1
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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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2
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Abstract
Malignant pleural mesothelioma (MPM) is a rare malignancy with some unique characteristics. Tumor biology is aggressive and prognosis is poor. Despite more knowledge on histology, tumor biology and staging, there is still a relevant discrepancy between clinical and pathologic staging resulting in difficult prediction of prognosis and treatment outcome, making treatment allocation more challenging than in most other malignancies. After years of nihilism in the late 80s, a period of activism started evaluating different treatment protocols combined with research driven mainly by academic centers; at the time, selection was based on histology and stage only. This period was important to gain knowledge about the disease. However, the interpretation of data was difficult since selection criteria and definitions varied substantially. Not surprisingly, until now there is no common agreement on best treatment even among specialists. Hence, a review of our current concepts is indicated and personalized treatment should become applicable in the future. Surgery was and still is an issue of debate. In principle, surgery is an effective approach as it allows macroscopic complete elimination of a tumor, which is relatively resistant to medical treatment. It helps to set the clock back and other therapies that have also just a limited effect can be applied sequentially before or after surgery. Furthermore, to date best long-term outcome is reported from surgical series in combination with other modalities. However, part of the community considers surgery associated with too high morbidity and mortality when balanced to the limited life expectancy. This criticism is understandable, since poor results after surgery are reported. The present article will review the indication for surgery and discuss the different procedures available for macroscopic complete resection-such as lung-preserving (extended) pleurectomy/decortication as well as extrapleural pneumonectomy to illustrate that 'The surgeon is still there!'
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Affiliation(s)
- I Opitz
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland.
| | - W Weder
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
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3
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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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4
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Bueno R, Opitz I. Surgery in Malignant Pleural Mesothelioma. J Thorac Oncol 2018; 13:1638-1654. [DOI: 10.1016/j.jtho.2018.08.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 07/31/2018] [Accepted: 08/01/2018] [Indexed: 01/05/2023]
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5
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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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6
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Perikleous P, Asadi N, Anikin V. Video-assisted thoracoscopic PlasmaJet ablation for malignant pleural mesothelioma. J Vis Surg 2018; 4:56. [PMID: 29682466 DOI: 10.21037/jovs.2018.02.07] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 02/06/2018] [Indexed: 11/06/2022]
Abstract
The role of surgery in malignant pleural mesothelioma (MPM) remains debatable; nonetheless the relative advantages of different surgical approaches are frequently reassessed and reconsidered. While extensive operations and longer recovery periods can be justified for a group of carefully selected patients, many will present at an advanced stage of their disease or with associated co-morbidities which will exclude them from selection criteria for radical treatment. For these patients, minimally invasive video-assisted procedures may be considered, for purposes of cytoreduction and/or symptomatic relief. Even though there is currently not enough clinical evidence to suggest an improvement in overall survival with limited debulking procedures, it has been suggested that they can improve quality of life over drainage and pleurodesis alone. We consider video-assisted PlasmaJet ablation to potentially have a role in mesothelioma surgery, as it may be used for effective cytoreduction while minimising the risk for complications often associated with extensive pleurectomy procedures, and we report on the use of the PlasmaJet Surgical System in our centre for surgical management of a patient with MPM. After demonstrating safety and absence of major adverse events with this approach, we feel justified in offering the procedure to more of our patients as we aim to collect additional data.
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Affiliation(s)
| | - Nizar Asadi
- Department of Thoracic Surgery, Harefield Hospital, Harefield, UK
| | - Vladimir Anikin
- Department of Thoracic Surgery, Harefield Hospital, Harefield, UK
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7
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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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8
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Perikleous P, Waller DA. Video assisted thoracoscopic and open chest surgery in diagnosis and treatment of malignant pleural diseases. J Vis Surg 2017; 3:85. [PMID: 29078648 DOI: 10.21037/jovs.2017.05.05] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 04/24/2017] [Indexed: 12/14/2022]
Abstract
Parenchymal cancers of lung, breast, gastrointestinal tract and ovaries as well as lymphomas and mesotheliomas are among the most common cancer types causing malignant effusions, though almost all tumour types have been reported to cause a malignant effusion. The prognosis heavily depends on patients' response to systemic therapy however, regardless of the causing pathology and histopathologic form, malignant pleural disease is normally associated with a poor prognosis. To date, there are not sufficient data to allow accurate predictions of survival that would facilitate decision making for managing patients with malignant pleural diseases. Interventions are directed towards drainage of the effusion and, when appropriate, concurrent or subsequent pleurodesis or establishing long-term drainage to prevent re-accumulation. The rate of re-accumulation of the pleural effusion, the patient's prognosis, and the severity of the patient's symptoms should guide the subsequent choice of therapy. In contemporary medicine, not many cancers have managed to generate as intense debates concerning treatment, as malignant pleural mesothelioma. The relative advantages of surgery, radiation, chemotherapy and any combination of the three are continuously reassessed and reconsidered, even though not always based on scientific evidence. The aim of surgery in mesothelioma may be prolongation of life, in addition to palliation of symptoms. Longer recovery periods from more extensive surgical procedures could be justified, in carefully selected patients. Surgical options include: Video assisted thoracoscopic (VATS) pleurodesis, VATS partial pleurectomy (VATS PP)-both parietal and visceral; open pleurectomy decortication (PD)-with an extended option (EPD) and extrapleural pneumonectomy (EPP). Current evidence implies that EPD can be performed reliably in specialised centres with good results, both in terms of mortality and survival; however, no operation has yet been shown to be beneficial in a prospective randomized controlled clinical trial.
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Affiliation(s)
- Periklis Perikleous
- Department of thoracic surgery, Glenfield Hospital, University Hospitals of Leicester, Leicester, UK
| | - David A Waller
- Department of thoracic surgery, Glenfield Hospital, University Hospitals of Leicester, Leicester, UK
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9
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Waller DA, Dawson AG. Randomized controlled trials in malignant pleural mesothelioma surgery-mistakes made and lessons learned. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:240. [PMID: 28706908 DOI: 10.21037/atm.2017.04.05] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Randomized surgical trials are of the most difficult to design and recruit, however, they are the only robust method available to establish a new surgical procedure. Mesothelioma is a disease with a perceived poor prognosis for which surgical intervention has relatively high complications and not insignificant mortality. This review will consider the mesothelioma and radical surgery (MARS) 1 and 2 trials, SAKK 17/04 trial and the EORTC 1205 trial all aimed at assessing the potential benefit of radical surgery for malignant pleural mesothelioma. In addition, MesoVATS and MesoTRAP will be explored assessing the value of debulking surgery for malignant pleural mesothelioma. We also endeavour to identify the mistakes made and the lessons learned which will inform future randomized controlled clinical trials in the field of malignant pleural mesothelioma. Despite the insurmountable problems with randomized controlled clinical trials, we show that they are possible and continuing with uncontrolled experiments will perpetuate unproven and potentially harmful operations.
