Recurrent Malignant Pleural Effusion Research Articles

Pleural Space Elastance and Its Relation to Success Rates of Pleurodesis in Malignant Pleural Effusion.

BackgroundPleurodesis fails in 10%–40% of patients with recurrent malignant pleural effusions malignant pleural effusion and dyspnea. This study aimed to assess the values of pleural elastance (PEL) after the aspiration of 500 mL of pleural fluid and their relation to the pleurodesis outcome, and to compare the pleurodesis outcome with the chemical characteristics of pleural fluid.MethodsA prospective study was conducted in Kasr El-Aini Hospital, Cairo University, during the period from March 2019 to January 2020. The study population consisted of 40 patients with malignant pleural effusion. The measurement of PEL after the aspiration of 500 mL of fluid was done with “PEL 0.5” (cm H2O/L), and the characteristics of the pleural fluid were chemically and cytologically analyzed. Pleurodesis was done and the patients were evaluated one month later. The PEL values were compared with pleurodesis outcomes.ResultsAfter 4-week of follow-up, the success rate of pleurodesis was 65%. The PEL 0.5 was significantly higher in failed pleurodesis than it was in successful pleurodesis. A cutoff point of PEL 0.5 >14.5 cm H2O/L was associated with pleurodesis failure with a sensitivity and specificity of 93% and 100%, respectively. The patients with failed pleurodesis had significantly lower pH levels in fluid than those in the successful group (p<0.001).ConclusionPEL measurement was a significant predictor in differentiating between failed and successful pleurodesis. The increase in acidity of the malignant pleural fluid can be used as a predictor for pleurodesis failure in patients with malignant pleural effusion.

Recent Developments in the Management of Malignant Pleural Effusions: a Narrative Review

The goal of this paper is to evaluate the literature published over past 3 years and emphasize the most recent updates in the diagnosis and management of malignant pleural effusions (MPE). The management of MPE is focused on palliation of symptoms and should take into account patient preferences and anticipated survival. Chemical pleurodesis and indwelling pleural catheters (IPC) are both definitive options for recurrent symptomatic MPE. IPC placement reduces hospitalization and can result in spontaneous pleurodesis, but these advantages must be weighed against the cost of materials and ongoing care. IPC is preferred over attempted pleurodesis in the presence of nonexpandable lung. The use of vacuum bottles during therapeutic thoracentesis is associated with increased pain and complications, and drainage via manual aspiration or to gravity is preferred. The routine use of manometry does not appear to reduce procedure-related discomfort. Several new advances have been made and discovered in relation to procedural aspects of thoracentesis, diagnosis, and management of MPE. We summarized the most relevant trials and studies and discuss their application in the clinical practice.

A novel pleural-bladder pump for the management of recurrent malignant pleural effusions: a feasibility animal study

BackgroundRecurrent malignant pleural effusions (MPE) are common and associated with significant morbidity in cancer patients. A new pump connecting the pleural cavity and the bladder may have application for the management of recurrent MPE. In a pre-clinical study, we investigated the utility of this pump in healthy pigs.MethodsA novel pump system (Pleurapump® system) was inserted into four pigs under general anaesthesia. A tunnelled-pleural catheter was connected to a subcutaneously implanted pump while the urinary bladder was connected by percutaneous technique. Animals were ventilated mechanically and pump functioning was tested using a range of ventilation parameters and spontaneous breathing. Fluid was added to the pleural space to mimic pleural effusion and to assess the effectiveness of the pump at removing fluid to the bladder.ResultsThe ‘pleurapump’ system successfully transported fluid from the pleural cavity to the bladder. Pressure variations caused by respiration and variations in the amount of fluid in the pleural cavity had no impact on the pumping. Pumping stopped when the pleural cavity was drained.ConclusionThis pump can be implanted into pigs and successfully removed fluid from the pleural cavity to the bladder and may represent a new treatment for management of recurrent MPE. Evaluation in humans is planned.

