Eosinophilic pleural effusion due to lung cancer has a better prognosis than non-eosinophilic malignant pleural effusion

Objective

Tumor-related eosinophilia may have extended survival benefits for some cancer patients. However, there has been no report on the prognosis difference between eosinophilic pleural effusion (EPE) and non-EPE in lung cancer patients. Our study aimed to investigate the prognosis difference between EPE and non-EPE due to lung cancer.

Patients and methods

We retrospectively reviewed patients diagnosed with lung cancer who presented with malignant pleural effusion (MPE) between May 2007 and September 2020 at the National Hospital Organization Kochi Hospital. EPE is defined as pleural fluid with a nucleated cell count containing 10% or more eosinophils.

Results

A total of 152 patients were included: 89 were male (59%). The median age was 74.4 years (range 37–101), and all patients were pathologically shown to have MPE. Most patients (140; 92%) had an Eastern Cooperative Oncology Group (ECOG) Performance Status (PS) of 0/1. Twenty patients had EPE. The median overall survival (OS) of all 152 lung cancer patients with MPE was 298 days. The median OS of the patients with EPE was 766 days, and the median OS of the patients with non-EPE was 252 days. Kaplan–Meier univariate analysis showed that lung cancer patients with EPE had a significantly better prognosis than patients with non-EPE (P < 0.05). Cox proportional regression analysis showed that EPE, ECOG PS, sex, and the neutrophil-to-lymphocyte ratio in the serum (sNLR) may be independent prognostic factors affecting survival in patients with MPE.

Conclusion

Lung cancer patients with EPE have a better prognosis than those with non-EPE.

Neutrophil-to-lymphocyte ratio in malignant pleural fluid: Prognostic significance

Predicting survival of patients with malignant pleural effusions (MPEs) is notoriously difficult. A robust prognostic marker can guide clinical decision making. The neutrophil-to-lymphocyte ratio (NLR) in blood has been shown to predict survival in many cancers. Pleural fluid bathes the malignant pleural tissues, thus the NLR of the pleural fluid may reflect more closely the local tumour environment. The objective of this study was to explore the prognostic significance of pleural effusion NLR for MPE. We analysed matched effusion and blood from 117 patients with malignant and 24 with benign pleural effusions. Those who had received recent chemotherapy or had a pleurodesis were excluded. Neutrophil and lymphocyte counts in effusions were performed by manual review of cytospin cell preparations by trained observers. Clinical data were extracted from a state-wide hospital database. We found significantly fewer neutrophils (expressed as percentage of total leukocyte count) in pleural fluid than in corresponding blood (9% vs 73%; p<0.001). The NLR was an order of magnitude lower in pleural fluid than in corresponding blood: median [IQR] = 0.20 [0.04-1.18] vs 4.9 [3.0-8.3], p<0.001. Correlation between blood and pleural fluid NLR in MPE patients was moderate (rs = 0.321, p<0.001). In univariate analysis, NLR (>0.745)) in malignant pleural fluid was predictive of poorer survival (HR = 1.698 [1.0054-2.736]; p = 0.030), and remained significant after adjustment for age, sex, presence of a chest drain, cancer type, concurrent infection and subsequent treatment with chemotherapy (HR = 1.786 [1.089-2.928]; p = 0.022). Patients with pleural fluid NLR > 0.745 had a significantly shorter median survival of 130 (95% CI 0-282) days compared to 312 (95% CI 195-428) days for pleural NLR < 0.745, p = 0.026. The NLR in blood was also predictive of poorer survival in MPE patients (HR = 1.959 [1.019-3.096]; p<0.001). The proportion of neutrophils in pleural fluid was predictive of prognosis more strongly than lymphocytes. This study provides evidence that NLR in malignant effusions can predict survival, and therefore may provide prognostic information for this cohort. This prognostic association in the fluid is driven by the presence of neutrophils.

High frequency of exon 20 S768I EGFR mutation detected in malignant pleural effusions: A poor prognosticator of NSCLC

BACKGROUND

Lung cancer is the cause of a fourth of all cancer-related deaths. About a third of all lung adenocarcinoma tumours harbour mutations on exons 18 to 21 of the epidermal growth factor receptor (EGFR) gene. Detection of these mutations allows for targeted therapies in the form of EGFR Tyrosine kinase inhibitors. Recently, "liquid biopsies" have emerged as an alternative to conventional tissue mutation detection.

AIM

In this pilot study, we attempted to optimize EGFR mutation detection from malignant pleural effusions (MPEs) as "liquid biopsies" when tissue biopsies were unavailable. Resulting mutations were then to be mapped on the EGFR gene and explored using cBioPortal, a public cancer genomic database.

METHODS AND RESULTS

We first attempted a direct sequencing approach and showed that single nucleotide variants (SNVs) were likely to be missed in MPEs. We then switched to and optimized an EGFR mutant-specific quantitative polymerase chain reaction-based assay. This assay was piloted on n = 10 pleural effusion samples (one non-malignant pleural effusion as a negative control). 5/9 (55.55%) samples harboured EGFR mutations with 2/9 (22.22%) being exon 19 deletions and 3/9 (33.33%) the S768I mutation. The frequency of the S768I SNV in our study was significantly higher than that observed in other studies (~0.2%). Utilizing cBioPortal data, we report that patients with S768I have a shorter median survival time (6 months vs 38 months), progression-free survival time (8 months vs 44 months) and lower tumor mutation count compared to patients with other EGFR mutations.

CONCLUSIONS

The shorter survival of patients with the S768I SNV predicts aggressive disease and poor prognosis as a result of this mutation. Studies in larger cohorts and/or animal models are necessary to confirm these findings.

Management of Respiratory Symptoms in Those with Serious Illness

Respiratory symptoms are common in patients living with serious illness, both in cancer and nonmalignant conditions. Common symptoms include dyspnea (breathlessness), cough, malignant pleural effusions, airway secretions, and hemoptysis. Basic management of respiratory symptoms is within the scope of primary palliative care. There are pharmacologic and nonpharmacologic approaches to treating respiratory symptoms. This article provides clinicians with treatment approaches to these burdensome symptoms.

Interventions for the management of malignant pleural effusions: a network meta-analysis

BACKGROUND

Malignant pleural effusion (MPE) is a common problem for people with cancer and usually associated with considerable breathlessness. A number of treatment options are available to manage the uncontrolled accumulation of pleural fluid, including administration of a pleurodesis agent (via a chest tube or thoracoscopy) or placement of an indwelling pleural catheter (IPC). This is an update of a review published in Issue 5, 2016, which replaced the original, published in 2004.

OBJECTIVES

To ascertain the optimal management strategy for adults with malignant pleural effusion in terms of pleurodesis success and to quantify differences in patient-reported outcomes and adverse effects between interventions.

SEARCH METHODS

We searched CENTRAL, MEDLINE (Ovid), Embase (Ovid) and three other databases to June 2019. We screened reference lists from other relevant publications and searched trial registries.

SELECTION CRITERIA

We included randomised controlled trials of intrapleural interventions for adults with symptomatic MPE, comparing types of sclerosant, mode of administration and IPC use.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data on study design, characteristics, outcome measures, potential effect modifiers and risk of bias. The primary outcome was pleurodesis failure rate. Secondary outcomes were adverse events, patient-reported breathlessness control, quality of life, cost, mortality, survival, duration of inpatient stay and patient acceptability. We performed network meta-analyses of primary outcome data and secondary outcomes with enough data. We also performed pair-wise meta-analyses of direct comparison data. If we deemed interventions not jointly randomisable, or we found insufficient available data, we reported results by narrative synthesis. For the primary outcome, we performed sensitivity analyses to explore potential causes of heterogeneity and to evaluate pleurodesis agents administered via a chest tube only. We assessed the certainty of the evidence using GRADE.

