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Xie LX, Wang XG, You WJ, Ma XB, Wang YG, Liu TT, Jiang SJ. Predictors of survival in non-small cell lung cancer patients with pleural effusion undergoing thoracoscopy. Thorac Cancer 2019; 10:1412-1418. [PMID: 31094069 PMCID: PMC6558471 DOI: 10.1111/1759-7714.13086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 04/09/2019] [Accepted: 04/19/2019] [Indexed: 12/02/2022] Open
Affiliation(s)
- Li-Xu Xie
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Xing-Guang Wang
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Wen-Jie You
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Xiao-Bin Ma
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Yong-Gang Wang
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Ting-Ting Liu
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Shu-Juan Jiang
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
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Abstract
PURPOSE OF REVIEW Patients with malignant pleural effusions (MPEs) are heterogenous in their disease course, symptom severity, responses to cancer therapies, fluid recurrence rates, and thus need for definitive fluid control measures. To tailor the most appropriate treatment for individual patients, clinicians need to 'phenotype' the patients and predict their clinical course. This review highlights the recent efforts to develop better predictive tools and knowledge gaps for further research. RECENT FINDINGS The LENT scoring system, which includes pleural fluid lactate dehydrogenase, performance status, serum neutrophil-to-lymphocyte ratio and tumor type, allows prediction of the survival of patients with MPE. Symptomatic response after therapeutic pleural drainage is highly variable; ongoing studies aim to identify those who would derive symptomatic benefit from fluid drainages. Multivariate analysis found that patients with low pleural fluid pH [odds ratio (OR) 37.04], large effusions (OR 3.31), and increasing age (OR 1.02) were more likely to require pleurodesis or indwelling pleural catheter placement for fluid control. Better predictive tools for rate of fluid recurrence and likelihood of successful pleurodesis would help guide clinical decision-making. SUMMARY Phenotyping MPE would guide the formulation of optimal management for individual MPE patients.
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Raices M, Czerwonko ME, Dietrich A, Da Lozzo A, Beveraggi E, Smith D. Sodium hydroxide as a sclerosing agent in patients with neoplastic pleural effusion non-candidates for VATS: results of a minimally invasive protocol. Updates Surg 2017; 70:535-544. [PMID: 28861859 DOI: 10.1007/s13304-017-0485-1] [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: 04/30/2017] [Accepted: 08/09/2017] [Indexed: 10/19/2022]
Abstract
Symptomatic neoplastic pleural effusion (SNPE) is a significant cause of morbidity in patients with advanced neoplastic disease. These patients often present a deteriorated general condition which prevents them from undergoing pleurodesis with video-assisted thoracic surgery (VATS). We developed a minimally invasive therapeutic protocol specially designed for this population, achieved by combining chemical pleurodesis with placement of small-bore pleural catheters (PC), which resulted in early hospital discharge, low morbimortality and good therapeutic results. This study reports the safety and efficacy of administration of sodium hydroxide (NaOH) through PC in 60 patients diagnosed with SNPE who were admitted to Hospital Italiano de Buenos Aires between January 2012 and December 2015. Successful pleurodesis was achieved in 96% of procedures. Recurrence occurred in 25% of patients during follow-up, with recurrence occurring earlier than 30 days after pleurodesis in 8% of patients. There were no reports of major morbidity or associated mortality. In total, 44% of patients were discharged within 48 h of pleurodesis. Administration of NaOH through a small-bore PC represents an effective and safe method of pleurodesis in patients who are not candidates for talc pleurodesis by VATS.
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Affiliation(s)
- Micaela Raices
- Department of Thoracic Surgery Service and Pulmonary Transplantation, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Matías E Czerwonko
- Department of Thoracic Surgery Service and Pulmonary Transplantation, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Agustin Dietrich
- Department of Thoracic Surgery Service and Pulmonary Transplantation, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Alejandro Da Lozzo
- Department of Thoracic Surgery Service and Pulmonary Transplantation, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Enrique Beveraggi
- Department of Thoracic Surgery Service and Pulmonary Transplantation, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - David Smith
- Department of Thoracic Surgery Service and Pulmonary Transplantation, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1199ABD, Buenos Aires, Argentina.
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Abstract
Malignant pleural effusions are a cause of significant symptoms and distress in patients with end-stage malignancies and portend a poor prognosis. Management is aimed at symptom relief, with minimally invasive interventions and minimal requirement for hospital length of stay. The management options include watchful waiting if no symptoms are present, repeat thoracentesis, medical or surgical thoracoscopic techniques to achieve pleurodesis, pleuroperitoneal shunts, placement of tunneled pleural catheters, or a combination of modalities. To determine the best modality for management, patients must be assessed individually with concern for symptoms, functional status, prognosis, and their social and financial situations.
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Affiliation(s)
- Justin M Thomas
- Division of Pulmonary and Critical Care, Department of Medicine, National Jewish Health, Denver, CO 80206, USA
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Kaifi JT, Toth JW, Gusani NJ, Kimchi ET, Staveley-O'Carroll KF, Belani CP, Reed MF. Multidisciplinary management of malignant pleural effusion. J Surg Oncol 2011; 105:731-8. [PMID: 21960207 DOI: 10.1002/jso.22100] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Accepted: 09/01/2011] [Indexed: 01/15/2023]
Affiliation(s)
- Jussuf T Kaifi
- Section of Surgical Oncology, Department of Surgery, Penn State Hershey Cancer Institute, Penn State College of Medicine, Hershey, Pennsylvania, USA.
