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Lau EPM, Ing M, Vekaria S, Tan AL, Charlesworth C, Fysh E, Shrestha R, Yap ELC, Smith NA, Kwan BCH, Saghaie T, Roy B, Goddard J, Muruganandan S, Badiei A, Nguyen P, Hamid MFA, George V, Fitzgerald D, Maskell N, Feller-Kopman D, Murray K, Chakera A, Lee YCG. Australasian Malignant PLeural Effusion (AMPLE)-4 trial: study protocol for a multi-centre randomised trial of topical antibiotics prophylaxis for infections of indwelling pleural catheters. Trials 2024; 25:249. [PMID: 38594766 PMCID: PMC11005276 DOI: 10.1186/s13063-024-08065-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 03/18/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Malignant pleural effusion (MPE) is a debilitating condition as it commonly causes disabling breathlessness and impairs quality of life (QoL). Indwelling pleural catheter (IPC) offers an effective alternative for the management of MPE. However, IPC-related infections remain a significant concern and there are currently no long-term strategies for their prevention. The Australasian Malignant PLeural Effusion (AMPLE)-4 trial is a multicentre randomised trial that evaluates the use of topical mupirocin prophylaxis (vs no mupirocin) to reduce catheter-related infections in patients with MPE treated with an IPC. METHODS A pragmatic, multi-centre, open-labelled, randomised trial. Eligible patients with MPE and an IPC will be randomised 1:1 to either regular topical mupirocin prophylaxis or no mupirocin (standard care). For the interventional arm, topical mupirocin will be applied around the IPC exit-site after each drainage, at least twice weekly. Weekly follow-up via phone calls or in person will be conducted for up to 6 months. The primary outcome is the percentage of patients who develop an IPC-related (pleural, skin, or tract) infection between the time of catheter insertion and end of follow-up period. Secondary outcomes include analyses of infection (types and episodes), hospitalisation days, health economics, adverse events, and survival. Subject to interim analyses, the trial will recruit up to 418 participants. DISCUSSION Results from this trial will determine the efficacy of mupirocin prophylaxis in patients who require IPC for MPE. It will provide data on infection rates, microbiology, and potentially infection pathways associated with IPC-related infections. ETHICS AND DISSEMINATION Sir Charles Gairdner and Osborne Park Health Care Group Human Research Ethics Committee has approved the study (RGS0000005920). Results will be published in peer-reviewed journals and presented at scientific conferences. TRIAL REGISTRATION Australia New Zealand Clinical Trial Registry ACTRN12623000253606. Registered on 9 March 2023.
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Affiliation(s)
- Estee P M Lau
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia
- School of Medical and Health Sciences, Edith Cowan University, Perth, Australia
| | - Matthew Ing
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia
- Medical School, Faculty of Health & Medical Sciences, University of Western Australia, Perth, Australia
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Sona Vekaria
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Australia
- Department of Pharmacy, Sir Charles Gairdner Hospital, Perth, Australia
| | - Ai Ling Tan
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia
| | - Chloe Charlesworth
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Edward Fysh
- Medical School, Faculty of Health & Medical Sciences, University of Western Australia, Perth, Australia
- Department of Respiratory Medicine, St John of God Hospital Midland, Perth, Australia
- Curtin University Medical School, Perth, Australia
| | - Ranjan Shrestha
- Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, Australia
| | - Elaine L C Yap
- Department of Respiratory Medicine, Middlemore Hospital, Auckland, New Zealand
| | - Nicola A Smith
- Department of Respiratory Medicine, Wellington Regional Hospital, Wellington, New Zealand
| | - Benjamin C H Kwan
- Department of Respiratory and Sleep Medicine, The Sutherland Hospital, Sydney, Australia
- University of New South Wales, Sydney, Australia
| | - Tajalli Saghaie
- Department of Respiratory Medicine, Concord Repatriation General Hospital, Concord, NSW, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Bapti Roy
- Department of Respiratory and Sleep Medicine, Westmead Hospital, Sydney, Australia
| | - John Goddard
- Department of Respiratory Medicine, Sunshine Coast University Hospital, Birtinya, QLD, Australia
- Griffith University, Brisbane, QLD, Australia
| | | | - Arash Badiei
- Thoracic Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia
- Adelaide Medical School, Faculty of Health and Medical Science, University of Adelaide, Adelaide, SA, Australia
| | - Phan Nguyen
- Thoracic Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia
- Adelaide Medical School, Faculty of Health and Medical Science, University of Adelaide, Adelaide, SA, Australia
| | | | - Vineeth George
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, New Lambton Heights, NSW, Australia
- Hunter Medical Research Institute, Newcastle, Australia
| | - Deirdre Fitzgerald
- Department of Respiratory Medicine, Tallaght University Hospital, Dublin, Ireland
| | - Nick Maskell
- Academic Respiratory Unit, Bristol Medical School, University of Bristol, Bristol, UK
| | - David Feller-Kopman
- Department of Medicine, Section of Pulmonary and Critical Care Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Kevin Murray
- School of Population and Global Health, University of Western Australia, Perth, Australia
| | - Aron Chakera
- Medical School, Faculty of Health & Medical Sciences, University of Western Australia, Perth, Australia
- Renal Unit, Sir Charles Gairdner Hospital, Perth, Australia
| | - Y C Gary Lee
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia.
- Medical School, Faculty of Health & Medical Sciences, University of Western Australia, Perth, Australia.
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Australia.