Complications after Indwelling Pleural Catheter Implant for Symptomatic Recurrent Benign and Malignant Pleural Effusions

Implant of indwelling pleural catheters (IPC) represents an established therapy method in addition to pleurodesis for symptomatic recurrent benign and malignant pleural effusions (BPE and MPE).There are only few studies on IPC safety during follow-up, especially with regard to infection and pneumothorax rates.The aim of our investigation was to determine the complication frequency after IPC implant and its predictive factors in patients with BPE vs. MPE. Retrospective analysis of all IPC implantations in the pneumology department at the University Hospital Dresden during 2015 - 2018. An IPC was implanted in 86 patients (43 m/f each; age 66.9 ± 13.3 years) with symptomatic BPE and MPE. BPE and MPE was present in 12.8 % (11/86) and 87.2 % (75/86) of the patients, respectively.A predominantly small and asymptomatic pneumothorax was detectable as an immediate complication in 43/86 (50 %) of patients; 34/43 (79 %) of patients did not require any specific therapy. For 9/43 patients, IPC suction was required for a median period of three days; 8/43 patients had a large pneumothorax with partial or complete regression after a median period of two days.Catheter infection developed in 15.1 % (13/86) of the total group and 36.4 % (4/11) of the BPE vs. 12 % (9/75) of the MPE after a median period of 87 (BPE/MPE 116/87) days. This was more common in BPE (p = 0.035), large pneumothorax (4/8 patients; p = 0.015) and longer catheter dwell times (124 ± 112 vs. 71 ± 112 days; p = 0.07). Small pneumothoraxes are frequent after IPC implantation, but usually do not require specific therapy. IPC infection was detected in 15.1 % of all patients after a median period of 87 days. This was more common in patients with BPE, longer catheter dwell times and large pneumothorax.

Adverse events after pleurodesis in patients with malignant pleural effusion.

BackgroundMalignant pleural effusion (MPE) is an important sign of advanced disease in metastatic cancer. Pleurodesis is one option to treat recurrent MPE. The Inflammatory response after pleurodesis may lead to important adverse events (AE) in a set of very ill patients.MethodsRetrospective analysis of patients submitted to pleurodesis (2009–2013). Clinical and laboratory data were collected. We compare the values in the day of pleurodesis, 2nd, 5th and 10th days after.ResultsOne hundred fourteen patients were undergone to pleurodesis with silver nitrate (46%), iodine (52%) and talc (2%). Female was the most frequent (86%) and the breast cancer was the most common primary site. The most frequent adverse event was low hemoglobin account (37), followed by pain (31). 68% of patients presented AEs and 28% had at least one AE with grade 3 or higher. The most altered was CRP that peaked in the 5th day after pleurodesis. Changes in CRP curve were less severe with the use of iodine when compared with the other two agents.ConclusionsPleurodesis leads to important systemic inflammatory response detected by different serum markers. The occurrence of adverse events in this set of patients was great number of events with being marked as grade 3 or higher.

Novel pleural-bladder pump in malignant pleural effusions: from animal model to man

Malignant pleural effusion is common and causes disabling symptoms such as breathlessness. Treatments are palliative and centred around improving symptoms and quality of life but an optimal management strategy is...

Heparan sulfate chains contribute to the anticoagulant milieu in malignant pleural effusion

BackgroundWhile malignant pleural effusion (MPE) is a common and significant cause of morbidity in patients with cancer, current treatment options are limited. Human heparanase, involved in angiogenesis and metastasis, cleaves...

Update on Management of Pleural Disease

The goal of this paper is to review and summarize the most recent updates in the management of both benign and malignant pleural diseases. Multiple trials evaluating the use of non-surgical techniques for the management of pleural infection have been published in the last 5 years. Additionally, the use of tunneled pleural catheter (TPC) placement in the management of non-infectious recurrent pleural effusions is being increasingly studied. Finally, the separate use of TPC placement or talc pleurodesis as well as a combined rapid pleurodesis protocol involving both talc poudrage and TPC placement has been published in the area of symptomatic recurrent malignant pleural effusion. Exciting advances have been made in the field of pleural disease management. In this paper, we summarize the most relevant trials, provide a list of pertinent references for review, and discuss future research directions.

When Do We Need Pleural Surgery?

