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Lovato JB, Laroumagne S, Tronchetti J, Nguyen NAT, Dutau H, Astoul P. Fast pleurodesis combining talc poudrage and indwelling pleural catheter for the management of recurrent malignant pleural effusions. Respir Med Res 2024; 86:101124. [PMID: 38968680 DOI: 10.1016/j.resmer.2024.101124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 06/12/2024] [Accepted: 06/18/2024] [Indexed: 07/07/2024]
Abstract
BACKGROUND AND OBJECTIVES Malignant pleural effusions (MPE) are a frequent and major turning point in neoplastic disease usually leading to poor life expectancy. Improve quality of life and relieve the dyspnea are the main objectives in this palliative care setting. This can be achieved by the placement of an indwelling catheter (IPC) or talc pleurodesis ideally performed by thoracoscopy route (talc poudrage). Beside to misidentify a trapped-lung, the latter requires a prolonged hospital stay and the IPC placement does not allow a high pleurodesis rate. To overcome these drawbacks, a combination of both technique could be proposed for the management of recurrent malignant pleural effusions. Safety and efficacy of this pragmatic approach are reported. METHODS Consecutive patients who have been managed for recurrent MPE by a combination of talc poudrage for pleural symphysis by thoracoscopy route ending with the insertion of IPC using the same thoracic point of entry. Demographic data, hospital length of stay (LOS), procedural-related complications, patients' quality of life (QoL) and success of pleurodesis were collected. Patients were followed-up for 6 months. RESULTS The data of twenty-five consecutive patients undergoing the procedure were analyzed. Successful pleurodesis was obtained for 14/25 patients (66 %) at one month, 17/20 patients (85 %) at 3 months and 13/15 patients (86 %) at 6 months respectively. On average, the hospital LOS after the procedure was 3.24 days (IQR 1-4) with a median of 1 day. A prolonged hospitalization (>1 day) was never due to the procedure except for one patient (pneumothorax). No IPC related infection or procedure related deaths were noted. CONCLUSION Among patients with recurrent MPE, the combination of talc poudrage symphysis by thoracoscopy route and IPC placement on the same time results in a shortened hospital LOS and higher rate of pleurodesis. Further randomized clinical trials are needed to confirm these results.
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Affiliation(s)
- Jean-Baptiste Lovato
- Department of Thoracic Oncology, Pleural Diseases, and Interventional Pulmonology, Hôpital Nord, Chemin des Bourrely, 13015 Marseille, France.
| | - Sophie Laroumagne
- Department of Thoracic Oncology, Pleural Diseases, and Interventional Pulmonology, Hôpital Nord, Chemin des Bourrely, 13015 Marseille, France
| | - Julie Tronchetti
- Department of Thoracic Oncology, Pleural Diseases, and Interventional Pulmonology, Hôpital Nord, Chemin des Bourrely, 13015 Marseille, France; Aix-Marseille University, Marseille, France
| | - Ngoc Anh Thu Nguyen
- CEReSS - Health Services and Quality of Life Research, Aix Marseille University, Marseille, France; Methodological Support Unit for Clinical and Epidemiological Research, University Hospital of Marseille (APHM), Marseille, France
| | - Hervé Dutau
- Department of Thoracic Oncology, Pleural Diseases, and Interventional Pulmonology, Hôpital Nord, Chemin des Bourrely, 13015 Marseille, France
| | - Philippe Astoul
- Department of Thoracic Oncology, Pleural Diseases, and Interventional Pulmonology, Hôpital Nord, Chemin des Bourrely, 13015 Marseille, France; Aix-Marseille University, Marseille, France
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2
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Castaldo N, Fantin A, Palou-schwartzbaum M, Viterale G, Crisafulli E, Sartori G, Aujayeb A, Patrucco F, Patruno V. Exploring the efficacy and advancements of medical pleurodesis: a comprehensive review of current research. Breathe (Sheff) 2024; 20:240002. [PMID: 39193457 PMCID: PMC11348907 DOI: 10.1183/20734735.0002-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 06/24/2024] [Indexed: 08/29/2024] Open
Abstract
This narrative review aims to provide an overview of medical pleurodesis techniques, and their indications and potential adverse effects. Pleurodesis is a procedure performed with the aim of obliterating the pleural space. It has indications in the management of both malignant and benign pleural effusions and pneumothorax. Various nonsurgical techniques exist to perform pleurodesis. The scope of this work is to review the different nonsurgical techniques and their indications. This narrative review was performed checking scientific databases for medical literature, focusing especially on the data derived from randomised controlled trials. Pleurodesis is an effective method to manage pleural effusions and pneumothorax, and minimally invasive techniques are now frequently used with good results. Further research is needed to assess the efficacy of new treatments and the possibility of using different techniques in association.
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Affiliation(s)
- Nadia Castaldo
- Department of Pulmonology, S. Maria della Misericordia University Hospital, Udine, Italy
| | - Alberto Fantin
- Department of Pulmonology, S. Maria della Misericordia University Hospital, Udine, Italy
| | - Michelangelo Palou-schwartzbaum
- Department of Medicine, Respiratory Medicine Unit, University of Verona and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Giovanni Viterale
- Department of Medicine, Respiratory Medicine Unit, University of Verona and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Ernesto Crisafulli
- Department of Medicine, Respiratory Medicine Unit, University of Verona and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Giulia Sartori
- Department of Medicine, Respiratory Medicine Unit, University of Verona and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Avinash Aujayeb
- Department of Respiratory Medicine, Northumbria Healthcare NHS Trust, Cramlington, UK
| | - Filippo Patrucco
- Respiratory Diseases Unit, Medical Department, AOU Maggiore della Carità di Novara, Novara, Italy
- Translational Medicine Department, University of Eastern Piedmont, Novara, Italy
| | - Vincenzo Patruno
- Department of Pulmonology, S. Maria della Misericordia University Hospital, Udine, Italy
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3
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Kwok C, Thavorn K, Amjadi K, Aaron SD, Kendzerska T. Resource Use and Costs of Indwelling Pleural Catheters versus Pleurodesis for Malignant Pleural Effusions: A Population-based Study. Ann Am Thorac Soc 2024; 21:940-948. [PMID: 38381853 DOI: 10.1513/annalsats.202304-333oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 02/20/2024] [Indexed: 02/23/2024] Open
Abstract
Rationale: Malignant pleural effusions (MPEs) are associated with significant health service use and healthcare costs, but the current evidence is limited. Objectives: To compare 12-month post-procedure: 1) health service utilization; and 2) healthcare costs after indwelling pleural catheter (IPC) insertion with at-home drainage performed by home care nursing services, versus in-hospital chemical pleurodesis. Methods: We performed a retrospective population-based study on a cohort of adults with MPEs who underwent IPC insertion or chemical pleurodesis between January 1, 2015 and December 31, 2019 using provincial health administrative data (Ontario, Canada). Patients were followed from the procedure date until death or until 12 months after the procedure. Inverse probability of treatment weighting was performed to adjust for imbalances in baseline characteristics. Differences in length of stay, readmissions, emergency department visits, home care visits, and healthcare costs were estimated using weighted regression analysis. Results: Of 5,752 included individuals, 4,432 (77%) underwent IPC insertion and 1,320 (23%) had pleurodesis. In the weighted sample, individuals who received an IPC had fewer inpatient days (12.4 d vs. 16 d; standardized mean difference, 0.229) but a higher proportion of subsequent admissions for empyema (2.7% vs. 1.1%; P = 0.0002) than those undergoing pleurodesis. Individuals with IPCs received more hours of nursing home care (41 h vs. 21.1 h; standardized mean difference, 0.671) but overall had lower average healthcare costs ($40,179 vs. $46,640 per patient; standardized mean difference, 0.177) than those receiving pleurodesis. Conclusions: IPCs with home nursing drainage are associated with reduced health resource use compared with pleurodesis in adults with MPEs, even after controlling for important baseline and clinical characteristics. Given that both procedures have similar health outcomes, our findings support the ongoing promotion of IPCs to increase outpatient management of patients with MPEs.
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Affiliation(s)
- Chanel Kwok
- Department of Medicine, Faculty of Medicine, and
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- ICES Ottawa, Ottawa, Ontario, Canada; and
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Kednapa Thavorn
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- ICES Ottawa, Ottawa, Ontario, Canada; and
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Kayvan Amjadi
- Department of Medicine, Faculty of Medicine, and
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Shawn D Aaron
- Department of Medicine, Faculty of Medicine, and
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Tetyana Kendzerska
- Department of Medicine, Faculty of Medicine, and
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- ICES Ottawa, Ottawa, Ontario, Canada; and
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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4
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Mishra EK, Stanton A. Patient-Reported Outcomes in Pleural Effusions: A Systematic Review. Cureus 2024; 16:e52430. [PMID: 38371010 PMCID: PMC10870697 DOI: 10.7759/cureus.52430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2024] [Indexed: 02/20/2024] Open
Abstract
Pleural effusions cause breathlessness, decreased activity levels, and impaired quality of life. Clinical trials of drainage of pleural effusion use patient-reported outcome measures (PROMs) to assess these variables. This systematic review aimed to identify which PROMs have been used in clinical trials in pleural effusions, what variables were assessed, whether they were responsive to pleural interventions, and whether they have been validated in patients with pleural effusions, including a defined minimal clinically important difference (MCID). A systematic review was performed to identify relevant clinical trials from Medline, EMBASE, Emcare, and CINAHL and data were extracted. From 329 abstracts, 29 clinical trials of pleural effusion drainage that used PROMs as an outcome measure were identified. A total of 16 different PROMs were used. The most used PROMs were unidimensional measurements of breathlessness, particularly the visual analogue scale for dyspnoea (VASD), all of which nearly showed improvements in breathlessness following pleural fluid drainage. Other variables commonly assessed included activity levels and health-related quality of life. Multidimensional PROMs showed inconsistent responsiveness to pleural fluid drainage. Only the VASD was validated in this patient group with a defined MCID. A range of PROMs are used in clinical trials of pleural fluid drainage. No single PROM measures all the outcomes of interest. Unidimensional measurements of breathlessness are responsive to pleural fluid drainage. Only the VASD is validated with an MCID. There is a need for properly validated, response PROMs which measure the key outcomes of interest in this patient group.
