Recurrent Symptomatic Pleural Effusions Research Articles

Indwelling pleural catheters for persistent pleural effusions secondary to post lung resection for malignancies.

Malignant and nonmalignant pleural effusions (NMPEs) such as those due to hepatic hydrothorax have been successfully treated with an indwelling pleural catheter (IPC) with a low complication rate. There is no literature on the utility or safety of this treatment modality for NMPE post lung resection. We aimed to assess the utility of IPC for recurrent symptomatic NMPE secondary to post lung resection in lung cancer patients over a period of 4 years. Patients who underwent lobectomy or segmentectomy as part of the treatment plan for lung cancer between January 2019 and June 2022 were identified, these patients were screened for post-surgical pleural effusion. A total of 422 underwent lung resection, of which 12 had recurrent symptomatic pleural effusions requiring IPC placement and were selected for final analysis. The primary end points were improved symptomatology and successful pleurodesis. Mean time to IPC placement was 78.4 days post-surgery. The mean length of IPC catheter was 77.7 days standard deviation (SD) 23.8. All 12 patients achieved spontaneous pleurodesis (SP), there was no second pleural intervention or re-accumulation of fluid on follow up imaging in any of the subjects after IPC removal. Two patients (16.7%) had skin infection related to catheter placement that was managed with oral antibiotics, there were no cases of pleural infections that required catheter removal. IPC is a safe and effective alternative in managing recurrent NMPE post lung cancer surgery with high rate of pleurodesis and acceptable complication rates.

Association between terminal pleural elastance and radiographic lung re-expansion after therapeutic thoracentesis in patients with symptomatic pleural effusion: a post-hoc analysis of a randomised trial

ObjectivesRecurrent symptomatic effusions can be durably managed with pleurodesis or placement of indwelling pleural catheters. Recent pleurodesis trials have largely relied on lung re-expansion on post-thoracentesis radiograph as an inclusion...

Efficacy and safety of autologous blood pleurodesis versus talc pleurodesis in symptomatic pleural effusions: A randomized trial

PURPOSE: This study aimed to compare the efficacy and safety of autologous blood pleurodesis with talc pleurodesis in patients with symptomatic pleural effusion.METHODS: This is a prospective, randomized, noninferiority trial. The smallest sample size was determined as 26 for each group by power analyses. For pleurodesis, 5 g of talc and 2 ml/kg blood were administered through the chest catheter. The success rate and complication were recorded in the 1st month after the procedures. The effect of the procedure on the successful pleurodesis was analyzed by univariate and then multivariate logistic regression analysis.RESULTS: A total of 60 patients were randomized. After randomization, 6 patients withdrew from the study. The overall success rate of pleurodesis was 72.0% in the autologous blood group and 69.0% in the talc group (P = 0.903). The most common complications were fever and pain, and both were higher in the talc group (P = 0.030 and P = 0.001, respectively). For successful pleurodesis, complete lung expansion and catheter duration (<7 days) were important factors in the talc group and in the autologous blood group, respectively (P = 0.001 and P = 0.034). The effect of the procedure on pleurodesis success was not significant (odds ratio [95% confidence interval): 1.51 [0.40–5.77]; P = 0.548) after adjustment for lung expansion and catheter duration.CONCLUSION: Autologous blood pleurodesis is a simple, inexpensive, effective procedure and no related to significant adverse events for patients with recurrent symptomatic pleural effusion. Especially, it can be preferred in patients with incomplete lung expansion. Further studies are required to confirm the results of this study.

