Clinical Efficacy and Safety of Thoracoscopic Talc Pleurodesis in Malignant Pleural Effusions

Therapeutic thoracentesis symptoms and activity: a qualitative study

INTRODUCTION

Malignant pleural effusions (MPEs) commonly occur in patients with advanced cancer. Drainage of fluid is used to relieve symptoms and improve quality of life.

OBJECTIVE

To improve our understanding of how therapeutic aspiration affects symptoms and activities in patients with MPE.

METHODS

Patients presenting to the Pleural Clinic at Norfolk and Norwich University Hospital with a confirmed or suspected MPE participated in up to three semistructured interviews during their diagnostic/therapeutic pathway. Interviews were analysed using framework analysis by two researchers independently.

RESULTS

Sixteen patients participated. Symptoms reported before drainage included breathlessness, cough, chest pain, fatigue and anorexia. Symptoms affected their activities, including walking, bending over and socialisation. Patients described anxiety about the underlying diagnosis and fear of over-reliance on others. Expectations of drainage outcome varied, with some hoping for a cure and others hoping for any improvement. After drainage, breathlessness, chest pain and cough improved in some patients. They reported feeling and sleeping better, but fatigue and poor appetite remained. Participants were more active after aspiration, but the duration of improvement was a few days only. Despite this, patients still felt the procedure worthwhile.

CONCLUSION

Overall health and respiratory symptoms improved following drainage, but constitutional symptoms did not improve. This may be because constitutional symptoms are caused by the underlying cancer. This study suggests that clinicians should consider a range of symptoms, rather than just breathlessness, in planning outcomes for clinical trials. These results are important to inform patients about the potential benefits and duration of symptom improvement after therapeutic aspiration.

Trial Protocol: Reaccumulation rate of pleural effusions after therapeutic aspiration: An observational cohort study to determine baseline factors associated with rate of pleural fluid reaccumulation following therapeutic aspiration in patients with malignant pleural effusion attending a pleural clinic (REPEAT)

Background

Malignant pleural effusion (MPE) is the build-up of pleural fluid in the space between the lung and chest wall due to advanced cancer. It is treated initially by large volume drainage (therapeutic aspiration). If the fluid reaccumulates, a definitive procedure is performed. There is wide variation in rate of reaccumulation. Patients with rapid reaccumulation often attend hospital as an emergency. Conversely, patients with slow reaccumulation do not need a definitive procedure and may experience cancelled or unnecessary procedures. This study aims to create and validate a multivariable prediction model to predict how quickly pleural fluid will reaccumulate in patients with MPE following therapeutic aspiration.

Research question

Can we predict how quickly pleural fluid will reaccumulate in patients with MPEs?

Methods

A total of 200 patients with known or suspected MPE attending for therapeutic aspiration will be recruited from 5-10 UK hospitals over 20 months. Patients will be enrolled prior to undergoing aspiration. Following this, they will undergo chest X-ray, which will be repeated one week later (treatment as usual). Rate of reaccumulation will be calculated based on change of size of the effusion seen on X-ray. Data will be collected on common clinical biomarkers e.g., size of effusion on pre-aspiration chest X-ray, volume of fluid drained. This data will be analysed to create a clinical score.A further validation cohort of 40 patients will be enrolled in parallel with creation of the score.

Anticipated impact

The ability to predict rate of reaccumulation of MPE will enable patients and clinicians to make better informed treatment decisions. For patients with predicted rapid reaccumulation, a definitive procedure could be offered as first-line treatment, rather than a therapeutic aspiration. This will prevent emergency hospital admissions and decrease number of procedures. By contrast, patients whose effusions will recur slowly may avoid an unnecessary procedure.

Complications of thoracoscopic talc insufflation for the treatment of malignant pleural effusions: a meta-analysis

Background

Talc pleurodesis is an effective treatment for malignant pleural effusions (MPEs). This study was designed to estimate complication rates of thoracoscopic talc insufflation.

Methods

Literature search was conducted in electronic databases and studies were selected if they reported complication rates of thoracoscopic talc insufflation in cancer patients with MPEs. Meta-analyses of proportions were performed to obtain incidence rates of complications.

Results

Twenty-six studies (4482 patients; age 62.9 years [95% confidence interval (CI): 61.5, 64.4]; 50% [95% CI: 43, 58] females) were included. Intraoperative, perioperative, 30-day, and 90-day mortality rates were 0% [95% CI: 0, 1], 2% [95% CI: 0, 4], 7% [95% CI: 3, 13] and 21% [95% CI: 5, 43] respectively. Incidence rates [95% CI] of various complications were: pain (20% [1, 2]), fever (14% [3, 4]), dyspnea (13% [5, 6]), pneumothorax (6% [7, 8]) pneumonia (4% [0, 12]), emphysema (3% [3, 7]), prolonged air leakage (3% [0, 7]), prolonged drainage (3% [9, 10]), thromboembolism (3% [9, 11]), lung injury (2% [7, 12]), respiratory insufficiency (2% [0, 5]), re-expansion pulmonary edema (1% [0, 3]), empyema (1% [0, 2]), respiratory failure (0% [0, 1]), and acute respiratory distress syndrome (ARDS; 0% [0, 1].

Conclusions

Whereas pain and fever were the most frequent complications of thoracoscopic talc insufflation, the incidence of ARDS was low. Pneumothorax, pneumonia, emphysema, prolonged air leakage, pulmonary embolism, arrythmia, re-expansion pulmonary edema, and empyema are important complications of thoracoscopic talc insufflation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-021-01475-1.

Survival and pleurodesis outcome in patients with malignant pleural effusion – a systematic review

Malignant pleural effusion (MPE) is a common condition that presents with progressive breathlessness. Long term solutions are often required due to recurrence of effusion after simple drainage. Pleurodesis is one of the main options resorted to for long term control of MPE. There is data to suggest there may be a survival benefit for patients with MPE who achieve successful pleurodesis. A systematic review was carried out to explore this correlation and results suggest that there could be a survival difference according to pleurodesis outcome in patients with MPE. Fifteen studies (reported in 13 papers) were included; 13 (86.6%) of the studies showed survival difference in favour of pleurodesis success. The median [interquartile range] difference in survival between the two groups among the different studies was five [3.5–5.8] months. Most of the included studies suffered moderate to severe risk of bias and, thus, large prospective studies of patients undergoing pleurodesis are required to ascertain this effect.

