Palliation Of Malignant Pleural Effusion Research Articles

Erector spine plane block as single loco-regional anesthesia in non-intubated video-assisted thoracic surgery for unfit patients: a case-match study.

In the present study, we analyzed the safety and efficacy of non-intubated video-assisted thoracoscopy (NI-VATS) for the diagnosis and palliation of malignant pleural effusion in the elderly population using erector-spinae plane block (ESPB) as single loco-regional anesthesia. From January 2016 to December 2020 a consecutive series of 158 patients who underwent surgery for malignant pleural effusion was analyzed. Of these, 20 patients were operated using ESPB NI-VATS, while 138 were operated under general anesthesia (GA). After propensity score matching, the NI-VATS population was older (81 vs. 76years p 0.006), and had more severe pre-existing comorbidities, evaluated using Charlson Comorbidity Index (p = 0.029) and ASA score (p < 0.001). GA and NI-VATS patients did not differ in terms of postoperative opioid consumption, complication rate and postoperative hospitalization. Both short- and long-term efficacy of talc poudrage was equal in the two populations. The overall length of stay in the operative room was significantly shorter for the NI-VATS than for the GA-VATS group (67.5 vs. 105min, p < 0.001), and operative time significantly differed in the two groups (35 vs. 47.5min, respectively, p < 0.001). ESPB NI-VATS can be a safe and effective option for the diagnosis and palliation of malignant pleural effusion for elderly and frail patients.

Pleural Drainage Strategy After IPC Placement: A Focused Clinical Review.

The first indwelling pleural catheter (IPC) received Federal Drug Administration approval in 1997, nearly 40 years after John Chambers first described instillation of talc into the pleural space for palliation of malignant pleural effusions. Since then IPCs have revolutionized the management of malignant pleural effusions, providing an effective means of controlling dyspnea in the end stages of life without the pain and prolonged hospital stays long associated with chemical sclerosing agents. While palliation of symptoms is the primary purpose of IPCs, development of pleurodesis in the outpatient setting is often an important secondary goal. Historically, decisions regarding IPC drainage frequency have been largely arbitrary and only recently has the evidence started to emerge regarding the effects of specific drainage strategies on both symptom control and pleurodesis development. This focused clinical review explores the current literature regarding IPC drainage strategies as well as novel methods designed to improve the efficacy of IPCs in a thorough and systematic manner. In addition, this review provides an in-depth analysis and synthesis of the data focusing on key considerations needed to develop patient-centered and cost-effective strategies for the use of IPCs in malignancy.

AABIP Evidence-informed Guidelines and Expert Panel Report for the Management of Indwelling Pleural Catheters.

While the efficacy of Indwelling pleural catheters for palliation of malignant pleural effusions is supported by relatively robust evidence, there is less clarity surrounding the postinsertion management. The Trustworthy Consensus-Based Statement approach was utilized to develop unbiased, scientifically valid guidance for the management of patients with malignant effusions treated with indwelling pleural catheters. A comprehensive electronic database search of PubMed was performed based on a priori crafted PICO questions (Population/Intervention/Comparator/Outcomes paradigm). Manual searches of the literature were performed to identify additional relevant literature. Dual screenings at the title, abstract, and full-text levels were performed. Identified studies were then assessed for quality based on a combination of validated tools. Appropriateness for data pooling and formation of evidence-based recommendations was assessed using predetermined criteria. All panel members participated in development of the final recommendations utilizing the modified Delphi technique. A total of 7 studies were identified for formal quality assessment, all of which were deemed to have a high risk of bias. There was insufficient evidence to allow for data pooling and formation of any evidence-based recommendations. Panel consensus resulted in 11 ungraded consensus-based recommendations. This manuscript was developed to provide clinicians with guidance on the management of patients with indwelling pleural catheters placed for palliation of malignant pleural effusions. Through a systematic and rigorous process, management suggestions were developed based on the best available evidence with augmentation by expert opinion when necessary. In addition, these guidelines highlight important gaps in knowledge which require further study.