Recurrent Pleural Effusion Secondary to Multicentric Castleman Disease

SESSION TITLE: Pulmonary Manifestations of Systemic Disease 4 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Castleman’s disease is a rare disorder which results from unregulated lymphoproliferation. When involving one lymph node group (unicentric), it is usually benign and asymptomatic. However, when widespread involvement of lymph nodes is present (multicentric) it is often accompanied by numerous symptoms. Pleural effusion has been reported as an uncommon manifestation of this rare disease. CASE PRESENTATION: A 25 year old male with AIDS presented with abdominal pain for three weeks. He also complained of progressively worsening shortness of breath and night sweats but denied any fever, diarrhea, nausea, orthopnea or cough. Medical history was significant for opportunistic infections including MAC, PCP in the past one year and recently diagnosed Kaposi’s sarcoma from skin biopsy. On exam, he had mild diffuse abdominal tenderness, chest auscultation revealed decreased breath sounds and dullness to percussion bilaterally. Diffuse lymphadenopathy was felt in cervical, axillary and inguinal regions. CT scan of the abdomen showed significant bilateral pleural effusion, new from prior imaging one month ago, and intra-abdominal adenopathy. No obvious mass or infiltrate was seen on subsequent chest CT. Right sided thoracentesis on admission drained 1L of exudative pleural fluid per light’s criteria, however, cytology and microbiology was unremarkable. He was found to have leukopenia, macrocytic anemia and, elevated LFT, ESR and CRP. His last CD4 count one month ago was 5. Excision biopsy of axillary lymph node showed Kaposi’s sarcoma and HHV-8 associated multicentric Caslteman’s disease (MCD). IL-6 level was found to be significantly elevated. Patient continued to have recurrent symptomatic pleural effusions requiring repeated taps three times and eventually a pleurx catheter was placed. During this time, patient was continued on ART, MCD was treated with rituximab, etoposide, prednisone and valgancyclovir. After two cycles of chemotherapy, pleural effusion remained stable. DISCUSSION: Pleural effusion can be a result of lymphatic blockage in malignancies. However, in MCD IL-6 is hypothesized to cause capillary leak resulting in exudative pleural effusion. Management of HHV-8 associated MCD remains unclear and challenging as it involves chemotherapy in an already immunocompromised patient. Immunotherapy with Siltuximab is FDA approved for MCD. Due to availability, we treated our patient with anti-CD20 agent rituximab with steroids and cytotoxic agent etoposide. Due to aggressive nature of MCD in our patient, HHV-8 was treated with valgancyclovir. MCD remains a progressive disease despite treatment. CONCLUSIONS: This case highlights the pulmonary complication of Castleman’s disease. Long term catheters are recommended for recurrent pleural effusions, however, treating MCD aggressively may slow down reaccumulation. Reference #1: Reynolds SP, Gibbs AR, Weeks R, et al. Massive pleural effusion: an unusual presentation of Castleman's disease. Eur Respir J 1992; 5:1150-53 DISCLOSURE: The following authors have nothing to disclose: Abdurrahman Husain, Mekedim Bekele, Kibrewessen Tefera No Product/Research Disclosure Information

Complications of indwelling pleural catheter use and their management

The growing utilisation of indwelling pleural catheters (IPCs) has put forward a new era in the management of recurrent symptomatic pleural effusions. IPC use is safe compared to talc pleurodesis,...

Tunneled Pleural Catheter Placement with and without Talc Poudrage for Treatment of Pleural Effusions Due to Congestive Heart Failure.

There is a paucity of evidence regarding the role of tunneled pleural catheters in pleural effusions caused by congestive heart failure that is refractory to medical management. The aim of this study was to assess the feasibility of tunneled pleural catheter drainage for treatment of refractory pleural effusions associated with congestive heart failure, either when used alone or with concomitant talc pleurodesis performed during thoracoscopy. This was a retrospective cohort study. We identified patients with congestive heart failure and recurrent symptomatic pleural effusions who were treated between 2005 and 2015 by placement of a tunneled pleural catheter. Patients underwent either thoracoscopy followed by talc poudrage and pleural catheter placement (group 1) or catheter insertion alone (group 2). Forthy-three catheters were inserted in 36 patients, with 15 placed in group 1 and 28 in group 2. Successful pleurodesis was seen in 80% in group 1 and 25% in group 2. The median time of catheter placement was 11.5 days in group 1 and 66 days in group 2. There was a significant decrease in hospital admissions and pleural interventions after catheter placement compared with before insertion (P < 0.05). This single-center, retrospective study demonstrated the feasibility of catheter placement used alone or with talc poudrage for the treatment of refractory pleural effusions associated with congestive heart failure. The addition of talc poudrage might increase the pleurodesis rate and reduce the days to catheter removal in highly selected patients. Prospective studies on a larger number of patients are warranted to verify the safety and efficacy of this intervention.

Safety and Efficacy of Fibrinolytic Therapy in Restoring Function of an Obstructed Tunneled Pleural Catheter.

