Rapid pleurodesis for malignant pleural effusions

Survival Benefits for Pulmonary Adenocarcinoma With Malignant Pleural Effusion After Thoracoscopic Surgical Treatment: A Real-World Study

Objectives

Malignant cells in the pleural fluid or pleural metastasis are classified as stage IV non-small cell lung cancer. Radical surgery is generally considered not suitable for such patients. The aim of our study was to discuss the effectiveness of video-assisted thoracoscopic surgery (VATS) in such patients.

Methods

A retrospective analysis of the clinical records of 195 patients was performed. These patients were all diagnosed with locally advanced pulmonary adenocarcinomas with malignant pleural effusion (MPE, M1a) but no distant organ metastasis. The 195 patients included 96 patients who underwent VATS plus chemotherapy and 99 patients who received thoracic drainage plus chemotherapy. The baseline characteristics of the patients included age, gender, smoking history, Eastern Cooperative Oncology Group (ECOG) score, and number of chemotherapy cycles (2–4 cycles or >4 cycles); we also analyzed clinical characteristics including the specific surgical options of the VATS group.

Results

In multivariate analysis, when compared to the thoracic drainage group, the VATS group remained significantly associated with the overall survival [HR=0.480 (95%CI 0.301-0.765)]; when compared to the lobectomy, the sub-lobectomy and the palliative surgery, remained significantly associated with the overall survival [HR=0.637 (95%CI 0.409-0.993) and HR=0.548 (95%CI 0.435-0.832), respectively]. The median survival time (MST) of patients who underwent VATS (n = 96, 49.2%) was 25 months (95% CI 22.373–27.627) whereas the patients who received thoracic drainage (n = 99, 50.8%) was 11 months (95% CI 9.978–12.022). For patients who underwent VATS, the MST of patients who received a lobectomy (n = 50, 52.1%) was 27 months (95% CI 22.432–31.568), the MST of patients who received a sub-lobectomy plus pleurodesis (n = 26, 27.1%) was 27 months (95% CI 19.157–34.843), and the MST of patients who received only pleurodesis (n = 20, 20.8%) was 12 months (95% CI 7.617–16.383).

Conclusion

For pulmonary adenocarcinomas with MPE, receiving a lobectomy or sub-lobectomy plus pleurodesis with VATS was associated with improved survival compared with patients who only received thoracic drainage and chemotherapy. Our results and previously published data may justify the use of VATS for treating pulmonary adenocarcinomas with MPE.

Malignant Pleural Effusion: Still a Long Way to Go

BACKGROUND

Malignant pleural effusion, which is a common clinical problem in patients with cancer, may be due to both primary thoracic tumours or to a metastatic spread in the chest and constitutes the first sign of disease in approximately 10% of patients. Almost all cancers can potentially produce a pleural effusion. The presence of malignant tumour cells in the pleural fluid is generally indicative of advanced disease and is associated with high morbidity and mortality with reduced therapeutic options. Dyspnoea during mild physical activity or at rest is generally the typical sign of restrictive respiratory failure.

METHODS

This is a systematic review of all the main articles in the English language on the topic of malignant pleural effusion and reported by the Pubmed database from 1959 to 2018. I reviewed the literature and guidelines with the aims to focus on what is known and on future pathways to follow the diagnosis and treatment of malignant pleural effusions.

RESULTS

The main goal of palliation of a malignant pleural effusion is a quick improvement in dyspnoea, while thoracentesis under ultrasound guidance is the treatment of choice for patients with a limited life expectancy or who are not candidates for more invasive procedures such as drainage using an indwelling small pleural catheter, chemical pleurodesis with sclerosing agents, pleurectomy or pleuro-peritoneal shunt.

CONCLUSION

Despite progress in therapeutic options, the prognosis remains severe, and the average survival is 4-9 months from the diagnosis of malignant pleural effusion. Moreover, mortality is higher for patients with malignant pleural effusion compared with those with metastatic cancer but no malignant pleural effusion. Therefore, the prognosis of these patients primarily depends on the underlying disease and the extension of a primary tumour. This review focuses on the most relevant updates in the management of malignant pleural effusion.

Effect of chest tube size on pleurodesis efficacy in malignant pleural effusion: a meta-analysis of randomized controlled trials

Background

Malignant pleural effusion (MPE) develops in approximately 50% of all patients with metastatic cancer. The efficacy of small- vs. large-bore chest tube for pleurodesis in patients with MPE is still not clear.

Methods

We performed a meta-analysis to evaluate the efficacy and safety of chest tube size in the management of MPE. A systematic search of Medline (Ovid) and Embase (from 1980 to March 2016) was performed. Randomized clinical trials (RCTs) evaluating the effect of small (≤14 French) vs. large (>14 French) chest tube size on successful pleurodesis for patients with MPE. Of 708 potentially relevant publications, four matched the selection criteria and were included in the meta-analysis.