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Sivakumar P, Fitzgerald DB, Ip H, Rao D, West A, Noorzad F, Wallace D, Haris M, Prudon B, Hettiarachchi G, Jayaram D, Goldring J, Maskell N, Holme J, Sharma N, Ismail I, Kadwani O, Simpson S, Read CA, Sun X, Douiri A, Lee YCG, Ahmed L. The impact of outpatient versus inpatient management on health-related quality of life outcomes for patients with malignant pleural effusion: the OPTIMUM randomised clinical trial. Eur Respir J 2024; 63:2201215. [PMID: 37996243 DOI: 10.1183/13993003.01215-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 10/22/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND The principal aim of malignant pleural effusion (MPE) management is to improve health-related quality of life (HRQoL) and symptoms. METHODS In this open-label randomised controlled trial, patients with symptomatic MPE were randomly assigned to either indwelling pleural catheter (IPC) insertion with the option of talc pleurodesis or chest drain and talc pleurodesis. The primary end-point was global health status, measured with the 30-item European Organisation for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ-C30) at 30 days post-intervention. 142 participants were enrolled from July 2015 to December 2019. RESULTS Of participants randomly assigned to the IPC (n=70) and chest drain (n=72) groups, primary outcome data were available in 58 and 56 patients, respectively. Global health status improved in both groups at day 30 compared with baseline: IPC (mean difference 13.11; p=0.001) and chest drain (mean difference 10.11; p=0.001). However, there was no significant between-group difference at day 30 (mean intergroup difference in baseline-adjusted global health status 2.06, 95% CI -5.86-9.99; p=0.61), day 60 or day 90. No significant differences were identified between groups in breathlessness and chest pain scores. All chest drain arm patients were admitted (median length of stay 4 days); seven patients in the IPC arm required intervention-related hospitalisation. CONCLUSIONS While HRQoL significantly improved in both groups, there were no differences in patient-reported global health status at 30 days. The outpatient pathway using an IPC was not superior to inpatient treatment with a chest drain.
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Affiliation(s)
- Parthipan Sivakumar
- Department of Thoracic Medicine, Guy's and St Thomas' NHS Trust, London, UK
- Western Sydney University, Sydney, Australia
- P. Sivakumar and L. Ahmed are joint first authors
| | - Deirdre B Fitzgerald
- Institute for Respiratory Health, University of Western Australia, Nedlands, Australia
- Respiratory Department, Sir Charles Gairdner Hospital, Nedlands, Australia
| | - Hugh Ip
- Centre for Respiratory Medicine, Royal Free Hospital, London, UK
| | - Deepak Rao
- Department of Thoracic Medicine, Princess Royal University Hospital, King's College Hospital NHS Foundation Trust, Orpington, UK
| | - Alex West
- Department of Thoracic Medicine, Guy's and St Thomas' NHS Trust, London, UK
| | | | - Deirdre Wallace
- Department of Thoracic Medicine, Guy's and St Thomas' NHS Trust, London, UK
| | - Mohamed Haris
- University Hospital of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Benjamin Prudon
- Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees, UK
| | | | | | - James Goldring
- Centre for Respiratory Medicine, Royal Free Hospital, London, UK
| | - Nick Maskell
- Academic Respiratory Unit, University of Bristol, Bristol, UK
| | - Jayne Holme
- North West Lung Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Neel Sharma
- Respiratory Medicine, East Sussex NHS Trust, Eastbourne, UK
| | - Iyad Ismail
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Owais Kadwani
- Department of Thoracic Medicine, Guy's and St Thomas' NHS Trust, London, UK
| | - Sanchez Simpson
- Department of Thoracic Medicine, Guy's and St Thomas' NHS Trust, London, UK
| | - Catherine A Read
- Institute for Respiratory Health, University of Western Australia, Nedlands, Australia
| | - Xiaohui Sun
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Abdel Douiri
- Institute for Respiratory Health, University of Western Australia, Nedlands, Australia
| | - Y C Gary Lee
- Institute for Respiratory Health, University of Western Australia, Nedlands, Australia
- Respiratory Department, Sir Charles Gairdner Hospital, Nedlands, Australia
| | - Liju Ahmed
- Department of Thoracic Medicine, Guy's and St Thomas' NHS Trust, London, UK
- Department of Thoracic Medicine, King Faisal Specialist Hospital and Research Centre, Madinah, Kingdom of Saudi Arabia
- P. Sivakumar and L. Ahmed are joint first authors
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Chinese Thoracic Society, Chinese Medical Association. [Chinese expert consensus on treatment of malignant pleural effusion (2023 Edition)]. Zhonghua Jie He He Hu Xi Za Zhi 2023; 46:1189-203. [PMID: 38044047 DOI: 10.3760/cma.j.cn112147-20230902-00126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
Malignant pleural effusion (MPE) is a pleural effusion that is caused by a malignant tumor originating in the pleura or by a metastatic malignant tumor from another site that has invaded the pleura. MPE is associated with poor prognosis. Members of the Pleural and Mediastinal Diseases Working Group (preparatory) of Chinese Thoracic Society and some external experts selected clinical issues related to the management of MPE and conducted rigorous evidence retrieval and evaluation. After several meetings and revisions of the manuscript, recommendations were made. This consensus applies to patients aged≥18 years old with MPE caused by various malignancies except for pleural mesothelioma. It included four chapters: pathogenesis of MPE, prognostic evaluation of MPE, local thoracic treatment, and systemic anticancer therapy for MPE.The main recommendations of this consensus are as follows:1. Prognosis evaluation of MPE was valuable in formulating treatment options. It is suggested to comprehensively evaluate the patient's prognosis by combining the patient's performance status, tumor type, and laboratory examination.2. It is recommended that in patients with symptomatic MPE, therapeutic thoracentesis could be used as the initial therapeutic option. Evaluate whether the lung is expandable after thoracentesis and drainage, and then develop a therapeutic regimen.3. In patients with MPE and known expandable or nonexpandable lung, an indwelling pleural catheter (IPC) is recommended as a first-line pleural management. Daily IPC drainages are recommended. In patients with MPE and expandable lung, talc pleurodesis by talc poudrage or talc slurry is recommended if the drug is accessible. Other pleurodesis agents include povidone iodine, bleomycin, and doxycycline.4. After drainage, it is suggested to consider the option of intrapleural use of recombinant human endostatin or bevacizumab alone or in combination with intrapleural chemotherapy. Intrapleural intervention including electrocautery, argon knife, cryotherapy, laser and radiofrequency ablation, is recommended for use in patients who have undergone rigorous evaluation in eligible hospitals. The use of intrapleural urokinase or streptokinase via pleural catheter is recommended for patients with symptomatic MPE and loculated effusion.5. For patients with good performance status and metastatic malignancies, systemic anti-cancer treatment is recommended as standard of care.