Survival and pleurodesis outcome in patients with malignant pleural effusion - a systematic review

Malignant pleural effusion (MPE) is a common condition that presents with progressive breathlessness. Long term solutions are often required due to recurrence of effusion after simple drainage. Pleurodesis is one of the main options resorted to for long term control of MPE. There is data to suggest there may be a survival benefit for patients with MPE who achieve successful pleurodesis. A systematic review was carried out to explore this correlation and results suggest that there could be a survival difference according to pleurodesis outcome in patients with MPE. Fifteen studies (reported in 13 papers) were included; 13 (86.6%) of the studies showed survival difference in favour of pleurodesis success. The median [interquartile range] difference in survival between the two groups among the different studies was five [3.5–5.8] months. Most of the included studies suffered moderate to severe risk of bias and, thus, large prospective studies of patients undergoing pleurodesis are required to ascertain this effect.

Bevacizumab plus chemotherapy in nonsquamous non-small cell lung cancer patients with malignant pleural effusion uncontrolled by tube drainage or pleurodesis: A phase II study North East Japan Study group trial NEJ013B

Background

Pleurodesis is the standard of care for non‐small cell lung cancer (NSCLC) patients with symptomatic malignant pleural effusion (MPE). However, there is no standard management for MPE uncontrolled by pleurodesis. Most patients with unsuccessful MPE control are unable to receive effective chemotherapy. Vascular endothelial growth factor (VEGF) plays an important role in the pathogenesis of MPE. This multicenter, phase II study investigated the effects of bevacizumab plus chemotherapy in nonsquamous NSCLC patients with unsuccessful management of MPE.

Methods

Nonsquamous NSCLC patients with MPE following unsuccessful tube drainage or pleurodesis received bevacizumab (15 mg/kg) plus chemotherapy every three weeks. The primary endpoint was pleural effusion control rate (PECR), defined as the percentage of patients without reaccumulation of MPE at eight weeks. Secondary endpoints included pleural progression‐free survival (PPFS), safety, and quality of life (QoL).

Results

A total of 20 patients (median age: 69 years; 14 males; 20 adenocarcinomas; six epidermal growth factor receptor mutations) were enrolled in nine centers. The PECR was 80% and the primary end point was met. The PPFS and the overall survival (OS) were 16.6 months and 19.6 months, respectively. Patients with high levels of VEGF in the MPE had shorter PPFS (P = 0.010) and OS (P = 0.002). Toxicities of grade ≥ 3 included neutropenia (50%), thrombocytopenia (10%), proteinuria (10%), and hypertension (2%). The cognitive QoL score improved after treatment.

Conclusions

Bevacizumab plus chemotherapy is highly effective with acceptable toxicities in nonsquamous NSCLC patients with uncontrolled MPE, and should be considered as a standard therapy in this setting.

Key points

Significant findings of the study

Bevacizumab plus chemotherapy is highly effective with acceptable toxicities in nonsquamous NSCLC patients with uncontrolled MPE.

What this study adds

Bevacizumab plus chemotherapy should be considered as a standard treatment option for patients with uncontrolled MPE.

Clinical trial registration

UMIN000006868 was a phase II study of efficacy of bevacizumab plus chemotherapy for the management of malignant pleural effusion (MPE) in nonsquamous non‐small cell lung cancer patients with MPE unsuccessfully controlled by tube drainage or pleurodesis (North East Japan Study Group Trial NEJ‐013B) (http://umin.sc.jp/ctr/).

Multimodal approach to the management of malignant pleural effusions: role of thoracoscopy with pleurodesis and tunneled indwelling pleural catheters

Malignant pleural effusion (MPE) is associated with a median survival of 3–6 months and causes significant symptoms affecting the overall quality of life in patients with advanced malignancies. Despite the high incidence of recurrent MPE, less than 25% of patients undergo a definitive pleural intervention as recommended by guidelines. In this review, we summarize the latest guidelines for management of MPE by various societies and discuss a multimodal approach in these patients using thoracoscopy with pleurodesis using talc insufflation and placement of tunneled indwelling pleural catheters (TIPC). We also address the role of diagnostic thoracoscopy for histologic and molecular diagnosis and outline our approach to patients with known or suspected MPE.

Predictors of outcome of pleurodesis in patients with malignant pleural effusion: a systematic review and meta-analysis

Objectives: Pleurodesis is an important management option to palliate breathlessness in patients with malignant pleural effusion (MPE). This systematic review aimed to examine available literature for studies investigating factors that predict pleurodesis outcome.Methods: The healthcare databases advanced search (HDAS) Medline and Embase in addition to Cochrane Database of Systematic Reviews were searched on for publications reporting on pleurodesis for MPE in English language. All study types reporting previously unpublished data on predictors of pleurodesis success were included. Thirty-four studies involving 4626 patients were included in the systematic review.Results: The most common pleurodesis agent used was talc which was used in 27 studies. Meta-analyses demonstrated that the strongest predictors of pleurodesis success were higher pleural fluid pH, smaller volume of effusion pre-pleurodesis and full lung re-expansion post effusion drainage. Shorter duration of tube drainage, higher pleural fluid glucose, lower LDH, and lower pleural tumor burden all seem to favor pleurodesis success, but with considerable statistical heterogeneity between studies. Available data do not suggest that chest tube size affects pleurodesis outcome.Conclusion: Overall, available results are difficult to interpret due to evidence quality. Prospective studies are needed to further explore these factors.Protocol registration: CRD42018115874 (Prospero database of systematic reviews).

Analysis of Quality of Life after Pleurodesis in Patients with Malignant Pleural Effusion

BACKGROUND

Malignant pleural effusion is one of the most important complications of metastatic cancer, and recurrent pleural effusions do not only have an impact on survival but also cause a huge repercussion on a patient's quality of life.

OBJECTIVES

The main objective was to describe quality of life status before and after pleurodesis in patients with malignant pleural effusion. Secondary, we aimed to find predictors of quality of life improvement in such a population.

METHODS

Retrospective analysis of a database collected prospectively. We included patients who underwent pleurodesis from June 2004 to July 2014. Quality of life was evaluated through the WHOQOL-BREF questionnaire and applied before and 30 days after pleurodesis. We used a paired t test and the Wilcoxon rank-sum to compare pre-/post-pleurodesis results, Kaplan-Meier curves for survival analysis, and multiple linear regressions to find predictors of quality of life improvement.

RESULTS

183 patients were included (145 were women). Mean age was 58.3 ± 12.3 years, the most numerous primary tumor was breast cancer. Median survival time was 9 months. Dyspnea was the most prevalent symptom. Baseline results showed that patients had low quality of life scores. After pleurodesis, there was a significant improvement in respiratory symptoms, physical domain, and general health. Linear regression showed an improvement in physical domain with the sclerosing agent nitrate (p = 0.005). Male gender (p = 0.002) and a higher lymphocyte count (p = 0.01) were inversely associated with improvement in physical domain.

CONCLUSIONS

Pleurodesis improved symptoms and quality of life in patients with malignant pleural effusion. Gender, lymphocyte count, and sclerosing agent might interfere with quality of life improvement.