MAIN RESULTS

We identified 80 randomised trials (18 new), including 5507 participants. We found all except three studies at high or unclear risk of bias for at least one domain. Due to the nature of the interventions, most studies were unblinded. Pleurodesis failure rate We included 55 studies of 21 interventions in the primary network meta-analysis. We estimated the rank of each intervention's effectiveness. Talc slurry (ranked 6, 95% credible interval (Cr-I) 3 to 10)  is an effective pleurodesis agent (moderate certainty for comparison with placebo) and may result in fewer pleurodesis failures than bleomycin and doxycycline (bleomycin versus talc slurry: odds ratio (OR) 2.24, 95% Cr-I 1.10 to 4.68; low certainty; ranked 11, 95% Cr-I 7 to 15; doxycycline versus talc slurry: OR 2.51, 95% Cr-I 0.81 to 8.40; low certainty; ranked 12, 95% Cr-I 5 to 18). There is little evidence of a difference between the pleurodesis failure rate of talc poudrage and talc slurry (OR 0.50, 95% Cr-I 0.21 to 1.02; moderate certainty). Evidence for any difference was further reduced when restricting analysis to studies at low risk of bias (defined as maximum one high risk domain in the risk of bias assessment) (pleurodesis failure talc poudrage versus talc slurry: OR 0.78, 95% Cr-I 0.16 to 2.08). IPCs without daily drainage are probably less effective at obtaining a definitive pleurodesis (cessation of pleural fluid drainage facilitating IPC removal) than talc slurry (OR 7.60, 95% Cr-I 2.96 to 20.47; rank = 18/21, 95% Cr-I 13 to 21; moderate certainty). Daily IPC drainage or instillation of talc slurry via IPC are likely to reduce pleurodesis failure rates. Adverse effects Adverse effects were inconsistently reported. We performed network meta-analyses for the risk of procedure-related fever and pain. The evidence for risk of developing fever was of low certainty, but suggested there may be little difference between interventions relative to talc slurry (talc poudrage: OR 0.89, 95% Cr-I 0.11 to 6.67; bleomycin: OR 2.33, 95% Cr-I 0.45 to 12.50; IPCs: OR 0.41, 95% Cr-I 0.00 to 50.00; doxycycline: OR 0.85, 95% Cr-I 0.05 to 14.29). Evidence also suggested there may be little difference between interventions in the risk of developing procedure-related pain, relative to talc slurry (talc poudrage: OR 1.26, 95% Cr-I 0.45 to 6.04; very-low certainty; bleomycin: OR 2.85, 95% Cr-I 0.78 to 11.53; low certainty; IPCs: OR 1.30, 95% Cr-I 0.29 to 5.87; low certainty; doxycycline: OR 3.35, 95% Cr-I 0.64 to 19.72; low certainty). Patient-reported control of breathlessness Pair-wise meta-analysis suggests there is likely no difference in breathlessness control, relative to talc slurry, of talc poudrage ((mean difference (MD) 4.00 mm, 95% CI -6.26 to 14.26) on a 100 mm visual analogue scale for breathlessness; studies = 1; participants = 184; moderate certainty) and IPCs without daily drainage (MD -6.12 mm, 95% CI -16.32 to 4.08; studies = 2; participants = 160; low certainty). Overall mortality There may be little difference between interventions when compared to talc slurry (bleomycin and IPC without daily drainage; low certainty) but evidence is uncertain for talc poudrage and doxycycline. Patient acceptability Pair-wise meta-analysis demonstrated that IPCs probably result in a reduced risk of requiring a repeat invasive pleural intervention (OR 0.25, 95% Cr-I 0.13 to 0.48; moderate certainty) relative to talc slurry. There is likely little difference in the risk of repeat invasive pleural intervention with talc poudrage relative to talc slurry (OR 0.96, 95% CI 0.59 to 1.56; moderate certainty).

AUTHORS' CONCLUSIONS

Based on the available evidence, talc poudrage and talc slurry are effective methods for achieving a pleurodesis, with lower failure rates than a number of other commonly used interventions. IPCs provide an alternative approach; whilst associated with inferior definitive pleurodesis rates, comparable control of breathlessness can probably be achieved, with a lower risk of requiring repeat invasive pleural intervention.  Local availability, global experience of agents and adverse events (which may not be identified in randomised trials) and patient preference must be considered when selecting an intervention. Further research is required to delineate the roles of different treatments according to patient characteristics, such as presence of trapped lung. Greater attention to patient-centred outcomes, including breathlessness, quality of life and patient preference is essential to inform clinical decision-making. Careful consideration to minimise the risk of bias and standardise outcome measures is essential for future trial design.

Clinical course of non-small cell lung cancer patients with dry pleural dissemination: Retrospective observational study

We investigated the prognosis of patients with dry pleural dissemination (DPD) of non-small cell lung cancer (NSCLC) and the risk factors of developing to malignant pleural effusion (MPE).We retrospectively reviewed 104 patients with NSCLC and DPD, confirmed surgically from 1996 to 2016. Incidence rate and risk factors of MPE were analyzed statistically. The prognosis of NSCLC patients with MPE was evaluated using the Kaplan-Meier method.The most common histologic type was adenocarcinoma in 95 (91.3%) patients. The median follow-up duration was 65.5 months and the median survival time was 37.7 months. MPE developed in 51 (49%) patients, and the median effusion-free interval was 41.9 months. The median survival time of the patients with and without MPE was not different (41.3 vs 31.7 months, P = .16). No predictive factors for the development of MPE were identified. Fifteen (14.4%) patients underwent invasive procedures for the management of MPE.Almost half of all patients with NSCLC and DPD experienced MPE, and 14.4% patients developed symptomatic MPE requiring invasive procedures. MPE in DPD did not affect the survival in NSCLC patients.

Survival in patients with malignant pleural effusion undergoing talc pleurodesis

OBJECTIVES

Recent observations indicate a potential survival benefit in patients with malignant pleural effusion (MPE) who achieve successful pleurodesis in comparison to patients who experience effusion recurrence post pleurodesis. This study aimed to explore this observation using two datasets of patients with MPE undergoing talc pleurodesis.

MATERIALS AND METHODS

Dataset 1 comprised patients who underwent talc pleurodesis at Oxford Pleural Unit for MPE. Dataset 2 comprised patients enrolled in the TIME1 clinical trial. Pleurodesis success was defined as absence of need for further therapeutic procedures for MPE in the three months following pleurodesis. Data on various clinical, laboratory and radiological parameters were collected and survival was compared according to pleurodesis outcome (success vs. failure) after adjusting for the aforementioned parameters.

RESULTS

Dataset 1 comprised 60 patients with mean age 74.1±10.3 years. The most common primary malignancies were mesothelioma, breast and lung cancer. 29 patients (48.3%) achieved pleurodesis. The adjusted odds ratio (aOR) for poor survival with pleurodesis failure was 2.85 (95% CI 1.08-7.50, =p 0.034). Dataset 2 comprised 259 patients from the TIME1 trial. The mean age was 70.8±10.3 and the most common primary malignancies were mesothelioma, lung and breast cancer. Pleurodesis was successful in 205 patients (79%). aOR for poor survival was 1.62 (95% CI 1.09-2.39, p = 0.015).

CONCLUSION

Achieving pleurodesis seems to impart a survival benefit in patients with MPE. Further studies are required to explore factors that may contribute to this phenomenon and to address the difference in survival between pleurodesis and indwelling pleural catheter interventions.

Rationale and Design of a Phase II Trial of Osimertinib Combined With Bevacizumab in Patients With Untreated Epidermal Growth Factor Receptor-mutated Non-small-cell Lung Cancer and Malignant Pleural and/or Pericardial Effusion (SPIRAL II Study)

Progression-free survival (PFS) of patients with non-small-cell lung cancer with pleural or pericardial effusion is expected to be prolonged with combination use of an epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor plus bevacizumab compared with that with an EGFR-tyrosine kinase inhibitor alone. Phase I clinical trial data have been reported for combined treatment with osimertinib plus bevacizumab and demonstrated their safety, but the efficacy remains unclear, particularly in patients with pleural or pericardial effusion. This is an ongoing single arm, prospective, open-label, multicenter, phase II trial to evaluate the efficacy and safety of osimertinib plus bevacizumab combination therapy in EGFR mutation-positive patients with untreated or recurrent non-small-cell lung cancer and pleural and/or pericardial effusion. Osimertinib will be administered orally once daily at a dose of 80 mg. One cycle consists of 21 days. Bevacizumab 15 mg/kg will be administered by drip infusion on Day 1 of each cycle. Treatment will be continued until progressive disease or any of the discontinuation criteria are met. The primary endpoint will be the 1-year PFS rate. Secondary endpoints are response rate, PFS, overall survival, survival not requiring pleural/pericardial drainage, and safety. Osimertinib plus bevacizumab combination therapy is expected to prolong PFS and reduce adverse events. TRIAL REGISTRATION NUMBER: UMIN000028071.

Prognostic value of platelet count and lymphocyte to monocyte ratio combination in stage IV non-small cell lung cancer with malignant pleural effusion

Introduction

A combination of platelet and lymphocyte to monocyte ratio (LMR) (abbreviated as COP-LMR) has been recently evaluated as systemic inflammatory marker for prognostication in lung cancer. While previous study on COP-LMR has evaluated its prognostic value in NSCLC patients who underwent curative resections, the combination of these two markers has not been evaluated in advanced NSCLC yet.

Objectives

In this study, we evaluated the prognostic value of COP-LMR in stage IV NSCLC with malignant pleural effusion under active anticancer treatment.

Methods

Between January 2012 and July 2016, 217 patients with stage IV NSCLC and MPE undergoing active anticancer treatment were selected for evaluation. If patients had both low LMR (< 2.47) and increased platelet (> 30.0 ×10⁴ mm-3), they were assigned to COP-LMR group 2. Patients with one parameter were assigned to COP-LMR group 1. If none, patients were assigned to COP-LMR group 0.

Results

Median overall survival (OS) (P < 0.001), progression free survival (PFS) (P < 0.001) and histological feature (P = 0.003) showed significant differences among COP-LMR groups. For COP-LMR groups 0, 1 and 2, median survival times were 35.9, 14.7 and 7.4 months, respectively, while median progression free times were 19.2, 13.3 and 7.4 months, respectively. Older age, male, low albumin, high CRP and high COP-LMR (0 vs 1, P = 0.021, hazard ratio (HR): 1.822, 95% confidence interval (CI): 1.096–3.027 and 0 vs 2, P = 0.003, HR: 2.464, 95% CI: 1.373–4.421) were independent predictive factors for shorter OS. Age, sex, histology, albumin, or CRP had no significant influence on PFS. High COP-LMR was the significant factor in predicting shorter PFS (0 vs 1, P = 0.116 and 0 vs 2, P = 0.007, HR: 1.902, 95% CI: 1.194–3.028).