Pleural sac is an enclosed sac covering the lung that consist of two membranes, i.e. parietal and visceral pleura. It has a cavity filled with small amount fluid that plays important role to provide smooth sliding of lung during respiration. Change or disturbance in the pleural cavity and or the pleura itself may result in restriction of lung expansion causing ventilation compromise. Pathology of pleura may result from varying etiology. It may present as inflammatory pleural effusion, non-inflammatory pleural effusion, pneumothorax, hematothorax, fibrothorax, pleural tumors, and cylothorax. Diagnostic tool for pleural diseases may be made from the simplest chest x-ray, ultrasound, computed tomography, MRI and histopathological studies. There are several treatment options for managing pleural diseases. It consist non operatif treatment, pleural drainage, decortication or pleurectomy, pleurodesis, and/ or resection of pleural tumor through procedure VATS, or open thoracotomy. Indications for surgery are traumatic or spontaneous pneumothorax, hematothorax, cylothorax, failure of non operatif treatment, fibrothorax or schwarte limiting lung expansion, mesothelioma, and recurrent pneumothorax or malignant pleural effusion. Decision for surgery need appropriate timing and planning regarding different pathology and different etiology.

Image-Guided Palliative Care (TH364)

•Develop a treatment plan that differentiates between those with a fully expanding lung and those with a fibrinothorax.•Determine different diagnostic tests and maintenance options that would be realistic and effective for that clinical setting.•List the 3 therapeutic options for celiac plexus blocks and their relative effectiveness areas of planning for physical therapy services. Image-guided palliative care is an underused therapy that can provide pain and symptom relief. These treatments can be provided by any physician with access to quality ultrasound, fluoroscopy, and computed tomography (CT) equipment. However, the efficacies and risks of the therapies may be different based on the technique and equipment used for the image-guided treatment and the timing of these treatments. This session will describe commonly encountered palliative problems that can be mitigated with image-guided and percutaneous therapies. A continuance of the 2018 interventional radiology presentation, this discussion will address different topics and will include efficacy, options, and risk data on each of the image-guided treatment options. Celiac plexus neurolysis will be reviewed again this year because of its importance in pain management, but we will concentrate on non-radiology based options (endoscopic ultrasound directed versus percutaneous CT-guided) and optimal timing of these 2 treatment options. The following topics will be discussed: the decision-making process and treatment of recurrent benign and malignant pleural effusions with special emphasis on the diagnosis and treatment of fibrinothorax (trapped lung), celiac plexus neurolysis for upper abdominal cancer pain, treatment options for recurrent cirrhotic and malignant ascites, gastrostomy tube insertion options and risks as well as recognition and treatment of late complications such as skin burns and intussusception, and catheter-based palliation of obstructive jaundice and cholecystitis. Finally, the presenters will review the efficacy and risks of intercostal neurolysis (rib blocks) for chest wall pain as well as how any physician can master this simple technique which can be performed without any image-guidance.

A META-ANALYSIS ON INDWELLING PLEURAL CATHETERS VS PLEURODESIS IN THE MANAGEMENT OF MALIGNANT PLEURAL EFFUSIONS: A MODERN DILEMMA

SESSION TITLE: Palliative Care and End-of-Life Issues SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/10/2018 01:00 PM - 02:00 PM PURPOSE: The choice between pleurodesis and indwelling pleural catheters (IPC) for the management of malignant pleural effusions (MPE) has been a significant controversial topic because not one of the two interventions has conclusively shown to be superior to each other. Pleurodesis was widely accepted as the treatment of choice for recurrent malignant pleural effusions (MPE). But, it still showed suboptimal results in terms of success rates, re-interventions, side effects, and complications. Recently, studies have shown that IPC can also be done even to patients who fit the criteria for pleurodesis. The paradigm shift revolutionized the goal of treating recurrent MPEs from treating the patient by radiologic evidence of pleural effusion to patient symptoms and quality of life. METHODS: We conducted an extensive search for published studies that compare pleurodesis with indwelling pleural catheters for malignant pleural effusions. Eligibility and bias assessments were done. The primary outcome was the control of effusion. The secondary outcomes were length of hospital stay, dyspnea, quality of life, chest pain and complication rates. RESULTS: Twenty four studies were initially screened until December 2017. However, only four studies with a total of 472 patients met the inclusion criteria. The studies were then analyzed and the results were as follows: A homogenous population (I2 = 14, P = 0.28) who underwent indwelling pleural catheter insertion had significantly decreased length of hospital stay by 3.63 days (95% CI -4.15, -3.16) compared to those who underwent pleurodesis. IPC also showed less loculations or effusions by 45% (CI 95%, 0.23, 1.31) that lead to reintervention by 40% (95% CI -1.78, 0.59), and better survival but it did not establish clinical significance. Pleurodesis, although not statistiscally significant, showed a trend towards better quality of life with a mean difference of 2.02 (CI 95% -5.41, 9.45). It also had reduced complication rates with a RR of 1.61 (CI 95% 0.85, 3.05), empyema of 2% (versus 5% in patients who had pleurodesis) and chest pain with a RR of 1.57 (95% CI 0.53, 4.66). CONCLUSIONS: Compared to pleurodesis, IPC significantly decreased the length of hospital stay and showed a trend towards less recurrence and improved survival. Pleurodesis had a trend towards favorable results in terms of quality of life, complication rates, empyema and chest pain. CLINICAL IMPLICATIONS: This is the first meta-analysis regarding indwelling pleural catheterization versus pleurodesis. Randomized controlled trials are very recent since the controversy of managing recurrent malignant pleural effusion was just brought to the health professionals' attention recently. Thus, the said meta-analysis brings new insight to the dilemma, urge researchers to investigate the findings for stronger validation, and most of all to give the patients the right intervention. DISCLOSURES: no disclosure on file for Ruth Marie Divinagracia; No relevant relationships by ANJULI MAY JAEN, source=Web Response No relevant relationships by Irene Rosellen Tan, source=Web Response no disclosure on file for Ralph Elvi Villalobos