ERS/EACTS statement on the management of malignant pleural effusions

Malignant pleural effusions (MPE) are a common pathology, treated by respiratory physicians and thoracic surgeons alike. In recent years, several well-designed randomized clinical trials have been published that have changed the landscape of MPE management. The European Respiratory Society (ERS) and the European Association for Cardio-Thoracic Surgery (EACTS) established a multidisciplinary collaboration of clinicians with expertise in the management of MPE with the aim of producing a comprehensive review of the scientific literature. Six areas of interest were identified, including the optimum management of symptomatic MPE, management of trapped lung in MPE, management of loculated MPE, prognostic factors in MPE, whether there is a role for oncological therapies prior to intervention for MPE and whether a histological diagnosis is always required in MPE. The literature revealed that talc pleurodesis and indwelling pleural catheters effectively manage the symptoms of MPE. There was limited evidence regarding the management of trapped lung or loculated MPE. The LENT score was identified as a validated tool for predicting survival in MPE, with Brims' prognostic score demonstrating utility in mesothelioma prognostication. There was no evidence to support the use of oncological therapies as an alternative to MPE drainage, and the literature supported the use of tissue biopsy as the gold standard for diagnosis and treatment planning.Management options for malignant pleural effusions have advanced over the past decade, with high-quality randomized trial evidence informing practice in many areas. However, uncertainties remain and further research is required http://ow.ly/rNt730jOxOS.

ERS/EACTS statement on the management of malignant pleural effusions

Malignant pleural effusions (MPE) are a common pathology, treated by respiratory physicians and thoracic surgeons alike. In recent years, several well-designed randomised clinical trials have been published that have changed the landscape of MPE management. The European Respiratory Society (ERS) and the European Association for Cardio-Thoracic Surgery (EACTS) established a multidisciplinary collaboration of clinicians with expertise in the management of MPE with the aim of producing a comprehensive review of the scientific literature.

Six areas of interest were identified, including the optimum management of symptomatic MPE, management of trapped lung in MPE, management of loculated MPE, prognostic factors in MPE, whether there is a role for oncological therapies prior to intervention for MPE and whether a histological diagnosis is always required in MPE.

The literature revealed that talc pleurodesis and indwelling pleural catheters effectively manage the symptoms of MPE. There was limited evidence regarding the management of trapped lung or loculated MPE. The LENT score was identified as a validated tool for predicting survival in MPE, with Brims' prognostic score demonstrating utility in mesothelioma prognostication. There was no evidence to support the use of oncological therapies as an alternative to MPE drainage, and the literature supported the use of tissue biopsy as the gold standard for diagnosis and treatment planning.

Pleural catheters after thoracoscopic treatment of malignant pleural effusion: a randomized comparative study on quality of life

Background

Malignant pleural effusion (MPE) complicates many neoplasms and its incidence is expected to rise in parallel with the aging population and longer survival of cancer patients. Although a clear consensus exists on indwelling catheters in patients with poor performance status, no study has hitherto compared different devices in patients requiring temporary or definitive drainage following talc poudrage.

Methods

This is a prospective, two-arm, pilot study on patients with MPE undergoing talc poudrage, comparing two different catheters (PleurX^® versus Pleurocath^®) positioned because of the inefficacy of the procedure or the high risk of short-term failure. End points of the study were quality of life (QoL), median dyspnea and chest pain assessment by EORTC questionnaires and a 100 mm visual analog scale, total in-hospital length of stay and frequency of serious adverse events.

Results

No difference was observed between the two groups in in mean dyspnea and mean chest pain in any questions of the EORTC QLQ-C30 and QLQ-LC13 questionnaires. Duration of the procedure was significantly longer in the PleurX^® group versus the Pleurocath^® group (72±33 versus 44±13 minutes; P=0.03). No difference was observed between the two groups in total length of hospital stay (P=1.00) or complication rate (P=1.00).

Conclusions

For the cohort of patients still needing indwelling pleural catheters (PC) after thoracoscopic talc poudrage, PleurX^® is suggested when drain removal is unlikely due to short life expectancy or the high chance of pleurodesis failure. Conversely, Pleurocath^® should be recommended in all other patients as it is faster to place and easier to remove.

Keywords

Malignant pleural effusion (MPE); talc poudrage; indwelling pleural catheter (indwelling PC).

Success rate of medical thoracoscopy and talc pleurodesis in malignant pleurisy: A single-centre experience

BACKGROUND AND OBJECTIVE

Malignant pleurisy is associated with advanced oncological disease and dyspnoea is the most common presenting symptom. Pleurodesis is the preferred palliative and supportive treatment option, targeting symptom relief. The identification of clinical and endoscopic features that determine the success of talc pleurodesis in malignant pleurisy could guide clinical decision-making.

METHODS

All symptomatic patients with malignant pleurisy subjected to talc pleurodesis through medical thoracoscopy between January 2012 and December 2015 were included. Univariate and multivariate analyses were performed to identify factors associated with successful pleurodesis.

RESULTS

Of the 155 patients, 122 (78%) were classified as having a successful pleurodesis based on clinical and radiological criteria. Factors associated with unsuccessful pleurodesis (univariate analysis) were the presence of pleural adhesions (odds ratio (OR): 0.43 (95% CI: 0.19-0.96); P = 0.04), extensive spread of pleural lesions (OR: 0.17 (95% CI: 0.05-0.59); P = 0.001), the use of systemic corticosteroids (OR: 0.28 (95% CI: 0.10-0.83); P = 0.02) and a prolonged time period between the clinical diagnosis of the pleural effusion and the moment of pleurodesis (OR: 0.14 (95% CI: 0.06-0.32); P < 0.0001). The latter being associated with failure of pleurodesis in a multivariate analysis (OR: 0.08 (95% CI: 0.01-0.25); P < 0.0001). Chest ultrasound prior to pleurodesis showed a sensitivity of 91% and a specificity of 88% in predicting the success of pleurodesis.

CONCLUSION

The success rate of pleurodesis in malignant pleurisy could potentially be enhanced by correct patient selection and early referral for pleurodesis. Ultrasonic assessment of pleural adhesions and potential lung expansion prior to pleurodesis is useful in clinical decision-making.

Comparison of Efficiency of Pleurodesis Between Video Assisted Thoracoscopic Surgery (VATS) and Standard Thoracostomy

Background

Chemical pleurodesis is generally accepted palliative dyspnea therapy and preventive of re-accumulation of pleural fluid in patients with malignant pleural effusions.

Aim

Comparative analyses of efficiency of chemical pleurodesis between Video Assisted Thoracoscopic Surgery (VATS) and standard thoracostomy.