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Sakr L, Maldonado F, Greillier L, Dutau H, Loundou A, Astoul P. Thoracoscopic assessment of pleural tumor burden in patients with malignant pleural effusion: prognostic and therapeutic implications. J Thorac Oncol 2011; 6:592-7. [PMID: 21258256 DOI: 10.1097/jto.0b013e318208c7c1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Malignant pleural effusion (MPE) is encountered at an advanced stage of disease progression and often heralds a poor prognosis. The most reliable predictive factor of survival in such patients is the primary tumor. Thoracoscopy is often performed for accurate diagnosis and/or thoracoscopic talc insufflation as a therapeutic modality. It remains unknown whether pleural tumor burden, as visualized on thoracoscopy, has potential prognostic value. The objective of this study was to determine the prognostic accuracy of pleural tumor extent and localization (parietal, visceral, or diaphragmatic involvement), as assessed during medical thoracoscopy. METHODS Medical records of all patients who underwent thoracoscopy for suspicion of MPE between 2001 and 2008 at a tertiary care referral hospital were reviewed. Patients were included if pleural metastatic invasion was confirmed on tissue biopsy and survival status ascertained. RESULTS Four hundred twenty-one patients underwent diagnostic or therapeutic medical thoracoscopy at our referral center. Among them, 122 had confirmed metastatic pleural spread, but survival data were lacking in 15. Primary tumor consisted of non-mall cell lung cancer in 56, breast cancer in 23, melanoma in eight, and other malignancies in 20. Median survival of the entire population was 9.4 months. On univariate analysis, the following variables were significantly associated with reduced median overall survival: pleural metastatic melanoma, age less than 60 years, bloody MPE, extensive pleural adhesions, and widespread visceral pleural nodules (p < 0.05). On multivariate analysis, only melanoma as a primary tumor, pleural fluid appearance and extent of pleural adhesions remained independent and significant predictors of survival. CONCLUSION No significant association was found between the extent or localization of pleural tumor burden and overall survival.
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Affiliation(s)
- Lama Sakr
- Division of Pulmonary Diseases, Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada
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Ozcakar B, Martinez CH, Morice RC, Eapen GA, Ost D, Sarkiss MG, Chiu HT, Jimenez CA. Does pleural fluid appearance really matter? The relationship between fluid appearance and cytology, cell counts, and chemical laboratory measurements in pleural effusions of patients with cancer. J Cardiothorac Surg 2010; 5:63. [PMID: 20718978 PMCID: PMC2933602 DOI: 10.1186/1749-8090-5-63] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Accepted: 08/18/2010] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Previous reports have suggested that the appearance of pleural effusions (i.e., the presence or absence of blood) might help to establish the etiology of the effusions. This study explores the relationship between pleural fluid appearance and the results of chemical and cytological analyses in a group of patients with recurrent symptomatic pleural effusions and a diagnosis of cancer. METHODS Medical records were reviewed from all 390 patients who were diagnosed with cancer, who underwent thoracentesis before placement of an intrapleural catheter (IPC) between April 2000 and January 2006. Adequate information for data analysis was available in 365 patients. The appearance of their pleural fluid was obtained from procedure notes dictated by the pulmonologists who had performed the thoracenteses. The patients were separated into 2 groups based on fluid appearance: non-bloody and bloody. Group differences in cytology interpretation were compared by using the chi square test. Cellular counts, chemical laboratory results, and survival after index procedure were compared by using the student's t test. RESULTS Pleural fluid cytology was positive on 82.5% of the non-bloody effusions and on 82.4% of the bloody ones. The number of red blood cells (220.5 x 103/microL vs. 12.3 x 103/microL) and LDH values (1914 IU/dl vs. 863 IU/dl) were statistically higher in bloody pleural effusions. CONCLUSION The presence or absence of blood in pleural effusions cannot predict their etiology in patients with cancer and recurrent symptomatic pleural effusions.
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Affiliation(s)
- Bulent Ozcakar
- Department of Pulmonary Medicine, The University of Texas M. D. Anderson Cancer Center, 1400 Hermann Pressler Dr, Unit 1462, Houston, TX, 77030-4008, USA
| | - Carlos H Martinez
- Department of Pulmonary Medicine, The University of Texas M. D. Anderson Cancer Center, 1400 Hermann Pressler Dr, Unit 1462, Houston, TX, 77030-4008, USA,Departments of Internal Medicine and Preventive Medicine and Community Health, The University of Texas Medical Branch, Galveston, TX, USA
| | - Rodolfo C Morice
- Department of Pulmonary Medicine, The University of Texas M. D. Anderson Cancer Center, 1400 Hermann Pressler Dr, Unit 1462, Houston, TX, 77030-4008, USA
| | - Georgie A Eapen
- Department of Pulmonary Medicine, The University of Texas M. D. Anderson Cancer Center, 1400 Hermann Pressler Dr, Unit 1462, Houston, TX, 77030-4008, USA
| | - David Ost
- Department of Pulmonary Medicine, The University of Texas M. D. Anderson Cancer Center, 1400 Hermann Pressler Dr, Unit 1462, Houston, TX, 77030-4008, USA
| | - Mona G Sarkiss
- Department of Pulmonary Medicine, The University of Texas M. D. Anderson Cancer Center, 1400 Hermann Pressler Dr, Unit 1462, Houston, TX, 77030-4008, USA,Department of Anesthesia and Preoperative Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Hsienchang T Chiu
- Department of Pulmonary Medicine, The University of Texas M. D. Anderson Cancer Center, 1400 Hermann Pressler Dr, Unit 1462, Houston, TX, 77030-4008, USA,Division of Pulmonary Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Carlos A Jimenez
- Department of Pulmonary Medicine, The University of Texas M. D. Anderson Cancer Center, 1400 Hermann Pressler Dr, Unit 1462, Houston, TX, 77030-4008, USA
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Phase I trial of intrapleural docetaxel administered through an implantable catheter in subjects with a malignant pleural effusion. J Thorac Oncol 2010; 5:75-81. [PMID: 19884858 DOI: 10.1097/jto.0b013e3181c07ddc] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Malignant pleural effusion (MPE) is a common complication in patients with advanced malignancy. This dose escalation phase I study was designed to determine the maximum tolerated dose of intrapleural docetaxel administered through an implantable catheter in subjects with MPE. METHODS Subjects with MPE (n = 15) with median age of 64.6 years and an Eastern Cooperative Oncology Group performance status of 0 to 2 at baseline were enrolled into four single dose levels of docetaxel administered intrapleurally after drainage of the pleural effusion and insertion of an intrapleural catheter. The study determined the pharmacokinetic properties, clinical response, and toxicity profile of intrapleural docetaxel. RESULTS All patients tolerated the therapy well and there were no significant toxicities. The majority of patients had a complete radiographic response. All patients receiving dose 100 mg/m2 or higher had a complete radiographic response. One dose-limiting toxicity was encountered in the dose 50 mg/m2. Pharmacokinetic data demonstrated peak plasma concentration of docetaxel between 30 minutes and 6 hours after infusion. Pleural exposure to docetaxel was 1000 times higher than systemic exposure. CONCLUSIONS Single-dose intrapleural administration of doxetaxel is well tolerated in patients with MPE with minimal toxicity. The excellent clinical responses in this study after treatment with intrapleural doxetaxel suggest that further investigation is warranted.