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Affiliation(s)
- Eleanor K Mishra
- Respiratory Medicine, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, GBR
- Faculty of Medicine and Health Science, University of East Anglia, Norwich, GBR
| | - Andrew Stanton
- Medicine, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, GBR
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5
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Asciak R, Bedawi EO, Bhatnagar R, Clive AO, Hassan M, Lloyd H, Reddy R, Roberts H, Rahman NM. British Thoracic Society Clinical Statement on pleural procedures. Thorax 2023; 78:s43-s68. [PMID: 37433579 DOI: 10.1136/thorax-2022-219371] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2023]
Affiliation(s)
- Rachelle Asciak
- Respiratory Medicine, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Eihab O Bedawi
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | | | - Maged Hassan
- Chest Diseases Department, Alexandria University Faculty of Medicine, Alexandria, Egypt
| | - Heather Lloyd
- Worcestershire Acute Hospitals NHS Trust, Worcester, UK
| | - Raja Reddy
- Kettering General Hospital NHS Foundation Trust, Kettering, UK
| | - Helen Roberts
- Sherwood Forest Hospitals NHS Foundation Trust, Sutton-In-Ashfield, UK
| | - Najib M Rahman
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Oxford NIHR Biomedical Research Centre, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
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6
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Agmy G, Adam MF, El Sagheir SA, Mahmoud MA. Transthoracic sonographic scores in evaluating the success of different scelerosing modalities in patients with malignant pleural effusion. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2022. [DOI: 10.1186/s43168-022-00169-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Abstract
Background
Malignant pleural effusions (MPE) mostly arises from metastases to the pleura from other sites. Management of malignant effusions aims to palliate dyspnea and prevent the reaccumulation of pleural fluid to improve patients’ quality of life. Pleurodesis is the most common palliative treatment for patients with refractory MPE. This study was carried out to evaluate the performance of transthoracic sonographic (TUS) scores (pleural sliding and pleural adherence score) in predicting the success of pleurodesis by different modalities in patients with malignant pleural effusion. One hundred malignant pleural effusion patients were enrolled to an interventional clinical trial from September 2019 to April 2021 for palliative management of dyspnea. Pleurodesis for palliative treatment of dyspnea was done either spontaneously by the intercostal chest tube or by a sclerosing agent such as tetracycline solution or tetracycline poudrage or iodopovidine. Patients were randomly allocated to one of these four groups where each group included 25 patients. Transthoracic ultrasound was performed at baseline, and 1 month after pleurodesis and the lung sliding score and pleural adherence score were evaluated.
Results
Majority of patients (78%) had high baseline lung sliding score (7-8). Post pleurodesis only 11.4% had high scores (p<0.001), also the mean lung sliding score decreased significantly in comparison to the baseline values (p˂ 0.001) in the spontaneous, tetracycline solution, tetracycline poudrage, and iodopovidine groups (7.04 ± 1.02 vs. 4.85 ± 1.60, 7.28± 0.98 vs. 4.48± 1.75, 7.20±0.96 vs. 4.44 ± 1.45, 7.04±0.93 vs. 3.35±1.81, respectively). Iodopovidine pleurodesis group in comparison to the other modalities showed the highest pleural adherence score (12.64 ± 2.98) and absent lung sliding in 72.7% of cases and 70 % success rate. Pleural adherence score at cut off ≥ 12 showed 92.75% sensitivity, 89.47% specificity, 92.1 accuracy, and 0.911 area under the curve (AUC) for predicting successful pleurodesis.
Conclusion
TUS scores is a feasible, bedside, and accurate method to detect the outcome of pleurodesis. Iodopovidone was more effective than tetracycline solution, tetracycline poudrage, and spontaneous pleurodesis.
Trial registration
ClinicalTrials.gov. NCT04074902. Registered on 29 August 2019
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Désage AL, Mismetti V, Jacob M, Pointel S, Perquis MP, Morfin M, Guezara S, Langrand A, Galor C, Trouillon T, Diaz A, Karpathiou G, Froudarakis M. Place du pneumologue interventionnel dans la gestion des pleurésies métastatiques. Rev Mal Respir 2022; 39:778-790. [DOI: 10.1016/j.rmr.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 09/14/2022] [Indexed: 11/09/2022]
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8
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Recuero Díaz JL, Figueroa Almánzar S, Gálvez Muñoz C, Lázaro Sierra J, López Porras M, Márquez Medina D, Nabal Vicuña M, Sánchez Moreno L, González Cantalejo M, Porcel JM. Recommendations of the Spanish Society of Thoracic Surgery for the management of malignant pleural effusion. Cir Esp 2022; 100:673-683. [PMID: 35667609 DOI: 10.1016/j.cireng.2022.06.009] [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: 02/21/2022] [Accepted: 05/04/2022] [Indexed: 06/15/2023]
Abstract
This article summarizes the clinical guidelines for the diagnosis and treatment of malignant pleural effusion (MPE) sponsored by the Spanish Society of Thoracic Surgery (SECT). Ten clinical controversies were elaborated under the methodology of PICO (Patient, Intervention, Comparison, Outcome) questions and the quality of the evidence and grading of the strength of the recommendations was based on the GRADE system. Immunocytochemical and molecular analyses of pleural fluid may avoid further invasive diagnostic procedures. Currently, the definitive control of MPE can be achieved either by pleurodesis (talc poudrage or slurry) or the insertion of a indwelling pleural catheter (IPC). It is likely that the combination of both techniques (i.e., thoracoscopy with talc poudrage and insertion of a IPC, or instillation of talc slurry through a IPC) will have a predominant role in the future therapeutic management.
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Affiliation(s)
- José Luis Recuero Díaz
- Servicio de Cirugía Torácica, Hospital Universitario Miguel Servet, Zaragoza, Spain; Instituto de Investigación Sanitaria (IIS) de Aragón, Zaragoza, Spain.
| | | | - Carlos Gálvez Muñoz
- Servicio de Cirugía Torácica, Hospital Universitario de Alicante, Alicante, Spain
| | - Javier Lázaro Sierra
- Instituto de Investigación Sanitaria (IIS) de Aragón, Zaragoza, Spain; Servicio de Neumología, Hospital Royo Villanova, Zaragoza, Spain
| | - Marta López Porras
- Servicio de Cirugía Torácica, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Diego Márquez Medina
- Instituto de Investigación Sanitaria (IIS) de Aragón, Zaragoza, Spain; Servicio de Oncología Médica, Hospital Universitario Miguel Servet, Zaragoza, Spain; Universidad de Zaragoza, Zaragoza, Spain
| | - María Nabal Vicuña
- Cuidados Paliativos, Hospital Universitario Arnau de Vilanova, Lleida, Spain
| | - Laura Sánchez Moreno
- Servicio de Cirugía Torácica, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Mar González Cantalejo
- Servicio de Información Biomédica y Biblioteca, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - José M Porcel
- Unidad de Medicina Pleural, Servicio de Medicina Interna, Hospital Universitario Arnau de Vilanova, Lleida, Spain; Institut de Recerca Biomèdica de Lleida Fundació Dr. Pifarré (IRBLleida), Lleida, Spain; Universitat de Lleida, Lleida. Spain
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9
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Recuero Díaz JL, Figueroa Almánzar S, Gálvez Muñoz C, Lázaro Sierra J, López Porras M, Márquez Medina D, Nabal Vicuña M, Sánchez Moreno L, González Cantalejo M, M. Porcel J. Recomendaciones de la Sociedad Española de Cirugía Torácica para el manejo del derrame pleural maligno. Cir Esp 2022. [DOI: 10.1016/j.ciresp.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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10
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Fitzgerald DB, Sidhu C, Budgeon C, Tan AL, Read CA, Kwan BCH, Smith NA, Fysh ET, Muruganandan S, Saghaie T, Shrestha R, Badiei A, Nguyen P, Burke A, Goddard J, Windsor M, McDonald J, Wright G, Czarnecka K, Sivakumar P, Yasufuku K, Feller-Kopman DJ, Maskell NA, Murray K, Lee YCG. Australasian Malignant PLeural Effusion (AMPLE)-3 trial: study protocol for a multi-centre randomised study comparing indwelling pleural catheter (±talc pleurodesis) versus video-assisted thoracoscopic surgery for management of malignant pleural effusion. Trials 2022; 23:530. [PMID: 35761341 PMCID: PMC9235203 DOI: 10.1186/s13063-022-06405-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 05/16/2022] [Indexed: 11/10/2022] Open
Abstract
Introduction Malignant pleural effusions (MPEs) are common. MPE causes significant breathlessness and impairs quality of life. Indwelling pleural catheters (IPC) allow ambulatory drainage and reduce hospital days and re-intervention rates when compared to standard talc slurry pleurodesis. Daily drainage accelerates pleurodesis, and talc instillation via the IPC has been proven feasible and safe. Surgical pleurodesis via video-assisted thoracoscopic surgery (VATS) is considered a one-off intervention for MPE and is often recommended to patients who are fit for surgery. The AMPLE-3 trial is the first randomised trial to compare IPC (±talc pleurodesis) and VATS pleurodesis in those who are fit for surgery. Methods and analysis A multi-centre, open-labelled randomised trial of patients with symptomatic MPE, expected survival of ≥ 6 months and good performance status randomised 1:1 to either IPC or VATS pleurodesis. Participant randomisation will be minimised for (i) cancer type (mesothelioma vs non-mesothelioma); (ii) previous pleurodesis (vs not); and (iii) trapped lung, if known (vs not). Primary outcome is the need for further ipsilateral pleural interventions over 12 months or until death, if sooner. Secondary outcomes include days in hospital, quality of life (QoL) measures, physical activity levels, safety profile, health economics, adverse events, and survival. The trial will recruit 158 participants who will be followed up for 12 months. Ethics and dissemination Sir Charles Gairdner and Osborne Park Health Care Group (HREC) has approved the study (reference: RGS356). Results will be published in peer-reviewed journals and presented at scientific meetings. Discussion Both IPC and VATS are commonly used procedures for MPE. The AMPLE-3 trial will provide data to help define the merits and shortcomings of these procedures and inform future clinical care algorithms. Trial registration Australia New Zealand Clinical Trial Registry ACTRN12618001013257. Registered on 18 June 2018. Protocol version: Version 3.00/4.02.19 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06405-7.