Methods

From 01.01.2016-01.01.2017 at the Clinic for Thoracic Surgery of University Clinical Center (UCC) Sarajevo retrospective analysis was performed. Studied patients underwent VATS pleurodesis (G1) and standard thoracostomy pleurodesis (G2), with 60 in each group, respecting defined inclusion and exclusion criteria. Pleurodesis success was examined radiologically over the next three months.

Results

Average age of all patients was 63.97±8.75 years. Gender related, 45% were men and 55% were women (F/M=1.47:1). Average hospitalization was 7.22±1.37 (G1: 6.68±1.16; G2: 7.44±1.40; Mann-Whitney U-test: p=0.0016) days. Average thoracic drainage duration was 5.45±1.69, (G1: 4.28±1.15,G2: 6.05±1.58; Mann-Whitney U-test p<0.0001) days. Pleurodesis success after first month was 98.30% in G1, 91.60% in G2 (G1 vs. G2; p=0.2089); after second month was 98.30% in G1, 78.30% in G2 (G1 vs. G2; p=0.0011) and after three months was 91.60% in G1, 63.30% in G2(G1 vs. G2; p=0.0006). Average dyspnea degree (0-5) after the pleurodesis was 0.050±0.22 in G1 and 0.62±0.76 in G2 (Mann-Whitney U-test; p=0.0001). Complication were noticed in 9.2% patients, in G1 3.3%, 15.0% in G2.

Conclusion

Difference in pleurodesis efficiency between the G1 and G2 was established after second month and was even more evident after third month in favor of G1. Results show the significant statistical improvement of the degree of dyspnea in G1 as opposite to the G2.

Pleuroscopic Pleurodesis Combined With Tunneled Pleural Catheter for Management of Malignant Pleural Effusion: A Prospective Observational Study

BACKGROUND

Malignant pleural effusion (MPE) is associated with poor prognosis and it often impinges upon quality of life; effective and efficient management is desirable. Combining pleuroscopic pleurodesis (PP) with a tunneled pleural catheter (TPC) could minimize hospitalization, effect rapid pleurodesis in most cases, and allow ongoing control of MPE for those not successfully pleurodesed.

METHODS

Consecutive patients with pleural effusion associated with malignancy and with documented lung reexpansion after pleural fluid drainage were prospectively enrolled to undergo PP with TPC placement. TPC was drained daily and was removed when output was <50 mL/d. Patients were followed for up to 6 months. The data collected were compared with historical controls as provided by a previously published study by our group on conventional pleuroscopic pleurodesis (CPP).

RESULTS

Thirty patients were enrolled between January 2012 and August 2013. Twenty-nine completed the protocol. Pleurodesis was successful in 92% of patients at 1 month. Of the patients alive at 6 months, 96% continued to have effective pleurodesis. The median duration of TPC placement was 6 days. The median LOS was 3 days (2 to 7.25). All patients experienced significant improvement in dyspnea scores. The median LOS was significantly lower than those who received CPP (median LOS, 9 d; range, 4 to 13 d; P=0.002). There was no significant difference in mortality rates and pleurodesis success rates.

CONCLUSIONS

The combination of PP with TPC can effect pleurodesis at a rate similar to CPP, shortens LOS, shortens time to pleurodesis, and helps to control symptoms when pleurodesis fails.

Talc Pleurodesis With Intense 18F-FDG Activity But No 68Ga-DOTA-TATE Activity on PET/CT

Talc pleurodesis (TP) is a technique, widely employed in the management of patients with persistent pleural effusions or pneumothoraces not amenable to other treatment options. It is well documented that talc deposits produce areas of highly increased F-FDG uptake, because of talc-induced inflammation. We present a case of a patient with history of TP who was evaluated with both F-FDG and Ga-DOTA-TATE. The hypermetabolic area seen on F-FDG-PET-CT in the region of talc placement showed no uptake by Ga-DOTA-TATE, suggesting the potential role of Ga-DOTA-TATE-PET-CT in elucidating F-FDG-postitive lesions in patients with history of both neuroendocrine malignancy and TP.

Interventional pulmonologist perspective: treatment of malignant pleural effusion

OPINION STATEMENT

The management of known malignant pleural effusions focuses around the initial thoracentesis and subsequent objective and subjective findings. A completely reexpanded lung after fluid removal and with symptomatic improvement predicts successful pleurodesis. Pleurodesis method depends on center expertise as well as patient preference. Medical thoracoscopy does not require the operating room setting and is performed on the spontaneously breathing patient with similar success rate to surgical thoracoscopy in the appropriately selected patients. However, it is not widely available. Talc insufflation is preferred for even distribution of sprayed particles to pleural surfaces. Most often, patients can be discharged home within 24 to 48 hours after continuous chest tube suction. Indwelling pleural catheter has become popular given the ease of insertion and patient centered home drainage. Coordinated care with good patient and family education and support is paramount to maximizing the beneficial potential of the catheter. Complications are minimal, and catheters are easily removed if patients can no longer benefit from drainage, or if pleurodesis has occurred. In the setting of trapped lung as a result of visceral pleura encasement from tumor, indwelling catheter can still be useful if the patient improves with thoracentesis. However, if no subjective improvement is seen after thoracentesis for trapped lung, then no procedure is recommended and other modes of palliation should be sought.

Efficacy of recombinant adenoviral human p53 gene in the treatment of lung cancer-mediated pleural effusion

Pleural effusion induced by lung cancer exerts a negative impact on quality of life and prognosis. The aim of the present study was to evaluate the value of the recombinant adenoviral human p53 gene (rAd-p53) in the local treatment of lung cancer and its synergistic effect with chemotherapy. The present study retrospectively recruited 210 patients with lung cancer-mediated pleural effusion who had adopted a treatment strategy of platinum chemotherapy. Pleurodesis was performed via the injection of cisplatin or rAd-p53. Long-term follow-up was conducted to investigate the therapeutic effects of cisplatin and rAd-p53 administration on pleural effusion and other relevant clinical indicators. The short-term effect of pleurodesis was as follows: The efficacy rate of rAd-p53 therapy was significantly higher compared with cisplatin therapy (71.26 vs. 54.47%), and the efficacy of treatment with ≥2×1012 viral particles of rAd-p53 for pleurodesis was significantly greater than treatment with 40 mg cisplatin (P<0.05). Furthermore, efficacy analysis performed 6 and 12 months after pleurodesis indicated that the efficacy rate of rAd-p53 was significantly greater than that of cisplatin (P<0.05). A comparison of median progression-free survival (PFS) time identified a significant difference (P<0.05) between rAd-p53 and cisplatin therapy (3.3 vs. 2.7 months); however, a comparison of median overall survival time identified no significant difference (P>0.05) between rAd-p53 and cisplatin therapy (9.6 vs. 8.7 months). In addition, Cox regression analysis indicated that PFS was not affected by clinical indicators such as age, gender, prognostic staging and smoking status; however, PFS was affected by pathological subtype (adenocarcinoma or squamous carcinoma) in the rAd-p53 group. rAd-p53 administration for pleurodesis exerts long-term therapeutic effects on the local treatment of lung cancer. Thus, a combination of rAd-p53 and chemotherapy may exert a synergistic effect and reverse multidrug resistance.