ES 06.05 Approach to Malignant Pleural Effusions

The onset of an MPE usually indicates a significant reduction in prognosis, with a median life expectancy of 3 to 12 months from onset. MPE associated with breast cancer is usually associated with a better than average prognosis whilst lung cancer has the worst prognosis. Confirmation of malignancy and determination of the cell type may be established by increasingly invasive techniques; pleural aspiration cytology, facilitated by ultrasound guidance if the effusion is small or loculated, pleural biopsy, blind or image guided, thoracoscopy (usually now video-assisted) under local or general anesthesia. Whilst it is reasonable to start with the least invasive procedure suitable in the circumstances, in patients who are reasonably fit it is important to avoid an escalating cascade of failed procedures, each with the risk of causing pleural adhesions and clot formation, making effective palliation more difficult. There is much to commend early acceptance of an approach which combines the best chance of a tissue diagnosis with the best chance of effective palliation. This decision will be influenced by an assessment of prognosis. Prognosis once an MPE has been confirmed is dependent upon the extent of metastatic disease and associated co-morbidity. In a surgically palliated population in-hospital and 30-day mortality was statistically related to blood albumen levels, being 0% and 0.98% in those with normal albumen levels and 6.8% and 19% in those with hypoalbumenaemia (p =0.001).1 In a series of 278 patients referred to the Department of Thoracic Surgery at the Royal Brompton Hospital over a 72 month period 195 underwent thoracoscopic talc pleurodesis, 39 had a pleuro-peritoneal shunt inserted, 38 had pleurodesis through an intercostal drain, 29 had pleural biopsy alone and 9 were treated with long-term pleural drainage, a total of 310 surgical procedures. Overall median survival was 211 days post operatively. Survival was not significantly different for tumor type or method of palliation but was related to leucocytosis (p<0.0001), hypoxemia (p =0.014) and hypoalbumenaemia (p<0.0001).2 The summative effect of these factors is shown in the table. How this information might be used to personalize treatment options in patients for whom effective systemic therapy does not exist. Those whose prognosis is judged to be less than 2 months (having all 3 adverse prognostic factors) palliation may be achieved by repeated pleural aspiration. If prognosis is judged to be greater than 2 months, and especially if the patient is in a poor general condition, adequate palliation could be achieved by the insertion of an indwelling pleural catheter under local anesthesia. In fitter patients with an estimated survival greater than 6 months VATS insufflation of talc or the insertion of a pleuro-peritoneal shunt should be considered. The choice of talc or shunt will be dictated by the adequacy of lung expansion during positive pressure ventilation. In many respects these 2 techniques are complementary but having both of these techniques available at thoracoscopy allows affective long-term palliation to be achieved in 95% of patients.3 However pleuro-peritoneal shunts can be complicated by occlusion within 4 months in 15% of cases but spontaneous pleurodesis has usually been achieved by this time.4 Pleurectomy is rarely indicated in the palliation of MPE. 1. Pilling JE, Dusmet M, Ladas G, Goldstraw P. Predictors of early mortality and morbidity follwoing surgical palliation of malignant pleural effusion. Journal of Thoracic Oncology 2[8], s430. 2007. 2. Pilling JE, Dusmet ME, Ladas G, Goldstraw P. Prognostic Factors for Survival after Surgical Palliation of malignant Pleural Effusion. J Thorac Oncol 5, 1544-1550. 2010. 3. Petrou M, Kaplan D, Goldstraw P. The management of recurrent malignant pleural effusions: The complementary role of talc pleurodesis and pleuroperitoneal shunting. Cancer 75, 801-805. 1995. 4. Genc O, Petrou M, Ladas G, Goldstraw P. The long-term morbidity of pleuroperitoneal shunts in the management of recurrent malignant effusions. European Journal of Cardio-thoracic Surgery 18, 143-146. 2000. Malignant effusions, palliation, pleural malignancyTabled 1No of factorsnMedian survival (days)95% CIpNone39702473-931<0.00001One or two74200111-289Three234223-61 Open table in a new tab

Implantation of permanent pleural catheter for palliation of malignant pleural effusion.

PurposeMalignant pleural effusion (MPE) is a disabling condition caused in most instances by far-advanced cancer. The treatment is palliative and should ideally be minimally invasive. The aim of this retrospective study was to evaluate the effectiveness of implantation of a permanent PleurX catheter in the treatment of recurrent MPE in patients with terminal cancer disease.Patients and methodsEighteen consecutive patients with terminal cancer and MPE, who had a permanent PleurX catheter implanted in the period from February 2014 to August 2015, were retrospectively evaluated. Medical records were reviewed for data on procedures and patients.ResultsTwenty-two PleurX catheters were implanted in the pleural cavity of 18 patients. The technical success rate was 100%. All patients had relief of symptoms. Catheter patency was 91%. Six patients experienced minor adverse events (AEs) and two patients experienced moderate-to-severe AEs. The median survival time for the 14 patients who died during follow-up was 45 days.ConclusionImplantation of a permanent PleurX catheter is a safe procedure with a high success rate and only few AEs. The procedure has the potential to serve as an effective procedure for palliation of recurrent MPE in terminal cancer patients.