Efficacy and safety of Viscum album extract (Helixor-M) to treat malignant pleural effusion in patients with lung cancer

Manifestations of malignant pleural effusions (MPEs) are alleviated by local therapies as well as by systemic treatment. After 2009, when commercial use of talc was discontinued in Korea, we have used Helixor-M, which is derived from the European mistletoe (Viscum album), as an alternative sclerosing agent for pleurodesis. We aimed to evaluate the efficacy and safety of Helixor-M for controlling MPE. Between 2009 and 2015, we consecutively enrolled 52 patients with lung cancer, who underwent pleurodesis to treat MPE and were analyzed retrospectively. On day 1, 100mg of Helixor-M was instilled via pleural catheter. If the procedure was not effective, it was repeated every other day up to five times, and the dose increased each time by 100mg. The primary study outcome was reappearance of pleural effusion at 1month after the last pleurodesis procedure. The median age of patient was 63years, and 77% of the 52 patients were male. About 85% of pleural effusions were found to be malignant by cytogenetic analysis. Forty-two (81%) patients were evaluable for recurrence of MPE. The 1-month recurrence rate was 48% (20/42). Among the 20 patients who developed recurrent MPE, 6 required therapeutic thoracentesis. Thirteen (25%) patients experienced procedure-related pain requiring medication. Eight (15%) had fever > 38°C. Our results suggest that a pleurodesis with Helixor-M was an effective and tolerable procedure for controlling MPE in lung cancer patients.

Indwelling pleural catheters: complications and management strategies.

Indwelling pleural catheters (IPCs) are increasingly being used for patients with recurrent malignant pleural effusions. They are simple to place and can be done on an outpatient basis under local anesthesia. IPCs uniformly relieve dyspnea and improve quality of life of patients with malignant pleural effusions. In some patients with recurrent non-malignant pleural effusions, IPCs proved to be effective as well. With increasing use of IPCs, physicians and patients are faced with complications related to the presence of an indwelling catheter for extended periods of time. The purpose of this review is to describe the various complications of IPCs and to present the available data on how to best treat and potentially prevent these complications.

Pleural effusions in hematologic malignancies and their management with indwelling pleural catheters

Pleural effusions in patients with hematologic malignancy may represent malignant pleural effusion (MPE) or occur secondary to infection, treatment effects, and other common causes. The impact of MPE on prognosis in this cohort remains unclear. Indwelling pleural catheters (IPCs) are routinely placed for palliation of recurrent symptomatic MPEs, but perceived concerns over infection and bleeding may limit their use in patients with hematologic malignancies. However, recent evidence suggests IPCs are both well tolerated and effective in this cohort. In this review, the evaluation of pleural effusions in hematologic malignancies and their management with an IPC are outlined. Two retrospective studies have been published regarding the use of IPCs in hematologic malignancies. Lymphomatous effusions are the most common cause of MPE in this cohort. The rates of complications and pleurodesis with IPC in hematologic malignancies are similar to those with solid organ tumors. Pleural effusions in patients with hematologic malignancies may be managed safely with an IPC. Sterile technique, barrier protection, standardized algorithms for placement and removal, and quality assurance initiatives are crucial to centers that place IPCs for all patients. The safety of IPC in hematologic malignancies warrants a paradigm shift in the management of pleural disease for this cohort.

