Thoracoscopic Talc Pleurodesis Research Articles

Small cell lung carcinoma presenting initially with recurrent pneumothoraces: a case report

BackgroundPneumothorax is a non-physiological collection of air in the pleural space. Pneumothoraces can be broadly divided into Primary, Secondary, and Traumatic. Cancer of the lung is a known cause of secondary pneumothorax in both primary and metastatic lesions, however, pneumothorax as the presentation of lung cancer is exceedingly rare. Non-small cell lung carcinoma (NSCLC) has been reported in the literature to present with a pneumothorax, particularly in adeno/squamous cell carcinomas. It is almost completely unheard of for small cell lung carcinoma (SCLC) to present with a pneumothorax.Case PresentationWe present the case of a 62-year-old male patient, presenting twice in two months with spontaneous pneumothorax. The initial management involved admission and chest drain insertion. The patient has a past medical history of COPD and a significant smoking history. On the second admission, he underwent a video-assisted thoracoscopic (VATS) bullectomy and talc pleurodesis. The pathology report of the resected specimen confirmed SCLC with extensive infiltration. No gross evidence of metastatic spread was present on CT. Due to the R1 resection and significant risk of recurrence, the management plan included four cycles of adjuvant chemotherapy with carboplatin and etoposide, and radiotherapy as a consideration upon completion.ConclusionsPneumothorax as the presentation of lung cancer imparts a very poor prognosis, however the reasons for this are largely unknown. Furthermore, the mechanisms underlying spontaneous pneumothorax in lung cancer are also not well understood.

Spontaneous pneumothorax rates following video-assisted thoracoscopic talc pleurodesis with or without resection of macroscopic bullous disease.

Recurrent primary spontaneous pneumothorax (PSP) is routinely treated by video-assisted thoracoscopic (VATS) talc pleurodesis (with or without localized resection of macroscopic bullous disease). There is a paucity of published data regarding durability of the procedure and the rate of recurrent pneumothorax after such surgery, and this has significant implications from a prognostic and employment limitation perspective. Patients who underwent a VATS talc pleurodesis (with or without localized resection of macroscopic bullous disease) for the treatment of their second or subsequent PSP or a PSP were followed for recurrent ipsilateral pneumothorax and new contralateral PSP. Follow up was by way of telephone interview and medical record verification out to 48 months. New contralateral pneumothorax occurred in 7 patients (11.1%) in the talc pleurodesis plus wedge resection group and 2 (1.8%) in the talc pleurodesis only group. There was one case of recurrent ipsilateral pneumothorax in a patient who had no inflammatory response to talc insufflation. Video-assisted thoracoscopic (VATS) talc pleurodesis (and lung resection for macroscopic bullous disease) is a durable treatment for recurrent PSP. Patients with macroscopic disease have a significant risk of subsequent contralateral PSP.

Spontaneous Pneumothorax Rates Following Video-Assisted Thoracoscopic Talc Pleurodesis With or Without Resection of Macroscopic Bullous Disease

Recurrent primary spontaneous pneumothorax (PSP) is routinely treated by video-assisted thoracoscopic (VATS) talc pleurodesis (with or without localised resection of macroscopic bullous disease). There is a paucity of published data regarding durability of the procedure and the rate of recurrent pneumothorax after such surgery, and this has significant implications from a prognostic and employment limitation perspective.

Efficacy and safety of thoracoscopic talc pleurodesis in the treatment of malignant pleural effusion

ObjectiveTo evaluate the efficacy and safety of thoracoscopic talc pleurodesis in the management of malignant pleural effusion (MPE).BackgroundMPE is a common complication of advanced malignancy. Pleurodesis is a well-recognized treatment for the management of MPE. Talc is considered the most effective sclerosing agents used to produce pleurodesis.Patients and methodsThis is a retrospective chart review of all patients with MPE who underwent thoracoscopic talc pleurodesis for the management of MPE from April 2020 to December 2021.ResultsA total of 24 patients with MPE who underwent thoracoscopic talc pleurodesis for the management of MPE were included in the study. The mean age was 63 ± 8.35 years, and included 12 (50%) males and 12 (50%) females. Overall, low-grade fever was seen in four (16.67%) patients, pleuritic chest pain in three (12.5%) patients, and no complication in 17 (70.83%) patients. No recurrence of pleural effusion happened in 21 (87.5%) patients, recurrence in the form of localized effusion that did not need medical interference happened in two (8.33%), and recurrence in the form of diffuse effusion that needed medical interference happened in one (4.17%) patient. Operative time was 43.75 ± 6.63 min, duration of chest tube insertion was 3.25 ± 0.44 days, and hospital stay was 6 ± 0.72 days.ConclusionsThoracoscopic talc pleurodesis for the treatment of MPE is a feasible and effective treatment with short operative time, is a minimally invasive procedure, and has few adverse effects, making it a safe and effective option for managing patients with MPE.