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Recuero Díaz JL, Figueroa Almánzar S, Gálvez Muñoz C, Lázaro Sierra J, López Porras M, Márquez Medina D, Nabal Vicuña M, Sánchez Moreno L, González Cantalejo M, Porcel JM. Recommendations of the Spanish Society of Thoracic Surgery for the management of malignant pleural effusion. Cir Esp 2022; 100:673-683. [PMID: 35667609 DOI: 10.1016/j.cireng.2022.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 05/04/2022] [Indexed: 06/15/2023]
Abstract
This article summarizes the clinical guidelines for the diagnosis and treatment of malignant pleural effusion (MPE) sponsored by the Spanish Society of Thoracic Surgery (SECT). Ten clinical controversies were elaborated under the methodology of PICO (Patient, Intervention, Comparison, Outcome) questions and the quality of the evidence and grading of the strength of the recommendations was based on the GRADE system. Immunocytochemical and molecular analyses of pleural fluid may avoid further invasive diagnostic procedures. Currently, the definitive control of MPE can be achieved either by pleurodesis (talc poudrage or slurry) or the insertion of a indwelling pleural catheter (IPC). It is likely that the combination of both techniques (i.e., thoracoscopy with talc poudrage and insertion of a IPC, or instillation of talc slurry through a IPC) will have a predominant role in the future therapeutic management.
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Affiliation(s)
- José Luis Recuero Díaz
- Servicio de Cirugía Torácica, Hospital Universitario Miguel Servet, Zaragoza, Spain; Instituto de Investigación Sanitaria (IIS) de Aragón, Zaragoza, Spain.
| | | | - Carlos Gálvez Muñoz
- Servicio de Cirugía Torácica, Hospital Universitario de Alicante, Alicante, Spain
| | - Javier Lázaro Sierra
- Instituto de Investigación Sanitaria (IIS) de Aragón, Zaragoza, Spain; Servicio de Neumología, Hospital Royo Villanova, Zaragoza, Spain
| | - Marta López Porras
- Servicio de Cirugía Torácica, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Diego Márquez Medina
- Instituto de Investigación Sanitaria (IIS) de Aragón, Zaragoza, Spain; Servicio de Oncología Médica, Hospital Universitario Miguel Servet, Zaragoza, Spain; Universidad de Zaragoza, Zaragoza, Spain
| | - María Nabal Vicuña
- Cuidados Paliativos, Hospital Universitario Arnau de Vilanova, Lleida, Spain
| | - Laura Sánchez Moreno
- Servicio de Cirugía Torácica, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Mar González Cantalejo
- Servicio de Información Biomédica y Biblioteca, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - José M Porcel
- Unidad de Medicina Pleural, Servicio de Medicina Interna, Hospital Universitario Arnau de Vilanova, Lleida, Spain; Institut de Recerca Biomèdica de Lleida Fundació Dr. Pifarré (IRBLleida), Lleida, Spain; Universitat de Lleida, Lleida. Spain
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Peters SP. NHLBI ASTHMA NETWORKS: IMPROVING PATIENT CARE, MOVING TOWARD PERSONALIZED MEDICINE. Trans Am Clin Climatol Assoc 2022; 132:44-60. [PMID: 36196171 PMCID: PMC9480564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
The first NHLBI Clinical Trials Research Network was the Asthma Clinical Research Network (ACRN 1), which was born in 1993 to perform multiple controlled clinical trials for asthma: "… dispassionately examine new & existing therapies for asthma" and "… rapidly communicate findings to medical community," and therefore, to perform clinical trials drug companies could not or would not do. Among the many areas studied by the ACRN and its successor networks, through 2019, was how to effectively and safely use long-acting beta-agonists and to find novel alternatives for them. In its Tiotropium Add-On Trial (TALC) trial, the ACRN demonstrated that tiotropium as add on-therapy to inhaled corticosteroids (ICS) was effective and non-inferior to long-acting beta-agonist add on-therapy. During the lifetime of the clinical trial networks (1993-2020), 71 manuscripts including 25 major clinical trials were published, many which have laid the groundwork for precision approaches for asthma therapy and the now ongoing PrecISE Asthma Network.
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Tanha K, Mottaghi A, Nojomi M, Moradi M, Rajabzadeh R, Lotfi S, Janani L. Investigation on factors associated with ovarian cancer: an umbrella review of systematic review and meta-analyses. J Ovarian Res 2021; 14:153. [PMID: 34758846 PMCID: PMC8582179 DOI: 10.1186/s13048-021-00911-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 10/26/2021] [Indexed: 12/25/2022] Open
Abstract
Following cervical and uterine cancer, ovarian cancer (OC) has the third rank in gynecologic cancers. It often remains non-diagnosed until it spreads throughout the pelvis and abdomen. Identification of the most effective risk factors can help take prevention measures concerning OC. Therefore, the presented review aims to summarize the available studies on OC risk factors. A comprehensive systematic literature search was performed to identify all published systematic reviews and meta-analysis on associated factors with ovarian cancer. Web of Science, Cochrane Library databases, and Google Scholar were searched up to 17th January 2020. This study was performed according to Smith et al. methodology for conducting a systematic review of systematic reviews. Twenty-eight thousand sixty-two papers were initially retrieved from the electronic databases, among which 20,104 studies were screened. Two hundred seventy-seven articles met our inclusion criteria, 226 of which included in the meta-analysis. Most commonly reported genetic factors were MTHFR C677T (OR=1.077; 95 % CI (1.032, 1.124); P-value<0.001), BSML rs1544410 (OR=1.078; 95 %CI (1.024, 1.153); P-value=0.004), and Fokl rs2228570 (OR=1.123; 95 % CI (1.089, 1.157); P-value<0.001), which were significantly associated with increasing risk of ovarian cancer. Among the other factors, coffee intake (OR=1.106; 95 % CI (1.009, 1.211); P-value=0.030), hormone therapy (RR=1.057; 95 % CI (1.030, 1.400); P-value<0.001), hysterectomy (OR=0.863; 95 % CI (0.745, 0.999); P-value=0.049), and breast feeding (OR=0.719, 95 % CI (0.679, 0.762) and P-value<0.001) were mostly reported in studies. Among nutritional factors, coffee, egg, and fat intake significantly increase the risk of ovarian cancer. Estrogen, estrogen-progesterone, and overall hormone therapies also are related to the higher incidence of ovarian cancer. Some diseases, such as diabetes, endometriosis, and polycystic ovarian syndrome, as well as several genetic polymorphisms, cause a significant increase in ovarian cancer occurrence. Moreover, other factors, for instance, obesity, overweight, smoking, and perineal talc use, significantly increase the risk of ovarian cancer.