Results

Overall relative risk (RR) with 95% confidence intervals (CI) was pooled using a random-effects model. Heterogeneity was assessed using Q statistic (significant at P<0.1). In the 231 patients, the success proportion of pleurodesis as well as complication proportion were comparable between large and small chest tube groups with a pooled RR of 0.90 (95% CI, 0.77-1.05; P=0.19; I² =17.4%) and 0.95 (95% CI, 0.42-2.15; P=0.90; I² =0.9%) respectively. Successful pleurodesis and complication proportion for small vs. large chest tubes were 73.8% vs. 82.0% and 13.0% vs. 10.5%, respectively.

Conclusions

This meta-analysis suggests that small and large chest tubes are both effective treatment for MPE with similar successful pleurodesis and complication proportion. Further RCTs are needed to more clearly determine which size tube is superior.

Can EGFR-Tyrosine Kinase Inhibitors (TKI) Alone Without Talc Pleurodesis Prevent Recurrence of Malignant Pleural Effusion (MPE) in Lung Adenocarcinoma

Abstract: Background and Objective: Epidermal Growth Factor Receptor-Tyrosine Kinase Inhibitors (EGFR-TKIs) are effective against lung adenocarcinoma. However, limited data is available assessing the effectiveness of EGFR-TKI use in preventing re-accumulation of MPE. To our knowledge, there is no literature on comparison of talc pleurodesis with EGFR-TKIs alone on re-accumulation of MPE in Asian population. We investigated if EGFR-TKI therapy for advanced lung adenocarcinoma with malignant pleural effusion (MPE) is also successful in preventing pleural fluid re-accumulation following initial drainage.

Methods: An observational cohort study of patients with lung adenocarcinoma and MPE in the year 2012 was conducted.

Results: 70 patients presented with MPE from lung adenocarcinoma. Fifty six underwent EGFR mutation testing of which 39 (69.6%) had activating EGFR mutation and 34 (87.1%) received TKI. 20 were managed by pleural fluid drainage only whereas 14 underwent talc pleurodesis following pleural fluid drainage. Time taken for the pleural effusion to re-accumulate in those with and without pleurodesis was 9.9 vs. 11.7 months, p=0.59 respectively. More patients (n=10, 25.6%) with activating EGFR mutation presented with complete opacification (white-out) of the hemithorax compared to none without activating EGFR mutation (p=0.02).

Conclusion: In TKI eligible patients, early talc pleurodesis may not confer additional benefit in preventing re-accumulation of pleural effusion and may be reserved for non-adenocarcinoma histology, or EGFR negative adenocarcinoma. Complete opacification of the hemithorax on presentation may serve as an early radiographic signal of positive EGFR mutation status.

Experience with Ambulatory Management of Pleural Pathologies Utilizing Small-Bore Indwelling Pleural Catheters

Introduction Pleural effusion is the excess fluid that accumulates in the pleural space. Pneumothorax is the collection of free air in the pleural cavity, while empyema is the collection of pus in the pleural cavity. Such pleural pathologies pose a great challenge to patients and health care professionals alike. While multiple management options exist, the major portion of it is carried out in the inpatient setting. We sought to evaluate the ambulatory use of indwelling pleural catheters for pleural pathologies, including malignant pleural effusion, empyema, and primary spontaneous pneumothorax. Methods We conducted a prospective case series analysis of 15 patients with various pleural pathologies in which an indwelling pleural catheter was placed by interventional radiologists on an outpatient basis and subsequently followed-up in a pulmonary clinic. Results were analyzed on the basis of clinical, as well as radiological progress with parameters being complete, partial, or no resolution. We also obtained prospective data on the quality of life of these patients. Results Six out of seven patients with malignant pleural effusion reported clinical (complete or partial) resolution, while three reported radiological (complete or partial) resolution. Two of the three patients with nonmalignant pleural effusions reported complete clinical as well as radiological resolution. All three patients with empyema reported complete clinical resolution and partial radiological resolution, while both patients with primary spontaneous pneumothorax reported complete clinical and radiological resolution. Patients reported preserved or improved quality of life with the whole process managed on an outpatient basis. Conclusion We report a high rate of clinical and radiological resolution in various pleural pathologies in our study, which is first of its kind from this part of the world. It demonstrates the feasibility of ambulatory management of pleural pathologies with a multidisciplinary approach.

US Hospitalizations for Malignant Pleural Effusions: Data From the 2012 National Inpatient Sample

BACKGROUND

Malignant pleural effusion (MPE) is a common complication of advanced malignancy, but little is known regarding its prevalence and overall burden on a population level.

METHODS

We conducted a retrospective analysis of MPE-associated hospitalizations using the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample, Agency for Healthcare Research and Quality (HCUP-NIS 2012). Cases were included if MPE was coded as a primary or secondary diagnosis or if an unspecified pleural effusion was coded in addition to a diagnosis of cancer with either of these being the primary diagnosis.

