteinase inhibitors, are being investigated, and the increase in knowledge into the mechanisms of pleural fluid formation and pleurodesis will hopefully lead to the development of targeted therapy in the future.
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Affiliation(s)
- Mark Weatherhead
- The James Cook University Hospital, Marton Road, Middlesbrough, TS4 3BW, UK
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Abstract
Primary and metastatic thoracic malignancies are often incurable. Surgeons caring for these patients must be familiar with the options,indications, techniques, and limitations of interventions for palliative treatments in these patients. This article is an overview of the current practices for palliation of a broad spectrum of complaints relating to patients with carcinomas of the lung, esophagus,and mesothelium. The information can be used for treatment of patients with complaints secondary to less common malignancies and metastatic disease of the thorax.
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Affiliation(s)
- Adam Berger
- Department of Surgical Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111, USA
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Antunes G, Neville E, Duffy J, Ali N. BTS guidelines for the management of malignant pleural effusions. Thorax 2003; 58 Suppl 2:ii29-38. [PMID: 12728148 PMCID: PMC1766015 DOI: 10.1136/thorax.58.suppl_2.ii29] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- G Antunes
- Department of Respiratory Medicine, James Cook University Hospital, Middlesborough TS4 3BW, UK.
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Ishikawa H, Satoh H, Yamashita YT, Kamma H, Naito T, Ohtsuka M, Hasegawa S. Curved chest tube for drainage of malignant pleural effusion. Respir Med 1998; 92:633-7. [PMID: 9659528 DOI: 10.1016/s0954-6111(98)90509-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Thoracentesis with a chest tube insertion and drainage of large pleural effusion is widely performed in patients with malignant lung diseases. One potential problem with a conventional chest tube placement is occasional incomplete evacuation of effusion owing to inappropriate position of the tip where the drainage holes opened. We have developed a curved chest tube and evaluated the position of tip placement just after the placement and before removal on plain chest X-ray in 20 patients with massive pleural effusions due to lung cancer. In 15 of the 20 patients, the tip of the tube was successfully positioned at the paravertebral gutter in posterobasal with higher drainage efficacy compared with other patients whose tube tips happened to be positioned at other sites. There were no significant complications. This study suggested that the curved chest tube would be safe and useful in completing drainage of pleural effusion.
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Affiliation(s)
- H Ishikawa
- Department of Respiratory Medicine, University of Tsukuba, Japan
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Abstract
BACKGROUND Malignant pleural effusions are seen frequently in clinical practice and are most commonly caused by breast cancer and lung cancer. Standard treatment usually consists of complete drainage of the pleural space via a chest tube and instillation of a pleural irritant to obtain pleural symphysis. In a majority of instances, such treatment effectively controls the pleural space; however, standard treatment fails in some cases. METHODS Twenty-four patients who did not respond to standard treatment for malignant pleural effusion were subjects for parietal pleurectomy, which was usually performed through an axillary thoracotomy. In several cases, decortication was also necessary. The study population was composed of 18 women and six men. Twelve of the patients had carcinoma of the breast, five carcinoma of the lung, and four carcinoma of the ovary. RESULTS Three patients died in the perioperative period to give an operative mortality of 12.5%. The other 21 patients all had satisfactory control of their recurrent malignant effusions. Their survival time ranged from 2 to 30 months (average 10.6). CONCLUSIONS Parietal pleurectomy is an effective operation for recurrent malignant pleural effusion. However, because of its significant morbidity and mortality, it should be reserved for failures of standard treatment, and patient selection is important.
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Affiliation(s)
- W A Fry
- Section of Thoracic Surgery, Evanston Hospital, Northwestern University Medical School, Illinois, USA
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Villanueva AG, Gray AW, Shahian DM, Williamson WA, Beamis JF. Efficacy of short term versus long term tube thoracostomy drainage before tetracycline pleurodesis in the treatment of malignant pleural effusions. Thorax 1994; 49:23-5. [PMID: 7512285 PMCID: PMC474079 DOI: 10.1136/thx.49.1.23] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND A study was undertaken to compare the efficacy of short term tube thoracostomy drainage with standard tube thoracostomy drainage before instillation of tetracycline for sclerotherapy of malignant pleural effusions. METHODS The study consisted of a randomised clinical trial in a sequential sample of 25 patients with malignant pleural effusions documented cytopathologically. Fifteen patients were randomly assigned to group 1 (standard protocol) and 10 to group 2 (short term protocol). Patients in group 1 had tube thoracostomy suction drainage until radiological evidence of lung re-expansion was obtained and the amount of fluid drained was < 150 ml/day, before tetracycline (1.5 g) was instilled. The chest tube was removed when the amount of fluid drained after instillation was < 150 ml/day. Patients in group 2 also had suction drainage, but the tetracycline (1.5 g) was instilled when the chest radiograph showed the lung to be re-expanded and the effusion drained, which was usually within 24 hours. The chest tube was removed the next day. RESULTS The response to tetracycline sclerotherapy in the two groups was the same (80%) but the duration of chest tube drainage was significantly shorter for patients in group 2 (median two days) than for those in group 1 (median seven days). CONCLUSIONS The duration of chest tube drainage before sclerotherapy for malignant pleural effusions need not be influenced by the amount of fluid drained daily but by radiographic evidence of fluid evacuation and lung re-expansion. Shorter duration of drainage will reduce the length of hospital stay without sacrificing the efficacy of pleurodesis.