Conclusions

A combination of pretreatment LMR and platelet levels can be used to predict short survival in stage IV NSCLC patients who underwent active anticancer treatment.

Development and validation of response markers to predict survival and pleurodesis success in patients with malignant pleural effusion (PROMISE): a multicohort analysis

BACKGROUND

The prevalence of malignant pleural effusion is increasing worldwide, but prognostic biomarkers to plan treatment and to understand the underlying mechanisms of disease progression remain unidentified. The PROMISE study was designed with the objectives to discover, validate, and prospectively assess biomarkers of survival and pleurodesis response in malignant pleural effusion and build a score that predicts survival.

METHODS

In this multicohort study, we used five separate and independent datasets from randomised controlled trials to investigate potential biomarkers of survival and pleurodesis. Mass spectrometry-based discovery was used to investigate pleural fluid samples for differential protein expression in patients from the discovery group with different survival and pleurodesis outcomes. Clinical, radiological, and biological variables were entered into least absolute shrinkage and selection operator regression to build a model that predicts 3-month mortality. We evaluated the model using internal and external validation.

FINDINGS

17 biomarker candidates of survival and seven of pleurodesis were identified in the discovery dataset. Three independent datasets (n=502) were used for biomarker validation. All pleurodesis biomarkers failed, and gelsolin, macrophage migration inhibitory factor, versican, and tissue inhibitor of metalloproteinases 1 (TIMP1) emerged as accurate predictors of survival. Eight variables (haemoglobin, C-reactive protein, white blood cell count, Eastern Cooperative Oncology Group performance status, cancer type, pleural fluid TIMP1 concentrations, and previous chemotherapy or radiotherapy) were validated and used to develop a survival score. Internal validation with bootstrap resampling and external validation with 162 patients from two independent datasets showed good discrimination (C statistic values of 0·78 [95% CI 0·72-0·83] for internal validation and 0·89 [0·84-0·93] for external validation of the clinical PROMISE score).

INTERPRETATION

To our knowledge, the PROMISE score is the first prospectively validated prognostic model for malignant pleural effusion that combines biological and clinical parameters to accurately estimate 3-month mortality. It is a robust, clinically relevant prognostic score that can be applied immediately, provide important information on patient prognosis, and guide the selection of appropriate management strategies.

FUNDING

European Respiratory Society, Medical Research Funding-University of Oxford, Slater & Gordon Research Fund, and Oxfordshire Health Services Research Committee Research Grants.

Outpatient Talc Administration by Indwelling Pleural Catheter for Malignant Effusion

BACKGROUND

Malignant pleural effusion affects more than 750,000 persons each year across Europe and the United States. Pleurodesis with the administration of talc in hospitalized patients is the most common treatment, but indwelling pleural catheters placed for drainage offer an ambulatory alternative. We examined whether talc administered through an indwelling pleural catheter was more effective at inducing pleurodesis than the use of an indwelling pleural catheter alone.

METHODS

Over a period of 4 years, we recruited patients with malignant pleural effusion at 18 centers in the United Kingdom. After the insertion of an indwelling pleural catheter, patients underwent drainage regularly on an outpatient basis. If there was no evidence of substantial lung entrapment (nonexpandable lung, in which lung expansion and pleural apposition are not possible because of visceral fibrosis or bronchial obstruction) at 10 days, patients were randomly assigned to receive either 4 g of talc slurry or placebo through the indwelling pleural catheter on an outpatient basis. Talc or placebo was administered on a single-blind basis. Follow-up lasted for 70 days. The primary outcome was successful pleurodesis at day 35 after randomization.

RESULTS

The target of 154 patients undergoing randomization was reached after 584 patients were approached. At day 35, a total of 30 of 69 patients (43%) in the talc group had successful pleurodesis, as compared with 16 of 70 (23%) in the placebo group (hazard ratio, 2.20; 95% confidence interval, 1.23 to 3.92; P=0.008). No significant between-group differences in effusion size and complexity, number of inpatient days, mortality, or number of adverse events were identified. No significant excess of blockages of the indwelling pleural catheter was noted in the talc group.

CONCLUSIONS

Among patients without substantial lung entrapment, the outpatient administration of talc through an indwelling pleural catheter for the treatment of malignant pleural effusion resulted in a significantly higher chance of pleurodesis at 35 days than an indwelling catheter alone, with no deleterious effects. (Funded by Becton Dickinson; EudraCT number, 2012-000599-40 .).

Effect of an Indwelling Pleural Catheter vs Talc Pleurodesis on Hospitalization Days in Patients With Malignant Pleural Effusion: The AMPLE Randomized Clinical Trial

IMPORTANCE

Indwelling pleural catheter and talc pleurodesis are established treatments for malignant pleural effusions among patients with poor prognosis.

OBJECTIVE

To determine whether indwelling pleural catheters are more effective than talc pleurodesis in reducing total hospitalization days in the remaining lifespan of patients with malignant pleural effusion.

DESIGN, SETTING, AND PARTICIPANTS

This open-label, randomized clinical trial included participants recruited from 9 centers in Australia, New Zealand, Singapore, and Hong Kong between July 2012 and October 2014; they were followed up for 12 months (study end date: October 16, 2015). Patients (n = 146) with symptomatic malignant pleural effusion who had not undergone indwelling pleural catheter or pleurodesis treatment were included.

INTERVENTIONS

Participants were randomized (1:1) to indwelling pleural catheter (n = 74) or talc pleurodesis (n = 72), minimized by malignancy (mesothelioma vs others) and trapped lung (vs not), and stratified by region (Australia vs Asia).

MAIN OUTCOMES AND MEASURES

The primary end point was the total number of days spent in hospital from procedure to death or to 12 months. Secondary outcomes included further pleural interventions, patient-reported breathlessness, quality-of-life measures, and adverse events.

RESULTS

Among the 146 patients who were randomized (median age, 70.5 years; 56.2% male), 2 withdrew before receiving the randomized intervention and were excluded. The indwelling pleural catheter group spent significantly fewer days in hospital than the pleurodesis group (median, 10.0 [interquartile range [IQR], 3-17] vs 12.0 [IQR, 7-21] days; P = .03; Hodges-Lehmann estimate of difference, 2.92 days; 95% CI, 0.43-5.84). The reduction was mainly in effusion-related hospitalization days (median, 1.0 [IQR, 1-3] day with the indwelling pleural catheter vs 4.0 (IQR, 3-6) days with pleurodesis; P < .001; Hodges-Lehmann estimate, 2.06 days; 95% CI, 1.53-2.58). Fewer patients randomized to indwelling pleural catheter required further ipsilateral invasive pleural drainages (4.1% vs 22.5%; difference, 18.4%; 95% CI, 7.7%-29.2%). There were no significant differences in improvements in breathlessness or quality of life offered by indwelling pleural catheter or talc pleurodesis. Adverse events were seen in 22 patients in the indwelling pleural catheter group (30 events) and 13 patients in the pleurodesis group (18 events).

CONCLUSIONS AND RELEVANCE

Among patients with malignant pleural effusion, treatment with an indwelling pleural catheter vs talc pleurodesis resulted in fewer hospitalization days from treatment to death, but the magnitude of the difference is of uncertain clinical importance. These findings may help inform patient choice of management for pleural effusion.

TRIAL REGISTRATION

anzctr.org.au Identifier: ACTRN12611000567921.

A randomized controlled trial comparing indwelling pleural catheters with talc pleurodesis (NVALT-14)

BACKGROUND

Symptomatic malignant pleural effusion (MPE) occurs frequently in patients with metastatic cancer. The associated prognosis is poor and the success rate of talc pleurodesis (TP) is low. Indwelling pleural catheters (IPCs) are commonly inserted when TP has been unsuccessful.

METHODS

We compared talc pleurodesis with the use of an indwelling pleural catheter in patients with recurrent MPE in a multicenter randomized controlled trial (superiority design). The primary endpoint was improvement from baseline in Modified Borg Score (MBS) 6weeks after randomized treatment. Secondary endpoints were hospitalization days, re-interventions, and adverse events.

RESULTS

Dyspnea improved significantly (p<0.01) after either treatment, but the magnitude of this improvement did not differ significantly between arms (median 3 and 1 for TP:IPC respectively in rest, p=0.16, (TP 13:IPC 16) and 3 and 1 during exercise, p=0.72 (TP 13:IPC 17)). There was no difference in dyspnea during exercise between TP and IPC at week 6 following treatment, while at rest TP patients (n=13) reported less dyspnea than IPC patients (n=18) (median 0 vs 1, p=0.002). Compared to TP, patients with an IPC had significantly less hospital days during randomized treatment (median: 0 vs 5, p<0.0001), and total hospitalizations for all causes (median: 1.6 vs 1.0, p=0.0035). Fewer IPC patients underwent more than one re-intervention (7/45 vs 15/43, p=0.09). The mean number of re-interventions was lower following IPC (0.21 vs 0.53, p=0.05). Equal number of adverse events occurred.