SWEET HYDROTHORAX: A RARE COMPLICATION OF PERITONEAL DIALYSIS

SESSION TITLE: Medical Student/Resident Disorders of the Pleura Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Hydrothorax is a rare complication of continuous ambulatory peritoneal dialysis (CAPD) with an incidence of approximately 2%(1). We present a case of hydrothorax secondary to CAPD. CASE PRESENTATION: 72-year-old female with past medical history of end-stage renal disease requiring peritoneal dialysis 4 times a day and type 2 diabetes mellitus presented with shortness of breath, productive cough, chest congestion and nausea for 2 days. She denied any fevers or chills. Vitals were stable with oxygen saturation of 97% on 2 L nasal cannula. Physical exam was significant for diminished breath sounds at the base of the right lung on auscultation. Electrocardiogram showed normal sinus rhythm with no ST changes. Laboratory results were significant for an elevated creatinine of 6.4 mg/dL whereas white blood cell count, lactic acid and troponins were unremarkable. A comprehensive respiratory panel including Influenza A & B, urine antigen testing for streptococcus pneumonia and legionella were also negative. Chest x-ray PA and lateral showed middle to lower lung lobe infiltrate with pleural effusion. Blood cultures that were obtained on admission did not grow any organisms. Patient was started on antibiotics for presumed community acquired pneumonia. Pulmonology performed right sided thoracentesis and 1600 mL of colorless clear fluid was drained. Patient experienced significant symptomatic relief post thoracentesis. Pleural fluid analysis revealed a pH of 7.3 and a high glucose concentration of 438 mg/dL (simultaneous blood glucose level of 103 mg/dL). Additionally, LDH and protein were suggestive of a transudative effusion as per Light’s criteria. Pleural fluid cultures remained negative. Given that pleural effusion was transudative with an elevated glucose level, the diagnosis of sweet hydrothorax was established. Antibiotics were discontinued. The patient was then transitioned to hemodialysis (HD). DISCUSSION: Sweet hydrothorax most commonly occurs on the right as compared to the left side and is more prevalent in women. Mechanisms of this phenomenon include pleuro-peritoneal pressure gradient, congenital diaphragmatic defects and lymphatic drainage disorders (2). Diagnoses involves thoracentesis with pleural fluid analysis revealing a marked elevation of glucose when compared to serum levels. This finding is pathognomonic for sweet hydrothorax. Imaging modalities used for diagnosis involve demonstrating the transfer of radiopaque dye across the diaphragm e.g. peritoneal scintigraphy, CT and MR Peritoneography, or direct visualization with video-assisted thoracoscopic surgery (VATS) (3). CONCLUSIONS: Management involves temporary cessation of CAPD, therapeutic thoracentesis, short dwell periods or dry days. Video-assisted thoracoscopic pleurodesis may be performed for patients who have failed conservative management. Most patients however end up switching permanently to HD. Reference #1: Szeto CC, Chow KM. Pathogenesis and management of hydrothorax complicating peritoneal dialysis. Current Opinion in Pulmonary Medicine. 2004 Jul;10(4):315-319. DOI: 10.1097/01.mcp.0000127901.60693.d0. Reference #2: Chow, K.M., Szeto, C.C. and Li, P.K.-T. (2003), Review Articles: Management Options for Hydrothorax Complicating Peritoneal Dialysis. Seminars in Dialysis, 16: 389-394. doi:10.1046/j.1525-139X.2003.16080.x Reference #3: Sydney Tang, Wing Hung Chui, Anthony W. C. Tang, Fu Keung Li, Wing Shun Chau, Yiu Wing Ho, Tak Mao Chan, Kar Neng Lai, Video-assisted thoracoscopic talc pleurodesis is effective for maintenance of peritoneal dialysis in acute hydrothorax complicating peritoneal dialysis, Nephrology Dialysis Transplantation, Volume 18, Issue 4, April 2003, Pages 804–808, https://doi.org/10.1093/ndt/gfg042 DISCLOSURES: No relevant relationships by Muhammad Hamza, source=Web Response No relevant relationships by Travis Hanson, source=Web Response No relevant relationships by Touba Naim, source=Web Response No relevant relationships by Muhammad Omar, source=Web Response

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

Patient evaluation for rapid pleurodesis of malignant pleural effusions.