Interpretation of PET/CT findings in patients with advanced lung cancer who have undergone pleurodesis

A consensus has not yet been reached for the ideal moment to carry out pleurodesis in patients with malignant pleural effusion among the majority of centres, especially those which don’t specialise in oncologic treatment. The PET (positron emission tomography)/CT (computed tomography) used in the staging of patients with non-small-cell lung cancer (NSCLC) and small-cell lung cancer (SCLC) has caused controversy when used in the evaluation of therapeutical response and in detection of recurrence in patients with pleurodesis. For not distinguishing between inflammatory and neoplasic processes while using PET or CT, suspicion of pleural involvement can result in the indication for invasive diagnostic procedures or inadequate exchange of therapy. In such cases, the hypothesis of the inflammatory process must be included in the differential diagnoses for positive findings with the PET/CT in patients with NSCLC who have undergone pleurodesis, independently of time since the procedure. The reports of two patients with NSCLC have been presented in order to illustrate situations in which pleurodesis has been performed at the moment of diagnosis, outside of a cancer centre.

Tumors that mimic asbestos-related mesothelioma: time to consider a genetics-based tumor registry?

The diagnosis of mesothelioma is not always straightforward, despite known immunohistochemical markers and other diagnostic techniques. One reason for the difficulty is that extrapleural tumors resembling mesothelioma may have several possible etiologies, especially in cases with no meaningful history of amphibole asbestos exposure. When the diagnosis of mesothelioma is based on histologic features alone, primary mesotheliomas may resemble various primary or metastatic cancers that have directly invaded the serosal membranes. Some of these metastatic malignancies, particularly carcinomas and sarcomas of the pleura, pericardium and peritoneum, may undergo desmoplastic reaction in the pleura, thereby mimicking mesothelioma, rather than the primary tumor. Encasement of the lung by direct spread or metastasis, termed pseudomesotheliomatous spread, occurs with several other primary cancer types, including certain late-stage tumors from genetic cancer syndromes exhibiting chromosomal instability. Although immunohistochemical staining patterns differentiate most carcinomas, lymphomas, and mestastatic sarcomas from mesotheliomas, specific genetic markers in tumor or somatic tissues have been recently identified that may also distinguish these tumor types from asbestos-related mesothelioma. A registry for genetic screening of mesothelioma cases would help lead to improvements in diagnostic criteria, prognostic accuracy and treatment efficacy, as well as improved estimates of primary mesothelioma incidence and of background rates of cancers unrelated to asbestos that might be otherwise mistaken for mesothelioma. This information would also help better define the dose-response relationships for mesothelioma and asbestos exposure, as well as other risk factors for mesothelioma and other mesenchymal or advanced metastatic tumors that may be indistinguishable by histology and staining characteristics.

From "awake" to "monitored anesthesia care" thoracic surgery: A 15 year evolution

Although general anesthesia still represents the standard when performing thoracic surgery, the interest toward alternative methods is increasing. These have evolved from the employ of just local or regional analgesia techniques in completely alert patients (awake thoracic surgery), to more complex protocols entailing conscious sedation and spontaneous ventilation. The main rationale of these methods is to prevent serious complications related to general anesthesia and selective ventilation, such as tracheobronchial injury, acute lung injury, and cardiovascular events. Trends toward shorter hospitalization and reduced overall costs have also been indicated in preliminary reports. Monitored anesthesia care in thoracic surgery can be successfully employed to manage diverse oncologic conditions, such as malignant pleural effusion, peripheral lung nodules, and mediastinal tumors. Main non-oncologic indications include pneumothorax, emphysema, pleural infections, and interstitial lung disease. Furthermore, as the familiarity with this surgical practice has increased, major operations are now being performed this way. Despite the absence of randomized controlled trials, there is preliminary evidence that monitored anesthesia care protocols in thoracic surgery may be beneficial in high-risk patients, with non-inferior efficacy when compared to standard operations under general anesthesia. Monitored anesthesia care in thoracic surgery should enter the armamentarium of modern thoracic surgeons, and adequate training should be scheduled in accredited residency programs.

Mechanisms of pleurodesis

Pleurodesis aims to obliterate the pleural space by producing extensive adhesion of the visceral and parietal pleura, in order to control relapse of either pleural effusions (mostly malignant) or pneumothorax. A tight and complete apposition between the two pleural layers is a necessary condition to obtain a successful pleurodesis, but--besides this mechanical aspect--there are many biological mechanisms that appear to be common to most of the sclerosing agents currently used. Following intrapleural application of the sclerosing agent, diffuse inflammation, pleural coagulation-fibrinolysis imbalance (favoring the formation of fibrin adhesions), recruitment and subsequent proliferation of fibroblasts, and collagen production are findings in the pleural space. The pleural mesothelial lining is the primary target for the sclerosant and plays a pivotal role in the whole pleurodesis process, including the release of several mediators like interleukin-8, transforming growth factor-β and basic fibroblast growth factor. When the tumor burden is high, normal mesothelial cells are scarce, and consequently the response to the sclerosing agent is decreased, leading to failure of pleurodesis. Also, the type of tumor in the pleural cavity may also affect the outcome of pleurodesis (diffuse malignant mesothelioma and metastatic lung carcinomas have a poorer response). There is general agreement that talc obtains the best results, and there are also preliminary experimental studies suggesting that it can induce apoptosis in tumor cells and inhibit angiogenesis, thus contributing to a better control of the malignant pleural effusion. There is concern about complications (possibly associated with talc but other agents as well) related to systemic inflammation and possible activation of the coagulation cascade. In order to prevent extrapleural talc dissemination, large-particle talc is recommended. Although it could--to some degree--interfere with the mechanisms leading to pleurodesis and a carefully balanced clinical decision has therefore to be made, prophylactic treatment with subcutaneous heparin is recommended during hospitalization (immediately before and after the pleurodesis procedure).

