Patient evaluation for rapid pleurodesis of malignant pleural effusions

Fast pleurodesis combining talc poudrage and indwelling pleural catheter for the management of recurrent malignant pleural effusions

BACKGROUND AND OBJECTIVES

Malignant pleural effusions (MPE) are a frequent and major turning point in neoplastic disease usually leading to poor life expectancy. Improve quality of life and relieve the dyspnea are the main objectives in this palliative care setting. This can be achieved by the placement of an indwelling catheter (IPC) or talc pleurodesis ideally performed by thoracoscopy route (talc poudrage). Beside to misidentify a trapped-lung, the latter requires a prolonged hospital stay and the IPC placement does not allow a high pleurodesis rate. To overcome these drawbacks, a combination of both technique could be proposed for the management of recurrent malignant pleural effusions. Safety and efficacy of this pragmatic approach are reported.

METHODS

Consecutive patients who have been managed for recurrent MPE by a combination of talc poudrage for pleural symphysis by thoracoscopy route ending with the insertion of IPC using the same thoracic point of entry. Demographic data, hospital length of stay (LOS), procedural-related complications, patients' quality of life (QoL) and success of pleurodesis were collected. Patients were followed-up for 6 months.

RESULTS

The data of twenty-five consecutive patients undergoing the procedure were analyzed. Successful pleurodesis was obtained for 14/25 patients (66 %) at one month, 17/20 patients (85 %) at 3 months and 13/15 patients (86 %) at 6 months respectively. On average, the hospital LOS after the procedure was 3.24 days (IQR 1-4) with a median of 1 day. A prolonged hospitalization (>1 day) was never due to the procedure except for one patient (pneumothorax). No IPC related infection or procedure related deaths were noted.

CONCLUSION

Among patients with recurrent MPE, the combination of talc poudrage symphysis by thoracoscopy route and IPC placement on the same time results in a shortened hospital LOS and higher rate of pleurodesis. Further randomized clinical trials are needed to confirm these results.

Diagnosis and Management of Malignant Pleural Effusion: A Decade in Review

Malignant pleural effusion (MPE) is a common complication of thoracic and extrathoracic malignancies and is associated with high mortality. Treatment is mainly palliative, with symptomatic management achieved via effusion drainage and pleurodesis. Pleurodesis may be hastened by administering a sclerosing agent through a thoracostomy tube, thoracoscopy, or an indwelling pleural catheter (IPC). Over the last decade, several randomized controlled studies shaped the current management of MPE in favor of an outpatient-based approach with a notable increase in IPC usage. Patient preferences remain essential in choosing optimal therapy, especially when the lung is expandable. In this article, we reviewed the last 10 to 15 years of MPE literature with a particular focus on the diagnosis and evolving management.

Malignant Pleural Effusions

Malignant pleural effusions have a significant burden on patients and the health care system. Diagnosis is typically via thoracentesis, although other times more invasive procedures are required. Management centers around relief of dyspnea and patient quality of life and can be done via serial thoracentesis, indwelling pleural catheter, or pleurodesis. This article focuses on the diagnosis and management of malignant pleural effusion.

Ambulatory Thoracoscopic Pleurodesis Combined With Indwelling Pleural Catheter in Malignant Pleural Effusion

Background and Objective: Malignant pleural effusion (MPE) often results in debilitating symptoms. Relief of dyspnoea and improvement in quality of life can be achieved with either talc pleurodesis or insertion of an indwelling tunneled pleural catheter (IPC). The former requires a lengthy hospital stay and the latter is associated with lower pleurodesis rates. In response to limited hospital bed capacity, we developed a pragmatic approach in managing MPE by combining thoracoscopic talc poudrage and insertion of IPC into a single day case procedure. We present data on the safety and efficacy of this approach.

Methods: Patients who had undergone the abovementioned procedure between 2017 and 2020 were analyzed. Demographic data, hospital length of stay (LOS), histological diagnosis, rates of pleurodesis success and procedural related complications were collated. Patients were followed-up for 6 months.

Results: Forty-five patients underwent the procedure. Mean age was 68.5 ± 10.4 years and 56% were male. Histological diagnosis was achieved in all cases. 86.7% of patients were discharged on the day of the procedure. Median LOS was 0 (IQR 0–0) days. Successful pleurodesis was attained in 77.8% at 6-month follow-up. No procedure related deaths or IPC related infections were recorded.

Conclusion: Ambulatory thoracoscopic poudrage and IPC insertion is a safe and effective option in the management of MPE. All patients received a definitive pleural intervention with 77.8% pleurodesis success at 6-months and majority of them discharged on the same day. Future randomized trials are required to confirm these findings.

Sodium hydroxide as a sclerosing agent in patients with neoplastic pleural effusion non-candidates for VATS: results of a minimally invasive protocol

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.

Diagnosis and management of malignant pleural effusions: state of the art in 2017

Malignant pleural effusion (MPE) is a known complication of both thoracic and extra thoracic malignancies. The presence of MPE regardless of the primary site translates into advanced stage disease. Diagnosis and management of MPE with the goals of palliation and improving quality of life poses a challenge for chest physicians. Recently, multiple studies have made attempts to answer questions regarding optimal management in various clinical scenarios. We will review the current evidence and available options for the management of MPE.