The effect of iodopovidone versus bleomycin in chemical pleurodesis.

Background Malignant pleural effusion continues to be a common problem in patients with metastatic disease. This study was conducted to compare the efficacy and safety of bleomycin pleurodesis with povidone-iodine pleurodesis through a chest drain as palliative treatment for recurrent malignant pleural effusion. Methods Sixty cancer patients (36 males and 24 females) with recurrent malignant pleural effusion were enrolled in a prospective randomized trial. Thirty patients received povidone-iodine pleurodesis and 30 received bleomycin pleurodesis. Age, sex, side of the primary pathology, treatment outcome (recurrence and relapse time), and complications were analyzed. Results The mean age was 59.63 ± 7.68 years in the povidone-iodine group and 57.97 ± 9.27 years in the bleomycin group ( p = 0.452). The complications were identical in both groups: 2 (6.7%) patients had chest pain, 2 (6.7%) had fever, and one (3.3%) had hypotension. There was a good response to therapy in 20 (66.7%) patients in the bleomycin group and 25 (83.3%) in the povidone-iodine group ( p = 0.136). Conclusion The results of this study indicate that povidone-iodine should be considered as a selective chemical agent to perform pleurodesis in patients with recurrent malignant pleural effusion because it has the same effect but costs less than bleomycin.

What happens to the pleural space affected by malignant effusion after bedside pleurodesis?

Evaluate radiological characteristics of postpleurodesis pleural space of patients with recurrent malignant pleural effusion(RMPE). Prospective cohort study including patients with RPME treated with bedside pleurodesis. We used CT scans to calculate pleural cavity volume immediately before pleurodesis(iCT) and 30 days after(CT30). Radiological evolution was calculated by the difference between pleural volumes on CT30 and iCT(Δvolume). We categorized initial pleural volume as small(<500 mL) or large space(≥500 mL) and Δvolume as positive(>254.49 mL), unchanged(≥-268.77-≤ 254.49 mL), or negative(<-268.77 mL). Futhermore, we analyzed clinical effectiveness, pleural elastance, and adverse events. A total of 87 patients were analyzed. Pleural volume varied from 35-2750 mL in iCT and from 0-2995 mL in CT30(P = 0.753). A total of 54 patients had initial small pleural space(62.06%) and 33 large(37.93%). Clinical failure occurred in 7.4% of small space group and in 24.6% of large(P = 0.051, OR4.0(CI:1.098-14.570)). In small space group, 27.77% evolved with positive, 66.66% with unchanged and 5.55% with negative Δvolume. In the large space group these numbers were respectively 21.21%, 27.27%, and 51.51%. There is significant variability on pleural space volume. However, pleural volume remains unchanged in many cases. Besides that, more than half patients with initial large space coursed with relevant reduction. Finally, patients with initial small space presented a greater chance of clinical success.

EFFICACY OF POVIDONE IODINE VERSUS OXYTETRACYCLINE IN PLEURODESIS OF PATIENTS WITH RECURRENT MALIGNANT PLEURAL EFFUSION

RespirologyVolume 22, Issue S3 p. 195-195 APSR Poster Abstracts EFFICACY OF POVIDONE IODINE VERSUS OXYTETRACYCLINE IN PLEURODESIS OF PATIENTS WITH RECURRENT MALIGNANT PLEURAL EFFUSION First published: 23 November 2017 https://doi.org/10.1111/resp.13207_278Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume22, IssueS3Supplement: 22nd Congress of the Asian Pacific Society of Respirology, International Convention Centre, Sydney, Australia, 23–26 November 2017November 2017Pages 195-195 RelatedInformation

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

Comparison of Practice Patterns and Outcomes for Recurrent Malignant Pleural Effusions