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Affiliation(s)
- David A Waller
- Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK
| | - Alan G Dawson
- Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK.,CRUK Leicester Centre, Department of Cancer Studies, University of Leicester, Leicester, UK
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10
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Walker S, Bibby AC, Maskell NA. Current best practice in the evaluation and management of malignant pleural effusions. Ther Adv Respir Dis 2016; 11:105-114. [PMID: 27777372 DOI: 10.1177/1753465816671697] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Malignant pleural effusions (MPEs) are an important cause of cancer-related mortality and morbidity. It is a heterogeneous group of conditions, which leads to debilitating symptoms and confers a poor prognosis. Recent well-designed randomized trials have provided a broader evidence base for an expanding range of treatment options. Together, with new prognostic scoring systems and a greater understanding of how different patient phenotypes respond to treatment, this allows greater personalization of management. This article will discuss the current evidence on evaluation and management of MPEs.
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Affiliation(s)
- Steven Walker
- Academic Respiratory Unit, University of Bristol, Bristol, UK
| | - Anna C Bibby
- Academic Respiratory Unit, University of Bristol, Bristol, UK
| | - Nick A Maskell
- Academic Respiratory Unit, University of Bristol, Southmead Road, Bristol BS10 5NB, UK
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11
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Novello S, Pinto C, Torri V, Porcu L, Di Maio M, Tiseo M, Ceresoli G, Magnani C, Silvestri S, Veltri A, Papotti M, Rossi G, Ricardi U, Trodella L, Rea F, Facciolo F, Granieri A, Zagonel V, Scagliotti G. The Third Italian Consensus Conference for Malignant Pleural Mesothelioma: State of the art and recommendations. Crit Rev Oncol Hematol 2016; 104:9-20. [PMID: 27286698 DOI: 10.1016/j.critrevonc.2016.05.004] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 03/17/2016] [Accepted: 05/10/2016] [Indexed: 11/26/2022] Open
Abstract
Malignant Pleural Mesothelioma (MPM) remains a relevant public health issue, and asbestos exposure is the most relevant risk factor. The incidence has considerably and constantly increased over the past two decades in the industrialized countries and is expected to peak in 2020-2025. In Italy, a standardized-rate incidence in 2011 among men was 3.5 and 1.25 per 100,000 in men and women, respectively, and wide differences are noted among different geographic areas. The disease remains challenging in terms of diagnosis, staging and treatment and an optimal strategy has not yet been clearly defined. The Third Italian Multidisciplinary Consensus Conference on Malignant Pleural Mesothelioma was held in Bari (Italy) in January 30-31, 2015. This Consensus has provided updated recommendations on the MPM management for health institutions, clinicians and patients.
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Affiliation(s)
- S Novello
- Department of Oncology, University of Turin, Italy.
| | - C Pinto
- Medical Oncology Unit, IRCCS-Arciospedale Santa Maria Nuova, Reggio Emilia, Italy
| | - V Torri
- Department of Oncology, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - L Porcu
- Department of Oncology, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - M Di Maio
- Department of Oncology, University of Turin, Italy
| | - M Tiseo
- Division of Medical Oncology, Azienda Ospedaliera Universitaria di Parma, Italy
| | - G Ceresoli
- Thoracic Oncology Unit, Humanitas Gavazzeni, Bergamo, Italy
| | - C Magnani
- Cancer Epidemiology, University of Eastern Piedmont and CPO-Piemonte, Novara, Italy
| | - S Silvestri
- Istituto per lo Studio e la Prevenzione Oncologica, Florence, Italy
| | - A Veltri
- Department of Oncology, University of Turin, Italy
| | - M Papotti
- Department of Oncology, University of Turin, Italy
| | - G Rossi
- Ospedale Policlinico, Division of Human Pathology, Modena, Italy
| | - U Ricardi
- Department of Oncology, University of Turin, Italy
| | - L Trodella
- Department of Radiotherapy, Campus Bio-Medico University, Rome, Italy
| | - F Rea
- Azienda Ospedaliera, Division of Thoracic Surgery, Padua, Italy
| | - F Facciolo
- Regina Elena Cancer Institute, Division of Thoracic Surgery, Rome, Italy
| | - A Granieri
- University of Torino, Department of Psychology, Italy
| | - V Zagonel
- Veneto Oncology Institute, IRCCS Padova, Italy
| | - G Scagliotti
- Department of Oncology, University of Turin, Italy
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12
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Bertoglio P, Waller DA. The role of thoracic surgery in the management of mesothelioma: an expert opinion on the limited evidence. Expert Rev Respir Med 2016; 10:663-72. [PMID: 27015594 DOI: 10.1586/17476348.2016.1171147] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Surgery has a key role at different points in the management of Malignant Pleural Mesothelioma. Diagnosis with video assisted thoracoscopy offers excellent sensitivity and specificity and a direct view of the pleural cavity to verify the extent of the tumor. Nodal involvement can be assessed by mediastinoscopy and either talc pleurodesis or partial pleurectomy can be used for symptom control in advanced stage disease. Extra Pleural Pneumonectomy (EPP) and Extended Pleurectomy Decortication (EPD) are used to prolong survival although the benefit of radical surgery has not has been fully clarified; EPP failed to show its benefit in the MARS trial and EPD is currently under investigation in the MARS2 trial. More randomized prospective trial data are needed to fully understand the role of radical surgery in the treatment of pleural mesothelioma.