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Affiliation(s)
- Deirdre B Fitzgerald
- Respiratory Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia.,Medical School, Faculty of Health & Medical Sciences, University of Western Australia, Perth, WA, Australia.,Pleural Medicine Unit, Institute for Respiratory Health, Perth, WA, Australia
| | - Calvin Sidhu
- Respiratory Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia.,Pleural Medicine Unit, Institute for Respiratory Health, Perth, WA, Australia.,School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia
| | - Charley Budgeon
- School of Population and Global Health, University of Western Australia, Perth, WA, Australia
| | - Ai Ling Tan
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, WA, Australia
| | - Catherine A Read
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, WA, Australia
| | - Benjamin C H Kwan
- Department of Respiratory and Sleep Medicine, The Sutherland Hospital, Sydney, NSW, Australia.,University of New South Wales, Sydney, NSW, Australia
| | - Nicola Ann Smith
- Respiratory Department, Wellington Regional Hospital, Wellington, New Zealand
| | - Edward T Fysh
- Medical School, Faculty of Health & Medical Sciences, University of Western Australia, Perth, WA, Australia.,Respiratory Medicine, St John of God Hospital Midland, Midland, WA, Australia
| | | | - Tajalli Saghaie
- Respiratory Medicine, Concord Repatriation General Hospital, Concord West, NSW, Australia.,Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
| | - Ranjan Shrestha
- Respiratory Medicine, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Arash Badiei
- Thoracic Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia.,Adelaide Medical School, Faculty of Health and Medical Science, University of Adelaide, Adelaide, SA, Australia
| | - Phan Nguyen
- Thoracic Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia.,Adelaide Medical School, Faculty of Health and Medical Science, University of Adelaide, Adelaide, SA, Australia
| | - Andrew Burke
- Thoracic Medicine, The Prince Charles Hospital, Brisbane, QLD, Australia.,School of Medicine, The University of Queensland School of Medicine, Brisbane, QLD, Australia
| | - John Goddard
- Respiratory Department, Sunshine Coast University Hospital, Birtinya, QLD, Australia.,Griffith University, Brisbane, QLD, Australia
| | - Morgan Windsor
- Thoracic Surgery, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Julie McDonald
- Respiratory and Sleep Medicine Department, St Vincent's Hospital, Melbourne, VIC, Australia
| | - Gavin Wright
- Department of Cardiothoracic Surgery & University of Melbourne Department of Surgery, St Vincent's Hospital, Melbourne, VIC, Australia
| | - Kasia Czarnecka
- Division of Thoracic Surgery, Toronto General Hospital University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | - Kazuhiro Yasufuku
- Division of Thoracic Surgery, Toronto General Hospital University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | - Nick A Maskell
- Academic Respiratory Unit, Bristol Medical School, University of Bristol, Bristol, UK
| | - Kevin Murray
- School of Population and Global Health, University of Western Australia, Perth, WA, Australia
| | - Y C Gary Lee
- Respiratory Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia. .,Medical School, Faculty of Health & Medical Sciences, University of Western Australia, Perth, WA, Australia. .,Pleural Medicine Unit, Institute for Respiratory Health, Perth, WA, Australia.
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11
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Guinde J, Dutau H, Astoul P. Management of Malignant Pleural Effusion: Where Are We Now? Semin Respir Crit Care Med 2022; 43:559-569. [PMID: 35613947 DOI: 10.1055/s-0042-1748185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Pleural malignancies are among the most common causes of pleural disease and form the basis of our daily pleural practice. There has been significant research and increase in both diagnostic and therapeutic management of malignant pleural diseases in the last decade. Good-quality data have led to a paradigm shift in the management options of pleural malignancies, and indwelling pleural catheter is now recommended and widely used as first-line intervention. Several trials compared different treatment modalities for pleural malignancies and continue to emphasize the need to reduce hospital length of stay and unnecessary pleural intervention, and the importance of patient choice in clinical decision making. This practical review aims to summarize the current knowledge for the management of pleural malignancies, and the understanding of the steps that we still have to climb to optimize management and reduce morbidity.
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Affiliation(s)
- Julien Guinde
- Department of Thoracic Oncology, Pleural Diseases, and Interventional Pulmonology, North University Hospital, Marseille, France
| | - Hervé Dutau
- Department of Thoracic Oncology, Pleural Diseases, and Interventional Pulmonology, North University Hospital, Marseille, France
| | - Philippe Astoul
- Department of Thoracic Oncology, Pleural Diseases, and Interventional Pulmonology, North University Hospital, Marseille, France.,Aix-Marseille University, Marseille, France
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12
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Update on the diagnosis and management of malignant pleural effusions. Respir Med 2022; 196:106802. [DOI: 10.1016/j.rmed.2022.106802] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 02/25/2022] [Accepted: 03/02/2022] [Indexed: 12/17/2022]
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Bal C, Falster C, Carvalho A, Hersch N, Brock J, Laursen CB, Walsh S, Annema J, Gompelmann D. ERS International Congress 2021: highlights from the Clinical Techniques, Imaging and Endoscopy Assembly. ERJ Open Res 2022; 8:00116-2022. [PMID: 35615419 PMCID: PMC9124868 DOI: 10.1183/23120541.00116-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 03/15/2022] [Indexed: 11/05/2022] Open
Abstract
This article summarises the highlights from the European Respiratory Society's “Clinical techniques, imaging and endoscopy” Assembly 14 presented at the virtual 2021 European Respiratory Society International Congress. Cutting-edge innovative developments in both diagnostic approaches and therapeutic strategies in patients with lung cancer, interstitial lung disease, obstructive airway disorders and infectious diseases were presented on this year's interactive congress platform. In this article, the Assembly 14 subgroups summarise the key take home messages given new research outcomes and place them in the context of the current knowledge.
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14
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Silver Nitrate-Coated Versus Standard Indwelling Pleural Catheter for Malignant Effusions: The SWIFT Randomized Trial. Ann Am Thorac Soc 2022; 19:1722-1729. [PMID: 35363591 DOI: 10.1513/annalsats.202111-1301oc] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Tunneled, indwelling pleural catheters (IPC) have been demonstrated to be an effective method of managing malignant pleural effusions. However, they allow pleurodesis and can therefore be removed in only a subset of patients. A novel, silver-nitrate coated IPC was developed with the intention of creating a rapid, effective chemical pleurodesis to allow more frequent and earlier catheter removal. This study represent the pivotal clinical trial evaluating that catheter vs the standard IPC. OBJECTIVES To compare the efficacy of a novel silver nitrate-eluting indwelling pleural catheter (SNCIPC) with that of a standard, uncoated catheter. METHODS The SWIFT trial was a multicentre, parallel-group, randomised, controlled, patient-blind trial. Central randomisation occurred following a computer-generated schedule, stratified by site. Recruitment was from 17 secondary or tertiary-care hospitals in the USA and 3 in the UK and included adult patients with malignant pleural effusion needing drainage, without evidence of lung entrapment or significant loculation. The intervention group underwent insertion of a SNCIPC with maximal fluid drainage, followed by a tapering drainage schedule. The control group received a standard, uncoated catheter. Follow up was until 90 days. The primary outcome measure was pleurodesis efficacy, measured by fluid drainage, at 30 days. RESULTS 119 patients were randomised. 5 withdrew before receiving treatment, leaving 114 (77 SNCIPC, 37 standard IPC) for intention-to-treat analysis. Mean age was 66 years (SD 11). More patients in the SNCIPC group were in-patients (39% vs 14%, p=0.009). For the primary outcome, pleurodesis rates were 12/37 (32%) in the control group and 17/77 (22%) in the SNCIPC group (rate difference -0.10, 95% CI -0.30-0.09). Median time to pleurodesis was 11 days (IQR 9-23) in the control group and 4 days (IQR 2-15) in the SNCIPC group. No significant difference in treatment-related adverse event rates was noted between groups. CONCLUSIONS The SNCIPC did not improve pleurodesis efficacy compared to a standard indwelling pleural catheter. This study does not support the wider use of the SNCIPC device. Clinical trial registered with ClinicalTrials.gov (NCT02649894).
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Dipper A, Welch H, Maskell N. Multimodal Approaches Toward Management of Malignant Pleural Effusion: Establishing Treatment Goals is Paramount. Arch Bronconeumol 2022; 58:640-641. [DOI: 10.1016/j.arbres.2021.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 12/16/2021] [Indexed: 11/24/2022]
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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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Abstract
Recurrent, symptomatic pleural effusions are common and can contribute to significant morbidity in affected patients. Various management options are available and indwelling pleural catheter placement is becoming more commonplace and is the preferred option in certain clinical scenarios. The body of literature pertaining to indwelling pleural catheter use has grown substantially over the last decade and the purpose of this review is to summarize the best available evidence.
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Affiliation(s)
- Audra J Schwalk
- Division of Pulmonary and Critical Care, The University of Texas Southwestern Medical Center, Professional Office Building II, 5939 Harry Hines Boulevard, Dallas, TX 75390, USA.
| | - David E Ost
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Unit 1462, 1515 Holcombe Boulevard, Houston, TX 77030, USA
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Foo CT, Pulimood T, Knolle M, Marciniak SJ, Herre J. Ambulatory Thoracoscopic Pleurodesis Combined With Indwelling Pleural Catheter in Malignant Pleural Effusion. Front Surg 2021; 8:738719. [PMID: 34760917 PMCID: PMC8572984 DOI: 10.3389/fsurg.2021.738719] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 10/05/2021] [Indexed: 11/13/2022] Open
Abstract
Background and Objective: Malignant pleural effusion (MPE) often results in debilitating symptoms. Relief of dyspnoea and improvement in quality of life can be achieved with either talc pleurodesis or insertion of an indwelling tunneled pleural catheter (IPC). The former requires a lengthy hospital stay and the latter is associated with lower pleurodesis rates. In response to limited hospital bed capacity, we developed a pragmatic approach in managing MPE by combining thoracoscopic talc poudrage and insertion of IPC into a single day case procedure. We present data on the safety and efficacy of this approach. Methods: Patients who had undergone the abovementioned procedure between 2017 and 2020 were analyzed. Demographic data, hospital length of stay (LOS), histological diagnosis, rates of pleurodesis success and procedural related complications were collated. Patients were followed-up for 6 months. Results: Forty-five patients underwent the procedure. Mean age was 68.5 ± 10.4 years and 56% were male. Histological diagnosis was achieved in all cases. 86.7% of patients were discharged on the day of the procedure. Median LOS was 0 (IQR 0–0) days. Successful pleurodesis was attained in 77.8% at 6-month follow-up. No procedure related deaths or IPC related infections were recorded. Conclusion: Ambulatory thoracoscopic poudrage and IPC insertion is a safe and effective option in the management of MPE. All patients received a definitive pleural intervention with 77.8% pleurodesis success at 6-months and majority of them discharged on the same day. Future randomized trials are required to confirm these findings.