CONCLUSIONS

IPC was not superior in the primary endpoint, improvement of the modified Borg scale (MBS). However, IPC patients had lower hospital stay, fewer admissions and fewer re-interventions. The IPC is an effective treatment modality in patients with symptomatic malignant pleural effusion.

[Survival of malignant and paramalignant pleural effusions in Ouagadougou]

This study aimed to present the survival of patients with malignant and paramalignant pleural effusion (MPE) in a context of resource-limited countries. We retrospectively studied patients received for malignant and paramalignant pleural effusion in three health facilities in Ouagadougou from 1st August 2009 to 30 July 2015. Survival was analyzed according to various characteristics related to patients and disease. Eighty patients with a mean age of 54 years were selected. The sex-ratio was 0.9. Sixteen patients had comorbidities. Pleural effusion was revealing, synchronous and metachronous in respectively 55 %, 26.3 % and 17.5 % of cases. Lung cancer was the most common cause of MPE (27.5 %), followed by breast cancer (18.7 %). The median overall survival was 3 months; it varied between primary cancers: 5 months for primary cancer unknown, 4 months for lung cancers and 2 months for breast cancers. Sex and the presence of comorbidities were independent factors influencing survival of patients. In this study, patient survival length is strongly compromised by inadequacies of medical technical equipment.

Current best practice in the evaluation and management of malignant pleural effusions

Malignant pleural effusions (MPEs) are an important cause of cancer-related mortality and morbidity. It is a heterogeneous group of conditions, which leads to debilitating symptoms and confers a poor prognosis. Recent well-designed randomized trials have provided a broader evidence base for an expanding range of treatment options. Together, with new prognostic scoring systems and a greater understanding of how different patient phenotypes respond to treatment, this allows greater personalization of management. This article will discuss the current evidence on evaluation and management of MPEs.

Survival Difference in Patients with Malignant Pleural Effusions Treated with Pleural Catheter or Talc Pleurodesis

Malignant pleural effusions (MPE) are commonly managed with either pleural catheter (PC) or talc pleurodesis (TP). The aim of this study was to compare survival in MPE patients treated with either PC or TP. A retrospective review of our cancer center database was performed. Patients with metastatic cancer and MPE were analyzed. Demographic and clinical data were tabulated and compared. A total of 238 patients with MPE treated by either PC or TP were included. Of these, 79 patients comprised the PC group and 159 the TP group. PC had a higher incidence of advanced disease (stage III or IV) at initial diagnosis compared with TP (70.9% vs 57.2%, P = 0.05). TP had a longer postprocedure length of stay compared with PC (7.1 vs 5.0 days, P = 0.02); however, overall length of stay was similar (9.7 vs 11.1 days, P = 0.34). Readmissions were significantly lower in TP (11.9% vs 22.8%, P = 0.04). Mean survival was higher in TP compared with PC (18.7 vs 4.1 months, P < 0.001). Patients with metastatic cancer and MPE treated with TP had significantly higher survival compared with PC. This is likely related to a greater disease burden in PC, as 70 per cent of patients in this group had stage III or IV disease on initial presentation.

Prognostic factors in patients with malignant pleural effusion: Is it possible to predict mortality in patients with good performance status?

BACKGROUND AND OBJECTIVES

The aim of this study was to identify predictors of mortality only in patients with malignant pleural effusion (MPE) showing good performance status which required pleural palliative procedures.

METHODS

All patients with MPE submitted to pleural palliative procedure were enrolled in a prospective study between 2013 and 2014. Patients with Eastern cooperative oncology group (ECOG) score zero, one, and two were considered with good performance status. The possible prognostic factors were tested for significance using the log-rank test (Kaplan-Meier method) and those with significance on univariate analysis were entered into a multivariable Cox model.

RESULTS

A total of 64 patients were included in the analysis. Median follow-up time for surviving patients was 263 days. Median survival for the entire cohort was not reached yet. In the multivariate analysis, gastrointestinal primary site (P = 0.006), low albumin concentration in the pleural fluid (P = 0.017), and high serum NLR (P = 0.007) were associated with mortality.

CONCLUSION

In our cohort of ECOG 0-2 patients with MPE submitted to pleural palliative procedures, gastrointestinal malignancy compared to other sites, low pleural fluid albumin and high NLR were significantly associated with mortality. The identification of these prognostic factors may assist the choice of the optimal palliative technique. J. Surg. Oncol. 2016;113:570-574. © 2016 Wiley Periodicals, Inc.

The Use of Indwelling Tunneled Pleural Catheters for Recurrent Pleural Effusions in Patients With Hematologic Malignancies: A Multicenter Study

BACKGROUND

Malignant pleural effusion is a common complication of advanced malignancies. Indwelling tunneled pleural catheter (IPC) placement provides effective palliation but can be associated with complications, including infection. In particular, hematologic malignancy and the associated immunosuppressive treatment regimens may increase infectious complications. This study aimed to review outcomes in patients with hematologic malignancy undergoing IPC placement.

METHODS

A retrospective multicenter study of IPCs placed in patients with hematologic malignancy from January 2009 to December 2013 was performed. Inclusion criteria were recurrent, symptomatic pleural effusion and an underlying diagnosis of hematologic malignancy. Records were reviewed for patient demographics, operative reports, and pathology, cytology, and microbiology reports.

RESULTS

Ninety-one patients (mean ± SD age, 65.4 ± 15.4 years) were identified from eight institutions. The mean × SD in situ dwell time of all catheters was 89.9 ± 127.1 days (total, 8,160 catheter-days). Seven infectious complications were identified, all of the pleural space. All patients were admitted to the hospital for treatment, with four requiring additional pleural procedures. Two patients died of septic shock related to pleural infection.

CONCLUSIONS

We present, to our knowledge, the largest study examining clinical outcomes related to IPC placement in patients with hematologic malignancy. An overall 7.7% infection risk and 2.2% mortality were identified, similar to previously reported studies, despite the significant immunosuppression and pancytopenia often present in this population. IPC placement appears to remain a reasonable clinical option for patients with recurrent pleural effusions related to hematologic malignancy.

Predicting survival in malignant pleural effusion: development and validation of the LENT prognostic score

BACKGROUND

Malignant pleural effusion (MPE) causes debilitating breathlessness and predicting survival is challenging. This study aimed to obtain contemporary data on survival by underlying tumour type in patients with MPE, identify prognostic indicators of overall survival and develop and validate a prognostic scoring system.

METHODS

Three large international cohorts of patients with MPE were used to calculate survival by cell type (univariable Cox model). The prognostic value of 14 predefined variables was evaluated in the most complete data set (multivariable Cox model). A clinical prognostic scoring system was then developed and validated.

RESULTS

Based on the results of the international data and the multivariable survival analysis, the LENT prognostic score (pleural fluid lactate dehydrogenase, Eastern Cooperative Oncology Group (ECOG) performance score (PS), neutrophil-to-lymphocyte ratio and tumour type) was developed and subsequently validated using an independent data set. Risk stratifying patients into low-risk, moderate-risk and high-risk groups gave median (IQR) survivals of 319 days (228-549; n=43), 130 days (47-467; n=129) and 44 days (22-77; n=31), respectively. Only 65% (20/31) of patients with a high-risk LENT score survived 1 month from diagnosis and just 3% (1/31) survived 6 months. Analysis of the area under the receiver operating curve revealed the LENT score to be superior at predicting survival compared with ECOG PS at 1 month (0.77 vs 0.66, p<0.01), 3 months (0.84 vs 0.75, p<0.01) and 6 months (0.85 vs 0.76, p<0.01).

CONCLUSIONS

The LENT scoring system is the first validated prognostic score in MPE, which predicts survival with significantly better accuracy than ECOG PS alone. This may aid clinical decision making in this diverse patient population.

Impact of cell arrangement of pleural effusion in survival of patients with breast cancer

OBJECTIVE

This study was performed to evaluate the potential influence of cytological differences between pleural effusions on the survival of women with metastatic breast cancer during 30 months of follow-up.

STUDY DESIGN

A hospital-based cohort study was performed. Pleural fluid cytology slides from patients with breast cancer were examined. Cases were grouped according to the pattern of tumor cells (spheroid and isolated), in order to access their prognostic value.

RESULTS

The study comprised 87 patients. An isolated cell pattern was associated with higher mortality 30 months after the pleural effusion when compared to a spheroid pattern (p = 0.038). Patients with an isolated cell pattern showed higher risk of dying than patients with spheroid formations. The relative risk after adjustment of intervening variables was 5.336 (95% CI 1.054-27.020). The presence of a triple-negative immunohistochemical pattern significantly increased the risk of mortality before 30 months.

CONCLUSION

Pleural effusion with isolated malignant cells is associated with worse prognosis after 30 months of follow-up.

Diagnosing malignant pleural effusions: how do we compare?

INTRODUCTION

Accurate and prompt diagnosis of malignant pleural effusion (MPE) is important as patients with suspected MPE often wait for many days before the diagnosis is secure.