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Affiliation(s)
- Pietro Bertoglio
- a Division of Thoracic Surgery , University Hospital of Pisa , Pisa, Italy.,b Division of Thoracic Surgery , Glenfield Hospital , Leicester , UK
| | - David A Waller
- b Division of Thoracic Surgery , Glenfield Hospital , Leicester , UK
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13
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Opitz I. Management of malignant pleural mesothelioma-The European experience. J Thorac Dis 2014; 6 Suppl 2:S238-52. [PMID: 24868442 DOI: 10.3978/j.issn.2072-1439.2014.05.03] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 05/08/2014] [Indexed: 12/29/2022]
Abstract
Management of malignant pleural mesothelioma (MPM) remains a clinical challenge and the incidence of the disease will continue to increase worldwide. Several aspects of mesothelioma treatment are discussed controversially, in particular, regarding extent and best type of surgery, radiotherapy, and the role of neoadjuvant or adjuvant treatment. However, best survival data is reported from groups using multimodality treatment including macroscopic complete resection (MCR) achieved by either extrapleural pneumonectomy (EPP) or (extended) pleurectomy/decortication for patients qualifying from the tumor biology, stage, and patient's performance status and comorbidities. Several aspects have to be considered during surgery but morbidity and mortality have been reduced at experienced centres. The final analysis of extended selection algorithms is pending.
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Affiliation(s)
- Isabelle Opitz
- Division of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
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14
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Thomas R, Francis R, Davies HE, Lee YCG. Interventional therapies for malignant pleural effusions: the present and the future. Respirology 2014; 19:809-22. [PMID: 24947955 DOI: 10.1111/resp.12328] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 05/01/2014] [Accepted: 05/01/2014] [Indexed: 11/29/2022]
Abstract
The approach to management of malignant pleural effusions (MPE) has changed over the past few decades. The key goals of MPE management are to relieve patient symptoms using the least invasive means and in the most cost-effective manner. There is now a realization that patient-reported outcome measures should be the primary goal of MPE treatment, and this now is the focus in most clinical trials. Efforts to minimize patient morbidity are complemented by development of less invasive treatments that have mostly replaced the more aggressive surgical approaches of the past. Therapeutic thoracentesis is simple, effective and generally safe, although its benefits may only be temporary. Pleurodesis is the conventional and for a long time the only definitive therapy available. However, the efficacy and safety of talc pleurodesis has been challenged. Indwelling pleural catheter (IPC) drainage is increasingly accepted worldwide and represents a new concept to improve symptoms without necessarily generating pleural symphysis. Recent studies support the effectiveness of IPC treatment and provide reassurance regarding its safety. An unprecedented number of clinical trials are now underway to improve various aspects of MPE care. However, choosing an optimal intervention for MPE in an individual patient remains a challenge due to our limited understanding of the underlying pathophysiology of breathlessness in MPE and a lack of predictors of survival and pleurodesis outcome. This review provides an overview of common pleural interventional procedures used for MPE management, controversies and limitations of current practice, and areas of research most needed to improve practice in future.
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Affiliation(s)
- Rajesh Thomas
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia; School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia, Australia; Pleural Disease Unit, Lung Institute of Western Australia, Perth, Western Australia, Australia
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15
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Meuris K, Hertoghs M, Lauwers P, Hendriks JM, Van Schil PE. Subtotal pleurectomy by video-assisted thoracic surgery for metastatic pleuritis. Multimed Man Cardiothorac Surg 2014; 2012:mms008. [PMID: 24414712 DOI: 10.1093/mmcts/mms008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Metastatic pleuritis can be a severely disabling condition. Recurrent pleural effusion often leads to severe shortness of breath. Treatment should consist of removal of the fluid as well as prevention of the re-accumulation of the pleural effusion. We describe the technique of subtotal pleurectomy by video-assisted thoracic surgery. We show several methods of stripping of the pleura as well as the application of talc. Subtotal parietal pleurectomy provides an effective treatment and control of recurrent effusion, but due to its invasive nature, it should be offered only to patients with a reasonable life expectancy.
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Affiliation(s)
- Kevin Meuris
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegen, Belgium
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16
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Lang-Lazdunski L. Surgery for malignant pleural mesothelioma: Why, when and what? Lung Cancer 2014; 84:103-9. [DOI: 10.1016/j.lungcan.2014.01.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Revised: 01/23/2014] [Accepted: 01/24/2014] [Indexed: 02/07/2023]
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17
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Ried M, Hofmann HS. The treatment of pleural carcinosis with malignant pleural effusion. DEUTSCHES ARZTEBLATT INTERNATIONAL 2013; 110:313-8. [PMID: 23720697 DOI: 10.3238/arztebl.2013.0313] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pleural carcinosis is caused by tumors of the chest (e.g., lung and breast cancer) or elsewhere in the body (e.g., ovarian carcinoma) that metastasize to the visceral and/or parietal pleura. Recurrent malignant pleural effusion due to pleural carcinosis is one of the most common findings in oncology. It affects about 56 000 patients per year in Germany alone. METHODS This review is based on pertinent literature retrieved by a selective search of the Medline database (key words: malignant pleural effusion, pleural carcinosis) and on the authors' clinical experience. RESULTS Although many retrospective studies have been published, there has been only one randomized controlled trial of treatment, in which permanent pleural catheters were compared with talcum pleurodesis. Patients with pleural carcinosis have a median survival of less than 12 months. Many are suffering from progression of their underlying disease, with generalized tumor involvement; thus, the symptomatic treatment of pain and dyspnea is often the main therapeutic issue. The underlying tumor, usually an adenocarcinoma, can be diagnosed either by histology or by cytology. The main complication is progressive respiratory failure. The treatment is palliative, rather than curative. The main approaches are drainage of the effusion (by thoracocentesis or with permanent pleural catheters) and pleurodesis (obliteration of the pleural space by causing the visceral and parietal pleura to adhere to each other). CONCLUSION Pleural carcinosis with symptomatic malignant pleural effusion is treated palliatively. The appropriate treatment in each case should be determined through discussion with the patient, with the goal of improving the patient's quality of life.
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Affiliation(s)
- Michael Ried
- Department of Thoracic Surgery, University Hospital Regensburg, Regensburg, Germany.