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Medford ARL, Bennett JA, Free CM, Agrawal S. Current status of medical pleuroscopy. Clin Chest Med 2010; 31:165-72, Table of Contents. [PMID: 20172442 DOI: 10.1016/j.ccm.2009.10.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Medical pleuroscopy (MP) offers a safe and minimally invasive tool for interventional pulmonologists. It allows diagnosis of unexplained effusion, while at the same time allowing drainage and pleurodesis. It can also help in the diagnosis of diffuse interstitial disease or associated peripheral lung abnormality in the presence of effusion. It can have a therapeutic role in pneumothorax and hyperhidrosis or chronic pancreatic pain. This article reviews the technical aspects and range of applications of MP.
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Affiliation(s)
- Andrew R L Medford
- Department of Respiratory Medicine, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester LE3 9QP, Leicestershire, UK.
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Gonlugur TE, Gonlugur U. Pleural fluid findings as prognostic factors for malignant pleural mesothelioma. J Clin Lab Anal 2008; 22:334-6. [PMID: 18803276 DOI: 10.1002/jcla.20266] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
The aim of this study was to determine the prognostic value of pleural fluid glucose, lactate dehydrogenase (LDH), albumin, total protein, and total leukocyte levels in patients with malignant pleural mesothelioma. We retrospectively analyzed 71 consecutive patients (33 men and 38 women) who were referred to the department of chest diseases in a university hospital. Pleural fluid glucose levels, the ratio of pleural fluid to serum LDH>1.0, and total leukocyte count were significant predictors for the survival in univariate analysis. However, none of these variables emerged as statistically significant from the multivariate Cox model. In conclusion, our results showed that there is an inverse correlation between the intensity of inflammation and survival.
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Predictors of talc pleurodesis outcome in patients with malignant pleural effusions. Lung Cancer 2008; 62:139-44. [PMID: 18403045 DOI: 10.1016/j.lungcan.2008.02.017] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2007] [Revised: 02/18/2008] [Accepted: 02/24/2008] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Chemical pleurodesis is an accepted palliative therapy for patients with recurrent, symptomatic, malignant pleural effusions (MPE). The purpose of the study was to determine the factors that have an effect on successful pleurodesis for MPE. PATIENTS AND INTERVENTIONS Eighty-four consecutive patients with biopsy-proven malignant pleural disease and recurrent, symptomatic MPE were eligible to participate in this study. Five grams of talc mixed in 150ml of normal saline were administered via tube thoracostomy or small-bore catheters after complete drainage of the pleural effusion. RESULTS Seven patients did not return for their 30-day follow-up visit and were excluded from further analysis. Successful pleurodesis was achieved in 63 of 77 eligible patients (81.8%) with MPE. In the univariate analysis, female gender, Karnofsky performance status, pleural fluid pH, cholesterol, and adenosine deaminase level showed a significant association with the probability of success. Multivariate logistic regression analysis showed that pleural fluid pH and ADA levels were independent predictors of talc pleurodesis outcome. CONCLUSION Our results show that pleurodesis using talc as the sclerosing agent is a simple and acceptable procedure with high efficacy for controlling MPE, especially when used in appropriate patients.
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Abstract
The surgeon's role in the treatment of malignant peritoneal disease has expanded over time, stemming from a better understanding of tumor biology. For the majority of patients, carcinomatosis is a terminal process with surgical intervention being reserved for palliation of bowel obstruction or symptomatic ascites. However, for select patients with favorable tumor biologies, aggressive surgical approaches may result in long-term survival. This review describes the patterns of peritoneal tumor dissemination, surgical palliation of malignant bowel obstruction or ascites, and the principles, indications, toxicities, and overall results of cytoreductive surgery with intraperitoneal hyperthermic chemotherapy. On the other hand, long-term survival is rarely expected for malignant pleural disease unless the causal tumor is highly responsive to systemic chemotherapy. There are controversies and considerable geographic variations in the management of malignant pleural effusions. However, less invasive ambulatory palliative treatments for patients so afflicted are gaining popularity.
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Affiliation(s)
- Yossef Aelony
- Harbor-UCLA Medical Center, Torrance, CA 90502, USA.
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14
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Yang SH. Pleural Disease. Tuberc Respir Dis (Seoul) 2007. [DOI: 10.4046/trd.2007.62.6.469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Sei Hoon Yang
- Department of Internal Medicine, Wonkwang Uneversity College of Medicine, Iksan, Korea
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Neragi-Miandoab S. Malignant pleural effusion, current and evolving approaches for its diagnosis and management. Lung Cancer 2006; 54:1-9. [PMID: 16893591 DOI: 10.1016/j.lungcan.2006.04.016] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2006] [Revised: 04/01/2006] [Accepted: 04/11/2006] [Indexed: 10/24/2022]
Abstract
Malignant pleural effusion is a common and debilitating complication of advanced malignant diseases. This problem seems to affect particularly those with lung and breast cancer, contributing to the poor quality of life. Approximately half of all patients with metastatic cancer develop a malignant pleural effusion at some point, which is likely to cause significant symptoms such as dyspnea and cough. Evacuation of the pleural fluid and prevention of its re-accumulation are the main goals of management. Optimal treatment is controversial and there is no universally standard approach. Intervention options range from observation in the case of asymptomatic effusions through simple thoracentesis to more invasive methods such as chemical and mechanical pleurodesis, pleur-X catheter drainage, pleuroperitoneal shunting, and pleurectomy. The best results are reported with thoracoscopy and talc insufflation, with an acceptable morbidity. Development of novel methods to control malignant pleural effusion should be a high priority in palliative care of cancer patients. This article reviews the current, as well as, novel approaches that show some promise for the future. The aim is to identify the proper approach for each individual patient.
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Affiliation(s)
- Siyamek Neragi-Miandoab
- Thoracic and Cardiovascular Surgery, Loyola University Chicago, Stritch School of Medicine, 2160 South First Ave., Building 110, Room 6243, Maywood, IL 60153, USA.