Intrapleural therapy

Numerous intrapleural therapies have been adopted to treat a vast array of pleural diseases. The first intrapleural therapies proposed focused on the use of fibrinolytics and DNase to promote fluid drainage in empyema. Numerous case series and five randomized controlled trials have been published to determine the outcomes of fibrinolytics in empyema treatment. In the largest randomized trial, the use of streptokinase had no reduction in mortality, decortication rates or hospital days compared with placebo in the treatment of empyema. Criticism over study design and patient selection may have potentially affected the outcomes in this study. The development of dyspnoea is common in the setting of malignant pleural effusions. Pleural fluid evacuation followed by pleurodesis is often attempted. Numerous sclerosing agents have been studied, with talc emerging as the most effective agent. Small particle size of talc should be avoided because of increased systemic absorption potentiating toxicity, such as acute lung injury. Over the past several years, the use of chronic indwelling pleural catheters have emerged as the preferred modality in the treating a symptomatic malignant pleural effusion. For patients with malignant-related lung entrapment, pleurodesis often fails due to the presence of visceral pleural restriction; however, chronic indwelling pleural catheters are effective in palliation of dyspnoea. Finally, the use of staphylococcal superantigens has been proposed as a therapeutic model for the treatment of non-small lung cancer. Intrapleural instillation of staphylococcal superantigens increased median survival by 5 months in patients with non-small cell lung cancer with a malignant pleural effusion.

Expert opinions of the first italian consensus conference on the management of malignant pleural mesothelioma

Malignant pleural mesothelioma (MPM) is a very important public health issue. A large amount of data indicates a relationship between mesothelioma and asbestos exposure. The incidence has both considerably and constantly increased over the past 2 decades in the industrialized countries and is expected to peak in 2010-2020. In Italy, a standardized-rate incidence in 2002 among men was 2.98 per 100,000 and 0.98 per 100,000 among women, with wide differences from one region to another. Stage diagnosis and definition may be difficult. Management of patients with MPM remains complex, so an optimal treatment strategy has not yet been clearly defined. The First Italian Consensus Conference on Malignant Pleural Mesothelioma was held Bologna (Italy) in May 20, 2008. The Consensus Conference was given the patronage of the Italian scientific societies AIOM, AIRO, AIPO, SIC, SICO, SICT, SIAPEC-IAP, AIOT, GOAM, and GIME. This Consensus did not answer all of the unresolved questions in MPM management, but the Expert Opinions have nonetheless provided recommendations, presented in this report, on MPM management for clinicians and patients.

Tumor type influences the effectiveness of pleurodesis in malignant effusions

Pleurodesis is commonly indicated for symptom relief in patients with malignant pleural effusions. A number of factors may influence pleurodesis outcome, but whether tumor type is one of them is a matter of debate. This study investigates the impact of tumor type on the efficacy of bedside doxycycline and thoracoscopic talc poudrage pleurodesis in order to determine which patients may benefit most from these procedures. A retrospective study of 138 and 450 doxycycline and talc poudrage pleurodesis procedures, respectively, evaluated their overall successes and failures, according to primary tumor types. In addition, a logistic regression model addressed whether the pleurodesis outcome in different tumor types was influenced by or attributable to pleural tumor burden. In the talc group, patients with lung cancer and mesothelioma had significantly lower complete response rates (63 and 61%, respectively) as compared with breast (77%) and other metastatic effusions (74%, p = 0.012). In the doxycycline group, the data followed the same trend in that complete response rates were lower in patients with lung carcinomas (31%) than in those with breast cancer (54%) or metastases from other primary sites (74%, p = 0.001). The regression analysis showed pleural burden and tumor type as independent predictors of pleurodesis failure in the talc group. The tumor type involving the pleural surfaces influences the success of a pleurodesis, regardless of the sclerosing agent used. Malignant effusions due to mesothelioma and lung cancer are particularly prone to a failed procedure.

Hepatic breast cancer dissemination after an iatrogenic hepatic laceration during talc pleurodesis: a case report

Background

Talc pleurodesis is an effective treatment for malignant pleural effusion. We present a case of an asymptomatic hepatic laceration that occurred during pleurodesis in a breast cancer patient and led to hepatic tumor dissemination.

Discussion

Pleurodesis is a relatively safe procedure, although previous studies have described malignant invasion of scar tissue.

Conclusion

To our knowledge, this is the first case report of tumor spread due to a liver puncture during talc pleurodesis in a breast cancer patient.

Ambulatory intercostal drainage for the management of malignant pleural effusion: a single center experience

BACKGROUND

Malignant pleural effusions are common and can be difficult to manage. We have reviewed our use of ambulatory drains (Pleurex drains) in this regard with particular reference to hospital stay, duration of drainage, and incidence of complications.

MATERIALS AND METHODS

Of 125 patients with malignant pleural effusion with trapped lung or failed previous pleurodesis who underwent insertion of ambulatory pleural drain, 41 patients were under local anesthesia and 84 patients were under general anesthesia. Mean age was 66.5 years with male:female = 80:45. Data were collected retrospectively from the clinical notes, and the family doctors' clinics were contacted to enquire about the patients' survival.

RESULTS

When data collection concluded, 48 patients (38.4%) had died, giving mean survival following drain insertion of 84.1 days. There were no in-hospital deaths related to the procedure. One procedure was converted to a mini-thoracotomy to control bleeding from a lung tear. Mean duration of catheter placement was 87.01 days (5-434). Video-assisted thoracoscopic surgery was used in 77 patients (61.6%), and Seldinger's technique was used in 48 patients (38.4%). Mesothelioma was the most common malignant cause. Minor complications were encountered in 15 patients (12%), and they were managed as outpatients.

CONCLUSION

The use of ambulatory pleural catheters for managing malignant pleural effusion is a safe and effective strategy. It has only minor complications that are related to prolonged drainage. We feel that this strategy should be considered the first choice option for these patients.

Treatment options for malignant pleural effusion

PURPOSE OF REVIEW

Thirty percent of lung cancers eventually result in malignant pleural effusion (MPE). Devastating consequences of MPE, such as dyspnea and cough, severely deteriorate the quality of life of these patients. Malignant pleural effusion portends a dismal prognosis of less than 6-month longevity, with the exception of breast and ovarian cancer. Given the poor prognosis of the majority of these patients, palliation, rather than cure, should be the goal of therapy.

RECENT FINDINGS

Chest tube insertion and sclerotherapy remain the standard of care. Emerging therapeutic options such as medical pleuroscopy and indwelling pleural catheters offer cost-effective and outpatient treatments for MPE.

SUMMARY

In the following review, the medical, economic, and social aspects of different current options for the management of MPE are discussed.

