INTRAPLEURAL MECHLORETHAMINE HYDROCHLORIDE THERAPY FOR MALIGNANT PLEURAL EFFUSION

Carbene-Catalyzed Activation of 2-Aminobenzaldehyde for Access to Chiral Fluorescent Quinazolinone

A carbene-catalyzed reaction to synthesize a chiral quinazolinone with a new activation mode of an "aniline-like" N-H moiety is disclosed. Addition of the nitrogen atom of diphenyl o-aminobenzaldehydes via NHC activation to imines leads to chiral quinazolinones with high yields and optical purities. The acidity of the N-H moiety was extremely increased through the formation of an acyl azolium intermediate, which was investigated by DFT calculations. Moreover, the chiral quinazolinones were found to have high fluorescence quantum efficiency.

Chemical pleurodesis - a review of mechanisms involved in pleural space obliteration

Chemical pleurodesis is a therapeutic procedure applied to create the symphysis between the parietal and visceral pleura by intrapleural administration of various chemical agents (e.g. talk, tetracycline, iodopovidone, etc.). The two major clinical conditions treated with chemical pleurodesis are recurrent pleural effusion (PE) and recurrent spontaneous pneumothorax. Although the history of chemical pleurodesis began over a century ago, detailed data on the mechanisms of action of sclerosing agents are highly incomplete. The following article aims to present the state of knowledge on this subject.It is believed that mesothelial cells are the main structural axis of pleurodesis. In response to sclerosing agents they secrete a variety of mediators including chemokines such as interleukin 8 (IL-8) and monocyte chemoattractant protein (MCP-1), as well as growth factors - vascular endothelial growth factor (VEGF), platelet-derived growth factor (PDGF), basic fibroblast growth factor (bFGF) and transforming growth factor- β (TGF-β). Numerous data suggest that intact mesothelial cells and the above cytokines play a crucial role in the initiation and maintenance of different pathways of pleural inflammation and pleural space obliteration.It seems that the process of pleurodesis is largely nonspecific to the sclerosant and involves the same ultimate pathways including activation of pleural cells, coagulation cascade, fibrin chain formation, fibroblast proliferation and production of collagen and extracellular matrix components. Of these processes, the coagulation cascade with decreased fibrinolytic activity and increased fibrinogenesis probably plays a pivotal role, at least during the early response to sclerosant administration.A better understanding of various pathways involved in pleurodesis may be a prerequisite for more effective and safe use of various sclerosants and for the development of new, perhaps more personalized therapeutic approaches.

Intrapleural Corynebacterium parvum for malignant pleural effusions

A pilot study of topical (intrapleural) treatment with Corynebacterium parvum was carried out in 10 patients with malignant pleural effusions complicating primary or secondary neoplasms and necessitating frequent thoracocentesis for symptomatic relief. The method was aspiration of all intrapleural fluid except a small portion left for dilution, and then injection of 7 mg of a preparation of Corynebacterium parvum suspended in 20 ml of normal saline solution. The treatment was repeated in each case as clinical conditions called for further thoracocentesis. In eight of these 10 patients the treatment resulted in prompt reduction of the rate of accumulation of pleural fluid and a striking change of cell sediment composition, with appreciable reduction in or complete disappearance of malignant cells and a rise in lymphocyte and neutrophil polymorph counts. The best responders were patients with primary pleural mesothelioma. Clinical improvement was evident in all responders.

Intrapleural immunotherapy with Corynebacterium parvum in recurrent malignant pleural effusions

Twenty-one patients with proven recurrent malignant pleural effusions were randomly allocated to treatment groups receiving either intrapleural Corynebacterium parvum in a dose of 7 mg or intrapleural mustine (20 mg). The designated intrapleural therapy was repeated on one occasion if further pleural aspiration was required. Corynebacterium parvum (nine patients) proved superior to mustine (12 patients) in suppressing the reaccumulation of pleural fluid, and was associated with only minimal side-effects of fever and nausea in two patients. Mustine caused marked nausea and vomiting in almost all patients. Three of the four patients who were deemed "failures" after mustine therapy had complete suppression of pleural fluid reaccumulation after a single dose of C parvum, the survival of the fourth being too short to assess a response adequately. There were no failures in the C parvum treated group. Corynebacterium parvum appears to be an effective, well-tolerated agent in the management of recurrent pleural effusions. The relative contribution of its potent immunological stimulant effect to its mode of action remains uncertain.

The treatment of recurrent malignant pleural effusion

Effective control of a recurrent malignant pleural effusion can greatly improve the quality of life of the cancer patient. At least a dozen different techniques have been advocated for controlling this common complication of malignant disease. The present review collects and examines the clinical results of all techniques designed to treat this problem. The pathophysiology and diagnostic evaluation of the effusion are also discussed. On the basis of comparisons involving effectiveness, morbidity, and convenience, we recommend intrapleurally administered tetracycline with thoracostomy drainage as the technique of choice. Instillation of a talc suspension with thoracostomy drainage is also a safe and effective technique and should be employed when tetracycline fails or is contraindicated.

Malignant pleural effusions

Recurrent malignant pleural effusion is a relatively common problem that often occurs many months before the terminal stages of a patient's malignant disease. Despite careful evaluation, it is often impossible to identify the exact physiologic cause of an effusion and difficult to identify a pragmatic course of therapy. Aggressive management including chest tube drainage, with or without instillation of inflammation-inducing drugs, and radiotherapy or surgery in selected cases is indicated for palliative treatment and probably for increased survival. In formulating a treatment plan, attention should be given to a variety of factors including pathogenic forces in the formation of malignant pleural effusion, tissue type of the metastatic malignancy, general clinical status of the patient, the presence of pleural loculations and adhesions, and the exclusion of other non-malignant causes of pleural effusion.

Cytostatic Therapy of Pleural Effusion Caused by Metastatic Carcinoma of the Breast

Effusions are a frequent complication in the course of disseminated breast cancer. Intracavitary instillation of radioactive gold, particulate irritants such as talc, alkylating agents, quinacrine, fluorouracil, bleomycin have been used for symptomatic control. The usefulness of intracavitary administration of antineoplastic agents in the management of recurrent, intractable neoplastic effusions has been evaluated in 43 patients in which 67 instillations were made and 58 were evaluable (table 1). Many drugs were used, particularly alkylating agents an HN2 and as Thio-TEPA and antimetabolite as fluorouracil (table 2). In the present series 19 of the 58 patients (32.7 %) with metastatic carcinoma of the breast had objective control of the neoplastic effusion for periods ranging from 45 to 485 days (table 2). In comparison with other methods of treatment, cytostatic therapy of pleural effusion caused by metastatic carcinoma of the breast does not produce a higher percentage of therapeutic response. Particularly talc poudrage has been employed with better results.

Treatment of recurrent malignant pleural effusion by iodized talc pleurodesis

Chemical pleurodesis using iodized talc is an effective method of treating symptomatic recurrent malignant pleural effusions. Twenty-three effusions occurring in 21 patients treated by this method are described with two illustrative case reports. The procedure eliminated the need for further chest aspiration in all but one instance. The histological appearances of the pleura at intervals after pleurodesis are also described.