RESULTS

A weighted sample of 126,825 admissions (0.35%) for MPE was identified among the 36,484,846 weighted admissions included in the database in 2012. Of these admissions, 70,750 (55.8%) were for female patients. The median age at admission was 68.0 years (interquartile range [IQR]), 58.4-77.2 years). Lung (37.8%), breast (15.2%), hematologic (11.2%), GI tract (11.0%), and gynecologic (9.0%) cancers were the most common primary malignancies associated with MPE. The median length of stay was 5.5 days (IQR, 2.7-10.1 days), and the inpatient mortality rate was 11.6%. Median hospitalization total charges were $42,376 (IQR, $21,618-$84,679). In the multivariate analyses, female sex, large fringe county residential area, Medicare insurance, and elective type of admission were independently associated with a lower risk of inpatient mortality.

CONCLUSIONS

There is a considerable inpatient burden and high inpatient mortality associated with MPE in the United States, with potential demographic, geographic, and socioeconomic disparities.

Patient evaluation for rapid pleurodesis of malignant pleural effusions

BACKGROUND

Malignant pleural effusions (MPEs) represent advanced stage disease with potentially significant patient discomfort due to dyspnea. Palliative management options include repetitive thoracenteses, placement of a tunneled pleural catheter (TPC), chemical pleurodesis, or some combination of these procedures. The rapid pleurodesis procedure combines thoracoscopic talc pleurodesis and insertion of a TPC at the same time with the goals of reducing both the length of hospitalization and the duration of catheter use. The rapid pleurodesis procedure has previously been described to achieve both of these goals in a pilot study of 30 patients with fully expandable lungs. Both symptoms of dyspnea and quality of life improved with few complications. Additional data on procedural effectiveness is needed to optimize patient selection for this procedure.

METHODS

We performed a retrospective analysis of patients who had undergone rapid pleurodesis protocol at two academic institutions over a 40-month period. Data was collected and analyzed on time to removal of the TPC, chemotherapy, malignancy type, complications, age, and catheter occlusion.

RESULTS

A total of 29 patients underwent the rapid pleurodesis protocol with a median hospital length of stay of 2 days. Total length of hospitalization was not significantly different between patients with and without primary lung cancer. Median duration of the indwelling TPC was 10 days. Patients with primary lung cancer and those actively or recently undergoing chemotherapy maintained the catheter longer than their counterparts.

CONCLUSIONS

The rapid pleurodesis protocol should be considered a viable treatment option for select patients with symptomatic recurrent MPEs undergoing chemical pleurodesis.

Pleuroscopic Pleurodesis Combined With Tunneled Pleural Catheter for Management of Malignant Pleural Effusion: A Prospective Observational Study

BACKGROUND

Malignant pleural effusion (MPE) is associated with poor prognosis and it often impinges upon quality of life; effective and efficient management is desirable. Combining pleuroscopic pleurodesis (PP) with a tunneled pleural catheter (TPC) could minimize hospitalization, effect rapid pleurodesis in most cases, and allow ongoing control of MPE for those not successfully pleurodesed.

METHODS

Consecutive patients with pleural effusion associated with malignancy and with documented lung reexpansion after pleural fluid drainage were prospectively enrolled to undergo PP with TPC placement. TPC was drained daily and was removed when output was <50 mL/d. Patients were followed for up to 6 months. The data collected were compared with historical controls as provided by a previously published study by our group on conventional pleuroscopic pleurodesis (CPP).

RESULTS

Thirty patients were enrolled between January 2012 and August 2013. Twenty-nine completed the protocol. Pleurodesis was successful in 92% of patients at 1 month. Of the patients alive at 6 months, 96% continued to have effective pleurodesis. The median duration of TPC placement was 6 days. The median LOS was 3 days (2 to 7.25). All patients experienced significant improvement in dyspnea scores. The median LOS was significantly lower than those who received CPP (median LOS, 9 d; range, 4 to 13 d; P=0.002). There was no significant difference in mortality rates and pleurodesis success rates.

CONCLUSIONS

The combination of PP with TPC can effect pleurodesis at a rate similar to CPP, shortens LOS, shortens time to pleurodesis, and helps to control symptoms when pleurodesis fails.

Interventional pulmonologist perspective: treatment of malignant pleural effusion

OPINION STATEMENT

The management of known malignant pleural effusions focuses around the initial thoracentesis and subsequent objective and subjective findings. A completely reexpanded lung after fluid removal and with symptomatic improvement predicts successful pleurodesis. Pleurodesis method depends on center expertise as well as patient preference. Medical thoracoscopy does not require the operating room setting and is performed on the spontaneously breathing patient with similar success rate to surgical thoracoscopy in the appropriately selected patients. However, it is not widely available. Talc insufflation is preferred for even distribution of sprayed particles to pleural surfaces. Most often, patients can be discharged home within 24 to 48 hours after continuous chest tube suction. Indwelling pleural catheter has become popular given the ease of insertion and patient centered home drainage. Coordinated care with good patient and family education and support is paramount to maximizing the beneficial potential of the catheter. Complications are minimal, and catheters are easily removed if patients can no longer benefit from drainage, or if pleurodesis has occurred. In the setting of trapped lung as a result of visceral pleura encasement from tumor, indwelling catheter can still be useful if the patient improves with thoracentesis. However, if no subjective improvement is seen after thoracentesis for trapped lung, then no procedure is recommended and other modes of palliation should be sought.