AIMS

(1) To evaluate the diagnostic yield of pleural fluid cytology for patients admitted to Middlemore Hospital (MMH) in Auckland, New Zealand with MPE between 31 May 2010-1 June 2011. (2) To document the waiting time for cytology results to be made available and whether this contributed to length of stay. (3) To evaluate whether the volume of pleural fluid analysed contributed to diagnostic yield.

METHODS

A retrospective audit of pleural fluid cytology results on 36 consecutive patients admitted to MMH with a pleural effusion which was subsequently proven to be due to malignancy. Data was obtained from hospital medical records and Web Eclair databases.

RESULTS

54.8% (17/31) of patients had positive pleural fluid cytology. Initial pleural fluid cytology was positive in 16 (51.6%). Only 4/15 patients with negative pleural fluid cytology had a repeat aspiration (1 was positive). Median cytology turnaround time was 6.72 days, range 2.23-43.06 days. Average length of stay (ALOS) was 7.78 days, range 1.11-20.8 days. Cytology turnaround times seem shorter for inpatients and when a diagnosis of cancer is unknown but the ALOS is longer if patients have negative initial cytology and when a diagnosis of cancer is uncertain. Samples >50mL appear to have a higher diagnostic yield compared to samples less than and equal to 50mL but this was not statistically significant (77.8% to 41.2%, p=0.08).

CONCLUSION

Diagnostic yield from pleural fluid cytology at our hospital is comparable with other documented studies. ALOS appears to be influenced by a negative initial pleural fluid cytology and the uncertainty of diagnosis of cancer, not cytology turnaround time. The results suggest a more efficient diagnostic and treatment algorithm could be considered with emphasis on Day Stay investigation and treatment.

Malignant pleural mesothelioma: incidence, etiology, diagnosis, treatment, and occupational health

BACKGROUND

The incidence of malignant mesothelioma in Germany is about 20 cases per million persons per year. Its association with asbestos exposure, usually occupational, has been unequivocally demonstrated. Even though the industrial use of asbestos was forbidden many years ago, new cases of mesothelioma continue to appear because of the long latency of the disease (median, 50 years). Its diagnosis and treatment still present a major challenge for ambulatory and in-hospital care and will do so for years to come.

METHODS

This article is based on a selective review of the literature, along with data from the German Mesothelioma Register.

RESULTS

1397 people died of mesothelioma in Germany in 2010. A plateau in the incidence of the disease is predicted between 2015 and 2030. Most mesotheliomas arise from the pleura. The histological subtype and the Karnofsky score are the main prognostic factors. Only limited data are now available to guide treatment with a combination of the available methods (chemotherapy, surgery, radiotherapy). The prognosis is still poor, with a median survival time of only 12 months. Symptom control and the preservation of the patient's quality of life are the main aspects of care for patients with mesothelioma.

CONCLUSION

The incidence of mesothelioma is not expected to drop in the next few years. The available treatments are chemotherapy, surgery, and radiotherapy. Specialized treatment centers now increasingly provide multimodal therapy for treatment of mesothelioma.

Talc pleurodesis as surgical palliation of patients with malignant pleural effusion. Analysis of factors affecting survival

Malignant pleural effusion (MPE) is common in most patients with advanced cancer, especially in those with lung cancer, metastatic breast carcinoma and lymphoma. This complication usually leads patients to suffer from significant dyspnea, which may impair their mobility and reduce their quality of life. In patients with MPE, several interventions have been shown to be useful for palliation of the symptoms, including talc pleurodesis. The aim of this study was to evaluate prognostic factors for survival of patients with symptomatic MPE who underwent palliative video-assisted thoracoscopic (VATS) talc pleurodesis. Thirty-five patients with MPE underwent VATS, evacuation of the pleural fluid and talc pleurodesis with large-particle talc. There were 22 (62.9%) males and 13 (37.1%) females, with an overall median age of 69 years (range 42-81 years). The main causes of MPE were non-small cell lung carcinoma, breast or ovarian cancer and malignant pleural mesothelioma. The age did not differ (p=0.88) between men (68.6±11.6 years) and women (68.0±8.7 years). The mean quantity of pleural effusion was 2005.7±1078.9 ml, while the overall survival was 11.2±8.9 months. We did not find any relationship between survival and gender (log-rank test, p=0.53) or underlying malignancy associated with MPE (p=0.89, 0.48 and 0.36 for secondary cancer, lung cancer and mesothelioma, respectively). Similarly, no correlation was found between survival and age of the patients (Cox's regression, p=0.44) or quantity of pleural effusion (p=0.88). Our results show that the prognosis of patients after talc pleurodesis is independent of age, gender, type of malignancy and amount of pleural effusion, thus, suggesting the utility of treating all patients with symptomatic MPE early.

Deaths due to differentiated thyroid cancer: a South Island, New Zealand experience: 1984-2009

AIM

To assess differentiated thyroid cancer (DTC) deaths from the northern half of New Zealand's South Island.

METHODS

Retrospective review of Christchurch Hospital Thyroid Clinic and Oncology Department clinical records of resident patients who died of differentiated thyroid cancer of follicular cell origin over the 25-year period 1984-2009.

RESULTS

During the 25-year study period 25 patients died from differentiated thyroid cancer. All patients (17 female, 8 male) were Caucasian, with median age 65 years (47-86 years) at presentation. Most (24/25) patients presented with advanced (15 Stage IV, 9 Stage III) disease. Three patients initially presented with cervical lymphadenopathy and four patients with distant metastases--three patients with bone metastases, and one with a pleural effusion. The pathological classification of the tumours included 14 papillary cancers (four were follicular variants), six follicular cancers and five Hurthle cell cancers. The majority of primary tumours were large (>4 cm) and 11 were locally invasive. However one patient had a small (1.3 cm) papillary cancer and presented with a pleural effusion. Surgical removal of the primary tumour was attempted in 24 of the 25 patients, 18 received postoperative radioiodine 131I therapy, and three had external beam radiation therapy. The median survival from diagnosis was 5.5 years (0.2-22 years) with two Stage IV patients (both with Hurthle cell cancers) dying within 4 months. The majority of patients died of metastatic disease but seven died of local disease.

CONCLUSIONS

During the 25-year study period, 25 patients died of differentiated thyroid cancer which approximates to one DTC death per year in our region. The median age at diagnosis was 65 years with no patients <45 years of age, and the female to male ration was 2.1:1. Most patients presented with advanced disease--7 patients (28%) had distant metastases. Hurthle cell cancers were over-represented (20%) in our series.

The value of expression of EGFR, telomerase and topoisomerase IIα in malignant effusion smears before and after chemotherapy

PURPOSE

To evaluate the significance of expression of epidermal growth factor receptor (EGFR), telomerase and topoisomerase IIα (topo IIα) in cells of malignant effusions of patients under chemotherapy.

METHODS

We studied the expression of EGFR, telomerase and topo IIα in malignant effusion smears of 95 cancer patients before and after chemotherapy. Immunocytochemical and in situ hybridization techniques were applied.

RESULTS

Positive expression before chemotherapy of telomerase, topo IIα and EGFR was found in 64.2, 63.2 and 69.5% of the cases, respectively; the expression of these markers following chemotherapy was 43.6, 28.2 and 53.8%, respectively. The stronger prognostic factor affecting survival before chemotherapy was telomerase (p=0.0002), whereas after chemotherapy the strongest factor was EGFR (p<0.0001). A positivity for all three markers following chemotherapy was associated with shorter survival compared with positivity for only 1 or 2 markers (p<0.0001) or with a negative expression.

CONCLUSION

It seems that expression of EGFR, telomerase and topo IIα in malignant effusion smears is adversely affecting prognosis and survival.

Predictors of mortality within three months in the patients with malignant pleural effusion

BACKGROUND

Malignant pleural effusion (MPE) has a limited life expectancy (3-12 months). We investigated the predictors of the early mortality (EM) within three months.

METHODS

The patients were retrospectively grouped according to the death within three months (Group I) and survival more than three months (Group II). Demographical, clinical, and biochemical parameters in the fluid were analysed to determine their effects on the EM. The 30-day response rate of talc pleurodesis was investigated.

RESULTS

The study included 85 patients (Group I/Group II=40/45). The patients in Group I died within a median of 28 days. Twenty-six patients in Group II died in a median of 205, but 19 were still alive (median 200 days). The median survival was longer in renal cell, colorectal, breast, liver, ovarian and oropharynx carcinoma, and mesothelioma. Sixty-two patients (63%) underwent talc pleurodesis, which prevented the fluid reaccumulation (p=0.04). The significant factors of the EM in the univariate analysis were the presence of high-risk tumors (lung, stomach, soft tissue, bladder, esophagus, prostate, cervix, and lymphoma), the low Karnofsky performance score (KPS) (p<0.0001), the low pH value of the fluid (p=0.05), and the low concentration of glucose (p=0.01), total protein (p<0.0001), and albumin (p<0.0001) in the fluid. According to the multivariate analysis high-risk tumors (p=0.03), a lower KPS (p<0.001), and glucose value (p=0.04) were the predictors of the EM.

CONCLUSION

Talc pleurodesis prevents the fluid reaccumulation. High-risk tumors, a poor performance status, and lower pleural fluid glucose concentration are predictors of the EM within three months in the patients with a MPE.