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Affiliation(s)
- Kiarash Tanha
- Department of Biostatistics, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Azadeh Mottaghi
- Research Center for Prevention of Cardiovascular Diseases, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran
| | - Marzieh Nojomi
- Preventive Medicine and Public Health Research Center, Psychosocial Health Research Institute, Community and Family Medicine Department, School of Medicine,Iran University of Medical Sciences, Tehran, Iran
- Department of Sociology & Anthropology, Nipissing University, Ontario North Bay, Canada
| | - Marzieh Moradi
- Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Rezvan Rajabzadeh
- School of Health, North Khorasan University of Medical Sciences, Bojnurd, Iran
| | - Samaneh Lotfi
- Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Leila Janani
- Imperial Clinical Trials Unit, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
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Abstract
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.
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Affiliation(s)
| | - Hayley E Jones
- University of BristolPopulation Health Sciences, Bristol Medical SchoolCanynge Hall39 Whatley RoadBristolUKBS8 2PS
| | | | - Nancy J Preston
- Lancaster UniversityInternational Observatory on End of Life CareFurness CollegeLancasterUKLA1 4YG
| | - Nick Maskell
- University of BristolAcademic Respiratory UnitBristolUK
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Gunt HB, Levy SB, Lutrario CA. A Natural Cream-to-Powder Formulation Developed for the Prevention of Diaper Dermatitis in Diaper-Wearing Infants and Children: Barrier Property and In-Use Tolerance Studies. J Drugs Dermatol 2018; 17:566-570. [PMID: 29742190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Diaper dermatitis is a common condition that develops in the diaper area due to factors such as elevated moisture, increased skin surface pH, and exposure to irritants from urine and feces. These factors suggest interventions to prevent or treat diaper dermatitis such as exposing the skin to air, frequent diaper changes, and thorough cleansing of the diaper area. Barrier creams and powders also have a role in preventing and treating diaper dermatitis. We developed a cream-to-powder product with a formula based on corn starch and other natural ingredients for use in the diaper area. METHODS Dye exclusion study: The barrier properties of the cream-to-powder product were assessed using a dye exclusion protocol. Skin color at treated and untreated forearm sites was measured at baseline and after exposure to crystal violet stain. The cream-to-powder product's ability to inhibit the water-soluble dye from reaching the skin was judged by comparing color changes at the treated and untreated sites. Tolerance-in-use study: The safety of the cream-to-powder product was assessed in a four-week tolerance-in-use study conducted in a group of 52 diaper-wearing infants and toddlers. Subjects' parents/guardians applied the cream-to-powder product at each diaper change. A pediatrician judged safety endpoints of erythema, dryness, and edema in the diaper area at baseline and at study end. Parents/guardians also completed a questionnaire at study end. These studies have complied with Good Clinical Practices (GCP/ICH). OUTCOMES The cream-to-powder product prevented about 70% of the test dye from reaching the skin surface, demonstrating its ability to supplement the skin barrier. The tolerance-in-use study showed no statistically significant changes in any of the safety endpoints; there were no adverse events. Parents/guardians responses to the cream-to-powder product were overwhelmingly positive. Taken together, these results support that the cream-to-powder formulation is safe and effective for helping to prevent diaper dermatitis. J Drugs Dermatol. 2018;17(5):566-570.
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Boshuizen RC, Vd Noort V, Burgers JA, Herder GJM, Hashemi SMS, Hiltermann TJN, Kunst PW, Stigt JA, van den Heuvel MM. A randomized controlled trial comparing indwelling pleural catheters with talc pleurodesis (NVALT-14). Lung Cancer 2017. [PMID: 28625655 DOI: 10.1016/j.lungcan.2017.01.019] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- R C Boshuizen
- Dep. of Thoracic Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands; Dep. of Respiratory Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands.
| | - V Vd Noort
- Biometrics Dep., The Netherlands Cancer Institute, Amsterdam, The Netherlands.
| | - J A Burgers
- Dep. of Thoracic Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
| | - G J M Herder
- Dep. of Pulmonary Diseases, St. Antonius Hospital Nieuwegein, The Netherlands.
| | - S M S Hashemi
- Dep. of Pulmonary Diseases, VU University Medical Center, Amsterdam, The Netherlands.
| | - T J N Hiltermann
- Dep. of Pulmonology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - P W Kunst
- Dep. of Respiratory Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands; Dep. of Respiratory Medicine, Academic Medical Center, Amsterdam, The Netherlands.
| | - J A Stigt
- Dep. of Pulmonolgy, Isala Klinieken, Zwolle, The Netherlands.
| | - M M van den Heuvel
- Dep. of Thoracic Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
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Leoncini G, Campisi CC, Fraternali Orcioni G, Patrone F, Ferrando F, Campisi C. Chylothorax as Rare Manifestation of Pleural Involvement in Waldenström Macroglobulinemia: Mechanisms and Management. Lymphology 2016; 49:210-217. [PMID: 29908554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Here we report the clinical, pathological, and immunological features of a rare case of Waldenström macroglobulinemia (WM) with pleural infiltrations. An atypical chylothorax, successfully treated by videothoracoscopy, represented the main clinical feature of this case of low-grade lymphoplasmacytic lymphoma. Pleuropulmonary manifestations are rare (from 0 to 5% of cases) in WM, with chylothorax observed in just seven patients worldwide. In addition to describing this uncommon clinical presentation, we investigate hypothetical pathogenetic mechanisms causing chylothorax and through an up-todate review of available literature furnish helpful suggestions for diagnosis and management of chylothorax in WM patients.