Malignant pleural effusions (MPEs) represent advanced stage disease with potentially significant patient discomfort due to dyspnea. Palliative management options include repetitive thoracenteses, placement of a tunneled pleural catheter (TPC), chemical pleurodesis, or some combination of these procedures. The rapid pleurodesis procedure combines thoracoscopic talc pleurodesis and insertion of a TPC at the same time with the goals of reducing both the length of hospitalization and the duration of catheter use. The rapid pleurodesis procedure has previously been described to achieve both of these goals in a pilot study of 30 patients with fully expandable lungs. Both symptoms of dyspnea and quality of life improved with few complications. Additional data on procedural effectiveness is needed to optimize patient selection for this procedure. We performed a retrospective analysis of patients who had undergone rapid pleurodesis protocol at two academic institutions over a 40-month period. Data was collected and analyzed on time to removal of the TPC, chemotherapy, malignancy type, complications, age, and catheter occlusion. A total of 29 patients underwent the rapid pleurodesis protocol with a median hospital length of stay of 2 days. Total length of hospitalization was not significantly different between patients with and without primary lung cancer. Median duration of the indwelling TPC was 10 days. Patients with primary lung cancer and those actively or recently undergoing chemotherapy maintained the catheter longer than their counterparts. The rapid pleurodesis protocol should be considered a viable treatment option for select patients with symptomatic recurrent MPEs undergoing chemical pleurodesis.

Sequential treatment strategy for malignant pleural effusion in non-small cell lung cancer with the activated epithelial grow factor receptor mutation

With the advent of molecularly targeted therapy, it is necessary to reconsider the strategy for malignant pleural effusion in non-small-cell lung cancer (NSCLC) with epidermal growth factor receptor (EGFR) mutations. The aim of this study was to evaluate the efficacy of a two-line sequential treatment strategy in this patient subgroup. First-line treatment was gefitinib (250 mg/day) until disease progression. Second-line treatment was thoracoscopic talc pleurodesis followed by chemotherapy. Primary endpoints were the overall response and progression-free survival rates after first-line treatment, and the overall survival rate after first- and second-line treatment. Secondary endpoints were the success rate of thoracoscopic talc pleurodesis and gefitinib toxicity. Among the 76 patients enrolled, 61 (80%) were female and the median age was 62 years. The overall response rate after first-line treatment was 92.1% and median progression-free survival was 15 months. The success rate for thoracoscopic talc pleurodesis in 33 patients was 94%. Median follow-up was 35 months. Median overall survival was 39 months. The 1- and 3-year overall survival rates were 86.4% and 46.1%, respectively. The two-line sequential treatment strategy enhanced survival. These preliminary findings provide an insight into novel therapeutic models for malignant pleural effusion in NSCLC harbouring EGFR mutations.