Talc pleurodesis through indwelling pleural catheters for malignant pleural effusions: retrospective case series of a novel clinical pathway

Malignant pleural effusions cause significant morbidity, but there is no gold standard minimally invasive treatment. A new therapeutic approach combines talc pleurodesis and indwelling pleural catheters (IPCs) to enable outpatient management. This case series summarizes the safety and efficacy data of all patients (24) with a symptomatic malignant pleural effusion who underwent talc pleurodeses via IPCs between December 2010 and July 2013. Successful pleurodesis was achieved in 22 procedures (92%). There was one empyema, one hydropneumothorax, one recurrent effusion, and two minor complications: one drain site wound infection and one complaint of chest pain. Twenty-two procedures (92%) were performed in the outpatient setting. This report confirms the safety and efficacy of administering talc slurry through IPCs in an outpatient setting. Studies in a larger cohort are necessary to define the role of this novel approach in the treatment algorithm of patients with this condition.

Rapid pleurodesis is an outpatient alternative in patients with malignant pleural effusions: a prospective randomized controlled trial

BACKGROUND

Chemical pleurodesis can be palliative for recurrent, symptomatic pleural effusions in patients who are not candidate for a thoracic surgical procedure. We hypothesized that effective pleurodesis could be accomplished with a rapid method of pleurodesis as effective as the standard method.

METHODS

A prospective randomized 'non-inferiority' trial was conducted in 96 patients with malignant pleural effusion (MPE) who are not potentially curable and/or not amenable to any other surgical intervention. They were randomly allocated to group 1 (rapid pleurodesis) and to group 2 (standard protocol). In group 1, following complete fluid evacuation, talc slurry was instilled into the pleural space. This was accomplished within 2 h of thoracic catheter insertion, unless the drained fluid was more than 1,500 mL. After clamping the tube for 30 min, the pleural space was drained for 1 h, after which the thoracic catheter was removed. In group 2, talc-slurry was administered when the daily drainage was lower than 300 mL/day.

RESULTS

No-complication developed due to talc-slurry in two groups. Complete or partial response was achieved in 35 (87.5%) and 33 (84.6%) patients in group 1 and group 2 respectively (P=0.670). The mean drainage time was 40.7 and 165.2 h in group 1 and group 2 respectively (P<0.001).

CONCLUSIONS

Rapid pleurodesis with talc slurry is safe and effective and it can be performed in an outpatient basis.

Successful use of central venous catheters in the management of recurrent malignant pleural effusions: one new option

BACKGROUND

Malignant pleural effusion (MPE) is a common clinical problem in patients with malignancy. To date, placement of various catheters has been suggested as an effective alternative method for traditional treatment of recurrent MPE. In this study, we report our experience in managing treatment of recurrent MPE by placing a central vein catheter without a radiologic guide.

METHODS

Patients with recurrent MPE who underwent triple-lumen central vein catheter insertion (2010-2013) were retrospectively reviewed. Clinical, procedural, complication, and outcome details were analyzed. Patients were carefully selected, and the central catheters were inserted as a palliative measure. We assessed the quality of life of patients using the EORTC QLQ-C30.

RESULTS

A total of 84 patients with recurrent MPE were enrolled in this study. Fifty-six males and 28 females with mean age of 57.8 ± 12.4 years old underwent the procedure. There were no preoperative or postoperative complications related to the procedure. The EORTC QLQ-C30 questionnaire showed a significant improvement following catheter placement in symptom scales at 30 days (p = 0.01) and at 60 days (p = 0.002).

CONCLUSIONS

Triple-lumen central catheter insertion is a simple, noninvasive option in patients with recurrent MPE that can be performed the patient's bedside. Further research is needed to confirm the results and to assess the impact of central catheter insertion on the quality of life of these patients.

Efficacy and safety of talc pleurodesis for malignant pleural effusion: a meta-analysis

Background

Talc pleurodesis has been widely used to control malignant pleural effusion; however, it is still not clear whether talc pleurodesis is more effective than other local therapies. We performed a meta-analysis to evaluate the efficacy and safety of talc pleurodesis in the management of malignant pleural effusion.

Methods

PubMed, Embase, and Web of Science were searched for English-language studies of clinical controlled trials comparing talc pleurodesis with control therapies until August 8, 2013. Success rate and incidence of adverse events were evaluated. Relative risks were estimated using random- or fixed- effects model and statistical heterogeneity was assessed using I² test.

Results

Twenty trials involving 1,525 patients with malignant pleural effusion were included. The success rate of talc pleurodesis was significantly higher than that of control therapies (relative risk, 1.21; 95% confidence interval, 1.01–1.45; p = 0.035) with similar adverse events. In addition, thoracoscopic talc poudrage was more effective than bedside talc slurry (relative risk, 1.12; 95% confidence interval, 1.01–1.23; p = 0.026).