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Abstract
STUDY OBJECTIVES To conduct a detailed morphologic and ultrastructural study of pleural adhesions following talc pleurodesis. METHODS Talc with a main particle size of 8.36 +/- 0.2 mum (mean +/- SEM) and at a dose of 200 mg/kg in a 2-mL slurry was instilled via a small catheter into the pleural cavity of 10 male rabbits. Five rabbits were killed at 1 week, and five rabbits were killed at 1 month after instillation. At autopsy, after macroscopically observing the pleural cavity, adhesions were excised from opposing pleural surfaces and processed for histopathologic, immunocytochemical, and ultrastructural study. RESULTS At 1 week, all adhesions examined were mesothelium-covered fibrovascular bands containing well-developed blood and lymphatic vessels establishing a structural continuity between both pleural layers. Nerves were present in adhesions from 20% of the rabbits. They consisted of a single fascicle containing 5 to 20 thin myelinated axons of various diameters (1 to 6 microm) uniformly distributed throughout the nerve section. The anatomic location of the adhesion did not appear to influence its overall morphology. CONCLUSIONS As early as at 1 week, adhesions are well-formed structures more resembling newly formed pleural tissue than a simple scar. Nerve fibers in pleural adhesions are reported for the first time, which suggests that these adhesions are potentially capable of conducting pain stimuli. Further studies are required in order to confirm our results in human pleural adhesions.
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Affiliation(s)
- Juan F Montes
- Departament de Biologia Cellular, Facultat de Biologia, Universitat de Barcelona, Barcelona, Spain.
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Fielding D, Hopkins P, Serisier D. Frozen section of pleural biopsies at medical thoracoscopy assists in correctly identifying benign disease. Respirology 2006; 10:636-42. [PMID: 16268918 DOI: 10.1111/j.1440-1843.2005.00761.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Medical thoracoscopy and thoracoscopic talc poudrage (TTP) are accepted procedures in the management of pleural effusions. The relative merits of TTP compared with pleurodesis via intercostal catheter (ICC) continue to be debated. However, of the two procedures, only medical thoracoscopy allows both tissue diagnosis and pleurodesis to be achieved reliably in one procedure. The aim of this study was to assess the feasibility and accuracy of using frozen section analysis of samples taken during medical thoracoscopy to assist the thoracoscopist's decision to complete the procedure with a TTP. METHODOLOGY Twenty patients with undiagnosed pleural effusions after at least one diagnostic pleurocentesis underwent medical thoracoscopy and biopsy. RESULTS Frozen sections were easily performed within the timeframe of medical thoracoscopy. The final diagnosis based on paraffin sections was malignant in 10 cases and benign in 10 cases. Frozen section at the time of thoracoscopy (before TTP) correctly identified nine of 10 cases as being benign and six of 10 cases as malignant. In the malignant group, reasons for incorrect identification as benign were sampling from superficial benign adipose tissue overlying the malignant deposits, difficult access to the most involved parts of the pleura and intense cellular infiltrate initially thought to be benign. CONCLUSION Frozen sections taken during medical thoracoscopy have the potential to facilitate decision-making prior to pleurodesis, particularly for accurate identification of benign histology on thoracoscopic pleural biopsies, in order that pleurodesis is not performed unnecessarily.
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Affiliation(s)
- David Fielding
- Department of Thoracic Medicine, Royal Brisbane Hospital, Australia.
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18
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Abstract
OBJECTIVE Malignant pleural mesothelioma is a fatal disease with a mean life expectancy of 6-12 months. Since 1982, we have performed thoracoscopic talc poudrage (TTP) as a primary therapy in mesothelioma patients presenting with pleural effusion. As the survival data for our patients surpassed that of many published series, the patient data was analyzed to determine whether talc poudrage can be considered as a contemporary palliative option. METHODOLOGY We reviewed all 26 patients with a final diagnosis of malignant pleural mesothelioma from our prospective database of 228 consecutive patients who received thoracoscopy from the same physician for recurrent symptomatic pleural effusion. Patients were followed up until their death. RESULTS Mean survival after TTP was 23.8 +/- 16.3 months (median 19.4, range 2.9-68). Pleurodesis palliated dyspnoea in all patients. No perioperative deaths and one postoperative complication (pneumonia) occurred. Mean hospital stay was 3.9 +/- 2.7 days. CONCLUSION TTP remains a safe, low-morbidity, inexpensive primary palliative treatment option for malignant pleural mesothelioma and a valid control arm option for therapeutic trials. TTP is ideal for patients who wish to avoid thoracotomy, long hospital stays and morbidity from multimodality therapy. Prospective randomized studies are needed to compare quality of life and survival after talc poudrage and other therapies.
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Affiliation(s)
- Yossef Aelony
- Department of Internal Medicine, Kaiser Permanente Medical Center, Harbor City, CA 90710, USA.
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19
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Marrazzo A, Noto A, Casà L, Taormina P, Lo Gerfo D, David M, Mercadante S. Video-thoracoscopic surgical pleurodesis in the management of malignant pleural effusion: the importance of an early intervention. J Pain Symptom Manage 2005; 30:75-9. [PMID: 16043010 DOI: 10.1016/j.jpainsymman.2005.01.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/29/2005] [Indexed: 10/25/2022]
Abstract
Thoracentesis plays an important role in cancer patients with symptomatic effusions, although its effect is short-lived and symptoms recur in almost all patients. Early video-thoracoscopic surgical pleurodesis may provide added benefit to a group of patients with advanced cancer presenting with symptomatic malignant pleural effusion. Seventy-six patients with advanced cancer and pleural effusion due to pulmonary-pleural metastases were recruited. In 51 cases (67.1%), at least one thoracentesis was performed before admission for surgery. Preoperative staging consisted of chest radiograph, CT scan, and blood gas analysis. The mean Karnofsky performance status was about 50. Pleurodesis with talc poudrage was completely successful in all patients, with a morbidity rate of 2.6%. There was no post-operative mortality. Three patients (3.9%) underwent further thoracenteses for recurrence of pleural effusion within two months after the procedure. Early use of talc insufflated by video-thoracoscopic surgery is an effective and relatively safe method for treating pleural effusion, and preventing recurrence, in advanced cancer patients.