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18
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Shamji FM, Deslauriers J. Surgeon's view: is palliative resection of lung cancer ever justified? Thorac Surg Clin 2013; 23:383-99. [PMID: 23931021 DOI: 10.1016/j.thorsurg.2013.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Thoracic surgeons are often asked to see patients with locally advanced primary lung cancer in whom the goal of treatment is palliation for relief of disabling symptoms. The last four decades have brought great changes in the care of patients with primary lung cancer. The goals of the treatment must be well-defined by the interdisciplinary team. The thoracic surgeon has to make the final decision on whether to consider an operation for palliation and what is the expectation of the recommended treatment.
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Affiliation(s)
- Farid M Shamji
- Division of Thoracic Surgery, Ottawa Hospital - General Campus, University of Ottawa, 501 Smyth Road, Room 6362, Box 708, Ottawa, Ontario K1H 8L6, Canada.
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Prazakova S, Thomas PS, Sandrini A, Yates DH. Asbestos and the lung in the 21st century: an update. CLINICAL RESPIRATORY JOURNAL 2013; 8:1-10. [PMID: 23711077 DOI: 10.1111/crj.12028] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Revised: 04/17/2013] [Accepted: 05/20/2013] [Indexed: 01/16/2023]
Abstract
The asbestos-related disorders (ARDs) are currently of significant occupational and public health concern. Asbestos usage has been banned in most developed countries, but asbestos is still used in many developing countries and the number of cases of ARDs worldwide is rising. Many countries are now experiencing an epidemic of ARDs that is the legacy of occupational exposure in the 1960s-1980s because of the long latency period between asbestos exposure and manifestation of disease. It is likely that asbestos-related mortality and morbidity will continue to increase. Although the most feared complications of asbestos inhalation are the malignant conditions such as mesothelioma and lung cancer, asbestos inhalation more frequently results in benign conditions such as pleural plaques, diffuse pleural thickening, and asbestosis (pulmonary fibrosis due to asbestos exposure). Over recent years, there have been changes in the epidemiology of mesothelioma, in clinical management of ARDs and developments in new techniques for early detection of malignancy. This review provides an update on the respiratory manifestations of asbestos exposure and also considers advances in screening methods that may affect future management in the workplace.
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Affiliation(s)
- Silvie Prazakova
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia; Respiratory Medicine Department, Prince of Wales Hospital, Sydney, NSW, Australia
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Rathinam S, Waller DA. Pleurectomy decortication in the treatment of the "trapped lung" in benign and malignant pleural effusions. Thorac Surg Clin 2013. [PMID: 23206717 DOI: 10.1016/j.thorsurg.2012.10.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Trapped lung is defined by the inability of the lung to expand and fill the thoracic cavity because of a restricting "peel." This restriction may be secondary to a benign inflammatory or fibrotic cortex or to a malignant visceral pleural tumor. This condition has a significant impact on the patient's quality of life by causing dyspnea. This article discusses the role of surgery in relieving the trapped lung, including decortication in benign disease and pleurectomy in malignant disease. The surgical approaches of video-assisted thoracoscopy and thoracotomy are contrasted and the future potential for surgical trials in this condition is outlined.
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Affiliation(s)
- Sridhar Rathinam
- Department of Thoracic Surgery, Glenfield Hospital, University Hospitals of Leicester, Groby Road, Leicester, LE3 9QP, UK.
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21
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Haas AR, Sterman DH. Malignant pleural mesothelioma: update on treatment options with a focus on novel therapies. Clin Chest Med 2013; 34:99-111. [PMID: 23411061 DOI: 10.1016/j.ccm.2012.12.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
There is evidence that improved treatments of malignant pleural mesothelioma are increasing the quality and quantity of life for patients with mesothelioma. Multimodality treatment programs that combine maximal surgical cytoreduction with novel forms of radiation therapy and more effective chemotherapy combinations may offer significant increases in survival for certain subgroups of patients with mesothelioma. Lung-sparing surgery may allow improvements in pulmonary function after surgery-based multimodality therapy, and potential longer overall survival than that seen with extrapleural pneumonectomy. Experimental treatments provide hope for all patients with mesothelioma, and in the future may be combined with standard therapy in multimodality protocols.
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Affiliation(s)
- Andrew R Haas
- Section of Interventional Pulmonology and Thoracic Oncology, Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania Medical Center, 833 West Gates Building, 3400 Spruce Street, Philadelphia, PA 19104-4283, USA
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22
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Abstract
Although the treatment of malignant pleural mesothelioma has been refined during the past two decades, overall survival from this rather uncommon disease is still extremely poor. Here we review the current multimodal diagnostic and treatment options for patients with mesothelioma and discuss promising new experimental concepts in this disease.
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Affiliation(s)
- David D Shersher
- Thoracic Oncology Program, Rush University Medical Center, Chicago, IL 60612, USA
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23
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Surmont VF, van Thiel ERE, Vermaelen K, van Meerbeeck JP. Investigational approaches for mesothelioma. Front Oncol 2011; 1:22. [PMID: 22666659 PMCID: PMC3364459 DOI: 10.3389/fonc.2011.00022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2011] [Accepted: 07/14/2011] [Indexed: 12/27/2022] Open
Abstract
Malignant pleural mesothelioma (MPM) is a rare, aggressive tumor with a poor prognosis. In view of the poor survival benefit from first-line chemotherapy and the lack of subsequent effective treatment options, there is a strong need for the development of more effective treatment approaches for patients with MPM. This review will provide a comprehensive state of the art of new investigational approaches for mesothelioma. In an introductory section, the etiology, epidemiology, natural history, and standard of care treatment for MPM will be discussed. This review provide an update of the major clinical trials that impact mesothelioma treatment, discuss the impact of novel therapeutics, and provide perspective on where the clinical research in mesothelioma is moving. The evidence was collected by a systematic analysis of the literature (2000-2011) using the databases Medline (National Library of Medicine, USA), Embase (Elsevier, Netherlands), Cochrane Library (Great Britain), National Guideline Clearinghouse (USA), HTA Database (International Network of Agencies for Health Technology Assessment - INAHTA), NIH database (USA), International Pleural Mesothelioma Program - WHOLIS (WHO Database), with the following keywords and filters: mesothelioma, guidelines, treatment, surgery, chemotherapy, radiotherapy, review, investigational, drugs. Currently different targeted therapies and biologicals are under investigation for MPM. It is important that the molecular biologic research should first focus on mesothelioma-specific pathways and biomarkers in order to have more effective treatment options for this disease. The use of array technology will be certainly an implicit gain in the identification of new potential prognostic or biomarkers or important pathways in the MPM pathogenesis. Probably a central mesothelioma virtual tissue bank may contribute to the ultimate goal to identify druggable targets and to develop personalized treatment for the MPM patients.