Conclusions

The current evidences suggested the benefit for talc pleurodesis in the treatment of malignant pleural effusion. Talc pleurodesis, especially thoracoscopic talc poudrage pleurodesis, should be performed in patients with malignant pleural effusion, especially those with life-expectancy longer than one month.

WITHDRAWN: Pleurodesis for malignant pleural effusions

A new review team are preparing a new protocol to replace this review. The new review is entitled 'Interventions for the management of malignant pleural effusions'. Publication of the full review is anticipated in early 2015.

The editorial group responsible for this previously published document have withdrawn it from publication.

Malignant pleural effusions: a review

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.

Management of Malignant Pleural Effusions

The development of pleural effusions is a common occurrence in patients with neoplastic disease. In one postmortem study, 15 % of patients who died with malignancies were found to have malignant pleural effusions, and the annual incidence of malignant pleural effusions (MPE) in the United States is estimated to be >150,000 cases. The presence of a MPE often portends a poor prognosis; the mean survival after the diagnosis of a MPE ranges from 3 to 12 months, depending on the underlying tumor (lung cancer is generally associated with the shortest average survival time). Patients with MPE often have symptoms that impair their quality of life, such as dyspnea, orthopnea, cough, and chest discomfort, some or all of which can be improved with palliative therapeutic measures.

Intrapleural chemo- and hyperthermotherapies for malignant pleural effusion: a randomized prospective study

OBJECTIVE

The current prospective randomized study was designed to evaluate the safety and efficacy of combined intrapleural cisplatin and OK-432 (picibanil) plus hyperthermotherapy in patients with malignant pleural effusion (MPE).

METHODS

A total of 358 patients with MPE due to end-stage malignancies were enrolled and randomly divided into two groups, A and B: the intrapleural combination of cisplatin and OK-432 with hyperthermotherapy (n = 179) or without hyperthermotherapy (n = 179), respectively. Mild toxicities such as nausea, vomiting or anorexia, bone marrow depression, and pyrexia were similar in both groups.

RESULT

Patients in Group A (with hyperthermotherapy) showed a significantly higher overall response (93.4%) compared to those in Group B (79.8%, χ(2) = 43.11, p < .05). The median survival time for patients in Group A and Group B were 8.9 and 6.2 months, respectively (p > .05). After treatment, the quality of life scores were significantly increased in both groups as compared to prior treatment (p < .05).

CONCLUSION

In conclusion, our study suggests that combined intrapleural cisplatin and OK-432 followed by hyperthermotherapy are more effective in the control of MPE and improve patients' quality of life.

Management of malignant pleural effusions

Malignant pleural effusions are a common clinical problem in patients with primary thoracic malignancy and metastatic malignancy to the thorax. Symptoms can be debilitating and can impair tolerance of anticancer therapy. This article presents a comprehensive review of pharmaceutical and nonpharmaceutical approaches to the management of malignant pleural effusion, and a novel algorithm for management based on patients' performance status.

Treatment options for malignant pleural effusion

PURPOSE OF REVIEW

Thirty percent of lung cancers eventually result in malignant pleural effusion (MPE). Devastating consequences of MPE, such as dyspnea and cough, severely deteriorate the quality of life of these patients. Malignant pleural effusion portends a dismal prognosis of less than 6-month longevity, with the exception of breast and ovarian cancer. Given the poor prognosis of the majority of these patients, palliation, rather than cure, should be the goal of therapy.

RECENT FINDINGS

Chest tube insertion and sclerotherapy remain the standard of care. Emerging therapeutic options such as medical pleuroscopy and indwelling pleural catheters offer cost-effective and outpatient treatments for MPE.

SUMMARY

In the following review, the medical, economic, and social aspects of different current options for the management of MPE are discussed.

Diagnosis and management of malignant pleural effusions

Malignant pleural effusions (MPEs) complicate the clinical course of patients with a broad array of malignancies, which are most often due to lymphomas or carcinomas of the breast, lung, gastrointestinal tract or ovaries. Patients may present with a MPE as the initial manifestation of a cancer or develop an effusion during the advanced phases of a known malignancy. In either circumstance, the median survival after presentation with a MPE is 4 months. Effusions may result from direct pleural invasion (MPE) or indirect effects (paraneoplastic effusions), such as impairment of fluid efflux from the pleural space by lymphatic obstruction or pleural effects of cancer radiation or drug therapy. Because only 50% of patients with cancer who develop a pleural effusion during their clinical course have a MPE, careful evaluation of the effusion to establish its aetiology is required to direct therapy. Management is palliative with interventions directed towards decreasing the volume of intrapleural fluid and the severity of associated symptoms.