Treatment of malignant pleural effusion with the trifunctional antibody catumaxomab (Removab) (anti-EpCAM x Anti-CD3): results of a phase 1/2 study

Catumaxomab is a trifunctional monoclonal antibody consisting of a mouse immunoglobulin G2a part and a rat immunoglobulin G2b part with 2 different antigen binding sites binding the epithelial cell adhesion molecule antigen on tumor cells and CD3 on T lymphocytes. The intact Fc region provides a third functional binding site, binding and activating selectively Fcgamma receptor I, IIa, and III-positive accessory cells. These binding properties lead to specific tumor cell killing. As catumaxomab demonstrated efficacy in patients with malignant ascites, we performed this phase 1/2 trial in patients with malignant pleural effusion (MPE). We investigated a series of 3 escalating doses of 5 to 200 microg catumaxomab administered intrapleurally to patients with MPE containing epithelial cell adhesion molecule -positive cells. Primary objectives were determination of dose-limiting toxicity, safety, and tolerability. Secondary objectives were efficacy and pharmacodynamics. Twenty-four patients were treated with catumaxomab. Most frequent adverse events were pyrexia, elevated liver enzymes, nausea, and decreased lymphocytes. Dose-limiting toxicities were observed in 2 patients: One had pleural empyema and fatal sepsis and 1 had grade 3 erythema and hepatobiliary disorder. Five patients with breast cancer out of 7 evaluable patients had a response to treatment. Intrapleural administration of catumaxomab is feasible although the substantial number of drop-outs and deaths in short proximity to study treatment raise questions whether MPE is the right indication for catumaxomab or whether the patient population should be defined different. Safety profile was as expected reflecting catumaxomab's mode of action. Preliminary efficacy showed a suggestion of improvement in some patients.

Bedside talc pleurodesis for malignant pleural effusion: factors affecting success

INTRODUCTION

To determine the factors affecting the success of bedside talc slurry (TS) used for symptomatic treatment of patients with malignant pleural effusion (MPE).

METHODS

Data of 113 effusions in 103 MPE patients treated between 1999 and 2007 were retrospectively evaluated for the study. The study group involved 73 patients whose follow-up information was available out of 81 patients treated by TS. Causes of MPE were lung cancer in 22 patients (30.1%) and breast carcinoma in 21 patients (28.8%).

RESULTS

The success rate of TS was significantly higher if the time period between radiological diagnosis of effusion and administration of TS was less than 30 days (P= .02), or spontaneous expansion was attained after chest tube drainage (CTD) (P= .01). Success rate was higher for patients with daily drainage of less than 200 ml before TS than patients with more than 200 ml of daily drainage (P= .01). Dose of talc, either 4 g or above (P= .34), primary cause of MPE (P= .53), time to termination of CTD (P= .57), amount of drainage when CTD was terminated (P= .23), and time period between CTD and administration of TS (P= .20) did not show a statistically significant effect on the success of TS.

CONCLUSION

In the treatment of malignant pleural effusion, patients with daily drainage of less than 200 ml before TS developed less recurrence than patients with daily drainage of more than 200 ml. Longer time period between the diagnosis of MPE and onset of CTD increased recurrence.

Do concomitant ascites influence the effectiveness of palliative surgical management of pleural effusion in patients with malignancies?

BACKGROUND

Both pleural and peritoneal effusions are associated with dismal prognosis for patients with malignancies. Pleural effusion often requires surgical palliative management to relieve symptoms. The aim of this study was assess the influence of concomitancy of ascites on the success rate of surgical management of pleural effusion in patients with solid malignancies.

METHODS

We retrospectively identified 33 patients with different primary malignancies, who underwent palliative surgical treatment for pleural effusion with concomitant ascites. The success rate of pleural effusion management was compared to that of a control group of patients with pleural effusion without ascites.

RESULTS

Ovarian and breast cancer were the most common primary sites in the group of patients with pleural and peritoneal effusions. Thoracocentesis was performed in 30 patients with concomitant ascites and in 29 patients without ascites. The median number of thoracocentesis procedures was two in both groups of patients. Talc pleurodesis was performed in 57.6 and 63.3% of patients with and without ascites, respectively. The success rate of pleurodesis was 68.4 and 71.9% for patients with and without concomitant ascites (P = 0.92), respectively. There was no significant difference in the median length of time of the chest tube placement between the two groups (with ascites, 6 days; without ascites, 5 days, P = 0.38). The overall survival was 5.6 months for patients with ascites and 7.8 months for patients without ascites (P = 0.51).

CONCLUSION

Our results suggest that concomitant ascites did not influence the effectiveness of palliative surgical management of pleural effusion in patients with malignancies.

Management of malignant pleural effusion

Malignant pleural effusion (MPE) often presents in patients with cancer at an advanced stage and thus carries a poor prognosis. This review updates the current knowledge on the management of MPE, focusing on recent literature about the efficacy and safety of the most common methods, including pleurodesis by either thoracoscopy with talc insufflation or thoracostomy with talc slurry, use of an indwelling pleural catheter, and intrapleural chemotherapy. Talc remains the agent of choice in pleurodesis, although the use of alternative agents continues to be explored. The choice of procedure to achieve pleurodesis depends on careful patient selection based on predictive factors and individual characteristics. Talc pleuro-desis is relatively well tolerated and safe, as is an indwelling pleural catheter, in an appropriate patient population. Because MPE is a common problem in cancer patients, future research with more randomized, prospective designs and innovative interventions is needed.

Diagnosis and management of malignant pleural effusions

Malignant pleural effusions (MPEs) complicate the clinical course of patients with a broad array of malignancies, which are most often due to lymphomas or carcinomas of the breast, lung, gastrointestinal tract or ovaries. Patients may present with a MPE as the initial manifestation of a cancer or develop an effusion during the advanced phases of a known malignancy. In either circumstance, the median survival after presentation with a MPE is 4 months. Effusions may result from direct pleural invasion (MPE) or indirect effects (paraneoplastic effusions), such as impairment of fluid efflux from the pleural space by lymphatic obstruction or pleural effects of cancer radiation or drug therapy. Because only 50% of patients with cancer who develop a pleural effusion during their clinical course have a MPE, careful evaluation of the effusion to establish its aetiology is required to direct therapy. Management is palliative with interventions directed towards decreasing the volume of intrapleural fluid and the severity of associated symptoms.

A simple and direct electrochemical detection of interferon-gamma using its RNA and DNA aptamers

Tuberculosis is the most frequent cause of infection-related death worldwide. We constructed a simple and direct electrochemical sensor to detect interferon (IFN)-gamma, a selective marker for tuberculosis pleurisy, using its RNA and DNA aptamers. IFN-gamma was detected by its 5'-thiol-modified aptamer probe immobilized on the gold electrode. Interaction between IFN-gamma and the aptamer was recorded using electrochemical impedance spectroscopy and quartz crystal microbalance (QCM) with high sensitivity. The RNA-aptamer-based sensor showed a low detection limit of 100 fM, and the DNA-aptamer-based sensor detected IFN-gamma to 1 pM in sodium phosphate buffer. With QCM analysis, the aptamer immobilized on the electrode and IFN-gamma bound to the aptamer probe was quantified. This QCM result shows that IFN-gamma exists in multimeric forms to interact with the aptamers, and the RNA aptamer prefers the high multimeric state of IFN-gamma. Such a preference may describe the low detection limit of the RNA aptamer shown by impedance analysis. In addition, IFN-gamma was detected to 10 pM by the DNA aptamer in fetal bovine serum, a mimicked biological system, which has similar components to pleural fluid.