SESSION TITLE: Pleural Effusions SESSION TYPE: Original Investigation Slide PRESENTED ON: Sunday, October 29, 2017 at 07:30 AM - 08:30 AM PURPOSE: Guidelines for treatment of recurrent malignant pleural effusions (MPE) recommend use of definitive procedures, such as indwelling pleural catheters (IPC) or pleurodesis, over repeat thoracentesis. However, there is a paucity of comparative effectiveness data assessing the impact of practice patterns on outcomes. We hypothesized that many patients receive multiple thoracenteses rather than receiving a definitive procedure as per guidelines and that guideline inconsistent care would result in more pleural procedures and complications. METHODS: Design: Retrospective cohort study of SEER-Medicare data from 2007-2011. The primary outcome was whether patients with rapidly recurring MPE, defined as recurrence within 2 weeks of their first thoracentesis, received guideline consistent care. Secondary outcomes included subsequent pleural procedures, pneumothorax from pleural procedures, location of care, and inpatient days associated with pleural procedures. Setting: Community and academic practices. Participants: Patients age 66-90 diagnosed with their first primary cancer with a MPE that had a thoracentesis were identified using ICD-9 and CPT codes. Thoracentesis for MPE was performed in 23,431 patients. Of these 12,967 (55%) required a second pleural procedure, 8,572 (37%) died without another pleural procedure and 1,892 (8%) were alive without recurrence at last follow-up. Of the 12,967 patients that required a second pleural procedure, 7,565 (58%) had it within 14 days of the first procedure. Exposure variable: Guideline consistent care, defined as a definitive second pleural procedure. RESULTS: Of the 7,565 patients with rapidly recurring MPE’s, only 1,811 (24%) received guideline consistent care. Definitive pleural procedures as compared to repeat thoracentesis for recurrence of MPE resulted in fewer future pleural procedures (0.62 vs. 1.44 procedures per patient respectively, p<0.0001), fewer pneumothoraxes (<0.0037 vs. 0.009 pneumothoraxes per patient, p=0.001), and fewer emergency room procedures (0.02 vs. 0.04 emergency room procedures per patient, p<0.001). However, repeat thoracentesis and IPCs resulted in fewer inpatient days as compared to chest tube or thoracoscopic pleurodesis (0.013 vs. 0.013 vs. 0.085 vs. 0.097 inpatient days per day of life respectively, p<0.001). Factors associated with guidelines consistent care included living in a big metropolitan area, specialists performing the first procedure, having the procedure in the emergency room, younger patient age, and having a diagnosis of lung cancer. CONCLUSIONS: Guideline consistent care using definitive procedures as compared to repeat thoracentesis is associated with fewer future procedures and complications. CLINICAL IMPLICATIONS: Attention to physician training and developing disease management pathways that facilitate prompt follow-up of MPE is needed to address the quality gap observed. DISCLOSURE: The following authors have nothing to disclose: David Ost, Jiangong Niu, Horiana Grosu, Sharon Giordano No Product/Research Disclosure Information

Quality Gaps and Comparative Effectiveness of Management Strategies for Recurrent Malignant Pleural Effusions

Guidelines for recurrent malignant pleural effusions (MPEs) recommend definitive procedures, such as indwelling pleural catheters (IPCs) or pleurodesis, over repeat thoracentesis. We hypothesized that many patients have multiple thoracenteses rather than definitive procedures and that this results in more procedures and complications. Retrospective cohort study using SEER-Medicare data from 2007 to 2011. Patients 66 to 90 years of age with an MPE were included. The primary outcome was whether patients with rapidly recurring MPE, defined as recurrence within 2weeks of first thoracentesis, received guideline consistent care. Guideline consistent care was defined as a definitive second pleural procedure. Thoracentesis for MPE was performed in 23,431 patients. A second pleural procedure because of recurrence was required in 12,967 (55%). Recurrence was rapid in 7,565 (58%) of the 12,967 patients that had a recurrence. Of the 7,565 patients with rapid recurrence, 1,811 (24%) received guideline consistent care. Definitive pleural procedures compared with repeat thoracentesis resulted in fewer subsequent pleural procedures (0.62 vs 1.44 procedures per patient, respectively; P< .0001), fewer pneumothoraxes (< 0.0037 vs 0.009 pneumothoraxes per patient, respectively; P= .001), and fewer ED procedures (0.02 vs 0.04 ED procedures per patient, respectively; P< .001). Repeat thoracentesis and IPCs resulted in fewer inpatient days compared with chest tube or thoracoscopic pleurodesis (0.013 vs 0.013 vs 0.085 vs 0.097 inpatient days per day of life, respectively; P< .001). Guideline consistent care using definitive procedures compared with repeat thoracentesis was associated with fewer subsequent procedures and complications; however, pleurodesis resulted in more inpatient days.