The evolving role of interventional pulmonary in the interdisciplinary approach to the staging and management of lung cancer. Part III: diagnosis and management of malignant pleural effusions

The diagnosis and management of a malignant pleural effusion can be one of the most vexing problems faced by physicians and their patients. Lung cancer is the most common primary tumor of origin with a prognosis that is limited, but variable and correlated with performance status (PS). Therefore, with a poor PS and known advanced lung cancer, establishing whether or not an effusion is malignant might not be necessary. Conversely, identifiable subsets of patients will have a much better survival, and establishing a definitive diagnosis could be of critical importance. In the great majority of cases, a diagnosis can be determined by serial thoracenteses with or without closed pleural biopsy. However, thoracoscopy is increasingly being utilized and can expedite the workup by obviating the need for repeated thoracenteses and/or closed pleural biopsy, while in the same setting providing definitive palliative treatment. Although studies comparing diagnostic and treatment strategies are limited, we will present the available data with the intention of providing the practicing oncologist with a practical strategy for the diagnosis and management of malignant pleural effusions due to lung cancer. The interventional pulmonologist can play an important role from diagnosis to palliation, greatly facilitating the care of patients with malignant pleural effusions.

Recent advances in the diagnosis and management of malignant pleural effusions

Malignant pleural effusions (MPEs) are an important complication for patients with intrathoracic and extrathoracic malignancies. Median survival after diagnosis of an MPE is 4 months. Patients can present with an MPE as a complication of far-advanced cancer or as the initial manifestation of an underlying malignancy. Common cancer types causing MPEs include lymphomas, mesotheliomas, and carcinomas of the breast, lung, gastrointestinal tract, and ovaries. However, almost all tumor types have been reported to cause MPEs. New imaging modalities assist the evaluation of patients with a suspected MPE; however, positive cytologic or tissue confirmation of malignant cells is necessary to establish a diagnosis. Even in the presence of known malignancy, up to 50% of pleural effusions are benign, underscoring the importance of a firm diagnosis to guide therapy. Rapidly evolving interventional and histopathologic techniques have improved the diagnostic yield of standard cytology and biopsy. Management of an MPE remains palliative; it is critical that the appropriate management approach is chosen on the basis of available expertise and the patient's clinical status. This review summarizes the pathogenesis, diagnosis, and management of MPE. Studies in the English language were identified by searching the MEDLINE database (1980-2007) using the search terms pleura, pleural, malignant, pleurodesis, and thoracoscopy.

Malignant pleural effusions: management options with consideration of coding, billing, and a decision approach

Malignant pleural effusions (MPEs) are a troublesome and debilitating complication of advanced malignancies, with > 150,000 cases in the United States each year. The standard management approach begins with a diagnostic and/or therapeutic thoracentesis. Should the MPE recur, a more definitive management strategy is often undertaken with several approaches available to the chest physician or surgeon. These options include repeat thoracentesis, tube thoracostomy with chemical pleurodesis, placement of an indwelling cuffed, tunneled pleural catheter with or without pleurodesis, or medical pleuroscopy or video-assisted thoracoscopic surgery with pleurodesis. Each approach has unique advantages, disadvantages, and likelihood of successful symptom relief and pleurodesis. This article will provide a general review of MPE management strategies including information concerning coding, billing, documentation, and a decision approach among these various methods.

Efficacy of short-term versus long-term chest tube drainage following talc slurry pleurodesis in patients with malignant pleural effusions: A randomised trial

Talc pleurodesis is commonly used in the palliative treatment of malignant pleural effusions but the shortest and most effective regime has not been determined. In particular, it is not clear when the intercostal drain should be removed following the insertion of sclerosant. We conducted a single-centre, randomised, open trial of drain removal at 24 h versus 72 h following talc slurry pleurodesis. The primary outcome measure was success of pleurodesis (no recurrence of effusion on chest radiograph at 1-month follow-up) and secondary outcome measures included length of hospital stay and mortality. We found no difference between recurrence of pleural effusion in those randomised to drain removal at 24 h and those randomised to drain removal at 72 h (p>0.5). However, length of stay was significantly reduced when the chest drain was removed at 24 h (4 days versus 8 days; p<0.01). Mortality did not differ between the two groups. We conclude that this shorter pleurodesis regime is safe and effective.

Rapid pleurodesis with doxycycline through a small-bore catheter for the treatment of metastatic malignant effusions

GOALS OF WORK

The goal of the study was to evaluate the safety and efficacy of bedside pleurodesis with doxycycline using a short-term indwelling chest catheter for the palliative treatment of malignant effusions.

MATERIALS AND METHODS

A prospective study of 36 rapid pleurodesis procedures in 34 patients with malignant pleural effusions was conducted over a 5-year period in a university hospital. A 12F chest catheter placement was facilitated utilizing the Seldinger percutaneous entry technique. Patients received 500 mg of intrapleural doxycycline combined in half of the cases with mepivacaine. We assessed success or failure of pleurodesis in addition to the frequency of complications and survival.