Tunneled pleural catheters have been established to be safe and effective in the management of recurrent symptomatic pleural effusions. Obstruction of the tunneled pleural catheter is rare; however, when obstructed the catheter fails to achieve its primary goal of symptom palliation. The management of pleural catheter obstruction has not been studied. We aimed to determine if the use of intracatheter fibrinolytic therapy is safe and effective in restoring catheter function. One hundred seventy-two patients with tunneled pleural catheters placed from 2009 to 2014 were reviewed to identify patients who received fibrinolysis for catheter obstruction, defined by a sudden reduction to less than 10 ml in pleural fluid drainage with fluid visualized in the thorax on ultrasound/radiography. The technique involved intracatheter instillation of 2 to 5 mg of alteplase, which was allowed to remain in the catheter for 60 to 120 minutes, after which drainage was performed. Obstruction occurred in 37 pleural catheters at a median of 2 months from insertion. One hundred percent (37/37) of obstructed catheters resumed drainage after fibrinolytic instillation, from a median of 4 ml before to 300 ml after fibrinolysis (P < 0.001). Twenty-four (65%) were performed in an outpatient setting, and no complications were encountered during or after fibrinolytic therapy. There were 18 episodes of reobstruction, all of which were successfully treated with intracatheter fibrinolytic therapy without complication. Fibrinolytic instillation through a tunneled pleural catheter is safe and effective in restoring function of an obstructed catheter, as evidenced by the lack of complications and success in achieving catheter patency. The procedure can also be performed safely in an outpatient setting. Patients who experience catheter obstruction may be prone to reobstruction; however, fibrinolysis was safe and effective in reestablishing patency of the reobstructed catheter.

Safety and Efficacy of Fibrinolytic Therapy in Restoring Function of an Obstructed Tunneled Pleural Catheter

Rationale: Tunneled pleural catheters have been established to be safe and effective in the management of recurrent symptomatic pleural effusions. Obstruction of the tunneled pleural catheter is rare; however, when obstructed the catheter fails to achieve its primary goal of symptom palliation. The management of pleural catheter obstruction has not been studied.Objectives: We aimed to determine if the use of intracatheter fibrinolytic therapy is safe and effective in restoring catheter function.Methods: One hundred seventy-two patients with tunneled pleural catheters placed from 2009 to 2014 were reviewed to identify patients who received fibrinolysis for catheter obstruction, defined by a sudden reduction to less than 10 ml in pleural fluid drainage with fluid visualized in the thorax on ultrasound/radiography. The technique involved intracatheter instillation of 2 to 5 mg of alteplase, which was allowed to remain in the catheter for 60 to 120 minutes, after which drainage was performed.Measurements and ...

Does pleural fluid appearance really matter? The relationship between fluid appearance and cytology, cell counts, and chemical laboratory measurements in pleural effusions of patients with cancer.

BackgroundPrevious reports have suggested that the appearance of pleural effusions (i.e., the presence or absence of blood) might help to establish the etiology of the effusions. This study explores the relationship between pleural fluid appearance and the results of chemical and cytological analyses in a group of patients with recurrent symptomatic pleural effusions and a diagnosis of cancer.MethodsMedical records were reviewed from all 390 patients who were diagnosed with cancer, who underwent thoracentesis before placement of an intrapleural catheter (IPC) between April 2000 and January 2006. Adequate information for data analysis was available in 365 patients. The appearance of their pleural fluid was obtained from procedure notes dictated by the pulmonologists who had performed the thoracenteses. The patients were separated into 2 groups based on fluid appearance: non-bloody and bloody. Group differences in cytology interpretation were compared by using the chi square test. Cellular counts, chemical laboratory results, and survival after index procedure were compared by using the student's t test.ResultsPleural fluid cytology was positive on 82.5% of the non-bloody effusions and on 82.4% of the bloody ones. The number of red blood cells (220.5 × 103/μL vs. 12.3 × 103/μL) and LDH values (1914 IU/dl vs. 863 IU/dl) were statistically higher in bloody pleural effusions.ConclusionThe presence or absence of blood in pleural effusions cannot predict their etiology in patients with cancer and recurrent symptomatic pleural effusions.

Chronic Indwelling Pleural Catheters Reduce Hospitalizations in Advanced Heart Failure with Refractory Pleural Effusions

Background: Patients with advanced heart failure (HF) frequently develop recurrent symptomatic pleural effusions requiring repeated hospitalizations for thoracentesis. While chronic indwelling pleural catheters have proven efficacy in the management of malignant pleural effusions, their utility in refractory pleural effusions related to HF is unknown. Methods: Subjects were consecutive HF patients seen at a large tertiary center (2005-2008) for recurrent symptomatic pleural effusions refractory to medical therapy.