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Affiliation(s)
- Veerle F Surmont
- Department of Respiratory Medicine, Ghent University Hospital Ghent, Belgium
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24
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Malignant pleural mesothelioma: The standard of care and challenges for future management. Crit Rev Oncol Hematol 2011; 78:92-111. [DOI: 10.1016/j.critrevonc.2010.04.004] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2009] [Revised: 03/24/2010] [Accepted: 04/09/2010] [Indexed: 11/20/2022] Open
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25
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Scherpereel A, Astoul P, Baas P, Berghmans T, Clayson H, de Vuyst P, Dienemann H, Galateau-Salle F, Hennequin C, Hillerdal G, Le Pe'choux C, Mutti L, Pairon JC, Stahel R, van Houtte P, van Meerbeeck J, Waller D, Weder W. [Guidelines of the European Respiratory Society and the European Society of Thoracic Surgeons for the management of malignant pleural mesothelioma]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2011; 13:C23-45. [PMID: 20976998 PMCID: PMC6134413 DOI: 10.3779/j.issn.1009-3419.2010.10.14] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
恶性胸膜间皮瘤(malignant pleural mesothelioma, MPM)是一种罕见肿瘤,但发病率正逐渐上升,且预后较差。2008年,欧洲呼吸学会(European Respiratory Society, ERS)和欧洲胸外科医师学会(European Society of Thoracic Surgeons, ESTS)特别工作组召集各方专家计划制定MPM诊治经验及更新指南。 为了使MPM得到及时准确的诊断,专家推荐对患者实施胸腔镜检查,有手术禁忌和胸腔粘连的病例除外。约10%的病例采用标准染色方法无法获得满意的结果。因此我们推荐在胸膜活检的基础上,采用特异性免疫组化标志物。由于目前缺乏一个统一的、切实有效的分期系统,我们推荐应用最新的TNM分期,并且提出三个阶段的治疗前评估。在MPM的治疗中,患者的体力状态评分和组织亚型是目前唯一的、具有重要临床价值的预后因素。在临床试验中,应对其它潜在因素进行初步探讨并予以报道。MPM对化疗高度耐受,仅有少数患者可接受根治性手术。本文对新的治疗方法和策略进行了综述。 目前由于最佳综合治疗的资料有限,适合采用多种方案联合治疗策略的患者应被纳入专业机构的前瞻性试验中。
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Affiliation(s)
- A Scherpereel
- Dept of Pulmonary and Thoracic Oncology,Hospital Calmette CHRU of Lille 59037 Lille Cedex, France.
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Abstract
The treatment of malignant pleural mesothelioma is controversial, particularly regarding the role of surgery. Though well accepted as a diagnostic modality, surgery is also frequently used to establish stage, provide palliation, and perhaps most controversially, to offer cytoreduction with the putative goal of delaying tumor progression and prolonging survival. Pleurectomy/decortication (PD) can achieve macroscopic complete resection; however, the ability to deliver effective postoperative radiation treatment is limited because of the risk of lung toxicity. Accordingly, it has been associated with higher rates of local recurrence compared to extrapleural pneumonectomy (EPP). Extrapleural pneumonectomy generally offers a more complete cytoreduction compared to PD but at the cost of increased morbidity and mortality. Adjuvant hemithoracic radiation is feasible following EPP and in most series local recurrence rates are lower after EPP than PD. There are no convincing data, however, to show that one procedure is superior to the other in terms of survival. Furthermore, no randomized data currently exist that demonstrate a survival benefit to any form of surgical cytoreduction over systemic treatment and supportive care. If cytoreductive surgery does have a beneficial effect on long-term survival, it will most likely be realized in patients with epithelioid tumors without nodal metastases.
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Affiliation(s)
- David Rice
- Department of Thoracic and Cardiovascular Surgery, The University of Texas, M.D. Anderson Cancer Center, Houston, TX 77030, USA.
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27
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Abstract
Minimally invasive thoracic surgery (MITS) has become part of the modern thoracic surgeon's armamentarium. Its applications include diagnostic and therapeutic procedures, and over the past one and a half decades, the scope of MITS has undergone rapid evolution. The role of MITS is well established in the management of pleural and mediastinal conditions, and it is beginning to move beyond diagnostic procedures for lung parenchyma conditions, to gain acceptance as a viable option for primary lung cancer treatment. However MITS poses technical challenges that are quite different from the conventional open surgical procedures. After a brief review of the history of MITS, an overview of the scope of MITS is given. Important examples of diagnostic and therapeutic indications are then discussed, with special emphasis on the potential complications specific to MITS, and their prevention and management.
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Affiliation(s)
- Michael K Y Hsin
- Department of Surgery, The Chinese University of Hong Kong, Hong Kong
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28
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Srivastava V, Dunning J, Au J. Does video-assisted thoracoscopic decortication in advanced malignant mesothelioma improve prognosis? Interact Cardiovasc Thorac Surg 2009; 8:454-6. [PMID: 19136533 DOI: 10.1510/icvts.2008.197160] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: Does video-assisted thoracoscopic (VATS) decortication in advanced malignant mesothelioma improve prognosis? Altogether more than 25 papers were found using the reported search, of which five represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that VATS decortication is useful as a palliative measure in advanced malignant mesothelioma. VATS provides a diagnostic tool, yielding tissue for histological diagnosis. Secondly, drainage of effusion and pleurectomy/decortication improves the quality of life and may increase survival as well.
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Affiliation(s)
- Vivek Srivastava
- Department of Cardiothoracic Surgery, Victoria Hospital, Blackpool, UK
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29
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Greillier L, Dutau H, Astoul P. [Specific emergencies in thoracic oncology: pleurisy, superior vena cava syndrome, and tracheobronchial obstruction]. REVUE DE PNEUMOLOGIE CLINIQUE 2008; 64:69-75. [PMID: 18589286 DOI: 10.1016/j.pneumo.2008.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
In patients with lung cancer, the appearance of pleurisy, superior vena cava syndrome, or tracheobronchial obstruction are complications that require specialized care, often in an emergency context. Our objective is to present the different therapeutic options available in each of these three complications and to suggest recommendations on the care to provide in everyday clinical practice.