Pathway to Definitive Palliation of Malignant Pleural Effusions

SESSION TITLE: Impact of Pleural Disorders SESSION TYPE: Original Investigation Slide PRESENTED ON: Monday, October 24, 2016 at 07:30 AM - 08:30 AM PURPOSE: Malignant pleural effusions (MPE) are a common clinical problem. Definitive management strategies for symptomatic patients include chemical pleurodesis and indwelling pleural catheters. The clinical pathway that patients with symptomatic MPE experience prior to definitive palliation, including all procedures and hospital admissions, has not been systematically examined. METHODS: This was a retrospective study. Thoracoscopic talc insufflation and indwelling pleural catheter placement are performed at the Montreal Chest Institute for definitive palliation of patients with symptomatic MPE. The charts of all patients referred over a 2-year period were reviewed, with attention to the clinical course preceding definitive MPE palliation. The number of thoracenteses and chest tube insertions performed, ER visits and hospital admissions were tabulated over the interval from initial symptomatic MPE presentation to definitive palliation. RESULTS: Over a 2-year period, 99 patients underwent definitive interventions for MPE. Data on the clinical course leading to definitive palliation was available in 69 patients, who underwent 72 definitive procedures (68 indwelling pleural catheter insertions and 4 thoracoscopic talc insufflations). The clinical course leading to definitive palliation was considered “ideal” in 36/72 (50%) cases, with patients undergoing ≤ 2 therapeutic thoracenteses, no chest tube insertions, ≤ 1 ER visit, and no hospital admissions. In the remaining patients, a mean of 2.4 (SD 1.65) pleural procedures were performed during the period leading to definitive palliation. Tube thoracostomy (without pleurodesis) was performed in 27/72 (38%) cases, with the chest tubes remaining in place for an average of 3.7 days (SD 3.0). Hospitalization for symptomatic MPE preceded definitive palliative intervention in 28/72 (39%) cases. Patients who initially presented to the ER with symptomatic MPE were more likely to undergo chest tube insertion and hospital admission. CONCLUSIONS: There is significant variability in the clinical pathway of patients with symptomatic MPE, prior to definitive palliation. Half of the patients in this series underwent potentially avoidable procedures and/or hospital admissions. CLINICAL IMPLICATIONS: Increased awareness and accelerated referral for definitive palliation may avoid unnecessary pleural procedures and hospitalizations. DISCLOSURE: The following authors have nothing to disclose: Benjamin Shieh, Stephane Beaudoin, Anne Gonzalez No Product/Research Disclosure Information

A Propensity-Matched Comparison of Pleurodesis or Tunneled Pleural Catheter in Patients Undergoing Diagnostic Thoracoscopy for Malignancy

Patients with a suspected malignant pleural effusion occasionally require thoracoscopy to achieve a diagnosis. It is unclear whether chemical pleurodesis or the placement of a tunneled pleural catheter (TPC) that can be used for intermittent pleural drainage produces superior palliation, a shorter hospital stay, and less morbidity. This investigation compares these 2 treatment groups. Patients with a recurrent, symptomatic, pleural effusion suspected of having a malignant etiology who underwent a thoracoscopic exploration after at least 2 nondiagnostic thoracenteses were identified. Two patient groups were formed, comprised of patients who received either talc pleurodesis or a TPC at the conclusion of the procedure, using propensity matching. Patient demographics, length of stay, interval until the initiation of systemic therapy, need for further intervention for the pleural effusion, and procedural morbidity and mortality were collected and compared. Over a 6-year period, 60 patients undergoing treatment were identified and propensity matched. No significant differences in mean age or palliation from their effusion were identified. However, the group treated with TPC realized a significantly shorter hospital stay and interval to systemic therapy for their malignancy as well as a lower rate of operative morbidity than patients undergoing talc pleurodesis. This investigation found that a TPC provided palliation of patients' malignant pleural effusions and freedom from reintervention equal to that of talc pleurodesis after thoracoscopy while resulting in a shorter mean length of hospital stay and interval to the initiation of systemic therapy. Lower rates of operative morbidity were also seen in the TPC treatment group. This method of palliation of a malignant pleural effusion should be considered when diagnostic thoracoscopy reveals a malignant pleural effusion.