Malignant pleural effusions in lymphoproliferative disorders

In order to determine variables that correlate with malignant pleural effusion and mortality in patients with lymphoproliferative disorders and pleural effusion, a retrospective study was performed. Clinical data of hospitalized patients with a lymphoid malignancy and pleural effusion who underwent thoracentesis from January 1993 to December 2002 were collected. A logistic regression analysis was carried out to determine prognostic variables that predict malignant pleural effusion and hospital mortality. There were 86 patients who were admitted on 91 occasions. The median age was 70 years (range 4 - 92) and the male:female ratio was 44:42. Sixty-four patients (74%) had advanced disease, 43 (50%) had received prior chemotherapy and 9 (10%) were in remission. Of 91 cases of pleural effusions, 44 (48%) were bilateral, 80 (88%) were exudates and 48 (53%) were due to malignant involvement of pleura. In multivariate analysis, symptomatic pleural effusion (odds ratio 10.3, 95% confidence interval 1.7 - 98.3), pleural fluid mesothelial cell count < 5% (odds ratio 8.0, 95% confidence interval 1.4 - 58.2), pleural fluid:serum lactate dehydrogenase (LDH) > or =1 (odds ratio 6.4, 95% confidence interval 1.2 - 45.6) and pleural fluid lymphocyte percentage > or =50 (odds ratio 6.4, 95% confidence interval 1.2 - 50) were significantly correlated with malignant effusion. A secondary cancer (odds ratio 11.9, 95% confidence interval 2.3 - 88.8), pleural fluid:serum LDH > or =1 (odds ratio 10.9, 95% confidence interval 2.6 - 64.9), and pneumonia (odds ratio 6.4, 95% confidence interval 1.7 - 28.6) were significantly correlated with hospital mortality. In conclusion, malignant pleural effusion is the common etiology of pleural effusion in patients with lymphoid malignancy. Many clinical and cytochemical markers have discriminatory values in identifying malignant effusion. A high pleural fluid to serum LDH level correlates with malignant pleural involvement and hospital mortality.

High levels of tumor markers in pleural fluid correlate with poor survival in patients with adenocarcinomatous or squamous malignant effusions

BACKGROUND

The aim of this study was to determine whether several pleural fluid (PF) tumor markers, either alone or in combination, could be used to predict survival time of patients with malignant pleural effusion secondary to adenocarcinoma or squamous cell carcinoma.

METHODS

A total of 224 patients with confirmed metastatic pleural malignancies due to adenocarcinoma or squamous cell carcinoma were enrolled. PF tumor markers were determined either by electrochemiluminescence immunoassay (CEA, CA 15-3, CYFRA 21-1) or microparticle enzyme immunoassay (CA 125) technologies. Cutoff points that predicted death during the first month after diagnoses, with a specificity of 60%, were selected for each marker, using receiver operating characteristic analysis.

RESULTS

In patients with adenocarcinomatous or squamous malignant effusion, the combination of PF CA 125>or=1000 U/mL and CYFRA 21-1>or=100 ng/mL predicted a lower survival (4 vs. 11.7 months, p=0.03; and 0.3 vs. 8.4 months, p=0.003 respectively). This tumor marker combination remained as an independent predictor of poor outcome when adjusted for age and tumor type.

CONCLUSION

High PF tumor marker levels identify a subgroup of patients with a shorter median survival.

Prognostic significance of pleural fluid data in patients with malignant effusion

BACKGROUND

To determine the effects of the biochemical and cytological properties of the pleural fluid (PF) on the survival of patients with malignant pleural effusion (MPE).

METHODS

A retrospective study of 284 patients with MPE was performed, which measured overall survival, survival of patients with different types of primary tumors, and survival as a function of PF biochemical variables transformed into quartiles.

RESULTS

Median overall survival of MPE patients was 5.4 months following diagnosis. Survival varied significantly depending on the type of the primary tumor: 17.4 months for mesothelioma, 13.2 months for breast cancer, 7 months for lymphoma and 2.6 months for lung cancer. A multivariate analysis of PF biochemical parameters showed that survival was lower as the concentration of lactate dehydrogenase (LDH) increased (11.3 months if LDH was between 140 U/L and 358 U/L vs 2.8 months if LDH was between 1027 U/L and 10,110 U/L) or the concentration of pleural proteins decreased (9.4 months if proteins were between 4.92 g/dL and 7.94 g/dL vs 2.2 months if proteins were between 0.97 g/dL and 3.85 g/dL). We also found that when mesotheliomas were excluded from the analysis, survival was lower in patients with a PF pH lower than 7.3 (2.4 months vs 6.8 months, p=0.03).

CONCLUSIONS

Tumor type as well as some biochemical features of the pleural fluid, such as pH and concentrations of proteins and LDH, influence survival in patients with MPE.

Docetaxel and irinotecan as first-line chemotherapy in patients with advanced non-small-cell lung cancer: a pilot study

AIMS

The aim of this study is to evaluate the activity and toxicity of the combination docetaxel and irinotecan as first-line therapy for advanced non-small-cell lung cancer (NSCLC).

MATERIALS & METHODS

Twenty-two chemotherapy-naive patients with stage IIIB with pleural effusion or stage IV NSCLC received irinotecan 50 mg/m2 on days 1, 8, and 15, and docetaxel 50 mg/m2 on day 2, every 28 days until disease progression.

RESULTS

Median follow-up was 10 months (range: 2-28 months). The overall response rate was 36.4% (8/22 patients; 95% confidence interval: 16.8-56.0), with no complete responses. Median time to disease progression was 5 months (range: 1-24 months) and median overall survival was 10 months (range: 2-28). Grade 3-4 diarrhea was observed in 2 patients (9.1%). Grade 3-4 neutropenia occurred in 2 patients (9.1%): 1 episode of febrile neutropenia in one patient, and 1 death due to neutropenic sepsis in another patient. One patient received transfusion for grade 4 anemia.

CONCLUSIONS

Irinotecan showed a moderate response rate and overall survival of clinical interest. Diarrhea was the main toxicity. This regimen may be suitable for patients unable to tolerate cisplatin-based therapy, for elderly and/or for patients with poor performance status, and should be investigated in a larger trial.

Weak telomerase activity in malignant cells in metastatic serous effusions: correlation to short survival time

OBJECTIVE

The purpose of this study was to evaluate whether the intensity of telomerase activity measured on the cellular level in effusions correlates to survival time in cases of metastatic spread to the serous cavities.

STUDY DESIGN

Telomere repeat amplification protocol (TRAP) in situ was applied to 46 effusions containing metastatic cancer cells.

RESULTS

Weak telomerase activity in tumor cells was seen in 7 cases, and moderate or strong activity in 39 cases. The intensity of the enzyme activity correlated significantly to survival (Kaplan-Meier survival analysis), the median survival time being 18 days for patients with weakly positive tumors and 100 days for patients with moderately or strongly positive tumors (Kruskal-Wallis test, p = 0.021).

CONCLUSION

The strong relationship between telomerase activity in tumor cells in effusions and survival time has never been described before. Determination of telomerase activity on the cellular level provides a way to identify a subgroup of patients with a high probability of short survival.

Aberrant promoter methylation profile in pleural fluid DNA and clinicopathological factors in patients with non-small cell lung cancer

The aim of this study was to investigate the prognostic value of hypermethylation of tumor suppressor genes in patients with non-small cell lung cancer (NSCLC). In samples from 34 lung patients with malignant pleural effusions, we used a methylation-specific polymerase chain reaction to detect aberrant hypermethylation of the promoters of the DNA repair gene O6-methylguanine-DNA methyltransferase (MGMT), p16INK4a, ras association domain family 1A (RASSF1A), apoptosis-related genes, death-associated protein kinase (DAPK), and retinoic acid receptor beta(RARbeta). There is no association between methylation status of five tumor suppressor genes including MGMT, p16INK4a, RASSF1A, DAPK and RARbeta in pleural fluid DNA and clinicopathological parameters including clinical outcome. Aberrant promoter methylation of tumor suppressor genes in pleural fluid DNA could not be a valuable prognostic marker of NSCLC patients with malignant pleural effusion.

Efficacy of short-term versus long-term chest tube drainage following talc slurry pleurodesis in patients with malignant pleural effusions: A randomised trial

Talc pleurodesis is commonly used in the palliative treatment of malignant pleural effusions but the shortest and most effective regime has not been determined. In particular, it is not clear when the intercostal drain should be removed following the insertion of sclerosant. We conducted a single-centre, randomised, open trial of drain removal at 24 h versus 72 h following talc slurry pleurodesis. The primary outcome measure was success of pleurodesis (no recurrence of effusion on chest radiograph at 1-month follow-up) and secondary outcome measures included length of hospital stay and mortality. We found no difference between recurrence of pleural effusion in those randomised to drain removal at 24 h and those randomised to drain removal at 72 h (p>0.5). However, length of stay was significantly reduced when the chest drain was removed at 24 h (4 days versus 8 days; p<0.01). Mortality did not differ between the two groups. We conclude that this shorter pleurodesis regime is safe and effective.