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Affiliation(s)
- Antonio Marrazzo
- Department of Experimental Oncology and Clinical Application, University of Palermo, Italy
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20
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Verfaillie G, Herreweghe RV, Lamote J, Noppen M, Sacre R. Use of a Port-a-Cath system in the home setting for the treatment of symptomatic recurrent malignant pleural effusion. Eur J Cancer Care (Engl) 2005; 14:182-4. [PMID: 15842469 DOI: 10.1111/j.1365-2354.2005.00568.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Symptomatic malignant pleural effusions represent a common problem in metastatic cancers and are associated with a significant morbidity. Pleurodesis still remains the primary therapy of choice. In a few cases, however, pleurodesis is unsuccessful because of a limited lung expansion and pleuroperitoneal shunts have been used. We describe two cases where an implantable PORT-A-CATH system is used for regular drainage of the pleural effusion. The main advantage of this technique is the fact that the procedure of drainage can be performed by a nurse in the home setting.
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Affiliation(s)
- G Verfaillie
- Department of Thoracic Surgery AZ-VUB Jette, Brussels, Belgium.
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Dresler CM, Olak J, Herndon JE, Richards WG, Scalzetti E, Fleishman SB, Kernstine KH, Demmy T, Jablons DM, Kohman L, Daniel TM, Haasler GB, Sugarbaker DJ. Phase III intergroup study of talc poudrage vs talc slurry sclerosis for malignant pleural effusion. Chest 2005; 127:909-15. [PMID: 15764775 PMCID: PMC4644736 DOI: 10.1378/chest.127.3.909] [Citation(s) in RCA: 355] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
STUDY OBJECTIVE To demonstrate the efficacy, safety, and appropriate mode of instillation of talc for sclerosis in treatment of malignant pleural effusions (MPEs). DESIGN A prospective, randomized trial was designed to compare thoracoscopy with talc insufflation (TTI) to thoracostomy and talc slurry (TS) for patients with documented MPE. MEASUREMENTS The primary end point was 30-day freedom from radiographic MPE recurrence among surviving patients whose lungs initially re-expanded > 90%. Morbidity, mortality, and quality of life were also assessed. RESULTS Of 501 patients registered, those eligible were randomized to TTI (n = 242) or TS (n = 240). Patient demographics and primary malignancies were similar between study arms. Overall, there was no difference between study arms in the percentage of patients with successful 30-day outcomes (TTI, 78%; TS, 71%). However, the subgroup of patients with primary lung or breast cancer had higher success with TTI than with TS (82% vs 67%). Common morbidity included fever, dyspnea, and pain. Treatment-related mortality occurred in nine TTI patients and seven TS patients. Respiratory complications were more common following TTI than TS (14% vs 6%). Respiratory failure was observed in 4% of TS patients and 8% of TTI patients, accounting for five toxic deaths and six toxic deaths, respectively. Quality-of-life measurement demonstrated less fatigue with TTI than TS. Patient ratings of comfort and safety were also higher for TTI, but there were no differences on perceived value or convenience of the procedures. CONCLUSIONS Both methods of talc delivery are similar in efficacy; TTI may be better for patients with either a lung or breast primary. The etiology and incidence of respiratory complications from talc need further exploration.
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Affiliation(s)
- Carolyn M Dresler
- Head, Tobacco Unit, International Agency for Research on Cancer, Lyon, France.
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Ukale V, Agrenius V, Hillerdal G, Mohlkert D, Widström O. Pleurodesis in recurrent pleural effusions: a randomized comparison of a classical and a currently popular drug. Lung Cancer 2004; 43:323-8. [PMID: 15165091 DOI: 10.1016/j.lungcan.2003.09.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2003] [Revised: 09/10/2003] [Accepted: 09/15/2003] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVES Pleurodesis is generally regarded to give the best palliation in recurrent pleural effusion. Talc is now increasingly recommended but in our department quinacrine has been used successfully for many decades with good results and only minor side effects. It was therefore decided to make a prospective randomized clinical study comparing quinacrine (500 mg) with talc (5 g) with regard to efficacy and safety. METHODS One hundred and ten eligible consecutive patients with recurrent and or malignant effusions, from 1 March 1996 till 31 March 1999 were randomized to chemical pleurodesis with either talc or quinacrine through a chest drainage tube after medical thoracoscopy. Patients were evaluated with chest radiographs at 2 weeks and 2, 4, and 6 months after pleurodesis. RESULTS Chi-square test showed 84% power to distinguish between the groups and 10% to determine the primary endpoint. Primary success (fluid production < 50ml/24h within the first 6 days) was 96% of 56 patients with talc and 91% of 54 patients with quinacrine, a non-significant difference (P = 0.46). Quinacrine patients needed a repeated treatment in 31% (17 patients) and talc patients in 7% (4 patients) (P < 0.05). Side effects were minor with no significant difference between the substances. CONCLUSIONS Both substances are effective. Talc treatment had less often to be repeated. This indicates that the recommendation of talc for pleurodesis is well founded. However, quinacrine is a good alternative.
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Affiliation(s)
- Valiant Ukale
- Department of Medicine, Division of Respiratory Medicine, Thoracic Clinics, Karolinska Sjukhuset, S-171 76 Stockholm, Sweden.
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Wolff AJ, Anderson ED, Read CA. Factores preditivos da formação de aderências pleurais e sucesso da pleurodese nos doentes com derrame pleural. REVISTA PORTUGUESA DE PNEUMOLOGIA 2004. [DOI: 10.1016/s0873-2159(15)30563-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Marchi E, Teixeira LR, Vargas FS. Management of malignancy-associated pleural effusion: current and future treatment strategies. ACTA ACUST UNITED AC 2004; 2:261-73. [PMID: 14720007 DOI: 10.1007/bf03256654] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Management of recurrent malignant pleural effusion, a common complication of malignancy, poses a challenge to clinicians. Although almost one century has elapsed since the introduction of the pleurodesis procedure, the ideal approach and best agent are still to be defined. Optimally, pleurodesis should be done at the bedside with a minimally invasive procedure, and suitable agents to achieve pleural symphysis should be inexpensive, available worldwide and free of adverse effects. To date, no substance completely fulfills these requirements. Silver nitrate should be considered for pleurodesis because of its low cost and ease of handling. Although talc has been used most frequently to induce pleurodesis, reports of death due to acute respiratory failure have raised concerns about the safety of this agent. Tetracycline, an effective alternative used in the past, is no longer commercially available. This agent has been substituted with derivatives of tetracycline, such as minocycline and doxycycline with success rates similar to those with tetracycline. Several antineoplastic agents have been injected into the pleural space with the aim of producing pleural symphysis, the most representative of this group being bleomycin. Recent knowledge of the molecular mechanisms involved in pleural inflammation has brought into focus new substances, such as transforming growth factor beta and vascular endothelial growth factor, which may be used as pleurodesis agents in the future. Nevertheless, more studies are necessary to better define the potential of these substances in the induction of pleural symphysis.Ideally, a sclerosing agent should be cost-effective, available worldwide and easily administered. Talc will probably stand as the preferred agent to be used for pleurodesis in malignant pleural effusion because of its efficacy, easy manipulation and handling. However, further investigation is necessary to minimize adverse effects related to talc.