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Chaithirayanon S. Comparative Study between Talcum and Zinc Oxide Cream for the Prevention of Irritant Contact Diaper Dermatitis in Infants. J Med Assoc Thai 2016; 99 Suppl 8:S1-S6. [PMID: 29901362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Baby powder which consists of talcum powder (magnesium silicate) as an active ingredient has been popularly used for prevention of irritant contact diaper dermatitis for a long time because it has water absorbent and friction-decreased properties. There are some case reports of its side effects of pulmonary complication from massive inhalation and the risk of ovarian tumors in adult. However the clinical research on the effectiveness of talcum powder for the prevention of diaper dermatitis has not been investigated. OBJECTIVE To compare the effectiveness between talcum powder with topical zinc oxide cream for the prevention of irritant diaper dermatitis. MATERIALS AND METHOD Fifty Thai infants at the age of 6-12 months old were randomized. Either topical talcum powder or zinc oxide cream was topically applied to their skin before changing new diapers. The follow-up were conducted at week 0, 2 and 8 to evaluate an occurrence of diaper dermatitis and to collect the median time-to-event data (the duration of disease occurrence). The clinical severity was assessed by using diaper dermatitis severity scoring scale and the side effects were recorded. RESULTS The average age of the infants was 8.8 months old. The incidence of irritant contact diaper dermatitis from the talcum group was 4 per 1,000 persons-day (95% confidence interval, 95% CI: 2-7) while the incidence of diaper dermatitis from the zinc oxide group was 2 per 1,000 persons-day (95% CI: 1-5). The median time-to-event outcome of diaper dermatitis for the talcum group was 19 days (interquartile range, IQR: 7-29) which was earlier than that of zinc oxide group, which was 39 days (IQR: 30-59). This showed statistically significant difference (p = 0.03, Log rank test). The average of disease duration of the talcum group (mean + SD) was 2.7+0.5 days whereas that of the zinc oxide group was 3.7+3.3 days. There is no significant difference between the two groups (p = 0.34). Most of the severity of the disease found in both groups is mild. The risk evaluation of diaper dermatitis at week 8, determined by using Cox proportional hazard analysis showed that the talcum group had 5.3 times greater risk than the zinc oxide group (hazard ratio, HR; 5.3, 95% confidence interval, CI: 1.4-20.0), with significant group difference (p = 0.01). There was no adverse effect detected on both groups. CONCLUSION Topical zinc oxide cream was better than talcum powder for the prevention of irritant contact diaper dermatitis.
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Food and Drug Administration, HHS. Use of Ozone-Depleting Substances. Direct final rule. Fed Regist 2016; 81:74298-302. [PMID: 27905700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The Food and Drug Administration (FDA, the Agency, or we) is amending its regulation on uses of ozone-depleting substances (ODSs), including chlorofluorocarbons (CFCs), to remove the designation for certain products as "essential uses" under the Clean Air Act. Essential-use products are exempt from the ban by FDA on the use of CFCs and other ODS propellants in FDA-regulated products and from the ban by the Environmental Protection Agency (EPA) on the use of ODSs in pressurized dispensers. The products that will no longer constitute an essential use are: Sterile aerosol talc administered intrapleurally by thoracoscopy for human use and metered-dose atropine sulfate aerosol human drugs administered by oral inhalation. FDA is taking this action because alternative products that do not use ODSs are now available and because these products are no longer being marketed in versions that contain ODSs.
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Abstract
BACKGROUND Malignant pleural effusion (MPE) is a common problem for people with cancer as a result of malignant infiltration of the pleura. It is 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 (either via a chest tube or at thoracoscopy) or indwelling pleural catheter insertion. OBJECTIVES To ascertain the optimal management strategy for adults with malignant pleural effusion in terms of pleurodesis success. Additionally, to quantify differences in patient-reported outcomes and adverse effects between management strategies. SEARCH METHODS We searched The Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Ovid EMBASE; EBSCO CINAHL; SCI-EXPANDED and SSCI (ISI Web of Science) to April 2015. SELECTION CRITERIA We included randomised controlled trials of intrapleural interventions for adults with symptomatic MPE in the review. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data on study design, study characteristics, outcome measures, potential effect modifiers and risk of bias.The primary outcome measure was pleurodesis failure rate. Secondary outcome measures were adverse effects and complications, patient-reported control of breathlessness, quality of life, cost, mortality, duration of inpatient stay and patient acceptability.We performed network meta-analysis with random effects to analyse the primary outcome data and those secondary outcomes with enough data. We also performed pair-wise random-effects meta-analyses of direct comparison data. If interventions were not deemed jointly randomisable, or insufficient data were available, we reported the results by narrative synthesis. We performed sensitivity analyses to explore heterogeneity and to evaluate only those pleurodesis agents administered via a chest tube at the bedside. MAIN RESULTS Of the 1888 records identified, 62 randomised trials, including a total of 3428 patients, were eligible for inclusion. All studies were at high or uncertain risk of bias for at least one domain.Network meta-analysis evaluating the rate of pleurodesis failure, suggested talc poudrage to be a highly effective method (ranked second of 16 (95% credible interval (Cr-I) 1 to 5)) and provided evidence that it resulted in fewer pleurodesis failures than eight other methods. The