[Chronic indwelling pleural catheter for malignant pleural effusion in 25 patients]

OBJECTIVE

To describe the experience with an indwelling pleural catheter in patients with pleuritis carcinomatosa.

DESIGN

Prospective follow-up study.

METHOD

The placement of an indwelling pleural catheter was considered as a treatment possibility for patients who presented with symptomatic accumulation of pleural fluid that returned following previous drainage or pleurodesis or when the fluid had not been drained off previously but there were strong radiological indications for a 'trapped lung'. The intervention was considered to be contraindicated by the following: dyspnoea that had not been reduced by previous pleural punctures performed for relief, dyspnoea caused by many different factors, a tendency for haemorrhaging that could not be corrected. The drain used was a Pleurx indwelling catheter, a thorax drain that is tunnelled subcutaneously, can remain in situ for a long time and offers the patient the opportunity to drain off fluid himself at any desired moment.

RESULTS

In the period September 2003-May 2005, the treatment was considered in 40 patients. Ultimately, the catheter was inserted in 25 patients; the clinical deterioration of most of the other patients was too quick. Of the group, 33 patients (82%) died with a median survival of 70 days. All catheters functioned until they were removed or until the patient died. In 3 patients, the drainage procedure was complicated by empyema and in 1 patient by haemoptysis. From the total number of catheters, 9 were removed while the patient was still alive and in 6 patients, spontaneous pleurodesis occurred following 3, 4, 4, 5, 6, and 8 months respectively. In general, the patients were able to handle the catheter without problems and the symptoms were brought and kept adequately under control.

CONCLUSION

The Pleurx indwelling pleural catheter was an efficacious treatment supplement for patients with malignant pleural effusion, in whom the standard pleurodesis was not effective.

Elevated pleural fluid RCAS1 is a diagnostic marker and outcome predictor in lung cancer patients

RCAS1, a type II membrane protein also secreted in soluble form, may be important in tumor cell evasion of immune surveillance and contribute to the aggressiveness of human tumors. We examined the implications of elevated pleural fluid RCAS1 at the onset of effusion in lung cancer patients. Of 102 patients presenting with pleural effusion, 59 proved to have a malignant effusion and 43, nonmalignant. Malignant effusions exhibited higher RCAS1 concentrations than nonmalignant effusions (mean +/- SD; 36.3 +/- 114 vs. 2.7 +/- 1.8 U/ml; p=0.014). Lung cancer patients with pleural fluid RCAS1 concentrations below 15 U/ml had a longer mean survival than those with higher concentrations (4.7 vs. 1.7 months; p<0.05). By multivariate analysis, pleural fluid RCAS1 was an independent prognostic factor in lung cancer patients with effusion. In conclusion, RCAS1 determination at onset of pleural effusion is informative for both diagnosis and outcome prediction in lung cancer patients.

Intrapleural urokinase for the treatment of loculated malignant pleural effusions and trapped lungs in medically inoperable cancer patients

BACKGROUND

Pleural fluid loculations or trapped lungs frequently render patients with symptomatic malignant pleural effusions (MPEs) unsuitable for pleurodesis. Thoracoscopic surgery or thoracotomy with decortication is generally not feasible for patients with a poor performance status. MPEs have augmented procoagulant and depressed fibrinolytic activity that contributes to fibrin deposition within the pleural space. The authors conducted an observational prospective cohort study to investigate the use of intrapleural urokinase (IPUK) for such patients and made a comparison with a historical control group.

METHODS

Between March of 2000 and August of 2005, 48 consecutive patients with symptomatic MPEs with an average Karnofsky performance scale score of 46.7% were recruited. Dyspnea persisted with the presence of substantial residual loculated MPEs in 36 patients and trapped lungs in 12 patients, when the effectiveness of 8-French intrapleural catheter drainage had decreased despite regular saline flushes. Urokinase was instilled daily through the catheter at a dose of 100,000 IU diluted in 100 ml of normal saline for 3 days. Additional IPUK instillation was required upon partial improvement. The records and chest radiographs of another 52 patients with symptomatic MPEs had met these eligibility criteria between January of 1995 and February of 2000 and received saline flushes only were also reviewed.

RESULTS

Immediate lung reexpansion and resolution of dyspnea was achieved in 29 of the 48 patients who underwent IPUK therapy (60.4%). The mean dose of urokinase instillations per patient was 360,000 IU. There were no major complications. A significant association of earlier intervention with the success of IPUK therapy was noted. Responders also had a significantly increased drainage within the 24 hours after the first dose of IPUK. Minocycline pleurodesis was subsequently performed for the 29 IPUK responders. Eighteen patients were followed up until death, with a median survival of 6.5 months. The other remained alive at the time of analysis with a median follow-up of 5 months. Two patients had an immediate failure of pleurodesis at 1 month. Three relapses occurred at 3, 4, and 7 months from pleurodesis, respectively. Twenty-three patients (79.3%) had lifelong pleural symphysis, including 21 having loculated MPEs and two having trapped lungs, respectively. Compared with the historical control group, the IPUK study group had significantly greater improvement on chest radiography and a shorter duration of pleural drainage.

CONCLUSION

These results suggest that IPUK is a safe and useful nonsurgical adjunct therapy for loculated MPEs or trapped lungs in medically inoperable cancer patients.

[Talc pleurodesis in malignant pleural effusions]

Pleural effusions associated with malignancy--either malignant or paramalignant diseases--were found in ca. 20% of these patients. Large pleural effusions cause mainly dyspnoea but also cough and chest pain. The presence and degree of dyspnoea depend on the size of the effusion and the patient's underlying pulmonary function. In acute cases and large effusions immediate chest drainage is indicated in symptomatic patients, followed by the treatment of the underlying disease, e. g. chemotherapy. The most effective therapy for controlling reiterated malignant pleural effusions is the thoracoscopic talc poudrage (2.5-10 g) which has been shown to have a success rate of > 90%. Talc induces a broad inflammatory reaction involving mesothelial cells of the pleura, coagulation parameters, fibroblast proliferation eventually leading to symphysis of the pleura. This procedure is reserved for patients who are in good general conditions, who are expected to have a reasonably long survival, and who failed chemical pleurodesis. A good predictor for longer survival time is a Karnofsky Performance Scale > or = 40 indicating a survival time > 30 days, which therefore should be considered prior to the procedure. The adult respiratory distress syndrome (ARDS) is the most important complication initially observed in the US in up to 9% of all cases. ARDS incidence was strongly related to high number (50%) of small talc particles < 15 microm. In summary, talc poudrage or slurry (talc particle size > 10 microm) in malignant pleura effusions is a safe and effective method to induce pleura symphysis. Complaints and complications such as chest pain, transient fever, and empyema are rare or very are which are almost exclusively related to the therapeutic procedure itself.

Soluble mesothelin-related peptides in the diagnosis of malignant pleural mesothelioma

BACKGROUND

Diagnosis of malignant pleural mesothelioma is a challenging issue. Potential markers in mesothelioma diagnosis include soluble mesothelin-related peptides (SMRPs) and osteopontin, but no subsequent validation has been published yet.

METHODS

We prospectively evaluated SMRPs in serum and pleural effusion from patients with mesothelioma (n = 74), pleural metastasis of carcinomas (n = 35), or benign pleural lesions associated with asbestos exposure (n = 28), recruited when first suspected for mesothelioma.

FINDINGS

Mean serum SMRP level was higher in patients with mesothelioma (2.05 +/- 2.57 nM/L [median +/- interquartile range]) than in patients with metastasis (1.02 +/- 1.79 nM/L) or benign lesions (0.55 +/- 0.59 nM/L). The area under the receiver operating characteristic curve (AUC) for serum SMRP was 0.872 for differentiating mesothelioma and benign lesions, cut-off = 0.93 nM/L (sensitivity = 80%, specificity = 82.6%). The AUC for serum SMRP differentiating metastasis and mesothelioma was 0.693, cut-off = 1.85 nM/L (sensitivity = 58.3%, specificity = 73.3%). SMRP values in pleural fluid were higher than in serum in all groups (mesothelioma: 46.1 +/- 83.2 nM/L; benign lesions: 6.4 +/- 11.1 nM/L; metastasis: 6.36 +/- 21.73 nM/L). The AUC for pleural SMRP-differentiating benign lesions and mesothelioma was 0.831, cut-off = 10.4 nM/L (sensitivity = 76.7%, specificity = 76.2%). The AUC for pleural SMRP-differentiating metastasis and mesothelioma was 0.793.

INTERPRETATION

We show that SMRPs may be a promising marker for mesothelioma diagnosis when measured either in serum or pleural fluid. The diagnostic value of SMRPs was similar in both types of samples, but pleural fluid SMRPs may better discriminate mesothelioma from pleural metastasis.

A Longitudinal Study of Idiopathic Exudative Lymphocytic Pleural Effusion in Older People

OBJECTIVES

To assess the long-term prognosis of older patients with idiopathic exudative lymphocytic pleural effusion.

DESIGN

Prospective observational study.

SETTING

A university-affiliated tertiary care center.

PARTICIPANTS

Forty-seven consecutive patients (aged 74.9+/-5.4) with idiopathic exudative lymphocytic pleural effusion were enrolled over a 42-month period.