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Affiliation(s)
- Chuan T Foo
- Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom
| | - Thomas Pulimood
- Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom
| | - Martin Knolle
- Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom
| | - Stefan J Marciniak
- Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom.,Cambridge Institute for Medical Research, University of Cambridge, Cambridge, United Kingdom
| | - Jurgen Herre
- Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom
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Green DB, Groner LK, Lee JJ, Shin J, Broncano J, Vargas D, Castro M, Shostak E. Overview of Interventional Pulmonology for Radiologists. Radiographics 2021; 41:1916-1935. [PMID: 34534017 DOI: 10.1148/rg.2021210046] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Interventional pulmonology is a growing field specializing in minimally invasive procedures of the mediastinum, lungs, airways, and pleura. These procedures have both diagnostic and therapeutic indications and are performed for benign and malignant diseases. Endobronchial US has been combined with transbronchial needle aspiration to extend tissue sampling beyond the airways and into the lungs and mediastinum. Recent innovations extending the peripheral access of bronchoscopy include electromagnetic navigational bronchoscopy and thinner bronchoscopes. An important indication for therapeutic bronchoscopy is the relief of central airway obstruction, which may be severe and life threatening. Techniques for restoring patency of the central airways include mechanical debulking and multiple modalities for ablation, stent placement, and balloon bronchoplasty. Bronchoscopic lung volume reduction improves quality of life in certain patients with severe emphysema and is an important less invasive alternative to lung volume reduction surgery. Bronchial thermoplasty is likewise a nonpharmacologic treatment in patients with severe uncontrolled asthma. Many of these procedures have unique selection criteria that require precise evaluations at preprocedure imaging. Postprocedure imaging is also essential in determining outcome success and the presence of complications. Radiologists should be familiar with these procedures as well as the relevant imaging features in both planning and later surveillance. Evolving techniques that may become more widely available in the near future include robotic-assisted bronchoscopy, bronchoscopic transparenchymal nodule access, transbronchial cryobiopsy, ablation of early-stage cancers, and endobronchial intratumoral chemotherapy. An invited commentary by Wayne et al is available online. ©RSNA, 2021.
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Affiliation(s)
- Daniel B Green
- From the Departments of Radiology (D.B.G., L.K.G., J.S.) and Cardiothoracic Surgery (E.S.), Weill Cornell Medicine, 525 E 68th St, Box 141, New York, NY 10065; Departments of Medicine (J.J.L.) and Radiology (D.V.), University of Colorado, Aurora, Colo; Department of Radiology, Hospital San Juan de Dios, Córdoba, Spain (J.B.); and Division of Pulmonary and Critical Care Medicine, University of Kansas Medical Center, Kansas City, Kan (M.C.)
| | - Lauren K Groner
- From the Departments of Radiology (D.B.G., L.K.G., J.S.) and Cardiothoracic Surgery (E.S.), Weill Cornell Medicine, 525 E 68th St, Box 141, New York, NY 10065; Departments of Medicine (J.J.L.) and Radiology (D.V.), University of Colorado, Aurora, Colo; Department of Radiology, Hospital San Juan de Dios, Córdoba, Spain (J.B.); and Division of Pulmonary and Critical Care Medicine, University of Kansas Medical Center, Kansas City, Kan (M.C.)
| | - Jared J Lee
- From the Departments of Radiology (D.B.G., L.K.G., J.S.) and Cardiothoracic Surgery (E.S.), Weill Cornell Medicine, 525 E 68th St, Box 141, New York, NY 10065; Departments of Medicine (J.J.L.) and Radiology (D.V.), University of Colorado, Aurora, Colo; Department of Radiology, Hospital San Juan de Dios, Córdoba, Spain (J.B.); and Division of Pulmonary and Critical Care Medicine, University of Kansas Medical Center, Kansas City, Kan (M.C.)
| | - James Shin
- From the Departments of Radiology (D.B.G., L.K.G., J.S.) and Cardiothoracic Surgery (E.S.), Weill Cornell Medicine, 525 E 68th St, Box 141, New York, NY 10065; Departments of Medicine (J.J.L.) and Radiology (D.V.), University of Colorado, Aurora, Colo; Department of Radiology, Hospital San Juan de Dios, Córdoba, Spain (J.B.); and Division of Pulmonary and Critical Care Medicine, University of Kansas Medical Center, Kansas City, Kan (M.C.)
| | - Jordi Broncano
- From the Departments of Radiology (D.B.G., L.K.G., J.S.) and Cardiothoracic Surgery (E.S.), Weill Cornell Medicine, 525 E 68th St, Box 141, New York, NY 10065; Departments of Medicine (J.J.L.) and Radiology (D.V.), University of Colorado, Aurora, Colo; Department of Radiology, Hospital San Juan de Dios, Córdoba, Spain (J.B.); and Division of Pulmonary and Critical Care Medicine, University of Kansas Medical Center, Kansas City, Kan (M.C.)
| | - Daniel Vargas
- From the Departments of Radiology (D.B.G., L.K.G., J.S.) and Cardiothoracic Surgery (E.S.), Weill Cornell Medicine, 525 E 68th St, Box 141, New York, NY 10065; Departments of Medicine (J.J.L.) and Radiology (D.V.), University of Colorado, Aurora, Colo; Department of Radiology, Hospital San Juan de Dios, Córdoba, Spain (J.B.); and Division of Pulmonary and Critical Care Medicine, University of Kansas Medical Center, Kansas City, Kan (M.C.)
| | - Mario Castro
- From the Departments of Radiology (D.B.G., L.K.G., J.S.) and Cardiothoracic Surgery (E.S.), Weill Cornell Medicine, 525 E 68th St, Box 141, New York, NY 10065; Departments of Medicine (J.J.L.) and Radiology (D.V.), University of Colorado, Aurora, Colo; Department of Radiology, Hospital San Juan de Dios, Córdoba, Spain (J.B.); and Division of Pulmonary and Critical Care Medicine, University of Kansas Medical Center, Kansas City, Kan (M.C.)
| | - Eugene Shostak
- From the Departments of Radiology (D.B.G., L.K.G., J.S.) and Cardiothoracic Surgery (E.S.), Weill Cornell Medicine, 525 E 68th St, Box 141, New York, NY 10065; Departments of Medicine (J.J.L.) and Radiology (D.V.), University of Colorado, Aurora, Colo; Department of Radiology, Hospital San Juan de Dios, Córdoba, Spain (J.B.); and Division of Pulmonary and Critical Care Medicine, University of Kansas Medical Center, Kansas City, Kan (M.C.)
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20
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Association between Tunneled Pleural Catheter Use and Infection in Patients Immunosuppressed from Antineoplastic Therapy. A Multicenter Study. Ann Am Thorac Soc 2021; 18:606-612. [PMID: 33026887 DOI: 10.1513/annalsats.202007-886oc] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rationale: Patients with malignant or paramalignant pleural effusions (MPEs or PMPEs) may have tunneled pleural catheter (TPC) management withheld because of infection concerns from immunosuppression associated with antineoplastic therapy.Objectives: To determine the rate of infections related to TPC use and to determine the relationship to antineoplastic therapy, immune system competency, and overall survival (OS).Methods: We performed an international, multiinstitutional study of patients with MPEs or PMPEs undergoing TPC management from 2008 to 2016. Patients were stratified by whether or not they underwent antineoplastic therapy and/or whether or not they were immunocompromised. Cumulative incidence functions and multivariable competing risk regression analyses were performed to identify independent predictors of TPC-related infection. Kaplan-Meier method and multivariable Cox proportional hazards modeling were performed to examine for independent effects on OS.Results: A total of 1,408 TPCs were placed in 1,318 patients. Patients had a high frequency of overlap between antineoplastic therapy and an immunocompromised state (75-83%). No difference in the overall (6-7%), deep pleural (3-5%), or superficial (3-4%) TPC-related infection rates between subsets of patients stratified by antineoplastic therapy or immune status was observed. The median time to infection was 41 (interquartile range, 19-87) days after TPC insertion. Multivariable competing risk analyses demonstrated that longer TPC duration was associated with a higher risk of TPC-related infection (subdistribution hazard ratio, 1.03; 95% confidence interval [CI], 1.00-1.06; P = 0.028). Cox proportional hazards analysis showed antineoplastic therapy was associated with better OS (hazard ratio, 0.84; 95% CI, 0.73-0.97; P = 0.015).Conclusions: The risk of TPC-related infection does not appear to be increased by antineoplastic therapy use or an immunocompromised state. The overall rates of infection are low and comparable with those of immunocompetent patients with no relevant antineoplastic therapy. These results support TPC palliation for MPE or PMPEs regardless of plans for antineoplastic therapy.
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21
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Zhang W, Zhao YL, Li SJ, Zhao YN, Guo NN, Liu B. Complications of thoracoscopic talc insufflation for the treatment of malignant pleural effusions: a meta-analysis. J Cardiothorac Surg 2021; 16:125. [PMID: 33947423 PMCID: PMC8097876 DOI: 10.1186/s13019-021-01475-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 04/05/2021] [Indexed: 11/10/2022] Open
Abstract
Background Talc pleurodesis is an effective treatment for malignant pleural effusions (MPEs). This study was designed to estimate complication rates of thoracoscopic talc insufflation. Methods Literature search was conducted in electronic databases and studies were selected if they reported complication rates of thoracoscopic talc insufflation in cancer patients with MPEs. Meta-analyses of proportions were performed to obtain incidence rates of complications. Results Twenty-six studies (4482 patients; age 62.9 years [95% confidence interval (CI): 61.5, 64.4]; 50% [95% CI: 43, 58] females) were included. Intraoperative, perioperative, 30-day, and 90-day mortality rates were 0% [95% CI: 0, 1], 2% [95% CI: 0, 4], 7% [95% CI: 3, 13] and 21% [95% CI: 5, 43] respectively. Incidence rates [95% CI] of various complications were: pain (20% [1, 2]), fever (14% [3, 4]), dyspnea (13% [5, 6]), pneumothorax (6% [7, 8]) pneumonia (4% [0, 12]), emphysema (3% [3, 7]), prolonged air leakage (3% [0, 7]), prolonged drainage (3% [9, 10]), thromboembolism (3% [9, 11]), lung injury (2% [7, 12]), respiratory insufficiency (2% [0, 5]), re-expansion pulmonary edema (1% [0, 3]), empyema (1% [0, 2]), respiratory failure (0% [0, 1]), and acute respiratory distress syndrome (ARDS; 0% [0, 1]. Conclusions Whereas pain and fever were the most frequent complications of thoracoscopic talc insufflation, the incidence of ARDS was low. Pneumothorax, pneumonia, emphysema, prolonged air leakage, pulmonary embolism, arrythmia, re-expansion pulmonary edema, and empyema are important complications of thoracoscopic talc insufflation. Supplementary Information The online version contains supplementary material available at 10.1186/s13019-021-01475-1.