Optimal Management of Malignant Pleural Effusions (Results of CALGB 30102)

The optimal strategy to achieve palliation of malignant pleural effusions (MPEs) is unknown. This multi-institutional, prospective, randomized trial compares 2 established methods for controlling symptomatic unilateral MPEs. Patients with unilateral MPEs were randomized to either daily tunneled catheter drainage (TCD) or bedside talc pleurodesis (TP). This trial is patterned after a previous randomized trial that showed that bedside TP was equivalent to thoracoscopic TP (CALGB 9334). The primary end point of the current study was combined success: consistent/reliable drainage/pleurodesis, lung expansion, and 30-day survival. A secondary end point, survival with effusion control, was added retrospectively. This trial randomized 57 patients who were similar in terms of age (62 years), active chemotherapy (28%), and histologic diagnosis (lung, 63%; breast, 12%; other/unknown cancers, 25%) to either bedside TP or TCD. Combined success was higher with TCD (62%) than with TP (46%; odds ratio, 5.0; P = .064). Multivariate regression analysis revealed that patients treated with TCD had better 30-day activity without dyspnea scores (8.7 vs. 5.9; P = .036), especially in the subgroup with impaired expansion (9.1 vs. 4.6; P = .042). Patients who underwent TCD had better survival with effusion control at 30 days compared with those who underwent TP (82% vs. 52%, respectively; P = .024). In this prospective randomized trial, TCD achieved superior palliation of unilateral MPEs than TP, particularly in patients with trapped lungs.

Prognostic Factors for Survival after Surgical Palliation of Malignant Pleural Effusion

To investigate prognostic factors for patient survival after surgical palliation of malignant pleural effusion (MPE). We reviewed 278 consecutive nonoverseas patients (108 men, median age: 60 years [range 26-89]) undergoing 310 surgical procedures for palliation of MPE over a 72-month period. There were 195 thoracoscopic talc pleurodesis, 39 pleuroperitoneal shunts, 38 pleurodesis by an intercostal drain, 29 pleural biopsies alone, and nine long-term drains. Referring physicians provided survival data. The significance of prognostic factors was examined with the log-rank test (Kaplan-Meier), those significant entered a Cox logistic multivariate regression analysis. Follow-up was complete until death (following 264 procedures) and for a median 648 days (range 173-2135) for surviving patients. Overall median postoperative survival was 211 days (95% confidence interval: 169-253). Survival was not significantly different for tumor type or method of palliation. In univarate analysis, preoperative leucocytosis, hypoxemia, raised alanine transaminase, body mass index below 18 and hypoalbuminemia were associated with a significantly reduced postoperative survival. In multivariate analysis, leucocytosis (p < 0.0001), hypoxemia (p = 0.014), and hypoalbuminemia (p < 0.0001) maintained significance. The survival reported demonstrates the necessity of an active approach to palliation of MPE. The identification of prognostic factors will assist the choice of palliative technique. In addition, an appreciation of the influence of selection on survival after surgical palliation of malignant pleural mesothelioma, especially that of unforeseen prognostic factors, is useful when evaluating the results of aggressive treatment such as chemoradiotherapy and radical surgery for these diseases.

Selective apoptosis of lung cancer cells with talc

To the Editors: Lung cancer is the leading cause of cancer deaths worldwide, with adenocarcinoma being the most common cell type. The majority of patients with lung cancer present at an advanced stage of disease with only 15% being amenable to surgery for cure; treatment is, therefore, palliative. For patients with malignant effusions due to pleural metastasis, chemical pleurodesis is one method by which to prevent recurrence. While there are many intrapleural sclerosing agents, most data pertaining to pleurodesis have been reported with tetracycline derivatives, bleomycin and talc 1. A number of studies have demonstrated superior efficacy of talc over other sclerosing agents commonly used for the palliation of malignant pleural effusions 2, and talc is the preferred pleurodesis agent according to a survey of chest physicians 3. Despite talc's wide clinical use, the exact mechanisms for its efficacy as well as its apoptotic effects on lung cancer cells in vitro have not been studied. The objectives of our study were to determine if talc caused apoptosis of lung cancer cells, and to compare talc against other commonly administered intrapleural sclerosing agents by extending the experiments to include bleomycin and doxycyline. The lung adenocarcinoma cell line (LAC, A549) was purchased from American Type Culture Collection (Rockville, MD, USA). Human pleural mesothelial cells (PMC) characterised by classic cobblestone morphology, cytokeratin and without factor VIII antigen were isolated from pleural fluid obtained via thoracentesis from patients with symptomatic transudative pleural effusions secondary to congestive heart failure, and …

PD6-2-6: Predictors of early mortality and morbidity following surgical palliation of malignant pleural effusion