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Affiliation(s)
- L Greillier
- Pôle Cardiovasculaire et Thoracique, Université de la Méditerranée, Hôpital Sainte-Marguerite, 270 Boulevard Sainte-Marguerite, 13009 Marseille, France
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Surgical and other invasive approaches to recurrent pleural effusion with malignant etiology. Support Care Cancer 2008; 16:1323-31. [PMID: 18259780 DOI: 10.1007/s00520-008-0405-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2007] [Accepted: 01/09/2008] [Indexed: 10/22/2022]
Abstract
With an increasing number of cancer survivors, the annual incidence of malignant pleural effusions has been rising in recent decades worldwide. Many patients with various forms of cancer develop malignant pleural effusions at some point in their life. Patients most commonly present with progressive dyspnea. These effusions are refractory and are associated with impaired quality of life for these patients. The main goals of management are evacuation of the pleural fluid and prevention of its re-accumulation. The therapy plan should consider the general health of the patients, their performance status, the presence of trapped lung, and the primary malignancy. However, there is no universally established, standard approach. Surgical options include thoracentesis, chest tube drainage, thoracoscopy followed by chemical and mechanical pleurodesis, Pleur-X catheter drainage, and pleurectomy. Chemical pleurodesis is the most common modality of therapy for patients with recurrent pleural effusion. For example, Talc is the most successful pleurodesis agent with similar equal to that of poudrage or slurry. Pleur-X catheter can reduce hospital stay and adds value to the treatment of patients with trapped lung, who are not appropriate candidates for pleurodesis. Furthermore, a mechanical pleurodesis has been shown to be effective particularly in pleural effusions with lower pH. This article reviews the surgical and other invasive options as well as their technical aspects in the management of recurrent malignant pleural effusions.
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BTS statement on malignant mesothelioma in the UK, 2007. Thorax 2007; 62 Suppl 2:ii1-ii19. [PMID: 17965072 PMCID: PMC2094726 DOI: 10.1136/thx.2007.087619] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2007] [Accepted: 08/13/2007] [Indexed: 12/29/2022]
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Kvale PA, Selecky PA, Prakash UBS. Palliative care in lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition). Chest 2007; 132:368S-403S. [PMID: 17873181 DOI: 10.1378/chest.07-1391] [Citation(s) in RCA: 133] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
UNLABELLED GOALS/OBJECTIVES: To review the scientific evidence on symptoms and specific complications that are associated with lung cancer, and the methods available to palliate those symptoms and complications. METHODS MEDLINE literature review (through March 2006) for all studies published in the English language, including case series and case reports, since 1966 using the following medical subject heading terms: bone metastases; brain metastases; cough; dyspnea; electrocautery; hemoptysis; interventional bronchoscopy; laser; pain management; pleural effusions; spinal cord metastases; superior vena cava syndrome; and tracheoesophageal fistula. RESULTS Pulmonary symptoms that may require palliation in patients who have lung cancer include those caused by the primary cancer itself (dyspnea, wheezing, cough, hemoptysis, chest pain), or locoregional metastases within the thorax (superior vena cava syndrome, tracheoesophageal fistula, pleural effusions, ribs, and pleura). Respiratory symptoms can also result from complications of lung cancer treatment or from comorbid conditions. Constitutional symptoms are common and require attention and care. Symptoms referable to distant extrathoracic metastases to bone, brain, spinal cord, and liver pose additional problems that require a specific response for optimal symptom control. There are excellent scientific data regarding the management of many of these issues, with lesser evidence from case series or expert opinion on other aspects of providing palliative care for lung cancer patients. CONCLUSIONS Palliation of symptoms and complications in lung cancer patients is possible, and physicians who provide such care must be knowledgeable about these issues.
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Affiliation(s)
- Paul A Kvale
- Division of Pulmonary, Critical Care, Allergy, Immunology, and Sleep Disorders Medicine, Henry Ford Health System, 2799 W Grand Blvd, Detroit, MI 48202, USA.
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Steger V, Mika U, Toomes H, Walker T, Engel C, Kyriss T, Ziemer G, Friedel G. Who Gains Most? A 10-Year Experience With 611 Thoracoscopic Talc Pleurodeses. Ann Thorac Surg 2007; 83:1940-5. [PMID: 17532375 DOI: 10.1016/j.athoracsur.2007.02.061] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2006] [Revised: 02/17/2007] [Accepted: 02/21/2007] [Indexed: 11/20/2022]
Abstract
BACKGROUND Thoracoscopic talc pleurodesis is a therapeutic option for recurrent pleural effusion. METHODS This retrospective study included 611 patients who underwent thoracoscopic talc pleurodesis between 1994 and 2003. We analyzed the risk factors, efficiency, outcome, follow-up, and survival, while taking into consideration primary disease and general condition. RESULTS The mean follow-up was 319 days (range, 31 to 1994). A total of 105 (17.2%) of 611 patients died within 30 days after treatment. Risk factors for death within 30 days included a Karnofsky index of less than 50%, a body mass index of less than 25 kg/m2, malignant disease, and male gender. Treatment was successful in 347 (68.6%) of 506 patients, and 451 (89.1%) reported an improvement in symptoms. Previous thoracic irradiation and a chest tube drainage time exceeding 10 days negatively influenced the outcome of pleurodesis. The survival rate was negatively influenced by a preoperative Karnofsky index of less than 60% and by malignant disease. CONCLUSIONS Patients with pleural effusion due to malignant disease gain from early pleurodesis. The most favorable outcome after talc pleurodesis was seen in women whose lungs were fully expandable, in patients whose Karnofsky index exceeded 60%, in patients whose body mass index was greater than 25 kg/m2, and in patients with benign disease.
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Affiliation(s)
- Volker Steger
- Department of Thoracic Surgery, Schillerhoehe Hospital, Gerlingen, Germany.
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35
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Abstract
Pleural disease remains a commonly encountered clinical problem for both general physicians and chest specialists. This review focuses on the investigation of undiagnosed pleural effusions and the management of malignant and parapneumonic effusions. New developments in this area are also discussed at the end of the review. It aims to be evidence based together with some practical suggestions for practising clinicians.