Prolonged survival after talc poudrage for malignant pleural mesothelioma: Case series

Malignant pleural mesothelioma is a fatal disease with a mean life expectancy of 6-12 months. Since 1982, we have performed thoracoscopic talc poudrage (TTP) as a primary therapy in mesothelioma patients presenting with pleural effusion. As the survival data for our patients surpassed that of many published series, the patient data was analyzed to determine whether talc poudrage can be considered as a contemporary palliative option. We reviewed all 26 patients with a final diagnosis of malignant pleural mesothelioma from our prospective database of 228 consecutive patients who received thoracoscopy from the same physician for recurrent symptomatic pleural effusion. Patients were followed up until their death. Mean survival after TTP was 23.8 +/- 16.3 months (median 19.4, range 2.9-68). Pleurodesis palliated dyspnoea in all patients. No perioperative deaths and one postoperative complication (pneumonia) occurred. Mean hospital stay was 3.9 +/- 2.7 days. TTP remains a safe, low-morbidity, inexpensive primary palliative treatment option for malignant pleural mesothelioma and a valid control arm option for therapeutic trials. TTP is ideal for patients who wish to avoid thoracotomy, long hospital stays and morbidity from multimodality therapy. Prospective randomized studies are needed to compare quality of life and survival after talc poudrage and other therapies.

Pancreatic Cancer And Malignant Pleural Effusion

Background: Aim of this study was to assess the efficacy of mitoxantrone sclerotherapy as a palliative treatment of malignant pleural effusions due to pancreatic cancer. Methods: Twenty-nine patients with known pancreatic cancer and malignant recurrent symptomatic pleural effusion were treated with chest tube drainage followed by intrapleural mitoxantrone sclerotherapy. Survival, complications and response to pleurodesis according to clinical and radiographic criteria were recorded. The data are expressed as the mean ± standard error of the mean (SEM) and the median. Results: The mean age of the entire group was 52 ± 10,27 years. The mean interval between diagnosis of pancreatic cancer and presentation of the effusion was 6 ± 2,3 months. Six patients (20,6%) had pleural effusion as the first evidence of recurrence. The mean volume of effusion drained was 970 ± 105 ml and chest tube was removed within 4 days in 72,4% (21/29) of patients. There were no deaths related to the procedure. Side effects of chemical pleurodesis included mainly fever, chest pain, nausea and vomiting. At 30 days among 28 treated effusions (one patient died within 1 month of pleurodesis), there was an 85,7% (24/28 patients) overall response rate, including 20 complete responses and 4 partial responses. At 60 days the overall response was 75% (19 complete responses and 2 partial responses). The mean survival of the entire population was 6,3 ± 1,1 months. Conclusions: Mitoxantrone is effective in the treatment of malignant pleural effusion secondary to pancreatic cancer without causing significant local or systemic toxicity.

Mitoxantrone pleurodesis to palliate malignant pleural effusion secondary to ovarian cancer.

BackgroundAdvanced ovarian cancer is the leading non-breast gynaecologic cause of malignant pleural effusion. Aim of this study was to assess the efficacy of mitoxantrone sclerotherapy as a palliative treatment of malignant pleural effusions due to ovarian cancer.MethodsSixty women with known ovarian cancer and malignant recurrent symptomatic pleural effusion were treated with chest tube drainage followed by intrapleural mitoxantrone sclerotherapy. Survival, complications and response to pleurodesis were recorded. The data are expressed as the mean ± SEM and the median.ResultsThe mean age of the entire group was 64 ± 11,24 years. The mean interval between diagnosis of ovarian cancer and presentation of the effusion was 10 ± 2,1 months. Eighteen patients (30%) had pleural effusion as the first evidence of recurrence. The mean volume of effusion drained was 1050 ± 105 ml and chest tube was removed within 4 days in 75% of patients. There were no deaths related to the procedure. Side effects of chemical pleurodesis included fever (37–38,5°C) chest pain, nausea and vomiting. At 30 days among 60 treated effusions, there was an 88% overall response rate, including 41 complete responses and 12 partial responses. At 60 days the overall response was 80% (38 complete responses and 10 partial responses). The mean survival of the entire population was 7,5 ± 1,2 months.ConclusionsMitoxantrone is effective in the treatment of malignant pleural effusion secondary to ovarian cancer without causing significant local or systemic toxicity.