Diagnostic and Therapeutic Outcome of Medical Thoracoscopy in India

SESSION TITLE: Procedures: Pleura SESSION TYPE: Original Investigation Poster PRESENTED ON: Saturday, April 16, 2016 at 11:45 AM - 12:45 PM PURPOSE: Though medical thoracoscopy is widely used globally, there are only a few centres in India performing this procedure. The objective of this study is to determine the diagnostic and therapeutic outcome of medical thoracoscopy in a tertiary care centre in India. METHODS: Retrospective analysis of all thoracoscopies done from May 2010 to Jan 2014 (45 months) in our centre. RESULTS: During this period, 87 medical thoracoscopic procedures were performed. Of these, 76 were diagnostic and 11 therapeutic. Mean age was 56.1 years for diagnostic and 61.3 for therapeutic indications. Main diagnostic indications were undiagnosed effusions (82.9%), empyema (7.9%) and recurrent pneumothorax (2.6%). Histopathology reports showed tuberculosis as the most common diagnosis (42.1%), followed by malignancy (39.5%) and chronic inflammation (7.9%). Rare diagnosis includes haemangioma of the lung. Therapeutic pleurodesis with talc (via thoracoscope) was done in 11 patients. Major indication was malignant pleural effusion (81.9%). Follow-up chest x-ray after one month showed no recurrence, indicating complete success. CONCLUSIONS: The major cause of recurrent effusion in India is tuberculosis, closely followed by malignancy. This is in contrast to many of the western literature which identifies malignancy as the most common cause. Though sample size is small, our data shows that success rate is very high for thoracoscopic talc pleurodesis. CLINICAL IMPLICATIONS: Medical Thoracoscopy should be widely practised for exudative pleural effusions in India so that a definitve diagnosis of tuberculosis or malignancy can be made. This also helps to avoid the practice of strarting empirical anti- Tb medications without a proper diagnosis. DISCLOSURE: The following authors have nothing to disclose: Binu Krishnan No Product/Research Disclosure Information

Massive fetal chylothorax successfully treated with postnatal talc pleurodesis: A case report and review of the literature

Abstract Despite the rapid advances in fetal medicine and pediatric surgery, congenital chylothoraces have an associated mortality of 22–65% and an increased morbidity resulting from pulmonary hypoplasia, severe infections secondary to immune globulin deficiencies, protein malnutrition, and coagulopathy. While the mainstay of therapy is medical management, large volume chylothoraces often require surgical management. In both the prenatal and postnatal periods, the recommended management of congenital chylothoraces is still controversial. We present a case of a prenatally diagnosed large chylothorax associated with a cervical lymphatic malformation. In our patient, the chylothorax persisted despite optimal postnatal medical management with drainage by tube thoracostomy, TPN, and octreotide. Adjuvant therapies included sirolimus and sclerotherapy directed toward the treatment of the macrocystic lymphatic malformation. We report the first case of a persistent congenital chylothorax associated with a lymphatic malformation successfully treated with thoracoscopic talc pleurodesis and sclerotherapy.

The MesoVATS trial: is there a future for video-assisted thoracoscopic surgery partial pleurectomy?

Malignant pleural mesothelioma, a uniformly fatal cancer caused by prior asbestos exposure, places a major burden on society. The MesoVATS trial was a multicenter randomized controlled trial that examined the role of video-assisted thoracoscopic partial pleurectomy (VAT-PP) versus talc pleurodesis in patients with malignant pleural mesothelioma. Overall there was no difference in survival between VAT-PP and talc pleurodesis. VAT-PP resulted in more complications, longer hospital stay and was more expensive. However, there was some evidence that VAT-PP improved EQ5D measured quality of life after 6 months particularly in the European Organisation for Research and Treatment of Cancer low-risk subgroup. At present the future role of VAT-PP is uncertain and may merit further investigation but this should be within the context of clinical trials. VAT-PP may also have a role to play in the specific situation of trapped lung.

MALIGNANT PLEURAL EFFUSION

Objectives: To assess the role of video assisted thoracoscopic talc pleurodesisin the surgical management of malignant pleural effusions by comparing this procedure withpleurodesis via talc slurry through an intercostals chest tube. Design: Prospective analysisof fifty patients with malignant pleural effusion which were divided into two groups. Groupone included twenty patients while group two included thirty patients. Setting: Department ofThoracic Surgery and the Department of Oncology, Combined Military Hospital, Rawalpindi.Period: October 2008 till November 2010. Subjects: Fifty patients of malignant pleural effusionwere included in the study. They were divided into two groups. Group one included twentypatients whereas group two included thirty patients. Interventions: Patients in group onewere subjected to videoassisted thoracoscopic talc pleurodesis. Patients in group two weresubjected to pleurodesis via talc slurry through an intercostal drainage tube. RESULTS: Fiftypatients were included in the study. The mean follow up time was 5.7 months for group oneand 5.5 months for group two. Out of the twenty patients in group one 95% had successfulpleurodesis (defined as satisfactory pleurodesis three months post procedure). Adverse effectsincluded fever in three patients (15%), empyema in one patient (5%) and malignant invasionof the scar in one patient (5%). Out of the thirty patients in group two 70% had successfulpleurodesis. Adverse effects included fever in five patients (17%), empyema in one patient (3%),and pulmonary infection in one patient (3%). No mortalities occurred during the procedures ineither of the group. Conclusions: Videoassisted thoracoscopic talc pleurodesis is a safe andeffective method of producing reliable pleurodesis in patients with malignant pleural effusion. It issuperior to pleurodesis via talc slurry through an intercostal drainage tube in terms of producinga reliable and complete pleurodesis. It should be performed early in patients presenting withmalignant pleural effusions to avoid the risk of respiratory failure, this being directly linked to thegeneral and respiratory status of the patients at the time of the procedure.