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Affiliation(s)
- A R Medford
- Southmead Hospital, Acute Lung Unit, Southmead Hospital, Bristol, UK
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36
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Sterman DH, Albelda SM. Advances in the diagnosis, evaluation, and management of malignant pleural mesothelioma. Respirology 2005; 10:266-83. [PMID: 15955137 DOI: 10.1111/j.1440-1843.2005.00714.x] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Malignant mesothelioma is an insidious neoplasm arising from the mesothelial surfaces of the pleural and peritoneal cavities, the pericardium, or the tunica vaginalis. A total of 80% of all cases are pleural in origin. The predominant cause of malignant mesothelioma is inhalational exposure to asbestos, although evidence is increasing to support the hypothesis that simian virus-40 virus plays a role in cocarcinogenesis. Immunohistochemical markers such as calretinin, WT-1, and cytokeratin 5/6 are becoming established diagnostic markers. Preliminary data suggests that a soluble form of mesothelin could serve as a serum marker for established and early cases of mesothelioma. Positron emission tomography with 18-fluorodeoxyglucose in conjunction with computed tomograhy scanning has improved preoperative imaging and staging. Prognostic factors have been identified and verified. Negative indicators include thrombocytosis, high leukocyte counts, poor performance status, and nonepithelial histology. For the first time, there is now evidence that some treatments are increasing the quality and quantity of life for patients with mesothelioma. Chemotherapy, with the new multi-targeted antifolate drug Pemetrexed, combined with cisplatin, has shown superior survival rates in a large phase III trial when compared to cisplatin alone. High-dose intensity-modulated radiotherapy when administered after extrapleural pneumonectomy has resulted in excellent local control. Multimodality treatment programs that combine surgical cytoreduction with novel forms of radiation therapy and more effective chemotherapy combinations may offer significant increases in survival for certain subgroups of mesothelioma patients. Innovative palliative approaches have proved successful in alleviation of the significant symptoms experienced by many mesothelioma patients. Experimental treatments such as immunotherapy and gene therapy present a window of hope for all mesothelioma patients, and in the future, may be combined with 'standard therapy' in multimodality protocols. Patients with adequate performance status should be enrolled into clinical trials where possible. Over the past decade, significant advances have been made on several fronts that have improved the ability to diagnose a stage, define prognosis, and treat malignant pleural mesothelioma.
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Affiliation(s)
- Daniel H Sterman
- Thoracic Oncology Research Laboratory, Interventional Pulmonology Program, Pulmonary, Allergy and Critical Care Division, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania 19104-4283, USA.
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Musani AI, Haas AR, Seijo L, Wilby M, Sterman DH. Outpatient Management of Malignant Pleural Effusions with Small-Bore, Tunneled Pleural Catheters. Respiration 2004; 71:559-66. [PMID: 15627865 DOI: 10.1159/000081755] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2003] [Accepted: 04/15/2004] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Malignant pleural effusions (MPEs) can produce significant respiratory symptoms and diminished quality of life in patients with terminal malignancies. Control of MPEs to palliate respiratory symptoms can be performed via several different approaches. Ideally, a minimally invasive procedure to control MPEs and to provide relief of respiratory symptoms would be optimal. OBJECTIVE To ascertain if control of MPEs can be achieved by outpatient management via a small-bore pleural catheter (PC) without the need for sclerosing agents. METHODS Retrospective chart analysis of 24 patients after outpatient insertion of PCs for recurrent, symptomatic MPEs followed by frequent home drainage of pleural fluid to relieve respiratory symptoms. RESULTS Symptomatic relief of respiratory symptoms was achieved in 100% of patients, while pleurodesis was achieved in 58% of patients in a mean of 39 days. Five patients (6 PCs) expired with the catheters in place. In these patients, all catheters remained in position and functional until the patients ultimately died from nonpleural disease progression. No major complications occurred during insertion of the catheter. Late complications included localized cellulitis and bacterial superinfection in three patients and tumor growth at the catheter site in one patient. CONCLUSIONS The PCs used in the present study provided an effective modality not only to alleviate respiratory symptoms associated with MPE, but also to achieve pleurodesis in 58% of our patients. These catheters may provide a significantly less invasive outpatient approach to the palliative management of MPEs.
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Affiliation(s)
- Ali I Musani
- Interventional Pulmonology Program, Division of Pulmonary, Allergy and Critical Care Medicine, University of Pennsylvania Medical Center, Philadelphia, PA 19104-4283, USA.
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Stewart DJ, Edwards JG, Smythe WR, Waller DA, O'Byrne KJ. Malignant pleural mesothelioma--an update. INTERNATIONAL JOURNAL OF OCCUPATIONAL AND ENVIRONMENTAL HEALTH 2004; 10:26-39. [PMID: 15070023 DOI: 10.1179/oeh.2004.10.1.26] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Exposure to asbestos is the most frequent, but not exclusive, cause of malignant mesothelioma. Clinical features include dyspnea, cough, nonspecific chest pain, weight loss and night sweats. Diagnosis may be complicated by histologic difficulties. Thoracoscopic techniques are proving beneficial, but no one method of imaging has proven superior, and disease staging is inconsistent. Conventional treatments such as chemotherapy, surgery, and radiotherapy have had variable impacts, although chemotherapy is useful in palliation and can improve both survival and quality of life. There is hope for new antimetabolite agents. The role of radical surgery is yet to be evaluated in a large trial. New radiotherapeutic techniques to improve local control are promising. Multimodality treatments appear to be the most successful for management of potentially resectable disease. It is likely that biological markers will improve accuracy in staging and prognosis. With new treatments based on better understanding of the biology of the disease, there is cautious optimism for the future for patients with malignant pleural mesothelioma.
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Affiliation(s)
- Duncan J Stewart
- University Department of Oncology, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
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Abstract
With the incidence of mesothelioma in the United Kingdom (UK) expected to attain epidemic proportions over the next 20 years, prospective randomised evaluation of the role of surgery in the treatment of mesothelioma is required so that appropriate resource planning can be made. Possible prospective trials to evaluate the role of radical surgery are proposed together with the principles which must be conceded in the approach to radical surgery, patient selection, resectability, operability, treatment modalities, debulking surgery, chemotherapy and radiotherapy.