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Affiliation(s)
- Evaldo Marchi
- Pulmonary Division, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
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Predictors of Pleural Adhesion Formation and Success of Pleurodesis in Patients With Pleural Effusion. ACTA ACUST UNITED AC 2004. [DOI: 10.1097/00128594-200401000-00003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Heffner JE, Heffner JN, Brown LK. Multilevel and continuous pleural fluid pH likelihood ratios for evaluating malignant pleural effusions. Chest 2003; 123:1887-94. [PMID: 12796164 DOI: 10.1378/chest.123.6.1887] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVE Expert consensus recommends testing pleural fluid for pH to assist the selection of patients with malignant pleural effusions for pleurodesis. Although published studies report an association between pleural fluid pH and patient outcomes after pleurodesis, clinicians have no definitive information on how to use pH to select patients for pleurodesis. Thus, we quantitatively assessed different methods for deriving likelihood ratios from pleural fluid pH and evaluated the potential role of pH in selecting patients for pleurodesis. DATA SOURCES MEDLINE, systematic reviews, article reference lists, and contact with primary authors. STUDY SELECTION Studies that assessed the impact of pleural fluid pH on survival and pleurodesis failure rates among patients with malignant pleural effusions. DATA EXTRACTION Primary authors provided their data in electronic spreadsheets. DATA SYNTHESIS Retrieved data sets included survival and pleurodesis failure rates for 417 patients and 433 patients, respectively. Binary, multilevel, and continuous likelihood ratios were calculated to estimate the likelihood of death within 3 months of pleurodesis or pleurodesis failure rates. Values for the likelihood ratios were compared for each of the three strategies, and relative clinical and statistical significance were assessed. Pleural fluid pH had marginal performance for identifying patients with < 3-month anticipated survival; binary likelihood ratios provided as much information as the multilevel and continuous strategies. Likelihood ratios for identifying patients likely to fail pleurodesis were clinically useful. Continuous likelihood ratios provided statistically more information as compared with the multilevel and binary strategies. CONCLUSIONS Pleural fluid pH has marginal value for estimating death within 3 months of pleurodesis, and binary likelihood ratios (cut point </= 7.20) perform as well as the other strategies assessed. Pleural fluid pH provides more useful information for estimating the likelihood of pleurodesis failure for which continuous likelihood ratios provide the most information as compared with binary or multilevel likelihood ratios.
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Affiliation(s)
- John E Heffner
- Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, SC 29425, USA.
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Abstract
BACKGROUND Malignant pleural effusion (MPE) is a common and distressing condition at the end of life for many patients with disseminated cancer. The challenge for the surgeon lies in managing this problem in order to deliver the most effective palliation with the least impact on the limited time available to these patients. METHODS Herein is reported a retrospective review of outcomes for a consecutive series of 66 MPE (61 patients) treated over a 5-year period from 1995 to 2000. A standard operative technique involving a single-lung anaesthetic and two-port thoracoscopy was employed. Outcomes were determined by contacting the referring practitioner or the patients themselves. Principal outcome measures included time to recurrence of the effusion and survival. RESULTS Complete follow up was achieved for 60 MPE (55 patients; five of whom were treated for metachronous, bilateral disease). The three most common primary sites were breast, lung and mesothelial tissue. The planned procedure was not completed in two cases due to encasement of the underlying lung by tumour. Primary failure (immediate recurrence of the effusion) occurred in six cases. Delayed recurrence of the effusion occurred in a further 23 MPE resulting in complete control in 31 cases (52%) until death. Overall median survival was 220 days and the 30-day mortality was 0. CONCLUSIONS Complete and permanent control of a malignant effusion is difficult to achieve. Management based on thoracoscopy and talc insufflation produces satisfactory results with an acceptable morbidity and no early mortality. The ability to inspect the pleural space, break down adhesions and completely drain pockets of fluid to achieve complete lung expansion probably contributes to this.
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Affiliation(s)
- David Love
- Division of Surgery, St John of God Hospital, Ryrie Street, Geelong, Victoria 3220, Australia
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Erickson KV, Yost M, Bynoe R, Almond C, Nottingham J. Primary Treatment of Malignant Pleural Effusions: Video-Assisted Thoracoscopic Surgery Poudrage versus Tube Thoracostomy. Am Surg 2002. [DOI: 10.1177/000313480206801105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The objective of this study is to show that primary treatment of malignant pleural effusions secondary to ovarian carcinoma with video-assisted thoracoscopic surgery (VATS)-assisted talc poudrage (VATS-ATP) results in shorter hospital stays and reduced time with a chest tube than primary treatment with a chest tube and chemical pleurodesis. We conducted a retrospective chart review of all patients with a symptomatic pleural effusion secondary to primary ovarian carcinoma receiving intervention from January 1996 to December 2000. Patients either received tube thoracostomy with pleurodesis (n = 22) or VATS-ATP (n = 12). Of the patients treated with tube thoracostomy 18 per cent (4/21) died in the hospital before pleurodesis, 77 per cent (14/19) had successful pleurodesis, and 22 per cent (4/18) failed pleurodesis requiring VATS-ATP. In the group treated primarily with tube thoracostomy the chest tube was in place 8.36 ± 2.61 days with a hospital stay of 12.64 ± 5.80 days after the procedure. In the group treated with VATS-ATP there was 100 per cent successful pleurodesis. There were no mortalities. There was one prolonged intubation of 3 days and one incomplete lung reexpansion. The chest tube was in place for 4.58 ± 1.78 days and a hospital stay of 7.50 ± 4.12 days postprocedure. Groups treated by tube thoracostomy and VATS were statistically different; P < 0.001 for days with a chest tube and P = 0.011 for hospital days. We conclude that both tube thoracostomy with chemical pleurodesis and VATS-ATP provide adequate treatment of ovarian carcinoma-associated malignant pleural effusions. VATS-ATP provides a shorter duration of chest tube placement and postprocedure hospital stay.