MAIN RESULTS

Chest tubes were removed within 24 h in 69% and within 48 h in 94% of the patients. Complete success of pleurodesis was achieved in 17 (55%), partial success in eight (26%), and failure in six (19%) out of 31 evaluative procedures. Thus, the overall success rate of pleurodesis was 81%. Toxicity was mild and included pain (36%), fever (8%), and pneumothorax (6%). The median survival was 105 days. There was no relationship between instillation of intrapleural anesthetics and development of pain.

CONCLUSIONS

Rapid pleurodesis with doxycycline, which can be accomplished within 24 to 48 h, is a valid option for the symptomatic treatment of malignant effusions. This technique can be used as a first-line procedure in the majority of cases, particularly if thoracoscopic facilities are not available.

Management of malignant pleural effusions

PURPOSE OF REVIEW

Although malignant pleural effusions are a common medical problem, research into their optimal management remains sparse. The aim of this review is to summarise recent developments in this area.

RECENT FINDINGS

Talc remains the most efficacious pleurodesis agent. However, concerns remain about its side effect profile, with a number of cases of acute respiratory distress syndrome documented in the literature. A recent trial showed that using calibrated talc particles reduced the risk of morbidity from this procedure. Work on novel pleurodesis agents, such as transforming growth factor-beta, appears to induce pleurodesis in animal models without any unwanted side effects. This is a promising development and human trials are awaited. With regard to mesothelioma, recent chemotherapy trials with pemetrexed/cisplatin and raltitrexed/cisplatin are encouraging and appear, for the first time, to offer a small but real survival advantage.

SUMMARY

In the authors' opinion, the major developments in the management of malignant effusions during the past year are the development of safer pleurodesis agents and the promise of better combination chemotherapy agents for the treatment of mesothelioma.

Supportive Care in Lung Cancer

Lung cancer often is associated with significant morbidity, which has a detrimental effect on quality of life. Supportive care plays a central role in the multimodal treatment of lung cancer. Palliation of symptoms often improves quality of life and compliance with therapy. New developments in supportive care, reviewed here, include management of symptoms of the disease, such as respiratory problems, pain, and cachexia, as well as effects of treatment, including chemotherapy-induced nausea and vomiting, neutropenia, anemia, and mucositis. In the past few years, significant advances have been made in this field; however, palliation of the symptoms of lung cancer remains an area of active investigation.

Chemotherapeutic management of malignant pleural effusion

The management of malignant pleural effusions are a common, and sometimes difficult, therapeutic problem. This article reviews the currently available sclerosing agents and discusses novel agents that show promise for the future. Talc, tetracycline and bleomycin are currently the most widely used agents but none is an ideal sclerosant and certain adverse effects are of concern. Novel agents, particularly transforming growth factor (TGF)-beta(2) and metalloproteinase inhibitors, are being investigated, and the increase in knowledge into the mechanisms of pleural fluid formation and pleurodesis will hopefully lead to the development of targeted therapy in the future.

Sonographically guided small-bore chest tubes and sonographic monitoring for rapid sclerotherapy of recurrent malignant pleural effusions

OBJECTIVE

To evaluate the role of sonographically guided small-bore chest catheters and sonographically based monitoring of fluid evacuation in rapid sclerotherapy of malignant pleural effusions.

METHODS

In 50 patients with recurrent malignant pleural effusions, a 9F catheter was inserted into the pleural space under sonographic guidance. When sonography documented complete fluid evacuation, bleomycin (0.75 mg/kg) was injected via the tube. Fluid drainage was monitored for 12 hours; if fluid output was less than 100 mL, the pleural catheter was removed; otherwise, a second dose of bleomycin was administered after 24 hours. If loculations or fluid reaccumulations due to tube malfunctioning were detected, they were evacuated by sonographically guided thoracentesis, and bleomycin (1.5 mg/100 mL of fluid) was injected through the thoracentesis needle. All patients were monitored for fluid recurrence with thoracic sonography.

RESULTS

Twenty-nine patients received 1 dose of bleomycin, and 21 received 2 doses. In 11 patients with residual loculations, sonographically guided thoracentesis was performed, and bleomycin was injected into the loculations. In 29 patients, pleurodesis was completed within 24 hours; in 21, it was completed within 48 hours. The 30-day response was 84%; the long-term response was 60%. No complications or serious side effects were observed.

CONCLUSIONS

Rapid pleurodesis can be accomplished within 24 to 48 hours, with good short- and long-term responses. Thoracic sonography plays a pivotal role. It guides placement of the pleural catheter and is valuable in the monitoring of fluid evacuation for determining the right time for sclerosing agent administration and in the detection and treatment of loculations or residual pleural fluid due to tube malfunctioning.

Prospective Randomized Trial of Intrapleural Bleomycin Versus Interferon Alfa-2b via Ultrasound-Guided Small-Bore Chest Tube in the Palliative Treatment of Malignant Pleural Effusions

Purpose

To compare bleomycin pleurodesis and immunotherapy with intrapleural interferon alfa-2b (IFN) in the palliation of malignant pleural effusions.