Effectiveness of thoracoscopic talc pleurodesis in the management of complicated spontaneous pneumothorax.

Complicated (recurring or persistent) spontaneous pneumothorax requires intervention either by surgical or nonsurgical pleurodesis or other interventions. As for high-risk patients, aggressive interventions may be associated with morbidity, the safety and effectiveness of less aggressive alternative interventions like thoracoscopic talc pleurodesis (TTP) should be evaluated. Data were extracted on patients who had undergone TTP for complicated spontaneous pneumothorax at Interventional Clinic, University Hospital, Brussels, Belgium. The complications, length of hospital stay, and success rate over a 24-month period were studied. A total of 41 TTP procedures were performed for 25 (61%) cases of primary spontaneous pneumothorax and for 16 (39%) cases of secondary spontaneous pneumothorax. Twenty-four cases were first episodes, whereas it was a recurrence in 17. Of 4 patients with blebs/bullae, 2 had recurrence after TTP.No patient had acute respiratory distress syndrome or any other serious complication after TTP. Recurrence rates after TTP in primary and secondary spontaneous pneumothorax were 9.5% and 25% at 24 months, respectively. The mean length of hospital stay after TTP was 3±3.2 days. TTP is a safe and effective intervention in complicated spontaneous pneumothorax.

Efficacy and cost of video-assisted thoracoscopic partial pleurectomy versus talc pleurodesis in patients with malignant pleural mesothelioma (MesoVATS): an open-label, randomised, controlled trial

Malignant pleural mesothelioma incidence continues to rise, with few available evidence-based therapeutic options. Results of previous non-randomised studies suggested that video-assisted thoracoscopic partial pleurectomy (VAT-PP) might improve symptom control and survival. We aimed to compare efficacy in terms of overall survival, and cost, of VAT-PP and talc pleurodesis in patients with malignant pleural mesothelioma. We undertook an open-label, parallel-group, randomised, controlled trial in patients aged 18 years or older with any subtype of confirmed or suspected mesothelioma with pleural effusion, recruited from 12 hospitals in the UK. Eligible patients were randomly assigned (1:1) to either VAT-PP or talc pleurodesis by computer-generated random numbers, stratified by European Organisation for Research and Treatment of Cancer risk category (high vs low). The primary outcome was overall survival at 1 year, analysed by intention to treat (all patients randomly assigned to a treatment group with a final diagnosis of mesothelioma). This trial is registered with ClinicalTrials.gov, number NCT00821860. Between Oct 24, 2003, and Jan 24, 2012, we randomly assigned 196 patients, of whom 175 (88 assigned to talc pleurodesis, 87 assigned to VAT-PP) had confirmed mesothelioma. Overall survival at 1 year was 52% (95% CI 41-62) in the VAT-PP group and 57% (46-66) in the talc pleurodesis group (hazard ratio 1·04 [95% CI 0·76-1·42]; p=0·81). Surgical complications were significantly more common after VAT-PP than after talc pleurodesis, occurring in 24 (31%) of 78 patients who completed VAT-PP versus ten (14%) of 73 patients who completed talc pleurodesis (p=0·019), as were respiratory complications (19 [24%] vs 11 [15%]; p=0·22) and air-leak beyond 10 days (five [6%] vs one [1%]; p=0·21), although not significantly so. Median hospital stay was longer at 7 days (IQR 5-11) in patients who received VAT-PP compared with 3 days (2-5) for those who received talc pleurodesis (p<0·0001). VAT-PP is not recommended to improve overall survival in patients with pleural effusion due to malignant pleural mesothelioma, and talc pleurodesis might be preferable considering the fewer complications and shorter hospital stay associated with this treatment. BUPA Foundation.