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Affiliation(s)
- Wen Zhang
- Department of Chest Surgery, The Fourth Medical Center of PLA General Hospital, No.51, Fucheng Road, Haidian District, Beijing, 100048, China
| | - Yun-Long Zhao
- Department of Chest Surgery, The Fourth Medical Center of PLA General Hospital, No.51, Fucheng Road, Haidian District, Beijing, 100048, China
| | - Shao-Jun Li
- Department of Chest Surgery, The Fourth Medical Center of PLA General Hospital, No.51, Fucheng Road, Haidian District, Beijing, 100048, China
| | - Ying-Nan Zhao
- Department of Chest Surgery, The Fourth Medical Center of PLA General Hospital, No.51, Fucheng Road, Haidian District, Beijing, 100048, China
| | - Nan-Nan Guo
- Department of Chest Surgery, The Fourth Medical Center of PLA General Hospital, No.51, Fucheng Road, Haidian District, Beijing, 100048, China.
| | - Bo Liu
- Department of Chest Surgery, The Fourth Medical Center of PLA General Hospital, No.51, Fucheng Road, Haidian District, Beijing, 100048, China.
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Bedawi EO, Guinde J, Rahman NM, Astoul P. Advances in pleural infection and malignancy. Eur Respir Rev 2021; 30:200002. [PMID: 33650525 PMCID: PMC9488125 DOI: 10.1183/16000617.0002-2020] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 06/12/2020] [Indexed: 02/03/2023] Open
Abstract
Pleural infection and malignancy are among the most common causes of pleural disease and form the mainstay of pleural practice. There has been significant research and increase in scientific understanding in these areas in the past decade. With regard to pleural infection, the rising incidence remains worrying. An increased awareness allowing earlier diagnosis, earlier escalation of therapy and the use of validated risk stratification measures may improve outcomes. In pleural malignancy, research has enabled clinicians to streamline patient pathways with focus on reducing time to diagnosis, definitive management of malignant pleural effusion and achieving these with the minimum number of pleural interventions. Trials comparing treatment modalities of malignant pleural effusion continue to highlight the importance of patient choice in clinical decision-making. This article aims to summarise some of the most recent literature informing current practice in these two areas.
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Affiliation(s)
- Eihab O Bedawi
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals, Oxford, UK
| | - Julien Guinde
- Dept of Thoracic Oncology, Pleural Diseases and Interventional Pulmonology, North University Hospital, Marseille, France
| | - Najiib M Rahman
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals, Oxford, UK
- NIHR Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Philippe Astoul
- Dept of Thoracic Oncology, Pleural Diseases and Interventional Pulmonology, North University Hospital, Marseille, France
- Aix-Marseille University, Marseille, France
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Pleurodesis: From Thoracic Surgery to Interventional Pulmonology. Respir Med 2021. [DOI: 10.1007/978-3-030-80298-1_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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24
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Recent Developments in the Management of Malignant Pleural Effusions: a Narrative Review. CURRENT PULMONOLOGY REPORTS 2020. [DOI: 10.1007/s13665-020-00261-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Banka R, George V, Rahman NM. Multidisciplinary approaches to the management of malignant pleural effusions: a guide for the clinician. Expert Rev Respir Med 2020; 14:1009-1018. [PMID: 32634337 DOI: 10.1080/17476348.2020.1793672] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Malignant pleural effusion (MPE) is a complication of advanced cancer, associated with significant mortality and morbidity. This entity is commonly treated by respiratory physicians, oncologists, and thoracic surgeons. There have been various randomized clinical trials assessing the relative merits of chest drain pleurodesis, indwelling pleural catheters, treatment of septated MPEs, the use of thoracoscopy and pleurodesis and pleurodesis through IPCs in the past decade which have addressed some key areas in the management of MPEs, with an increasing focus on patient related outcome. AREAS COVERED In this review, we examine and review the literature for management strategies for MPEs and discuss future directions. A detailed search of scientific literature and clinical trial registries published in the past two decades was undertaken. EXPERT OPINION Tremendous progress has been made in management of MPE in the past decade and current strategy involves patient preference along with local expertise that is available.
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Affiliation(s)
- Radhika Banka
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust , Oxford, UK
| | - Vineeth George
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust , Oxford, UK
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust , Oxford, UK.,University of Oxford Respiratory Trials Unit, Churchill Hospital , Oxford, UK.,NIHR Oxford Biomedical Research Centre, University of Oxford , Oxford, UK
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Agrawal A, Murgu S. Multimodal approach to the management of malignant pleural effusions: role of thoracoscopy with pleurodesis and tunneled indwelling pleural catheters. J Thorac Dis 2020; 12:2803-2811. [PMID: 32642188 PMCID: PMC7330308 DOI: 10.21037/jtd.2020.03.57] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Malignant pleural effusion (MPE) is associated with a median survival of 3–6 months and causes significant symptoms affecting the overall quality of life in patients with advanced malignancies. Despite the high incidence of recurrent MPE, less than 25% of patients undergo a definitive pleural intervention as recommended by guidelines. In this review, we summarize the latest guidelines for management of MPE by various societies and discuss a multimodal approach in these patients using thoracoscopy with pleurodesis using talc insufflation and placement of tunneled indwelling pleural catheters (TIPC). We also address the role of diagnostic thoracoscopy for histologic and molecular diagnosis and outline our approach to patients with known or suspected MPE.
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Affiliation(s)
- Abhinav Agrawal
- Interventional Pulmonology, Section of Pulmonary & Critical Care, The University of Chicago Medicine, Chicago, IL, USA
| | - Septimiu Murgu
- Interventional Pulmonology, Section of Pulmonary & Critical Care, The University of Chicago Medicine, Chicago, IL, USA
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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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Update on Management of Pleural Disease. CURRENT PULMONOLOGY REPORTS 2019. [DOI: 10.1007/s13665-019-00242-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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29
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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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Talc Pleurodesis: A Medical, Medicolegal, and Socioeconomic Review. Ann Thorac Surg 2019; 109:1294-1301. [PMID: 31593652 DOI: 10.1016/j.athoracsur.2019.08.104] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 08/13/2019] [Accepted: 08/29/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Talcum has been used in pleurodesis for more than 8 decades. Despite a wealth of research, controversy remains over the optimal sclerosant for pneumothorax and pleural effusions. Talc's historical primacy has been challenged because of its potential for pulmonary toxicity, possible carcinogenicity, and recent concerns surrounding availability and legal liability, thus making this an ideal time for a review. METHODS This systematic review of the talc literature, focused on publications after the year 2000, evaluated mechanism of action, efficacy, side effect profile, and alternative sclerosants; included is an overview of current socioeconomic and legal controversies. RESULTS The data support talc as the most effective agent for pleurodesis. There is evidence to suggest that mean particle size has a direct relationship with the side effect profile and that significant hypoxemic events after talc administration are exceedingly rare when using available graded talc preparations. Concerns regarding the development of malignant diseases after topical talc application remain incompletely resolved but appear related to cosmetic powder preparations that were contaminated with asbestos. Purified talc in the pleural space has not been implicated. Recent difficulties accessing commercial talc preparations have been solved. Although safe and effective talc alternatives do exist, these agents are not as well studied. CONCLUSIONS Talc pleurodesis with modern, purified, graded talc preparations is safe and highly effective. Talc is an inexpensive and accessible option that remains appropriate for pleurodesis despite existing controversies.
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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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Bibby AC, Dorn P, Psallidas I, Porcel JM, Janssen J, Froudarakis M, Subotic D, Astoul P, Licht P, Schmid R, Scherpereel A, Rahman NM, Maskell NA, Cardillo G. ERS/EACTS statement on the management of malignant pleural effusions. Eur J Cardiothorac Surg 2019; 55:116-132. [PMID: 30060030 DOI: 10.1093/ejcts/ezy258] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Accepted: 03/28/2018] [Indexed: 12/26/2022] Open
Abstract
Malignant pleural effusions (MPE) are a common pathology, treated by respiratory physicians and thoracic surgeons alike. In recent years, several well-designed randomized clinical trials have been published that have changed the landscape of MPE management. The European Respiratory Society (ERS) and the European Association for Cardio-Thoracic Surgery (EACTS) established a multidisciplinary collaboration of clinicians with expertise in the management of MPE with the aim of producing a comprehensive review of the scientific literature. Six areas of interest were identified, including the optimum management of symptomatic MPE, management of trapped lung in MPE, management of loculated MPE, prognostic factors in MPE, whether there is a role for oncological therapies prior to intervention for MPE and whether a histological diagnosis is always required in MPE. The literature revealed that talc pleurodesis and indwelling pleural catheters effectively manage the symptoms of MPE. There was limited evidence regarding the management of trapped lung or loculated MPE. The LENT score was identified as a validated tool for predicting survival in MPE, with Brims' prognostic score demonstrating utility in mesothelioma prognostication. There was no evidence to support the use of oncological therapies as an alternative to MPE drainage, and the literature supported the use of tissue biopsy as the gold standard for diagnosis and treatment planning.Management options for malignant pleural effusions have advanced over the past decade, with high-quality randomized trial evidence informing practice in many areas. However, uncertainties remain and further research is required http://ow.ly/rNt730jOxOS.