Recent advances in the diagnosis and management of malignant pleural effusions

Malignant pleural effusions (MPEs) are an important complication for patients with intrathoracic and extrathoracic malignancies. Median survival after diagnosis of an MPE is 4 months. Patients can present with an MPE as a complication of far-advanced cancer or as the initial manifestation of an underlying malignancy. Common cancer types causing MPEs include lymphomas, mesotheliomas, and carcinomas of the breast, lung, gastrointestinal tract, and ovaries. However, almost all tumor types have been reported to cause MPEs. New imaging modalities assist the evaluation of patients with a suspected MPE; however, positive cytologic or tissue confirmation of malignant cells is necessary to establish a diagnosis. Even in the presence of known malignancy, up to 50% of pleural effusions are benign, underscoring the importance of a firm diagnosis to guide therapy. Rapidly evolving interventional and histopathologic techniques have improved the diagnostic yield of standard cytology and biopsy. Management of an MPE remains palliative; it is critical that the appropriate management approach is chosen on the basis of available expertise and the patient's clinical status. This review summarizes the pathogenesis, diagnosis, and management of MPE. Studies in the English language were identified by searching the MEDLINE database (1980-2007) using the search terms pleura, pleural, malignant, pleurodesis, and thoracoscopy.

Prospective evaluation of flex-rigid pleuroscopy for indeterminate pleural effusion: accuracy, safety and outcome

OBJECTIVE

This study aimed to assess prospectively the accuracy, safety and outcome of flex-rigid pleuroscopy in the diagnosis of patients with indeterminate pleural effusions.

METHODS

Included in the study were all patients with unilateral exudative pleural effusions of unknown aetiology who underwent diagnostic flex-rigid pleuroscopy from July 2003 to June 2005, and were followed until December 2005. The procedure was conducted in the endoscopy suite under local anaesthesia and, where indicated, talc poudrage was carried out at the same time. Clinical data, length of hospitalization, chest tube drainage, outcome, diagnostic accuracy of pleuroscopy and procedure-related adverse events were recorded prospectively.

RESULTS

Fifty-one patients were recruited (20 male and 31 female). Median age was 53 years (range 45-67). Flex-rigid pleuroscopy was 96% accurate and yielded a diagnosis in 49 out of 51 patients. It was safely carried out without need for surgical intervention, blood transfusion or endotracheal intubation. Culture-negative fever was observed in eight patients (16%), and five patients (10%) required additional analgesia for postoperative pain. Duration of chest tube drainage and length of stay for patients who underwent diagnostic pleuroscopy were 1 and 2 days, respectively, while they were both 3 days when talc poudrage was carried out. Success rates with pleuroscopic talc pleurodesis for malignant pleural effusions were 94%, 92% and 89.5% at 3, 6 and 12 months, respectively, and the 30-day mortality was 0%.

CONCLUSION

Flex-rigid pleuroscopy is a safe procedure with a high diagnostic accuracy and should be considered for the evaluation of indeterminate pleural effusion.

Palliation of thoracic malignancies

The sequelae of advanced malignancies of the chest, whether primary or metastatic, can be severely debilitating. In this review, we discuss the advances in palliative treatment for several intrathoracic complications of malignancy. The treatment of malignant pleural and pericardial effusions now includes a range of chemical sclerosants and percutaneous or surgical interventions. A new generation of promising stent and ablation technologies allows for the treatment of intrinsic or extrinsic airway obstruction. Similar techniques are being explored for esophageal obstruction, while the possible benefit of palliative radiation and chemotherapy continues to be investigated. Although their symptoms are often severe, patients with advanced thoracic malignancies have a growing number and variety of palliative treatment options to improve their quality of life.

Malignant pleural effusions: management options with consideration of coding, billing, and a decision approach

Malignant pleural effusions (MPEs) are a troublesome and debilitating complication of advanced malignancies, with > 150,000 cases in the United States each year. The standard management approach begins with a diagnostic and/or therapeutic thoracentesis. Should the MPE recur, a more definitive management strategy is often undertaken with several approaches available to the chest physician or surgeon. These options include repeat thoracentesis, tube thoracostomy with chemical pleurodesis, placement of an indwelling cuffed, tunneled pleural catheter with or without pleurodesis, or medical pleuroscopy or video-assisted thoracoscopic surgery with pleurodesis. Each approach has unique advantages, disadvantages, and likelihood of successful symptom relief and pleurodesis. This article will provide a general review of MPE management strategies including information concerning coding, billing, documentation, and a decision approach among these various methods.

Management of Morel-Lavallee lesion of the knee: twenty-seven cases in the national football league

BACKGROUND

The Morel-Lavallee lesion is a closed degloving injury most commonly described in the region of the hip joint after blunt trauma. It also occurs in the knee as a result of shearing trauma during football and is a distinct lesion from prepatellar bursitis and quadriceps contusion.

PURPOSE

To review the authors' experience with Morel-Lavallee lesion of the knee in the elite contact athlete to construct a diagnostic and treatment algorithm.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Twenty-seven knees in 24 players were identified from 1 National Football League team's annual injury database as having sustained a Morel-Lavallee lesion between 1993 and 2006. Their charts were retrospectively reviewed.

RESULTS

The most common mechanism of injury was a shearing blow on the playing surface (81%). The most common motion deficit was active flexion (41%). The mean time for resolution of the fluid collection and achievement of full active flexion was 16.3 days. The mean number of practices missed was 1.5. The mean number of games missed was 0.1. Fourteen knees (52%) were treated successfully with compression wrap, cryotherapy, and motion exercises. Thirteen knees (48%) were treated with at least 1 aspiration, and 6 knees (22%) were treated with multiple aspirations for recurrent serosanguineous fluid collections. In 3 cases (11%), the Morel-Lavallee lesion was successfully treated with doxycycline sclerodesis after 3 aspirations failed to resolve the recurrent fluid collections; return to play was immediate thereafter in each case.

CONCLUSION

In football, Morel-Lavallee lesion of the knee usually occurs from a shearing blow from the playing field. Diagnosis is confirmed when examination reveals a large suprapatellar area of palpable fluctuance. Elite athletes are typically able to return to practice and game play long before complete resolution of the lesion. Recurrent fluid collections can occur, necessitating aspiration in approximately half the cases for successful treatment. Recalcitrant fluid collections can be safely and expeditiously treated with doxycycline sclerodesis.