Challenges in treating HIV-infected patient with disseminated Kaposi`s sarcoma and miliary TB

Kaposi`s Sarcoma (KS) is the most common malignancy in HIV-infected patients. It`s induced by an infection with the Human Herpesvirus 8. AIDS-related Kaposi sarcoma tends to have an aggressive clinical course because it may involve all skin, membranes, lymph nodes, stomach, gut, lung or liver. A 32-year-old patient was diagnosed in 2009 with HIV infection and disseminated KS. Purple macules and nodules were disseminated on the trunk, limbs and lingual mucosa. He was a late presenter with CD4-T cell count 30 cells/µL and 108,000 copies/mL HIV-RNA. With antiretroviral therapy (ART) the clinical, virological and immunological evolution were very good: the CD4-T cell count increased to 156 cells/µL and the viral load was undetectable. Unfortunately, he became non adherent, and after 2 years of absence he returned in very bad condition with pericarditis, pleurisy, ascites and a low CD4-T cell count (13 cells/µL). The changes showed by the chest CT scan, the results of pleural biopsy, the clinical findings raised the suspicion of disseminated KS and miliary tuberculosis. Despite all the treatments (Mega-ART, antituberculosis chemotherapy, opportunistic infections prophylaxis) the pericarditis and pleural fluid was always recovered. Weekly thoracentesis were needed and CD-4 T cell number had not increased as we expected (the maximal value was 88 cells/µL), although the viremia was undetectable. There are 5 years since our patient was diagnosed with HIV infection and disseminated KS. In front of a patient with HIV-infection and symptomatic visceral or pulmonary KS, regardless the viral load, cytotoxic chemotherapy is recommended after the immunological status is improved. Another option is thoracoscopic talc pleurodesis which has been reported extremely effective in the malignant pleural effusion.

Is there any benefit in using awake anesthesia with thoracic epidural in thoracoscopic talc pleurodesis?

Is there any benefit in using awake anesthesia with thoracic epidural in thoracoscopic talc pleurodesis?

Awake epidural anesthesia for thoracoscopic pleurodesis: A prospective cohort study

BackgroundIt has been suggested that there is some benefit when awake thoracic epidural anesthesia (ATEA) is used for minimally invasive thoracoscopic procedures in critical patients. We tested the hypothesis that ATEA is superior to general anesthesia (GA) when comparing early pulmonary complications in this setting. MethodsA prospective cohort study was carried out over a 36-month period, comparing patients with malignant pleural effusion scheduled for thoracoscopic talc pleurodesis (TTP) using GA vs. ATEA. Postoperative pulmonary, cardiac, and renal complications, death rate, quality of analgesia and events were analyzed. Univariate and bivariate analyses were performed and time survival probability curves were developed in order to find a possible relation between a particular anesthetic technique and postoperative complications. A p value of <0.05 was considered significant. ResultsForty-seven patients were included in the analysis. Preoperative characteristics were comparable between groups (GA n=24; ATEA n=23). Incidence of pulmonary complications [GA=19 (86%) vs. ATEA=3 (14%). RR 6.0 (95% CI 2.07–17.7); p<0.001] and severity of postoperative pain (VAS>8) at 24h [GA=7 vs. ATEA=1 RR 6.7 (95% CI 1.13–18.2); p=0.023] were significantly higher when patients received GA. Time required to absence of any postoperative ventilatory support and mobilization with no major restrictions [GA=4 (3.5–5) vs. ATEA=3 (2–3.5) days; p=0.029] and global LOS [GA=10 (3.5–29.5) vs. ATEA=4 (3–15.2) days; p=0.003] were significantly reduced in the ATEA group. ConclusionsOur study suggests that ATEA is not only a safe anesthetic approach for cancer patients undergoing TTP but is also associated with a significant reduction in pulmonary postoperative events, hospital stay, and a better postoperative pain control. Randomized studies are required to corroborate these findings.