estimated ranks of other commonly used agents were: talc slurry (fourth; 95% Cr-I 2 to 8), mepacrine (fourth; 95% Cr-I 1 to 10), iodine (fifth; 95% Cr-I 1 to 12), bleomycin (eighth; 95% Cr-I 5 to 11) and doxycyline (tenth; 95% Cr-I 4 to 15). The estimates were imprecise as evidenced by the wide credible intervals and both high statistical and clinical heterogeneity.Most of the secondary outcomes, including adverse events, were inconsistently reported by the included studies and the methods used to describe them varied widely. Hence the majority of the secondary outcomes were reported descriptively in this review. We obtained sufficient data to perform network meta-analysis for the most commonly reported adverse events: pain, fever and mortality. The fever network was imprecise and showed substantial heterogeneity, but suggested placebo caused the least fever (ranked first of 11 (95% Cr-I 1 to 7)) and mepacrine and Corynebacterium parvum (C. parvum) appeared to be associated with the most fever (ranked tenth (95% Cr-I 6 to 11) and eleventh (95% Cr-I 7 to 11) respectively). No differences between interventions were revealed by the network meta-analysis of the pain data. The only potential difference in mortality identified in the mortality network was that those receiving tetracycline appeared to have a longer survival than those receiving mitoxantrone (OR 0.16 (95% Confidence Interval (CI) 0.03 to 0.72)). Indwelling pleural catheters were examined in two randomised studies, both of which reported improved breathlessness when compared to talc slurry pleurodesis, despite lower pleurodesis success rates.The risk of bias in a number of the included studies was substantial, for example the vast majority of studies were unblinded, and the methods used for sequence generation and allocation concealment were often unclear. Overall, however, the risk of bias for all studies was moderate. We have not reported the GRADE quality of evidence for the outcomes, as the role of GRADE is not well established in the context of Network Meta-analysis (NMA). AUTHORS' CONCLUSIONS Based on the available evidence, talc poudrage is a more effective pleurodesis method in MPE than a number of other frequently used methods, including tetracycline and bleomycin. However further data are required to definitively confirm whether it is more effective than certain other commonly used interventions such as talc slurry and doxycycline, particularly in view of the high statistical and clinical heterogeneity within the network and the high risk of bias of many of the included studies. Based on the strength of the evidence from both direct and indirect comparisons of randomised data of sclerosants administered at the bedside, there is no evidence to suggest large differences between the other highly effective methods (talc slurry, mepacrine, iodine and C. parvum). However, local availability, global experience of these agents and their adverse events, which may not be identified in randomised trials, must also be considered when selecting a sclerosant. Further research is required to delineate the roles of different treatments according to patient characteristics (e.g. according to their prognosis or presence of trapped lung) and to explore patient-centred outcomes, such as breathlessness and quality of life, in more detail. Careful consideration to minimise the risk of bias and standardise outcome measures is essential for future trial design.
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Affiliation(s)
- Amelia O Clive
- University of BristolAcademic Respiratory UnitSouthmead RoadBristolUKBS10 5NB
| | - Hayley E Jones
- University of BristolSchool of Social and Community MedicineCanynge Hall39 Whatley RoadBristolUKBS8 2PS
| | - Rahul Bhatnagar
- University of BristolAcademic Respiratory UnitSouthmead RoadBristolUKBS10 5NB
| | - Nancy J Preston
- Lancaster UniversityInternational Observatory on End of Life CareFurness CollegeLancasterUKLA1 4YG
| | - Nick Maskell
- University of BristolAcademic Respiratory UnitSouthmead RoadBristolUKBS10 5NB
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Kolesnik AP, Kajoyan AV, Kuzmenko VA. [MODERN ASPECTS OF TREATMENT FOR EXUDATIVE PLEURITIS OF TUMORAL GENESIS]. Klin Khir 2016:71-73. [PMID: 30265791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Habal P, Omran N, Kovacicova K, Chek J, Jankovicova K, Mandak J. Perspective in predicting the effect of pleurodesis in the treatment of malignant pleural effusions. ACTA ACUST UNITED AC 2015; 116:285-8. [PMID: 25924636 DOI: 10.4149/bll_2015_054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Pleurodesis with talc has been used for many years. No objective criteria of inflammatory symptoms are known in order to use them to predict the effect of therapy and selection of patients. PURPOSE OF THE STUDY To objectify the course of local inflammatory changes in the pleural cavity, quantify their dynamics in a clinically used procedure, and to determine specific predictors of inflammation as perspective markers of selection of patients suitable for talcage. MATERIAL AND METHOD A total of 114 patients were retrospectively divided into Group A (n1 = 98) of patients without relapse and Group B (n2 = 16) of patients with relapse of exudate. The need for repeated thoracic punctures or drainages over the course of a 12-month monitoring period was the criterion of treatment failure. RESULTS The groups were not different as for the baseline values of sTLR-2 (p₀ = 0.638). Group A showed a marked growth during the monitoring period in 2 hours following talcage (p₂= 0.002) and in 24 hours (p24 = 0.016). Group B showed higher sCD-163 levels (p0 < 0.001). The initial sTREM-1 values and those after two hours were similar in both groups (p0 = 0.146; p2 < 0.0641). In 24 hours, Group A had markedly higher values (p24 < 0.001). CONCLUSION The sTLR-2, sCD-163 and sTREM-1 values can be prospectively determined. High sCD-163 values predict unsuitable selection of a candidate for talcage. The degree of inflammatory response can be evaluated using sTLR-2 or sTREM-1. Talcage using an inserted thoracic drain can be repeated at low levels. The cost of ELISA examination is approximately 18 euros (Tab. 1, Fig. 4, Ref. 20).
