Prognostic factors of recurrence of malignant pleural effusion: what is the role of neoplasia progression?

Lymph nodes rather than pleural metabolic activity in 18F-FDG PET/CT correlates with malignant pleural effusion recurrence in advanced non-small cell lung cancer

Background

Frequently recurrent malignant pleural effusion (MPE) significantly hampers the life quality of advanced non-small cell lung cancer (NSCLC) patients. We aimed to explore the effects of progression patterns and local intervention on MPE recurrence and apply fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) to establish a predictive model for MPE recurrence in NSCLC.

Methods

We retrospectively recruited two cohorts of patients including treatment-naïve NSCLC diagnosed with MPE at the onset and receiving PET/CT scanning, as well as those with MPE and undergoing first-line epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitor (TKI) treatment. Pleural maximum standardized uptake value (SUVmax), metabolic tumor burden (MTV), total lesion glycolysis (TLG), and uptake patterns as well as SUVmax of lymph nodes (LN) were extracted. The primary outcome was MPE recurrence defined as re-accumulation of cytologically proven ipsilateral MPE. Step-wise multivariate Cox regression was used to identify candidate variables. Cox regression analysis and random survival forest were applied to establish models.

Results

A total of 148 treatment-naïve patients with EGFR-TKI treatment and MPE were recruited during the median follow-up period of 683 days, with 69 (46.6%) and 35 (23.6%) witnessing MPE recurrence at least once and twice. Intrapleural perfusion therapy at first recurrence was a protective factor for the second MPE recurrence (P=0.006), while intrapleural perfusion therapy at baseline could not benefit the first MPE recurrence (P=0.14). Conversely, prior systemic progression indicative of the change of systemic treatment was a protective factor for time to the first MPE recurrence (P<0.001); instead, the change of systemic treatment at the first MPE recurrence was not associated with second MPE recurrence (P=0.53). In another cohort with treatment-naïve NSCLC patients with MPE and PET/CT scanning, 103 patients regardless of the actionable mutation status were recruited during the median follow-up period of 304 days. Multivariate analysis suggested that the LN SUVmax >4.50 g/mL [hazard ratio (HR), 2.54; P=0.01], female gender (HR, 0.40; P=0.01), bone metastases (HR, 3.16; P=0.001), and systemic treatment (targeted therapy vs. chemotherapy: HR, 0.32; P=0.002; immunotherapy therapy vs. chemotherapy: HR, 0.99; P=0.97) could collectively indicate MPE recurrence with an optimal 300-day area under the curve (AUC) of 0.83. For patients with actionable mutation, LN SUVmax >4.50 g/mL (P=0.02) could forecast MPE recurrence independently.

Conclusions

In summary, LN rather than pleural metabolic activity or uptake patterns could predict MPE recurrence for patients with or without targeted therapy. We should re-consider the application of intrapleural perfusion treatment for first-onset MPE and prompt it more at the moment of recurrent MPE. Promisingly, we could probably apply the non-invasive tool to identify the risk factors for MPE recurrence.

Risk factors for symptomatic malignant pleural effusion recurrence in patients with actionable mutations in advanced lung adenocarcinoma

Background

Malignant pleural effusion (MPE) comes generally with high mortality and poor prognosis. Recurrence of symptomatic MPE is always accompanied by poor survival quality. In lung adenocarcinoma, researchers speculate whether patients with actionable mutation or without are applicable to different management models for MPE. Under the background of the high mutation probability and the encouraging therapeutic response in Asians, researches on the risk factors of MPE are in need.

Methods

This retrospective review included 343 metastatic lung adenocarcinoma patients with MPE. Recurrence was defined as recurrent symptomatic MPE requiring the second thoracentesis to relieve symptoms within 300 days after the first thoracentesis. Univariable and multivariable Cox regression analysis were utilized to investigate independent risk factors for MPE recurrence.

Results

Of the 343 patients involved, 139 experienced MPE recurrence within 300 days; 34.3% in 201 patients with actionable mutations and 51.2% in 129 patients without actionable mutations are in the recurrence. The median recurrence-free survival (RFS) of the group without mutations was 161 days. The median RFS of the other group with mutations was 300 days. Patients with actionable mutations showed a significantly lower hazard of MPE recurrence on univariate analysis. The multivariate analysis indicated that receiving targeted therapy after the first thoracentesis within 30 days, lower neutrophil-to-lymphocyte ratio (NLR) level, lower serum lactate dehydrogenase (s-LDH) level, and lower serum carcinoembryonic antigen (s-CEA) level were independent protective factors. In subgroup analysis, risk factors differed. Receiving targeted therapy after the first thoracentesis within 30 days remained an independent factor in the mutated patients.

Conclusions

The findings herein indicated the characteristics of specific patients at high risk for MPE recurrence in lung adenocarcinoma. Patients with actionable mutations benefit more in MPE recurrence and could benefit from targeted therapy and active intrapleural management.

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.

A Retrospective Analysis of the Palliative Surgical Treatment in Patients with Malignant Pleural Effusion

Introduction: The formation of malignant pleural effusion (MPE) is a clinical manifestation of an advanced malignancy or its dissemination. The focus of treatment is primarily palliative and aimed at relieving symptoms, especially dyspnoea.

Material and Methods: Clinical data from patients who were hospitalized at the Clinic of Thoracic Surgery, JFMED CU and Martin University Hospital, in the years 2015–2019 were retrospectively explored and statistically analyzed based on their medical records.

Results: From the group of patients with proven MPE (n=67), 32 patients were male (48%) and 35 were female (52%). The mean age was 62.3 years (65.4 for males and 59.4 for females). The three most common primary malignancies were lung cancer (n=24), breast cancer (n=14), and kidney cancer (n=6). In 38 patients with MPE a talc pleurodesis via VATS was performed, with a median survival of 341 days (95% CI 256–859). Drainage following the talc slurry pleurodesis was performed in 10 patients with a median survival of 91.5 days (95% CI 64-NA). Ten patients with MPE underwent drainage only. The overall median survival time after all types of surgical interventions was 301 days (95% CI 207-389 days).

Conclusion: Management of MPE depends on the patient´s prognosis. A definitive intervention is required in patients with a long-term survival, while in patients with a short life expectancy procedures leading to the shortest hospital stay are preferred. Videothoracoscopic procedures with pleurodesis represent an effective treatment for patients with symptomatic MPE with a good performance status, presence of lung re-expansion following pleural drainage or expected survival.