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Affiliation(s)
- Anna C Bibby
- Academic Respiratory Unit, University of Bristol Medical School Translational Health Sciences, Bristol, UK
- North Bristol Lung Centre, North Bristol NHS Trust, Bristol, UK
| | - Patrick Dorn
- Division of Thoracic Surgery, University Hospital Bern, Bern, Switzerland
| | | | - Jose M Porcel
- Pleural Medicine Unit, Arnau de Vilanova University Hospital, IRB Lleida, Lleida, Spain
| | - Julius Janssen
- Department of Pulmonary Diseases, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Marios Froudarakis
- Department of Respiratory Medicine, Medical School of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - Dragan Subotic
- Clinic for Thoracic Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Phillippe Astoul
- Department of Thoracic Oncology, Pleural Diseases and Interventional Pulmonology, Hospital North Aix-Marseille University, Marseille, France
| | - Peter Licht
- Department of Cardiothoracic Surgery, Odense University Hospital, Odense, Denmark
| | - Ralph Schmid
- Division of Thoracic Surgery, University Hospital Bern, Bern, Switzerland
| | - Arnaud Scherpereel
- Pulmonary and Thoracic Oncology Department, Hospital of the University (CHU) of Lille, Lille, France
| | - Najib M Rahman
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- Oxford Centre for Respiratory Medicine, University Hospitals, NHS Foundation Trust, Oxford, UK
| | - Nick A Maskell
- Academic Respiratory Unit, University of Bristol Medical School Translational Health Sciences, Bristol, UK
- North Bristol Lung Centre, North Bristol NHS Trust, Bristol, UK
- Task force chairperson
| | - Giuseppe Cardillo
- Task force chairperson
- Department of Thoracic Surgery, Carlo Forlanini Hospital, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
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Meriggi F. Malignant Pleural Effusion: Still a Long Way to Go. Rev Recent Clin Trials 2019; 14:24-30. [PMID: 30514193 DOI: 10.2174/1574887114666181204105208] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 11/26/2018] [Accepted: 11/27/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Malignant pleural effusion, which is a common clinical problem in patients with cancer, may be due to both primary thoracic tumours or to a metastatic spread in the chest and constitutes the first sign of disease in approximately 10% of patients. Almost all cancers can potentially produce a pleural effusion. The presence of malignant tumour cells in the pleural fluid is generally indicative of advanced disease and is associated with high morbidity and mortality with reduced therapeutic options. Dyspnoea during mild physical activity or at rest is generally the typical sign of restrictive respiratory failure. METHODS This is a systematic review of all the main articles in the English language on the topic of malignant pleural effusion and reported by the Pubmed database from 1959 to 2018. I reviewed the literature and guidelines with the aims to focus on what is known and on future pathways to follow the diagnosis and treatment of malignant pleural effusions. RESULTS The main goal of palliation of a malignant pleural effusion is a quick improvement in dyspnoea, while thoracentesis under ultrasound guidance is the treatment of choice for patients with a limited life expectancy or who are not candidates for more invasive procedures such as drainage using an indwelling small pleural catheter, chemical pleurodesis with sclerosing agents, pleurectomy or pleuro-peritoneal shunt. CONCLUSION Despite progress in therapeutic options, the prognosis remains severe, and the average survival is 4-9 months from the diagnosis of malignant pleural effusion. Moreover, mortality is higher for patients with malignant pleural effusion compared with those with metastatic cancer but no malignant pleural effusion. Therefore, the prognosis of these patients primarily depends on the underlying disease and the extension of a primary tumour. This review focuses on the most relevant updates in the management of malignant pleural effusion.
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Affiliation(s)
- Fausto Meriggi
- Oncology Department - Poliambulanza Foundation, Brescia, Italy
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Sivakumar P, Saigal A, Ahmed L. Quality of life after interventions for malignant pleural effusions: a systematic review. BMJ Support Palliat Care 2019; 10:45-54. [DOI: 10.1136/bmjspcare-2018-001610] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 02/28/2019] [Accepted: 04/15/2019] [Indexed: 02/04/2023]
Abstract
BackgroundMalignant pleural effusion (MPE) results in breathlessness and impairment of health-related quality of life (HRQOL). This study reviews the existing literature on HRQOL following invasive interventions in MPE.MethodsFive electronic databases were systematically searched and assessed three times during the review process and last completed on 15 June 2018. We included all studies evaluating HRQOL outcomes for the following interventions: therapeutic thoracocentesis, talc slurry (TS) pleurodesis, indwelling pleural catheter (IPC) insertion and thoracoscopic talc poudrage (TTP) pleurodesis. Meta-analysis was not performed due to substantial heterogeneity in the published data.Results17 studies were included in the review reporting HRQOL outcomes in 2515 patients. TTP, TS and IPC were associated with modest but inconsistent improvements in HRQOL up to 12 weeks. No intervention was significantly different from another in HRQOL outcomes at any time point. The attrition to follow-up was 48.3% (664/1374) at 3 months. The overall quality of studies was inadequate.ConclusionTTP, TS and IPC seem to improve HRQOL in MPE over 4–12 weeks, but there are insufficient longer term data due to high attrition rates. Evidence on the most effective treatment strategy is limited by the small number of randomised or comparative studies.Trial registration numberCRD42016051003.
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Duysinx B, Heinen V, Corhay JL, Vaillant F, Gomez A, Louis R. [Medical thoracoscopy in respiratory medicine: The Liège University Hospital experience]. Rev Mal Respir 2019; 36:688-696. [PMID: 31030998 DOI: 10.1016/j.rmr.2019.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 02/04/2019] [Indexed: 01/11/2023]
Abstract
INTRODUCTION The incidence of pleural disease continues to increase worldwide. Medical thoracoscopy remains the standard method for exploration of the pleural cavity. METHOD We report the retrospective evaluation, the efficacy and the observed complications in 1024 medical thoracoscopies undertaken in the University Hospital of Liège between 2000 and 2017. RESULTS In total, 100 pneumothoraces and 400 benign and 501 malignant pleural diseases were identified. The main indication for thoracoscopy remains the diagnosis of an exudative, lymphocytic pleural effusion of unknown aetiology after thoracocentesis. The diagnostic sensibility of thoracoscopy was 99.2% in distinguishing benign from malignant pleural disease. Talc pleurodesis was performed in 69.5% of the total population and in 66.1% of pleural effusions or thickening. Failure of pleurodesis was observed in 11% of the patients with recurrent pneumothorax and in 7.8% of neoplastic pleural effusion. We report a mortality of 0.6% in the 30 days post procedure, long duration of drainage in 8.3% and serious complications in 4.7%. In 22/1024 (2.1%) thoracoscopic evaluation was not feasible because of dense pleural fibrosis. CONCLUSION Medical thoracoscopy is a safe, well-tolerated procedure with high accuracy in the diagnostic and therapeutic management of pleural disease.
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Affiliation(s)
- B Duysinx
- Service de pneumologie, CHU de Sart-Tilman B35, B4000 Liège, Belgique.
| | - V Heinen
- Service de pneumologie, CHU de Sart-Tilman B35, B4000 Liège, Belgique
| | - J-L Corhay
- Service de pneumologie, CHU de Sart-Tilman B35, B4000 Liège, Belgique
| | - F Vaillant
- Service de pneumologie, CHU de Sart-Tilman B35, B4000 Liège, Belgique
| | - A Gomez
- Service de pneumologie, CHU de Sart-Tilman B35, B4000 Liège, Belgique
| | - R Louis
- Service de pneumologie, CHU de Sart-Tilman B35, B4000 Liège, Belgique
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Guinde J, Georges S, Bourinet V, Laroumagne S, Dutau H, Astoul P. Recent developments in pleurodesis for malignant pleural disease. CLINICAL RESPIRATORY JOURNAL 2019; 12:2463-2468. [PMID: 30252207 DOI: 10.1111/crj.12958] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 08/18/2018] [Accepted: 08/28/2018] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Metastatic pleural effusion (MPE) is one of the most frequent causes of pleural effusion. The aims of the therapeutic management are palliation of symptoms and improvement in patient's quality of life. The first step is a therapeutic thoracentesis. In case of a recurrent MPE, pleural maneuvers can be used to manage symptoms based on either ambulatory pleural drainage or pleurodesis to prevent fluid accumulation. The aim of this review is to describe recent advances, according to the best available evidence, in the field of pleurodesis for the management of MPE. DATA SOURCE AND STUDY SELECTION Three different searches of the most clinically relevant articles and up-to-date results in the field of pleurodesis for the management of MPE were performed using PubMed. Different indexing terms and time restriction were chosen. From these PubMed searches, 322 articles were respectively found. After cross-checking these three lists and the selection of articles published after January 2010 specially dedicated to the management of MPE by pleurodesis, the abstracts of 106 articles were extracted to feed the corpus of this review. RESULTS AND CONCLUSION Treatment approaches of recurrent MPE should take into account multiple factors in particular patient's life expectancy and preference. If talc is the best sclerosing agent alone or in combination with indwelling pleural catheter which is a promising strategy, the pathophysiology of MPE has to be revisited in order to propose a personalized management targeting intrapleural key molecules involved in the genesis of malignant process.
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Affiliation(s)
- Julien Guinde
- Department of Thoracic Oncology, Pleural Diseases and Interventional Pulmonology, Hôpital Nord, Marseille, France
| | - Samer Georges
- Department of Thoracic Oncology, Pleural Diseases and Interventional Pulmonology, Hôpital Nord, Marseille, France.,Department of Pulmonology, Hôpital du Sacré Coeur, Montreal, Canada
| | - Valerian Bourinet
- Department of Thoracic Oncology, Pleural Diseases and Interventional Pulmonology, Hôpital Nord, Marseille, France
| | - Sophie Laroumagne
- Department of Thoracic Oncology, Pleural Diseases and Interventional Pulmonology, Hôpital Nord, Marseille, France
| | - Herve Dutau
- Department of Thoracic Oncology, Pleural Diseases and Interventional Pulmonology, Hôpital Nord, Marseille, France
| | - Philippe Astoul
- Department of Thoracic Oncology, Pleural Diseases and Interventional Pulmonology, Hôpital Nord, Marseille, France.,Aix-Marseille University, Marseille, France
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Koegelenberg CFN, Shaw JA, Irusen EM, Lee YCG. Contemporary best practice in the management of malignant pleural effusion. Ther Adv Respir Dis 2019; 12:1753466618785098. [PMID: 29952251 PMCID: PMC6048656 DOI: 10.1177/1753466618785098] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Malignant pleural effusion (MPE) affects more than 1 million people globally. There is a dearth of evidence on the therapeutic approach to MPE, and not surprisingly a high degree of variability in the management thereof. We aimed to provide practicing clinicians with an overview of the current evidence on the management of MPE, preferentially focusing on studies that report patient-related outcomes rather than pleurodesis alone, and to provide guidance on how to approach individual cases. A pleural intervention for MPE will perforce be palliative in nature. A therapeutic thoracentesis provides immediate relief for most. It can be repeated, especially in patients with a slow rate of recurrence and a short anticipated survival. Definitive interventions, individualized according the patient's wishes, performance status, prognosis and other considerations (including the ability of the lung to expand) should be offered to the remainder of patients. Chemical pleurodesis (achieved via intercostal drain or pleuroscopy) and indwelling pleural catheter (IPC) have equal impact on patient-based outcomes, although patients treated with IPC spend less time in hospital and have less need for repeat pleural drainage interventions. Talc slurry via IPC is an attractive recently validated option for patients who do not have a nonexpandable lung.