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Bhatnagar R, Laskawiec-Szkonter M, Piotrowska HEG, Kahan BC, Hooper CE, Davies HE, Harvey JE, Miller RF, Rahman NM, Maskell NA. Evaluating the efficacy of thoracoscopy and talc poudrage versus pleurodesis using talc slurry (TAPPS trial): protocol of an open-label randomised controlled trial. BMJ Open 2014; 4:e007045. [PMID: 25428632 PMCID: PMC4248086 DOI: 10.1136/bmjopen-2014-007045] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION The management of recurrent malignant pleural effusions (MPE) can be challenging. Various options are available, with the most efficacious and widely used being talc pleurodesis. Talc can either be applied via a chest drain in the form of slurry, or at medical thoracoscopy using poudrage. Current evidence regarding which method is most effective is conflicting and often methodologically flawed. The TAPPS trial is a suitably powered, multicentre, open-label, randomised controlled trial designed to compare the pleurodesis success rate of medical thoracoscopy and talc poudrage with chest drain insertion and talc slurry. METHODS AND ANALYSIS 330 patients with a confirmed MPE requiring intervention will be recruited from UK hospitals. Patients will be randomised (1:1) to undergo either small bore (<14 Fr) Seldinger chest drain insertion followed by instillation of sterile talc (4 g), or to undergo medical thoracoscopy and simultaneous poudrage (4 g). The allocated procedure will be performed as an inpatient within 3 days of randomisation taking place. Following discharge, patients will be followed up at regular intervals for 6 months. The primary outcome measure is pleurodesis failure rates at 3 months. Pleurodesis failure is defined as the need for further pleural intervention for fluid management on the side of the trial intervention. ETHICS AND DISSEMINATION The trial has received ethical approval from the National Research Ethics Service Committee North West-Preston (12/NW/0467). There is a trial steering committee which includes independent members and a patient and public representative. The trial results will be published in a peer-reviewed journal and presented at international conferences, as well as being disseminated via local and national charities and patient groups. All participants who wish to know the study results will also be contacted directly on their publication. TRIAL REGISTRATION NUMBER ISRCTN47845793.
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Affiliation(s)
- Rahul Bhatnagar
- Respiratory Research Unit, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
- Academic Respiratory Unit, University of Bristol, Bristol, UK
| | | | | | - Brennan C Kahan
- Pragmatic Clinical Trials Unit, Queen Mary University of London, London, UK
| | - Clare E Hooper
- Respiratory Department, Worcestershire Royal Hospital, Worcester, UK
| | - Helen E Davies
- Cardiff and Vale University Health Board, Cardiff, Wales, UK
| | - John E Harvey
- Respiratory Research Unit, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
- Academic Respiratory Unit, University of Bristol, Bristol, UK
| | - Robert F Miller
- Research Department of Infection and Population Health, Institute of Epidemiology and Healthcare, University College London, London, UK
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Najib M Rahman
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, UK
| | - Nick A Maskell
- Respiratory Research Unit, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
- Academic Respiratory Unit, University of Bristol, Bristol, UK
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Xia H, Wang XJ, Zhou Q, Shi HZ, Tong ZH. Efficacy and safety of talc pleurodesis for malignant pleural effusion: a meta-analysis. PLoS One 2014; 9:e87060. [PMID: 24475222 PMCID: PMC3903610 DOI: 10.1371/journal.pone.0087060] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 12/17/2013] [Indexed: 11/18/2022] Open
Abstract
Background Talc pleurodesis has been widely used to control malignant pleural effusion; however, it is still not clear whether talc pleurodesis is more effective than other local therapies. We performed a meta-analysis to evaluate the efficacy and safety of talc pleurodesis in the management of malignant pleural effusion. Methods PubMed, Embase, and Web of Science were searched for English-language studies of clinical controlled trials comparing talc pleurodesis with control therapies until August 8, 2013. Success rate and incidence of adverse events were evaluated. Relative risks were estimated using random- or fixed- effects model and statistical heterogeneity was assessed using I2 test. Results Twenty trials involving 1,525 patients with malignant pleural effusion were included. The success rate of talc pleurodesis was significantly higher than that of control therapies (relative risk, 1.21; 95% confidence interval, 1.01–1.45; p = 0.035) with similar adverse events. In addition, thoracoscopic talc poudrage was more effective than bedside talc slurry (relative risk, 1.12; 95% confidence interval, 1.01–1.23; p = 0.026). Conclusions The current evidences suggested the benefit for talc pleurodesis in the treatment of malignant pleural effusion. Talc pleurodesis, especially thoracoscopic talc poudrage pleurodesis, should be performed in patients with malignant pleural effusion, especially those with life-expectancy longer than one month.
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Affiliation(s)
- Huan Xia
- Department of Respiratory and Critical Care Medicine, Beijing Chaoyang Hospital, Beijing Institute of Respiratory Medicine, Capital Medical University, Beijing, China
| | - Xiao-Juan Wang
- Department of Respiratory and Critical Care Medicine, Beijing Chaoyang Hospital, Beijing Institute of Respiratory Medicine, Capital Medical University, Beijing, China
| | - Qiong Zhou
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Huan-Zhong Shi
- Department of Respiratory and Critical Care Medicine, Beijing Chaoyang Hospital, Beijing Institute of Respiratory Medicine, Capital Medical University, Beijing, China
- Center of Medical Research, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Zhao-Hui Tong
- Department of Respiratory and Critical Care Medicine, Beijing Chaoyang Hospital, Beijing Institute of Respiratory Medicine, Capital Medical University, Beijing, China
- * E-mail:
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Lumachi F, Mazza F, Ermani M, Chiara GB, Basso SMM. Talc pleurodesis as surgical palliation of patients with malignant pleural effusion. Analysis of factors affecting survival. Anticancer Res 2012; 32:5071-5074. [PMID: 23155281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
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.
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Affiliation(s)
- Franco Lumachi
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, School of Medicine, Via Giustiniani 2, 35128 Padova, Italy.
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Chavda LK, Vaidya RA, Vaidya ADB. Yellow nail syndrome: missed diagnosis of a rare syndrome. J Assoc Physicians India 2011; 59:258-260. [PMID: 21755767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
A 61 year old male, with a bilateral persistent and recurrent pleural effusion, had undergone frequent tapping over a period of eight months, prior to the referral. The patient was treated earlier to the referral empirically for pulmonary tuberculosis with no response to the treatment. Malignancy was suspected and ruled out. A detailed examination showed that he also had atrophic nails with yellow discoloration and lymphedema of feet. Yellow nail syndrome was diagnosed on the basis of the clinical findings of the triad viz. yellow atrophic nails, lymphedema and bilateral pleural effusions. Pathogenesis still remains elusive for the syndrome. Pleurodesis provided both symptomatic relief and a respite from repeated tapping. The case is presented as a rare condition, which was missed for diagnosis, for quite some time by several specialists.