PD6-2-6: Predictors of early mortality and morbidity following surgical palliation of malignant pleural effusion

Use of tunneled pleural catheters for outpatient treatment of malignant pleural effusions

Malignant pleural effusion is a common complication in advanced malignancy that causes debilitating symptoms which result in impaired quality of life. The primary therapeutic goal in malignant pleural effusion management is effective palliation of the associated respiratory symptoms. Pleurodesis by chest tube or thoracoscopy is widely accepted as the gold standard treatment, although these treatments are not without problems. Tunneled pleural catheters represent a new safe and effective outpatient treatment option for these patients, with no reported mortality and minimal morbidity. Chest tube insertion with talc slurry and thoracoscopy with talc insufflation are effective methods for achieving spontaneous pleurodesis, although associated with significant morbidity and mortality. A growing body of evidence is confirming that long-term palliation of malignant pleural effusion can be achieved by using tunneled pleural catheters in a large proportion of relatively unselected patients on an outpatient basis. The optimal method for palliative management of malignant pleural effusion remains controversial. The high success rates, low complication rates and efficacy in patients with a wide range of performance status support the use of tunneled pleural catheters as a first-line treatment for symptomatic malignant pleural effusion.

Tunneled Pleural Catheters for Palliation of Malignant Pleural Effusions

Tunneled Pleural Catheters for Palliation of Malignant Pleural Effusions

Early experience with videothoracoscopic hydrodissection pleurectomy in the treatment of malignant pleural effusion.

Parietal pleurectomy is our preferred procedure for management of malignant pleural effusion. However, the morbidity of a major thoracotomy has precluded all but highly selected patients from the conventional (open) procedure. Recently, we have been able to perform parietal pleurectomy by means of a video-assisted, thoracoscopic technique. We have retrospectively analyzed the results of this procedure performed on 11 patients between March 1993 and February 1995. These patients ranged in age from 40 to 87 years of age, with a mean age of 61.5 years. Primary tumors were non-small cell lung cancer (5), breast cancer (4), mesothelioma (1), and unknown (1). There was one operative mortality (9.1%). All were relieved of symptoms of pleural effusion. Median survival was 128 days. Early experience indicates we are accomplishing an operation equivalent to that formerly performed by "open" technique. If continued results are similar to our initial experience, we will be able to offer this superior palliation of malignant pleural effusion to a wider range of patients.

Comparison of insufflated talc under thoracoscopic guidance with standard tetracycline and bleomycin pleurodesis for control of malignant pleural effusions

The standard palliation of malignant pleural effusions involves tube thoracostomy drainage with chemical pleurodesis. The insufflation of intrapleural talc under thoracoscopic guidance (n = 39) was evaluated against documented controls that consisted of patients (n = 85) who participated in a randomized study with tube thoracostomy drainage followed by either bleomycin or tetracycline sclerosis. Under local anesthesia, which was supplemented by intravenous sedation, patients in the talc group underwent complete pleural fluid evacuation. The talc was then insufflated evenly on the entire pleural surface under thoracoscopic guidance. Of the patients in the talc group who survived their disease process, 97% had a successful pleurodesis at 30 days and 95% at 90 days. In comparison, the bleomycin group demonstrated a success rate of 64% at 30 days and 70% at 90 days (p = 0.003 and p = 0.047 versus the talc group). The tetracycline group had successful pleurodesis in only 33% at 30 days and 47% at 90 days (p < 0.001 and p < 0.001 versus the talc group). There were only two patients in the talc group in whom pleurodesis was not successful, and both were subsequently found to have extraluminal compression of the right lower lobe bronchus, which prevented lung reexpansion. These data demonstrate that the insufflation of talc into the pleural cavity under thoracoscopic guidance is a safe and efficacious procedure in the control of malignant pleural effusions.

Clinical Experience With Tetracycline Pleurodesis of Malignant Pleural Effusions

Because many patients with malignant pleural effusions could survive for months to years beyond its onset, definitive management must be safe and effective. Chemical pleurodesis with tetracycline has gained general acceptance as the therapy of choice, even though no large series confirming this viewpoint has appeared in the literature. We reviewed 108 procedures involving tube thoracostomy and tetracycline pleurodesis, and report a success rate of 94.4% without serious complications. Considering all patients, 49% were symptom-free at three months, and 13% were alive one year later. Several potentially important changes in technique have emerged since the initial description of this procedure. With adherence to meticulous technique, tetracycline pleurodesis provides rapid, effective, and safe palliation of malignant pleural effusions.