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Affiliation(s)
- Coenraad F N Koegelenberg
- Division of Pulmonology, Department of Medicine, Stellenbosch University and Tygerberg Academic Hospital, PO Box 241, Cape Town, 8000, South Africa
| | - Jane A Shaw
- Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
| | - Elvis M Irusen
- Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
| | - Y C Gary Lee
- University of Western Australia and Sir Charles Gairdner Hospital, Perth, Australia
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Feller-Kopman DJ, Reddy CB, DeCamp MM, Diekemper RL, Gould MK, Henry T, Iyer NP, Lee YCG, Lewis SZ, Maskell NA, Rahman NM, Sterman DH, Wahidi MM, Balekian AA. Management of Malignant Pleural Effusions. An Official ATS/STS/STR Clinical Practice Guideline. Am J Respir Crit Care Med 2018; 198:839-849. [DOI: 10.1164/rccm.201807-1415st] [Citation(s) in RCA: 192] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Muruganandan S, Azzopardi M, Fitzgerald DB, Shrestha R, Kwan BCH, Lam DCL, De Chaneet CC, Rashid Ali MRS, Yap E, Tobin CL, Garske LA, Nguyen PT, Stanley C, Popowicz ND, Kosky C, Thomas R, Read CA, Budgeon CA, Feller-Kopman D, Maskell NA, Murray K, Lee YCG. Aggressive versus symptom-guided drainage of malignant pleural effusion via indwelling pleural catheters (AMPLE-2): an open-label randomised trial. THE LANCET RESPIRATORY MEDICINE 2018; 6:671-680. [DOI: 10.1016/s2213-2600(18)30288-1] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 06/25/2018] [Accepted: 06/26/2018] [Indexed: 12/14/2022]
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40
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Bibby AC, Dorn P, Psallidas I, Porcel JM, Janssen J, Froudarakis M, Subotic D, Astoul P, Licht P, Schmid R, Scherpereel A, Rahman NM, Cardillo G, Maskell NA. ERS/EACTS statement on the management of malignant pleural effusions. Eur Respir J 2018; 52:13993003.00349-2018. [DOI: 10.1183/13993003.00349-2018] [Citation(s) in RCA: 116] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Accepted: 03/28/2018] [Indexed: 02/07/2023]
Abstract
Malignant pleural effusions (MPE) are a common pathology, treated by respiratory physicians and thoracic surgeons alike. In recent years, several well-designed randomised clinical trials have been published that have changed the landscape of MPE management. The European Respiratory Society (ERS) and the European Association for Cardio-Thoracic Surgery (EACTS) established a multidisciplinary collaboration of clinicians with expertise in the management of MPE with the aim of producing a comprehensive review of the scientific literature.Six areas of interest were identified, including the optimum management of symptomatic MPE, management of trapped lung in MPE, management of loculated MPE, prognostic factors in MPE, whether there is a role for oncological therapies prior to intervention for MPE and whether a histological diagnosis is always required in MPE.The literature revealed that talc pleurodesis and indwelling pleural catheters effectively manage the symptoms of MPE. There was limited evidence regarding the management of trapped lung or loculated MPE. The LENT score was identified as a validated tool for predicting survival in MPE, with Brims' prognostic score demonstrating utility in mesothelioma prognostication. There was no evidence to support the use of oncological therapies as an alternative to MPE drainage, and the literature supported the use of tissue biopsy as the gold standard for diagnosis and treatment planning.
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Li P, Graver A, Hosseini S, Mulpuru S, Cake L, Kachuik L, Zhang T, Amjadi K. Clinical predictors of successful and earlier pleurodesis with a tunnelled pleural catheter in malignant pleural effusion: a cohort study. CMAJ Open 2018; 6:E235-E240. [PMID: 29898894 PMCID: PMC7868087 DOI: 10.9778/cmajo.20170163] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Tunnelled pleural catheters used to treat malignant pleural effusions may achieve pleurodesis. We aimed to identify factors associated with higher pleurodesis rates and earlier catheter removal. METHODS We retrospectively reviewed a prospective database of tunnelled pleural catheters inserted consecutively between May 2006 and June 2013 for confirmed malignant pleural effusion. The cohort included patients who underwent medical thoracoscopy. Clinical, radiologic and pleural fluid data were recorded. We used logistic regression and Cox regression to assess rates of and days to pleurodesis, respectively. RESULTS We analyzed data for 1071 tunnelled pleural catheters in 956 patients. Increased rates of pleurodesis were associated with lymphoma (odds ratio [OR] 3.49, 95% confidence interval [CI] 1.93-6.33), ovarian cancer (OR 2.93, 95% CI 1.68-5.11), Eastern Cooperative Oncology Group Scale of Performance Status grade 2 or less (OR 2.79, 95% CI 1.79-4.34), medical thoracoscopy (OR 2.21, 95% CI 1.28-3.85), protein level (OR 1.03, 95% CI 1.01-1.06), albumin level (OR 1.07, 95% CI 1.03-1.12) and percent eosinophils (OR 1.04, 95% CI 1.00-1.07). Reduced rates of pleurodesis were associated with gastrointestinal cancers (OR 0.41, 95% CI 0.19-0.87), hydropneumothorax on the postdrainage chest radiograph (OR 0.62, 95% CI 0.41-0.94) and percent other cells on cell count (OR 0.98, 95% CI 0.97-0.99). Earlier pleurodesis was associated with ovarian cancer (hazard ratio [HR] 1.48, 95% CI 1.06-2.08), medical thoracoscopy (HR 1.45, 95% CI 1.10-1.92), protein level (HR 1.03, 95% CI 1.01-1.04) and percent eosinophils (HR 1.02, 95% CI 1.00-1.04). Delayed pleurodesis was associated with breast cancer (HR 0.61, 95% CI 0.46-0.81), hydropneumothorax with 80% or less lung expansion (HR 0.55, 95% CI 0.38-0.80) and percent other cells (HR 0.99, 95% CI 0.98-1.00). INTERPRETATION Clinicians should consider numerous factors to predict the probability of and timing to pleurodesis with tunnelled pleural catheters.
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Affiliation(s)
- Pen Li
- Division of Respirology (Li), Department of Medicine, University of Alberta, Edmonton, Alta.; Division of Respirology (Li, Mulpuru, Amjadi), Department of Medicine, The Ottawa Hospital, General Campus; Division of Respirology (Graver, Hosseini), Department of Medicine, Queensway Carleton Hospital; The Ottawa Hospital (Cake, Kachuik); Ottawa Methods Centre (Zhang), The Ottawa Hospital Research Institute, Ottawa, Ont
| | - Alison Graver
- Division of Respirology (Li), Department of Medicine, University of Alberta, Edmonton, Alta.; Division of Respirology (Li, Mulpuru, Amjadi), Department of Medicine, The Ottawa Hospital, General Campus; Division of Respirology (Graver, Hosseini), Department of Medicine, Queensway Carleton Hospital; The Ottawa Hospital (Cake, Kachuik); Ottawa Methods Centre (Zhang), The Ottawa Hospital Research Institute, Ottawa, Ont
| | - Sarah Hosseini
- Division of Respirology (Li), Department of Medicine, University of Alberta, Edmonton, Alta.; Division of Respirology (Li, Mulpuru, Amjadi), Department of Medicine, The Ottawa Hospital, General Campus; Division of Respirology (Graver, Hosseini), Department of Medicine, Queensway Carleton Hospital; The Ottawa Hospital (Cake, Kachuik); Ottawa Methods Centre (Zhang), The Ottawa Hospital Research Institute, Ottawa, Ont
| | - Sunita Mulpuru
- Division of Respirology (Li), Department of Medicine, University of Alberta, Edmonton, Alta.; Division of Respirology (Li, Mulpuru, Amjadi), Department of Medicine, The Ottawa Hospital, General Campus; Division of Respirology (Graver, Hosseini), Department of Medicine, Queensway Carleton Hospital; The Ottawa Hospital (Cake, Kachuik); Ottawa Methods Centre (Zhang), The Ottawa Hospital Research Institute, Ottawa, Ont
| | - Lorraine Cake
- Division of Respirology (Li), Department of Medicine, University of Alberta, Edmonton, Alta.; Division of Respirology (Li, Mulpuru, Amjadi), Department of Medicine, The Ottawa Hospital, General Campus; Division of Respirology (Graver, Hosseini), Department of Medicine, Queensway Carleton Hospital; The Ottawa Hospital (Cake, Kachuik); Ottawa Methods Centre (Zhang), The Ottawa Hospital Research Institute, Ottawa, Ont
| | - Lynn Kachuik
- Division of Respirology (Li), Department of Medicine, University of Alberta, Edmonton, Alta.; Division of Respirology (Li, Mulpuru, Amjadi), Department of Medicine, The Ottawa Hospital, General Campus; Division of Respirology (Graver, Hosseini), Department of Medicine, Queensway Carleton Hospital; The Ottawa Hospital (Cake, Kachuik); Ottawa Methods Centre (Zhang), The Ottawa Hospital Research Institute, Ottawa, Ont
| | - Tinghua Zhang
- Division of Respirology (Li), Department of Medicine, University of Alberta, Edmonton, Alta.; Division of Respirology (Li, Mulpuru, Amjadi), Department of Medicine, The Ottawa Hospital, General Campus; Division of Respirology (Graver, Hosseini), Department of Medicine, Queensway Carleton Hospital; The Ottawa Hospital (Cake, Kachuik); Ottawa Methods Centre (Zhang), The Ottawa Hospital Research Institute, Ottawa, Ont
| | - Kayvan Amjadi
- Division of Respirology (Li), Department of Medicine, University of Alberta, Edmonton, Alta.; Division of Respirology (Li, Mulpuru, Amjadi), Department of Medicine, The Ottawa Hospital, General Campus; Division of Respirology (Graver, Hosseini), Department of Medicine, Queensway Carleton Hospital; The Ottawa Hospital (Cake, Kachuik); Ottawa Methods Centre (Zhang), The Ottawa Hospital Research Institute, Ottawa, Ont.