Anestesia epidural para pleurodesis por toracoscopia: un estudio prospectivo de cohorte

BackgroundIt has been suggested that there is some benefit when awake thoracic epidural anesthesia (ATEA) is used for minimally invasive thoracoscopic procedures in critical patients. We tested the hypothesis that ATEA is superior to general anesthesia (GA) when comparing early pulmonary complications in this setting. MethodsA prospective cohort study was carried out over a 36-month period, comparing patients with malignant pleural effusion scheduled for thoracoscopic talc pleurodesis (TTP) using GA vs. ATEA. Postoperative pulmonary, cardiac, and renal complications, death rate, quality of analgesia and events were analyzed. Univariate and bivariate analyses were performed and time survival probability curves were developed in order to find a possible relation between a particular anesthetic technique and postoperative complications. A p value of <0.05 was considered significant. ResultsForty-seven patients were included in the analysis. Preoperative characteristics were comparable between groups (GA n = 24; ATEA n = 23). Incidence of pulmonary complications [GA = 19 (86%) vs. ATEA = 3 (14%). RR 6.0 (95% CI 2.07–17.7); p < 0.001] and severity of post-operative pain (VAS > 8) at 24 h [GA = 7 vs. ATEA = 1 RR 6.7 (95% CI 1.13–18.2); p = 0.023] were significantly higher when patients received GA. Time required to absence of any postoperative ventilatory support and mobilization with no major restrictions [GA = 4 (3.5–5) vs. ATEA = 3 (2–3.5) days; p = 0.029] and global LOS [GA = 10 (3.5–29.5) vs. ATEA = 4 (3–15.2) days; p = 0.003] were significantly reduced in the ATEA group. ConclusionsOur study suggests that ATEA is not only a safe anesthetic approach for cancer patients undergoing TTP but is also associated with a significant reduction in pulmonary postoperative events, hospital stay, and a better postoperative pain control. Randomized studies are required to corroborate these findings.

Interventional therapy for symptomatic bronchial carcinoma

Symptoms such as dyspnoea, haemoptysis, coughing frequently occur in patients with bronchial carcinoma. Usually, central airway obstruction, pleural effusion or vena cava compression syndrome cause dyspnoea. Interventional bronchoscopy techniques, e.g. laser coagulation, electrocautery and cryosurgery offer very effective means for the re-canalisation of central airway obstruction. Stent placement and high-dose radiation brachytherapy are the procedures of choice for the treatment of extrinsic stenoses. The use of bronchoscopic coagulation, balloon catheters and embolisation of bronchial arteries may control severe haemoptysis. All interventional bronchoscopic techniques show symptomatic improvement and overall survival benefit in patients with bronchial carcinoma. Pleural involvement and effusion reflect progression of disease. Treatment consists of thoracoscopic talc pleurodesis and the use of various types of pleural catheters. Angiographic interventions (bronchial artery embolisation, dilatation and stenting of the vena cava superior) are needed for massive haemoptysis and the cava compression syndrome respectively.

Clinical Outcomes and Health-Related Quality of Life after Thoracoscopic Talc Pleurodesis

Thoracoscopic pleurodesis is a safe and effective method of palliative care for patients suffering from malignant pleural effusion. Health-related quality of life (QOL) is an important factor in palliative therapy; however, we are not aware of any studies that have examined the QOL of patients following thoracoscopic pleurodesis. A total of 123 patients underwent thoracoscopic pleurodesis between January 2006 and February 2009. A total of 45 patients agreed to take part at the QOL assessment and were enrolled in our prospective study. In addition to clinical outcome, the patients' QOL data were assessed prior to thoracoscopic pleurodesis and for 12 months after surgery using the European Organization for Research and Treatment of Cancer (EORTC) QLQ C-30 questionnaire. We compared the patients' QOL scores at each time point with their preoperative scores and analyzed these data relative to the scores of a healthy age-matched population. Due to the advanced clinical status of the patients in our study, the overall median survival time was 7.5 months versus 10.2 months for patients' QOL data. Following discharge from the hospital, most functional scales (with exception of emotional function, p=0.035) did not significantly differ from preoperative scores. Throughout the study period, patients experienced statistically and clinically significant improvements in functional scales. Global health values increased after surgery throughout the entire study period. There was a clear decline in dyspnea upon discharge, followed by a continuous remote increase throughout the subsequent months. QOL of the study population remained lower than that of the healthy cohort. Our data are consistent with clinical findings that pleurodesis decreases respiratory symptoms, but does not alleviate impairments in the patient's general condition.