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Brega-Massone PP, Lequaglie C, Magnani B, Ferro F, Cataldo I. Chemical Pleurodesis to Improve Patients’ Quality of Life in the Management of Malignant Pleural Effusions. Surg Laparosc Endosc Percutan Tech 2004; 14:73-9. [PMID: 15287604 DOI: 10.1097/00129689-200404000-00005] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We analyzed chemical pleurodesis role in recurrent neoplastic pleural effusions management, performed by two different techniques: VATS and minimal lateral thoracotomy. We compared the results obtained using the two different procedures, and we also evaluated the two sclerosing agents used (talc and alcohol). From January 1987 to March 2002, we treated 565 patients with malignant pleural effusion: 355 (63%) by VATS and 210 (37%) through mini-thoracotomy all of them underwent chemical pleurodesis: 442 (78%) by means of talc and 123 (22%) by alcohol. Chemical pleurodesis therapeutic success was globally obtained in 436 patients (77%). Dealing with surgical approaches, VATS reduced operating time (33 versus 44 minutes: P < 0.001), mean drainage time (3 versus 5 days: P < 0.001), complications (2% versus 7%: P = 0.006) and mean postoperative course (5 versus 7 days: P < 0.001). Therapeutic success of VATS-treated patients was 81% versus 65% of those undergoing thoracotomy (P < 0.001). We obtained a significantly lower relapse rate in the patients of all the two groups treated with talc versus alcohol (12% versus 35% in VATS group and 25% versus 59% in thoracotomic group). Our data indicate that chemical pleurodesis represents a good palliative treatment of neoplastic pleural effusion. Talc was superior to alcohol as sclerosant agent regardless of the surgical procedure. Comparing the two techniques, VATS should be preferred to minimal thoracotomy. We can suggest talc pleurodesis by VATS as the choice treatment in case of recurrent pleural effusions.
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Affiliation(s)
- C Parker
- Respiratory Centre, St Mary's Hospital, Portsmouth PO3 6AD, Hants, UK
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Antunes G, Neville E, Duffy J, Ali N. BTS guidelines for the management of malignant pleural effusions. Thorax 2003; 58 Suppl 2:ii29-38. [PMID: 12728148 PMCID: PMC1766015 DOI: 10.1136/thorax.58.suppl_2.ii29] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- G Antunes
- Department of Respiratory Medicine, James Cook University Hospital, Middlesborough TS4 3BW, UK.
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Abstract
The role of surgery in the management of mesothelioma has largely been confined to obtaining a tissue diagnosis or to effect symptom control by pleurodesis. Noninvasive, image-guided methods of obtaining pleural tissue are reducing the need for surgical biopsy, and increased use of thoracoscopy under sedation by pulmonologist is also reducing surgical involvement. However, the increasing incidence of the disease together with reports of long-term survivors has resulted in a more aggressive surgical approach toward therapy. Surgical debulking may have a role in symptom control beyond that of pleurodesis. Radical surgery, with the aim of macroscopic clearance of the tumor, may not be of prognostic benefit alone but, as part of a multimodality treatment regime, may result in long-term survivors. Adjuvant treatments with chemotherapy and radiotherapy appear to prolong survival, whereas photodynamic therapy may be detrimental. Selection criteria for radical treatment need to be refined and a radical multimodality protocol must be subjected to a randomized, controlled evaluation.
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Affiliation(s)
- David A Waller
- Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK.
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Diacon AH, Wyser C, Bolliger CT, Tamm M, Pless M, Perruchoud AP, Solèr M. Prospective randomized comparison of thoracoscopic talc poudrage under local anesthesia versus bleomycin instillation for pleurodesis in malignant pleural effusions. Am J Respir Crit Care Med 2000; 162:1445-9. [PMID: 11029359 DOI: 10.1164/ajrccm.162.4.2002030] [Citation(s) in RCA: 91] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Induction of pleurodesis offers benefit for patients with metastatic tumors and symptomatic malignant pleural effusions, but the best method for achieving this is still unknown. In this prospective, randomized comparison of two well-established pleurodesis procedures, 36 patients with malignant pleural effusions, expanded lungs after drainage, and expected survival of > 1 mo received either bleomycin instillation (60E) via a small-bore thoracostomy tube or thoracoscopic talc poudrage (5 g) under local anesthesia. Efficacy, safety, and cost could be evaluated for 32 treatments (17 bleomycin, 15 talc) in 31 patients. Recurrence rates of effusion with bleomycin and talc poudrage after 30 d were 41% and 13% (p = 0.12), respectively, those after 90 d were 59% and 13%, respectively (p = 0.01), and those after 180 d were 65% and 13% (p = 0.005), respectively. Neither procedure showed any major adverse effect, and both were equally well tolerated. Cost estimation favored thoracoscopic talc poudrage, both for the initial hospitalization and with regard to recurrences. In conclusion, thoracoscopic talc pleurodesis under local anesthesia is superior to bleomycin instillation for pleurodesis in cases of malignant pleural effusion.
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Affiliation(s)
- A H Diacon
- Department of Internal Medicine, University Hospital, Basel, Switzerland
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Affiliation(s)
- A Melville
- NHS Centre for Reviews and Dissemination, University of York, UK
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Abstract
Malignant pleural effusions (MPEs) represent a common complication of advanced malignancies. However, adequate palliation of this highly symptomatic accompaniment to cancer can be achieved in most patients by adopting the appropriate therapy. Several options are available for the treatment of MPE. Systemic therapy may control the effusion in patients whose underlying malignancy is sensitive to anti-cancer agents. Repeated thoracocentesis can be appropriate for patients with limited life expectancy or slowly recurrent effusions. In the majority of the remaining cases the treatment of choice is pleurodesis with sclerosing agents administered via tube thoracostomy. Controversy still exists as to which drug produces the best results: talc and bleomycin appear to be among the most cost-effective agents. The debate over the best agent to be used for pleurodesis refers to the difficulty in comparing results of studies using different eligibility criteria, response assessment and end-points. This article describes the various treatments which have been reported in the literature to play a role in the management of MPEs. It is also aimed at providing guidelines in allocating patients to appropriate treatments.
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Affiliation(s)
- F Grossi
- Division of Medical Oncology I, Istituto Nazionale per la Ricerca sul Cancro, Genova, Italy
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