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Affiliation(s)
- Kurt V. Erickson
- Department of Surgery, School of Medicine, University of South Carolina, Columbia, South Carolina
| | - Michael Yost
- Department of Surgery, School of Medicine, University of South Carolina, Columbia, South Carolina
| | - Raymond Bynoe
- Department of Surgery, School of Medicine, University of South Carolina, Columbia, South Carolina
| | - Carl Almond
- Department of Surgery, School of Medicine, University of South Carolina, Columbia, South Carolina
| | - James Nottingham
- Department of Surgery, School of Medicine, University of South Carolina, Columbia, South Carolina
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Abstract
The management of pleural effusions and, in particular, recurrent MPE require an accurate assessment of the characteristics of the pleural fluid and the relief of the patient's symptoms. Although a common problem, treatment of pleural effusions and MPE is highly variable. Selection of optimal treatment for the individual patient (or population of patients) requires a careful assessment of the benefits and associated risks of the therapy. Pleurodesis is an artificial measure of success that is hospital centered, not patient centered. Because patients with MPE have limited life expectancy, efforts to palliate or eliminate dyspnea, optimize function, eliminate hospitalization, and reduce excessive end-of-life medical care costs may be best achieved with a chronic indwelling pleural catheter. The need for expensive supplies may temper the use of such outpatient management. Alternative techniques of tube thoracostomy, drainage, and sclerosis or thoracoscopy with drainage and talc poudrage also have benefits but are associated with variable hospitalization and increased medical costs.
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Affiliation(s)
- Joe B Putnam
- Department of Thoracic and Cardiovascular Surgery, The University of Texas, M.D. Anderson Cancer Center, 1515 Holcombe Boulevard, Box 445 Houston, TX 77030-4095, USA.
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Antony VB, Loddenkemper R, Astoul P, Boutin C, Goldstraw P, Hott J, Rodriguez Panadero F, Sahn SA. Management of malignant pleural effusions. Eur Respir J 2001; 18:402-19. [PMID: 11529302 DOI: 10.1183/09031936.01.00225601] [Citation(s) in RCA: 200] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- V B Antony
- VA Medical Center, Indianapolis, IN, USA
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Affiliation(s)
- L M Seijo
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania Medical Center, Philadelphia, USA
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O Talco deve ser utilizado para Pleurodese. REVISTA PORTUGUESA DE PNEUMOLOGIA 2001. [DOI: 10.1016/s0873-2159(15)30822-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Pleura: Anatomy, Physiology, and Disorders. Surgery 2001. [DOI: 10.1007/978-3-642-57282-1_56] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Putnam JB, Walsh GL, Swisher SG, Roth JA, Suell DM, Vaporciyan AA, Smythe WR, Merriman KW, DeFord LL. Outpatient management of malignant pleural effusion by a chronic indwelling pleural catheter. Ann Thorac Surg 2000; 69:369-75. [PMID: 10735665 DOI: 10.1016/s0003-4975(99)01482-4] [Citation(s) in RCA: 153] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Previous studies have shown that a chronic indwelling pleural catheter (PC) safely and effectively relieved dyspnea, maintained quality of life, and reduced hospitalization in patients with malignant pleural effusions. Outpatient management of malignant pleural effusion with a PC may reduce length of stay and early (7-day) charges compared with inpatient management with chest tube and sclerosis. METHODS A retrospective review of consecutive PC patients (n = 100; 60 outpatient, 40 inpatient) were treated from July 1, 1994 to September 2, 1998 and compared with 68 consecutive inpatients treated with chest tube and sclerosis between January 1, 1994 and December 31, 1997. Hospital charges were obtained from date of insertion (day 0) through day 7. RESULTS Demographics were similar in both groups. Pretreatment cytology was positive in 126 of 168 patients (75%), negative in 21 (12.5%), and unknown in 21 (12.5%). Primary histology included lung (n = 61, 36%), breast (n = 39, 23%), lymphoma (n = 12, 7%), or other (n = 56, 34%). Median survival was 3.4 months and did not differ significantly between treatment groups. Overall median length of stay was 7.0 days for inpatient chest tube and inpatient PC versus 0.0 days for outpatient Pleurx. No mortality occurred related to the PC. Eighty-one percent (81/100) of PC patients had no complications. One or more complications occurred in 19 patients (19%). Patients treated with outpatient PC (n = 60) had early (7-day) mean charges of $3,391 +/- $1,753 compared with inpatient PC (n = 40, $11,188 +/- $7,964) or inpatient chest tube (n = 68, $7,830 +/- $4,497, SD) (p < 0.001). CONCLUSIONS Outpatient PC may be used effectively and safely to treat malignant pleural effusions. Hospitalization is not required in selected patients. Early (7-day) charges for malignant pleural effusion are reduced in outpatient PC patients compared with inpatient PC patients or chest tube plus sclerosis patients.
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Affiliation(s)
- J B Putnam
- Department of Thoracic and Cardiovascular Surgery, The University of Texas M.D. Anderson Cancer Center, Houston 77030, USA.
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Heffner JE, Nietert PJ, Barbieri C. Pleural fluid pH as a predictor of pleurodesis failure: analysis of primary data. Chest 2000; 117:87-95. [PMID: 10631204 DOI: 10.1378/chest.117.1.87] [Citation(s) in RCA: 87] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES To determine the predictive accuracy of pH for identifying patients with malignant pleural effusions who will fail pleurodesis. DESIGN Analysis of published and unpublished individual patient-level data retrieved from a MEDLINE search and correspondence with primary investigators. STUDY SELECTION Studies that reported pleural fluid pH values and outcomes of pleurodesis for patients with malignant pleural effusions. DATA COLLECTION AND ANALYSIS Primary investigators supplied data for 433 patients. Receiver operating characteristic analysis and logistic regression estimated the predictive accuracy, decision thresholds, and value of pleural fluid pH compared with other clinical factors. The primary investigations were graded for study design. RESULTS Pleural fluid pH was the only independent predictor of pleurodesis failure (odds ratio, 4.46; 95% confidence interval [CI], 2.69 to 7.45; p < 0.0001) and had an area under the receiver operating characteristic curve (decision threshold, < or = 7.28) of 0.671 (95% CI, 0.624 to 0.715). The pH model fit the data well (p = 0.48) with the probability of pleurodesis failure increasing as pH decreased; specificity and negative predictive values for pleurodesis failure exceeded 90% and 80%, respectively, with a positive predictive value of 45.7% at pH values < or = 7.15. The primary studies had several important design limitations. CONCLUSIONS Using patient-level data, this study showed that pleural fluid pH has only modest predictive value for predicting symptomatic failure and should be used with caution, if at all, in selecting patients for pleurodesis. The limitations of the primary studies and low predictive accuracy should be considered when using pleural fluid pH for patient care.