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42
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Mercer RM, Hassan M, Rahman NM. The role of pleurodesis in respiratory diseases. Expert Rev Respir Med 2018; 12:323-334. [DOI: 10.1080/17476348.2018.1445971] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Rachel M. Mercer
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Maged Hassan
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
- Chest Diseases Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Najib M. Rahman
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
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43
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Affiliation(s)
- David Feller-Kopman
- From the Division of Pulmonary, Critical Care, and Sleep Medicine, Johns Hopkins University, Baltimore (D.F.-K.); and the Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University, Nashville (R.L.)
| | - Richard Light
- From the Division of Pulmonary, Critical Care, and Sleep Medicine, Johns Hopkins University, Baltimore (D.F.-K.); and the Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University, Nashville (R.L.)
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44
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Fortin M, Taghizadeh N, Tremblay A. Procedures Performed during Hospitalizations for Malignant Pleural Effusions: Data from the 2012 National Inpatient Sample. Respiration 2018; 95:228-234. [DOI: 10.1159/000485934] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 11/30/2017] [Indexed: 11/19/2022] Open
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Abstract
Pleural metastasis is a common occurrence in up to 30% of patients with metastatic cancer. When lung entrapment and loculation of fluid occur, treatment is more difficult and we have named this condition "oncothorax." The malignant adhesions that entrap the lung in an oncothorax are not typically amenable to surgical decortication. The standard approach for managing these patients is to place an indwelling catheter. Other options may include pleurectomy and decortication, intrapleural hyperthermic chemoperfusion, and intrapleural photodynamic therapy. However, these procedures should be provided selectively depending on patient performance status, extent of metastatic disease, and level of experience.
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Affiliation(s)
- Roman Petrov
- Division of Thoracic Surgery, Department of Thoracic Medicine and Surgery, Temple University Hospital, Fox Chase Cancer Center, Lewis Katz School of Medicine, 3401 North Broad Street, Philadelphia, PA 19140, USA
| | - Charles Bakhos
- Division of Thoracic Surgery, Department of Thoracic Medicine and Surgery, Temple University Hospital, Fox Chase Cancer Center, Lewis Katz School of Medicine, 3401 North Broad Street, Philadelphia, PA 19140, USA
| | - Abbas E Abbas
- Division of Thoracic Surgery, Department of Thoracic Medicine and Surgery, Temple University Hospital, Fox Chase Cancer Center, Lewis Katz School of Medicine, 3401 North Broad Street, Philadelphia, PA 19140, USA.
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46
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Komissarov AA, Rahman N, Lee YCG, Florova G, Shetty S, Idell R, Ikebe M, Das K, Tucker TA, Idell S. Fibrin turnover and pleural organization: bench to bedside. Am J Physiol Lung Cell Mol Physiol 2018; 314:L757-L768. [PMID: 29345198 DOI: 10.1152/ajplung.00501.2017] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Recent studies have shed new light on the role of the fibrinolytic system in the pathogenesis of pleural organization, including the mechanisms by which the system regulates mesenchymal transition of mesothelial cells and how that process affects outcomes of pleural injury. The key contribution of plasminogen activator inhibitor-1 to the outcomes of pleural injury is now better understood as is its role in the regulation of intrapleural fibrinolytic therapy. In addition, the mechanisms by which fibrinolysins are processed after intrapleural administration have now been elucidated, informing new candidate diagnostics and therapeutics for pleural loculation and failed drainage. The emergence of new potential interventional targets offers the potential for the development of new and more effective therapeutic candidates.
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Affiliation(s)
- Andrey A Komissarov
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler , Tyler, Texas
| | - Najib Rahman
- Oxford Pleural Unit and Oxford Respiratory Trials Unit, University of Oxford, Churchill Hospital; and National Institute of Health Research Biomedical Research Centre , Oxford , United Kingdom
| | - Y C Gary Lee
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital; Pleural Medicine Unit, Institute for Respiratory Health , Perth ; School of Medicine and Pharmacology, University of Western Australia , Perth , Australia
| | - Galina Florova
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler , Tyler, Texas
| | - Sreerama Shetty
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler , Tyler, Texas
| | - Richard Idell
- Department of Behavioral Health, Child and Adolescent Psychiatry, The University of Texas Health Science Center at Tyler , Tyler, Texas
| | - Mitsuo Ikebe
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler , Tyler, Texas
| | - Kumuda Das
- Department of Translational and Vascular Biology, The University of Texas Health Science Center at Tyler , Tyler, Texas
| | - Torry A Tucker
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler , Tyler, Texas
| | - Steven Idell
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler , Tyler, Texas
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47
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Ha T, Madoff DC, Li D. Symptomatic Fluid Drainage: Tunneled Peritoneal and Pleural Catheters. Semin Intervent Radiol 2017; 34:337-342. [PMID: 29249857 DOI: 10.1055/s-0037-1608704] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Malignant ascites and pleural effusion are significant contributors to patient symptoms such as shortness of breath, abdominal distension, and nausea in the setting of cancer. There are numerous methods employed to control such symptoms such as serial drainages, pleurodesis, and tunneled drainage catheters. Tunneled drainage catheters are a safe, effective, and a minimally invasive procedure to palliate the symptoms of malignant ascites and pleural effusion.
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Affiliation(s)
- Tony Ha
- Division of Interventional Radiology, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
| | - David C Madoff
- Department of Radiology, Division of Interventional Radiology, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
| | - David Li
- Department of Radiology, Division of Interventional Radiology, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
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48
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Abstract
Malignant pleural effusion is a common complication of cancer and denotes a poor prognosis. It usually presents with dyspnea and a unilateral large pleural effusion. Thoracic computed tomography scans and ultrasound are helpful in distinguishing malignant from benign effusions. Pleural fluid cytology is diagnostic in about 60% of cases. In cytology-negative disease, pleural biopsies are helpful. Current management is palliative. Previously, first-line treatment for recurrent symptomatic malignant pleural effusion was chest drain insertion and talc pleurodesis, with indwelling pleural catheter insertion reserved for patients with trapped lung or failed talc pleurodesis. However, catheter insertion is an increasingly acceptable first-line treatment.
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Affiliation(s)
- Rachelle Asciak
- Respiratory Medicine, Oxford University Hospitals, Churchill Hospital, Old Road, Headington, Oxford OX3 7LE, Great Britain
| | - Najib M Rahman
- Respiratory Medicine, Oxford University Hospitals, Churchill Hospital, Old Road, Headington, Oxford OX3 7LE, Great Britain.
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49
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Tunneled pleural catheter use for pleural palliation does not increase infection rate in patients with treatment-related immunosuppression. Support Care Cancer 2017; 26:1525-1531. [PMID: 29188375 DOI: 10.1007/s00520-017-3989-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 11/20/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE Concerns for infections resulting from antineoplastic therapy-associated immunosuppression may deter referral for symptom palliation with a tunneled pleural catheter (TPC) in patients with malignant/para-malignant pleural effusions (MPE/PMPE). While rates of TPC-related infections range from 1 to 21%, those in patients receiving antineoplastic therapy with correlation to immune status has not been established. We aimed to assess TPC-related infection rates in patients on antineoplastic therapy, determine relation to immune system competency, and assess impact on the patient. METHODS Patients with a MPE/PMPE undergoing TPC management associated with antineoplastic therapy, from 2008 to 2016, were reviewed and categorized into those with an immunocompromised versus immunocompetent immune status. RESULTS Of the 150 patients, a TPC-related infection developed in 13 (9%): pleural space in 11 (7%) and superficial in 2 (1%). Ninety-three percent (139/150) were identified to be immunocompromised during their antineoplastic therapy. No difference in TPC-related infections was seen in patients with an immunocompromised (9%, 12/139) versus immunocompetent status (9%, 1/11); p = 0.614. The presence of a catheter-related infection did not negatively impact overall survival over a median follow-up of 144 days (interquartile range 41-341); p = 0.740. CONCLUSIONS These results suggest that antineoplastic therapy may not significantly increase the overall risk of TPC-related infections, as the rate remains low and comparable to rates in patients not undergoing antineoplastic therapy. Regardless of immune status, the presence of a catheter-related infection did not negatively impact overall survival. These results should reassure clinicians that the need to initiate antineoplastic therapy should not delay definitive pleural palliation with a TPC.
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50
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Fitzgerald DB, Koegelenberg CFN, Yasufuku K, Lee YCG. Surgical and non-surgical management of malignant pleural effusions. Expert Rev Respir Med 2017; 12:15-26. [PMID: 29111830 DOI: 10.1080/17476348.2018.1398085] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Optimal management of malignant pleural effusion (MPE) is important in the care of patients with advanced cancer. Surgical (especially video-assisted thoracoscopic surgery (VATS)) and non-surgical strategies are available. Clinicians should be aware of the evidence supporting the use of different modalities to guide treatment choice. Areas covered: This review covers published evidence of the advantages and disadvantages of VATS and non-surgical alternatives for MPE management. Expert commentary: Randomized clinical trials (RCTs) are needed to define the roles and benefits of VATS as existing literature is often flawed by selection bias. Three RCTs have failed to show benefits of VATS talc poudrage over bedside talc pleurodesis. VATS-pleurectomy offered no survival advantage in a RCT of mesothelioma patients. Modification of VATS techniques has reduced the invasiveness and associated risks. Future trials should compare VATS with contemporary, non-surgical approaches (especially combined Indwelling Pleural Catheter (IPC) and chemical pleurodesis therapy). Individualized management for different subgroups of MPE patients should be a long-term research goal. Studies are needed on better patient selection, and adjunct non-invasive, supportive (e.g. nutrition and exercise) therapies.
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Affiliation(s)
- Deirdre B Fitzgerald
- a School of Medicine & Pharmacology , University of Western Australia , Crawley , WA , Australia.,b Pleural Medical Unit , Institute for Respiratory Health , Nedlands , WA , Australia.,c Department of Respiratory Medicine , Sir Charles Gairdner Hospital , Nedlands , WA , Australia
| | - Coenraad F N Koegelenberg
- d Division of Pulmonology, Department of Medicine , Stellenbosch University and Tygerberg Academic Hospital , Cape Town , South Africa
| | - Kazuhiro Yasufuku
- e Division of Thoracic Surgery , Toronto General Hospital University Health Network, University of Toronto , Toronto , ON , Canada
| | - Y C Gary Lee
- a School of Medicine & Pharmacology , University of Western Australia , Crawley , WA , Australia.,b Pleural Medical Unit , Institute for Respiratory Health , Nedlands , WA , Australia.,c Department of Respiratory Medicine , Sir Charles Gairdner Hospital , Nedlands , WA , Australia
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