Results of chemical pleurodesis with mitoxantrone in malignant pleural effusion from breast cancer

BackgroundCarcinoma of the breast is the second leading cause of malignant pleural effusions. This study reports on the efficacy of mitoxantrone as a sclerosing agent in patients with breast cancer who had a pleural effusion as a direct consequence of metastatic disease.Patients and methodsOver a 5-year period, 114 patients with a known breast malignancy and having recurrent symptomatic pleural effusion referred for chest tube drainage and sclerotherapy were considered eligible. They had received no prior intrapleural therapy and had a predicted survival of >1 month. All of them underwent pleural drainage and chemical pleurodesis with mitoxantrone. Survival, complications and response to pleurodesis according to clinical and radiographic criteria were recorded. The data are expressed as the mean ± standard error of the mean (SEM) and the median. The χ2 test was used for statistical analysis. To assess the prognostic value of Karnofsky's performance status score a Cox proportional hazards model was used.ResultsThe mean age of the patients was 53.5 ± 2.1 years. Effusion occurred after 38.2 ± 6.2 months (range: 1–229 months) after the diagnosis. Ipsilateral effusion was seen in 73%, contralateral in 20% and bilateral in 7%. Forty patients (35%) had pleural effusion as the first evidence of recurrence. The mean volume of effusion drained was 1020 ± 125 ml and the chest tube was removed within 5 days in 82% of patients. Side effects of chemical pleurodesis included mainly fever, chest pain, nausea and vomiting. At 30 days 64 patients (56.3%) had a complete response (CR) and 30 patients (26.3%) partial response (PR) to pleurodesis (overall response: 82.6%). At 60 days the overall response was 78.5% (CR:53.5%, PR: 25%). The mean survival was 15.6 ± 2 months. Karnofsky's performance status score was found to be a statistically significant predictor. Patients with Karnofsky's performance status score >70 had a median survival of 513 days, as opposed to a median survival of only 63 days for patients with a Karnofsky's performance status score <30.ConclusionsMitoxantrone is effective in the treatment of malignant pleural effusion due to breast carcinoma with relatively low local or systemic toxicity. Karnofsky's performance status score at the time of pleurodesis is predictive of survival.

Safety And Efficacy Of Mitoxantrone In The Palliative Treatment Of Malignant Pleural Effusions Due To Breast Cancer

The purpose of this study was to assess the efficacy and safety of mitoxantrone in the palliative treatment of pleural effusions due to breast cancer. 114 patients with a known breast malignancy and recurrent symptomatic pleural effusion referred for chest tube drainage and sclerotherapy were studied. They had received no prior intrapleural therapy and had a predicted survival of >1 month. Survival, complications and response to pleurodesis according to radiographic criteria were recorded. The data are expressed as the mean +/- SEM and the median. The mean age of the entire group was 53,5 +/- 2,1 years. The mean volume of effusion drained was 1020 +/- 125 ml and the chest tube was removed within 5 days in 82% of patients. There were no deaths related to the procedure. Side effects of chemical pleurodesis included mainly fever, chest pain, nausea and vomiting. At 30 days 64 patients (56,3%) had a complete response (CR) and 30 patients (26,3%) partial response (PR) to pleurodesis (overall response: 82,6%). At 60 days the overall response was 78,5% (CR:53,5%, PR: 25%). The mean survival of the entire population was 15,6 +/- 2 months. Mitoxantrone is effective in the treatment of malignant pleural effusion due to breast carcinoma without causing significant local or systemic toxicity.

Thoracoscopy with Talc Pleurodesis Shortens Hospitalization

A retrospective review of patients with recurrent symptomatic pleural effusions was done to assess whether thoracoscopy with talc pleurodesis shortens chest tube duration and hospital length of stay while maintaining a satisfactory success rate compared with thoracostomy. Thirty consecutive patients with recurrent symptomatic malignant or undiagnosed pleural effusions underwent 32 thoracoscopies with talc pleurodesis (74% women; mean age, 59.4 years). They were compared with 47 historic control subjects who underwent 50 chest tube thoracostomies and pleurodesis with doxycycline (55% women; mean age, 59.6 years). Patients were followed for 6 months. Failure of pleurodesis was defined as reaccumulation of a symptomatic effusion, continued chest tube drainage at the time of death, or the need for subsequent drainage procedures. The majority of the effusions were the result of malignant disease. Thoracoscopy was successful for 91% (29 of 32) of the procedures performed. The mean length of hospital stay was 4.6 days with a mean chest tube duration of 3.1 days. This was significantly less than the control group, which had a mean length of stay of 13.9 days and a mean chest tube duration of 7.3 days (p < 0.001). Thoracoscopy is an effective mode of relieving symptomatic pleural effusions. The procedure is minimally invasive with a low incidence of complications. It shortens hospital length of stay, which can translate into lower healthcare cost and improved quality of life in patients with a limited life expectancy.

Management of recurrent spontaneous pneumothorax and recurrent symptomatic pleural effusion with chest tube pleurodesis.

Management of recurrent spontaneous pneumothorax and recurrent symptomatic pleural effusion with chest tube pleurodesis.