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Affiliation(s)
- J E Heffner
- Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, SC 29425, USA.
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Burrows CM, Mathews WC, Colt HG. Predicting survival in patients with recurrent symptomatic malignant pleural effusions: an assessment of the prognostic values of physiologic, morphologic, and quality of life measures of extent of disease. Chest 2000; 117:73-8. [PMID: 10631202 DOI: 10.1378/chest.117.1.73] [Citation(s) in RCA: 155] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
PURPOSE To determine the prognostic value of pleural fluid pH, pleural fluid glucose, extent of pleural carcinomatosis (EPC) score, and Karnofsky Performance Scale (KPS) score in patients with recurrent symptomatic malignant pleural effusions. DESIGN Prospective 53-month study. SETTING Referral center for interventional pulmonology. PATIENTS Eighty-five consecutive patients (42 men and 43 women) with recurrent symptomatic malignant pleural effusions who were referred to the interventional pulmonary service for thoracoscopic pleurodesis. MEASUREMENTS Pleural fluid pH, pleural fluid glucose, EPC score, and KPS score. RESULTS The KPS score was the only statistically significant predictor variable. Patients with a KPS score >/= 70 had a median survival of 395 days, as opposed to a median survival of only 34 days for patients with a KPS score </= 30. No prognostic advantage was evident when patients were categorized by pleural fluid pH, pleural fluid glucose, or EPC score. CONCLUSION When assessing the prognosis of a patient with a recurrent symptomatic malignant pleural effusion, only the KPS score at the time of thoracoscopy is predictive of survival. Pleural fluid pH, pleural fluid glucose, and EPC scores are not as reliable as initially reported. For patients with a KPS score >/= 70, it may be very reasonable to proceed with thoracoscopic talc pleurodesis for management of their malignant pleural effusions.
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Affiliation(s)
- C M Burrows
- University of California at San Diego Medical Center, San Diego, CA, USA
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Heffner JE, Nietert PJ, Barbieri C. Pleural fluid pH as a predictor of survival for patients with malignant pleural effusions. Chest 2000; 117:79-86. [PMID: 10631203 DOI: 10.1378/chest.117.1.79] [Citation(s) in RCA: 122] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES To assess the accuracy of pleural fluid (PF) pH in predicting duration of survival of patients with malignant pleural effusions. DESIGN Analysis of patient-level data from nine sources retrieved from a MEDLINE search and correspondence with primary investigators. STUDY SELECTION Published and unpublished studies that report PF pH values and duration of survival of patients with malignant pleural effusions. DATA COLLECTION AND ANALYSIS Primary investigators supplied patient-level data (n = 417), which was examined by receiver operating characteristic (ROC) analysis, logistic regression, and survival time modeling to determine the utility of PF pH for predicting survival compared with other clinical factors. The primary investigations were graded for study design. MEASUREMENTS AND RESULTS Median survival (n = 417) was 4.0 months: PF pH (p < 0.0039) was an independent predictor of survival duration. A PF pH test threshold < or = 7.28 had the highest accuracy for identifying poor 1-, 2-, and 3-month survivals. The predictive accuracies of PF pH (area under the ROC curve range, 0.571 to 0.662) and a PF pH-high-risk tumor (lung, soft tissues, renal, ovary, gastrointestinal, prostate, and oropharynx) model (odds ratio range, 2.91 to 6.67), however, were modest for predicting 1-, 2-, and 3-month survival. Only 54.4% and 62.7% of patients identified by PF pH < or = 7.28 or the PF pH-high-risk tumor model to die within 3 months were correctly classified. Weaknesses of the primary data were identified. CONCLUSIONS PF pH has insufficient predictive accuracy for selecting patients for pleurodesis on the basis of estimated survival.
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Affiliation(s)
- J E Heffner
- Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, SC 29425, USA.
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Abstract
The increasing incidence of malignant pleural mesothelioma (MPM), better knowledge of its pathogenesis with a strong implication of asbestos fibers, and some promising therapeutic results have led to a new interest in the management of patients with this disease. The diagnosis of MPM is easier because of new immunohistochemical markers that recognize the mesothelial cells with good specificity and sensitivity on pleural biopsy samples ideally obtained by thoracoscopy. Moreover, this endoscopic procedure allows the physician to make the diagnosis of MPM at an early stage, which is the key of the therapeutic management of this disease. If radiotherapy is necessary in preventing the malignant seeding after pleural procedures in patients, the lack of comparative studies did not show the superiority of a given treatment against another. A new international staging of the disease, however, allows physicians to discriminate several groups of patients for such comparative studies--in particular, for testing the efficacy of intrapleural therapy, e.g., cytokines--for early-stage MPM and multimodal management, i.e., extrapleural pneumonectomy, radiotherapy, and chemotherapy for more advanced diseases, has led to prolonged survival in carefully selected patients. To reach this target, all patients must be enrolled in protocols. The usual pessimism for the management of patients with malignant pleural mesothelioma is over.
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Affiliation(s)
- P Astoul
- Department of Pulmonology, Hôpital de La Conception, Marseille, France.
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Goldwirth M, Krasin E, Goodwin DR. Talcum powder in revision surgery for olecranon bursitis. Good outcome in 11 patients. ACTA ORTHOPAEDICA SCANDINAVICA 1999; 70:286-7. [PMID: 10429607 DOI: 10.3109/17453679908997809] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We adapted the use of talcum powder in chest surgery to create a reactive pleuritis for treating recurrent olecranon bursitis. The 11 patients who underwent this procedure all had favorable outcomes.
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Affiliation(s)
- M Goldwirth
- Department of Orthopaedic Surgery A, Tel Aviv Sourasky Medical Centre, Israel
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