Patients and Methods

One hundred sixty patients with rapidly recurrent malignant pleural effusion were randomly assigned to intrapleural bleomycin (83 patients) or IFN (77 patients). A 9-French intrapleural catheter was placed under sonographic guidance, and pleural effusion was completely drained before starting the treatment. Bleomycin 0.75 mg/kg was administered as a single dose. An additional dose was given if daily fluid output did not drop to less than 100 mL/d within 3 days. IFN 1 million units/10 kg was administered for six courses at 4-day intervals. Thirty-day and long-term responses were evaluated under the intention-to-treat principle.

Results

Thirty-day response was 84.3% in the bleomycin arm and 62.3% in IFN arm (P = .002). Median time to progression was 93 days (range, 12 to 395 days) in bleomycin group, and 59 days (range, 7 to 292 days) in the IFN group (P < .001). Median survival was 96 days (range, 15 to 395) and 85 days (range, 16 to 292) in the bleomycin and IFN groups, respectively. Twenty-three patients received two doses of bleomycin, as their daily fluid output remained higher than 100 mL after the first dose. Thirteen of them had complete response, which lasted until death.

Conclusion

Intrapleural bleomycin is more effective than IFN and is a valid option for the palliative treatment of massive, rapidly recurrent malignant pleural effusions. The administration of a second dose of bleomycin to patients not responding to the first one can remarkably improve the overall outcome of the treatment.

Pleurodesis for malignant pleural effusions

BACKGROUND

Approximately half of all patients with metastatic cancer develop a malignant pleural effusion which is likely to lead to a significant reduction in quality of life secondary to symptoms such as dyspnoea and cough. The aim of pleurodesis in these patients is to prevent re-accumulation of the effusion and thereby of symptoms, and avoid the need for repeated hospitalization for thoracocentesis. Numerous clinical studies have been performed to try to determine the optimal pleurodesis strategy, and synthesis of the available evidence should facilitate this.

OBJECTIVES

The aims of this review were to ascertain the optimal technique of pleurodesis in cases of malignant pleural effusion; to confirm the need for a sclerosant; and to clarify which, if any, of the sclerosants is the most effective.

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials was searched for studies on 'pleurodesis'. Studies for inclusion were also identified from MEDLINE (1980 to June 2002) and EMBASE (1980 to May 2002). No language restriction was applied.

SELECTION CRITERIA

RCTs of adults subjects undergoing pleurodesis for pleural effusion in the context of metastatic malignancy (or a malignant process leading to pleural effusion) were included.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected studies for inclusion in the review, and extracted data using a standard data collection form. Primary outcome measures sought were effectiveness of pleurodesis as defined by freedom from recurrence of effusions, and mortality after pleurodesis. Secondary outcomes were adverse events due to pleurodesis. Dichotomous data were meta-analysed using a fixed effect model and expressed as relative risk. The number-needed-to-treat (NNT) was calculated for pleurodesis efficacy. In addition, for adverse events, the overall percentage of patients across studies exhibiting a particular adverse effect such as fever, pain, or gastrointestinal symptoms was calculated.

MAIN RESULTS

A total of 36 RCTs with 1499 subjects were eligible for meta-analysis. The use of sclerosants (mitozantrone, talc and tetracycline combined)compared with control (instillation of isotonic saline or equivalent pH isotonic saline or tube drainage alone) was associated with an increased efficacy of pleurodesis. The relative risk (RR) of non-recurrence of an effusion is 1.20 (95% CI 1.04 to 1.38) in favour of the use of sclerosants based on five studies with a total 228 subjects. Comparing different sclerosants, talc was found to be the most efficacious. The RR of effusion non-recurrence was 1.34 (95% CI 1.16 to 1.55) in favour of talc compared with bleomycin, tetracycline, mustine or tube drainage alone based on 10 studies comprising 308 subjects. This was not associated with increased mortality post pleurodesis. The RR of death was 1.19 (95% CI 0.08 to 1.77) for talc compared to bleomycin, tetracycline, mustine and tube drainage alone based on six studies of 186 subjects. Death was not reported in all studies and, when reported, was attributed to underlying disease, only one death being reported as procedure-related. In the comparison of thoracoscopic versus medical pleurodesis, thoracoscopic pleurodesis was found to be more effective. The RR of non-recurrence of effusion is 1.19 (95% CI 1.04 to 1.36) in favour of thoracoscopic pleurodesis compared with tube thoracostamy pleurodesis utilizing talc as sclerosant based on two studies with 112 subjects. Comparing thoracoscopic versus bedside instillation (with different sized chest tubes) of various sclerosants (tetracycline, bleomycin, talc or mustine) the RR of non-recurrence of effusion is 1.68 (95% CI 1.35 to 2.10) based on five studies with a total of 145 participants.Adverse events were not reported adequately to enable meta-analysis.

REVIEWER'S CONCLUSIONS

The available evidence supports the need for chemical sclerosants for successful pleurodesis, the use of talc as the sclerosant of choice, and thoracoscopic pleurodesis as the preferred technique for pleurodesis based on efficacy. There was no evidence for an increase in mortality following talc pleurodesis.