MEASUREMENTS

Baseline sociodemographic information, clinical data, and Charlson Comorbidity Index score were obtained. After an exhaustive examination, clinical evaluation and periodic chest radiographs were taken until one of the endpoints was met: complete resolution of the pleural effusion, death from all causes, or the end of the study period.

RESULTS

The mean follow-up period was 16.3+/-17.0 months. During the course of the study, complete resolution of the pleural effusion occurred in 17% of the patients, whereas it remained stable in 45%, and progressed in 38%. In seven cases, the cause of the effusion was established after an average of 84 days, and in another two, the diagnosis was made postmortem. Malignancy was documented in eight of the nine cases. Although the burden of comorbidities and cardiac function at baseline were similar in the three categories, the 3-year survival rate was 63%, 5%, and 0%, respectively. None of the patients developed active tuberculosis, although 15% had positive tuberculin test.

CONCLUSION

By categorizing the presence of idiopathic effusion into resolving, persistent, or progressive, this study may provide a more practical approach to the long-term prognosis of older patients with idiopathic exudative lymphocytic effusion who refuse or are considered too frail to undergo an invasive procedure.

[Thoracoscopic pleurodesis in malignant pleural effusions]

We performed retrospectively study on 136 thoracoscopies done in our clinic in the period January 2000 and December 2004. We reviewed 136 thoracoscopies, 71 patients were male and 65 were female (mean age 58.4 years). Straw colored effusions were present in 78 cases (57%) and hemorrhagic in 58 cases (43%). The surgical procedure consist in diagnostic of thoracoscopy with drainage of pleural effusion, multiply pleural biopsy, pleurodesis and continuous pleural drainage. In our study, the talc powder (5g) was successfully as sclerosing agent. The primary tumor was: lung-63 (46%), breast-26 (19%), mesothelioma-21 (15.5%), stomach-3, ovarian-3, prostate-3, colon-2, lymphoma-1, leukemia-2, plasmocytoma-1 and unknown primary tumor in 11 cases (8%). Adverse effects included-chest pain-35 cases (25%), fever-20 cases (15%), empyema-6 cases (4.5%), prolonged air leak-5 cases (4%), pulmonary infection-2 cases, acute respiratory failure-1 case, malignant invasion of scar-1 patient. For statistical analysis, the success of talc pleurodesis was defined as the absence of pleural fluid on the follow-up chest radiographs. Pleurodesis was successful in 125 cases (92%) of the patients after 1 month-follow-up. Thoracoscopic talc pleurodesis is a safe, economical and effective treatment for malignant pleural effusion.

Management of patients with "ex vacuo" pneumothorax after thoracentesis

RATIONALE AND OBJECTIVES

To determine clinical outcome in patients who developed "ex vacuo" pneumothorax following thoracentesis and to assess the benefit of chest tube placement for this complication.

MATERIALS AND METHODS

We retrospectively reviewed records of 282 patients who underwent 437 thoracenteses at a single institution during a 6-year period. We identified 34 patients (12.1%) who developed a pneumothorax following 39 thoracenteses (8.8%) and then identified a subset of patients with pneumothorax "ex vacuo" defined as a moderate to large hydropneumothorax or small pneumothorax persisting for more than 3 days. Patient charts were reviewed to document the treatment strategy employed and subsequent clinical outcome, which included length of hospital stay, resolution of pneumothorax, reaccumulation of pleural effusion, and overall survival.

RESULTS

Ten patients developed "ex vacuo" pneumothroax following thoracentesis. None complained of significant worsening of symptoms following thoracentesis. Seven patients were treated by observation alone and 3 patients underwent tube thorocostomy. A decrease in size of the pneumothorax was observed in only 3 patients, none of whom had a chest tube placed. Effusion completely reaccumulated in 7 patients. All 10 patients died during the follow-up period; the mean survival was 157 days (range: 13-402 days). Survival among patients treated by observation was 191.4 days versus 71.7 days for patients receiving chest tubes.

CONCLUSION

Life expectancy for most patients who develop "ex vacuo" pneumothorax following therapeutic thoracentesis is short (<6 months). Chest tube placement is not necessary in asymptomatic patients and is unlikely to provide clinical benefit.

Video-thoracoscopic surgical pleurodesis in the management of malignant pleural effusion: the importance of an early intervention

Thoracentesis plays an important role in cancer patients with symptomatic effusions, although its effect is short-lived and symptoms recur in almost all patients. Early video-thoracoscopic surgical pleurodesis may provide added benefit to a group of patients with advanced cancer presenting with symptomatic malignant pleural effusion. Seventy-six patients with advanced cancer and pleural effusion due to pulmonary-pleural metastases were recruited. In 51 cases (67.1%), at least one thoracentesis was performed before admission for surgery. Preoperative staging consisted of chest radiograph, CT scan, and blood gas analysis. The mean Karnofsky performance status was about 50. Pleurodesis with talc poudrage was completely successful in all patients, with a morbidity rate of 2.6%. There was no post-operative mortality. Three patients (3.9%) underwent further thoracenteses for recurrence of pleural effusion within two months after the procedure. Early use of talc insufflated by video-thoracoscopic surgery is an effective and relatively safe method for treating pleural effusion, and preventing recurrence, in advanced cancer patients.

Thoracentesis in Patients With Hematologic Malignancy

BACKGROUND

Pleural effusions occur in patients with hematologic malignancies, particularly during periods of hospitalization. Thoracentesis is often performed to diagnose infection and to exclude the presence of complicated parapneumonic effusions. The efficacy and safety of thoracentesis in this setting has not been well-studied.

DESIGN

Retrospective chart review of hospitalized patients with hematologic malignancies undergoing thoracentesis. The aim of this study was to assess the role of thoracentesis in establishing a diagnosis of infection in this population and to determine the risk of complications.

RESULTS

A total of 100 thoracentesis findings were analyzed in patients with lymphoma (52 patients) and leukemia (27 patients), and in patients who had undergone bone marrow or stem cell transplantation (21 patients). The indication for performing thoracentesis was to exclude infection in 69% of cases. Fever was present in 59% of the patients, and a concomitant lung parenchymal abnormality was present in 69% of cases. Effusions were moderate to large in size (87% of cases), and were both bilateral (62%) and unilateral (38%). Exudates were documented in 83%of the cases. A specific diagnosis was found in 21 patients and was more frequently established in those with lymphoma (31%) compared to the other groups of patients. Diagnoses found included malignancy in 14 cases, chylous effusions in 6 cases, and infection in 1 case. The one patient in whom empyema was found required drainage. The criteria for a parapneumonic effusion were not found in any other patients. The complication rate of 9% (pneumothorax, seven patients; hemothorax, two patients) was comparable to that in other populations of patients.

CONCLUSIONS

Despite a high propensity for developing pulmonary infections, hospitalized patients with hematologic malignancies rarely developed complex parapneumonic effusions. The etiology of many of the effusions that occurred in this setting was unclear.

[The usefulness of videothoracoscopy in survival evaluation in patients with malignant pleural effusion]

Videothoracoscopy is a useful diagnostic tool in patients with suspicion of malignant pleural effusion, because of both: the high accuracy in diagnosis and the possibility of assessing the extent of pleural involvement and producing the pleurodesis. An analysis of characteristics of 110 patients with suspected pleural dissemination is presented, including final diagnosis established with the use of VTS. In patients with confirmed malignant pleural effusion following characteristics were analyzed: the extent of pleural metastatic involvement, type of the primary malignancy, possibility of re-expansion of the lung and patients survival according to the primary tumor and extent of involvement of the pleura.

The clinical significance of malignant pleural effusions in patients with optimally debulked ovarian carcinoma

BACKGROUND

The objective of this study was to determine the impact of malignant pleural effusions on survival in patients with optimally debulked, advanced epithelial ovarian carcinoma.

METHODS

The authors conducted a retrospective review of all patients with advanced epithelial ovarian carcinoma who underwent optimal primary cytoreduction at their institution between January 1987 and August 2000. Survival rates were compared between patients with optimally debulked Stage IIIC epithelial ovarian carcinoma and patients with optimally debulked Stage IV epithelial ovarian carcinoma (according to the International Federation of Gynecology and Obstetrics [FIGO] staging system) based on cytology-proven malignant pleural effusions.

RESULTS

Ninety-nine patients were identified, and 97 of those patients were evaluable. The group with Stage IIIC disease included 76 patients, and the group with Stage IV disease included 21 patients. The median age at diagnosis was 55 years (range, 26-88 years). The majority of patients received platinum-based chemotherapy after undergoing optimal primary cytoreduction. Age, tumor grade and histology, and the percentage of patients with ascites were similar in the two groups. The median survival rate was 58 months for patients who had Stage IIIC disease and 30 months for patients who had Stage IV disease (P = 0.016).

CONCLUSIONS

Although both groups underwent optimal cytoreduction in the abdomen/pelvis and were treated in a similar fashion, the median survival rate of patients with malignant pleural effusions was significantly shorter than the survival of patients without effusions. Many factors that led to or were manifested by pleural effusions, such as undetected bulky residual intrathoracic disease, may have been the cause for this survival difference. In the patients with effusions, one or more of these contributing factors may have led to the observed decreased survival rate, warranting further investigation.