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Affiliation(s)
- A G Villanueva
- Section of Pulmonary and Critical Care Medicine, Lahey Clinic, Burlington, Massachusetts 01805
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Kodama K, Doi O, Higashiyama M, Yokouchi H, Tatsuta M. Long-term results of postoperative intrathoracic chemo-thermotherapy for lung cancer with pleural dissemination. Cancer 1993; 72:426-31. [PMID: 8319173 DOI: 10.1002/1097-0142(19930715)72:2<426::aid-cncr2820720218>3.0.co;2-s] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND To overcome the poor prognosis of lung cancer with pleural dissemination, the authors developed postoperative intrathoracic chemo-thermotherapy (PICT). In this report, they present the long-term results for 31 consecutive patients who underwent resection, followed by PICT for lung cancer with pleural dissemination between April 1985 and December 1991. METHODS Among the patients, there were 26 cases of adenocarcinoma, 3 cases of squamous cell carcinoma, and 1 case each of large and adenosquamous cell carcinoma. Twenty-four of these patients had an initial diagnosis of pleural involvement at thoracotomy. The other seven patients had massive malignant effusion at the time of the initial diagnosis. PICT was started between days 10 to 14 postoperatively. When possible, three courses of this procedure were administered at intervals of 5-7 days. RESULTS The 5-year cumulative and 5-year local relapse-free survival rates were 24.6% and 76.3%, respectively. The 3-year and 5-year cumulative survival rates for 14 patients without mediastinal lymph node involvement were 68.4% and 42.7%, respectively. Those rates for 17 patients with mediastinal lymph node involvement were 22.7% and 0%, respectively. The 3-year survival rate in the former group was significantly better than that in the latter group. CONCLUSIONS These results strongly suggest that in patients with pleural dissemination, PICT may be beneficial for regional disease control and improvement of survival, particularly for patients without mediastinal lymph node involvement.
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Affiliation(s)
- K Kodama
- Department of Thoracic Surgery, Center for Adult Diseases, Osaka, Japan
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Robinson LA, Fleming WH, Galbraith TA. Intrapleural doxycycline control of malignant pleural effusions. Ann Thorac Surg 1993; 55:1115-21; discussion 1121-2. [PMID: 8494419 DOI: 10.1016/0003-4975(93)90017-c] [Citation(s) in RCA: 55] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The intrapleural instillation of agents for pleural sclerosis has proved effective in preventing the reaccumulation of symptomatic malignant pleural effusions. Because manufacture of the most popular agent, tetracycline, was recently discontinued, a preliminary study was undertaken to evaluate an alternative agent, doxycycline, for treating symptomatic malignant pleural effusions. From November 1991 to September 1992, 21 patients with symptomatic malignant pleural effusions have undergone overnight chest tube drainage followed by intrapleural instillation of 10 mL 1% lidocaine and then doxycycline, 500 mg in 30 mL 0.9% saline solution. The chest tube was clamped 2 hours with patient repositioning every 15 minutes. Tubes were removed when drainage was less than 50 mL/8 h. Of surviving patients, a complete objective response at 1 month was obtained in 88% (15/17), who were free of a symptomatic or radiographic recurrence of the effusion. Complications included mild pain in 23% (5/21), moderate pain requiring analgesics in 19% (4/21), and mild fever in 5% (1/21). There were no treatment-related deaths. The mean time for chest tube removal was 1.7 +/- 0.7 days after the last treatment. Based on this preliminary study, we conclude that doxycycline is a highly effective agent for the palliative treatment of symptomatic malignant pleural effusions. Its safety profile and efficacy compare favorably with those of tetracycline and other agents used for pleural sclerosis.
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Affiliation(s)
- L A Robinson
- Section of Thoracic and Cardiovascular Surgery, University of Nebraska Medical Center, Omaha 68198-2315
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Affiliation(s)
- D W Miles
- Imperial Cancer Research Fund Clinical Oncology Unit, Guy's Hospital, London
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