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Ak G, Metintaş M, Yildirim H, Metintaş S, Dündar E, Erginel S, Alataş F. Pleurodesis in follow-up and treatment of malignant pleural mesothelioma patients. Tuberk Toraks 2009; 57:22-31. [PMID: 19533434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
We analyzed the necessity of pleurodesis in the follow-up of the patients with malignant pleural mesothelioma (MPM), and how much it contributes to the survival period by determining the indications, efficiency, and reliability of the pleurodesis application. 191 patients were assessed retrospectively and 69 (36%) of them were established with a pleurodesis indication. In 42 patients accepting pleurodesis, the pleurodesis success was evaluated. Factors affecting the success of pleurodesis and the effect of pleurodesis on survival were assessed. Pleurodesis was a success in 26 (62%) of the 42 patients. In the group in which the pleurodesis process was a success, it was observed that KPS and pleural fluid pH were higher (p= 0.030, p= 0.032, respectively). In case of KPS > or = 80, the sensitivity was: 76.9%, specificity: 50.0%, PPV: 71.4%, and NPV was established as 57.1%. In case of pleural fluid pH > 7.27, the sensitivity was: 92.9%, specificity: 50.0%, PPV: 76.5%, and NPV was observed as 80.0%. In the group in which pleurodesis was a success, the median survival was longer (Log-rank: 11.2; p= 0.0008). Independently from chemotherapy, the chance of living longer for patients whose pleurodesis was a success was 2.6 times higher. A severe complication concerning the process was not observed. Pleurodesis is performed less frequently than it is assumed on patients with MPM. In patients with KPS > or = 80, pleural fluid pH > 7.27, and with indication, pleurodesis must be administered. In feasible patients, a successful pleurodesis with talc increases the survival of patients with MPM, and it can be safely administered.
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Affiliation(s)
- Güntülü Ak
- Department of Chest Diseases, Faculty of Medicine, Eskişehir Osmangazi University, Eskişehir, Turkey.
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Das SK, Saha SK, Das A, Halder AK, Banerjee SN, Chakraborty M. A study of comparison of efficacy and safety of talc and povidone iodine for pleurodesis of malignant pleural effusions. J Indian Med Assoc 2008; 106:589-592. [PMID: 19552086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Pleurodesis is considered as the best palliative therapy for the treatment of symptomatic malignant pleural effusion. Several chemical agents are used for this purpose with variable efficacy and safety. The present study is to compare the effectiveness and safety of talc and povidone iodine as chemical agents for pleurodesis in patients of malignant pleural effusion. Fifty-two patients with malignant pleural effusion admitted in the department of chest of Calcutta National Medical College, Kolkata were selected for the study. Pleurodesis with povidone iodine and talc in slurry was done in 28 and 24 patients respectively. Efficacy and safety of these agents were assessed during a follow-up period of six months. Among the 52 patients, 42 were males and 10 females. Age ranged from 40 to 64 years with mean age of 56.4 years. In 41 patients effusion was secondary to bronchogemic carcinoma, 8 had effusion secondary to breast carcinoma, 1 had effusion due to non-Hodgkin's lymphoma, while primary malignancy was unknown in 2 patients. Among the 24 patients treated with talc pleurodesis, 20 had bronchogenic carcinoma, 3 had breast carcinoma and 1 had unknown primary malignancy. Out of the 28 patients treated with povidone iodine pleurodesis, bronchogenic carcinoma was present in 21 patients, breast carcinoma in 5 patients, non-Hodgkin's lymphoma and unknown primary malignancy was present in 1 patient each. Pleurodesis with talc showed complete success in 19 patients, partial success in 3 patients and failure in 2 patients. Pleurodesis with povidone iodine showed complete response in 24 patients, partial response in 1 patient and failure in 3 patients. Chest pain occurred in 4 patients of talc pleurodesis and 5 patients of povidone iodine pleurodesis, 3 patients of each group had fever. There was no death in the peripleurodesis period. During the 6 months follow-up, 12 patients of talc pleurodesis and 18 patients of povidone iodine pleurodesis died. Talc is slurry and povidone iodine is equally effective and safe pleurodesing agent for symptomatic malignant pleural effusion. However povidone iodine can be preferred option because of easy availability and low cost.
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Affiliation(s)
- Sibes Kumar Das
- Department of Respiratory Medicine, Calcutta National Medical College and Hospital, Kolkata 700014
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Ahmadzadehfar H, Palmedo H, Strunk H, Biersack HJ, Habibi E, Ezziddin S. False positive 18F-FDG-PET/CT in a patient after talc pleurodesis. Lung Cancer 2007; 58:418-21. [PMID: 17624474 DOI: 10.1016/j.lungcan.2007.05.015] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2007] [Revised: 05/17/2007] [Accepted: 05/23/2007] [Indexed: 11/19/2022]
Abstract
A 61-year-old man presented with spontaneous pneumothorax. After diagnosis of emphysemic bullae, the patient underwent talc pleurodesis and had no further complaints. Five years later a routine chest X-ray showed suspicious pleural lesions in addition to the emphysema, which was deemed compatible with the known history of talc pleurodesis. Subsequent chest CT, however, revealed one lesion in the right lung that appeared not typical for this condition in addition to multiple lesions in pleural proximity. FDG-PET/CT demonstrated high glucose uptake in all the lesions. Subsequent needle biopsy of the suspicious intrapulmonary and also of one mediastinal lesion yielded the histopathological diagnosis of talcum granuloma with long-standing calculous fibrotic changes and no evidence of malignancy. This report on PET/CT after talc pleurodesis addresses the potential pitfalls caused by this condition, as chronic granulomatous reactions, like other inflammatory lesions, may account for highly increased FDG uptake which should be interpreted with caution and not simply read as a sign of malignancy. PET/CT offers the opportunity to exactly localize the areas of increased FDG uptake within regions of pleural thickening caused by talc deposition, however, the dilemma of misleading FDG accumulation cannot be solved by this hybrid imaging modality.
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Affiliation(s)
- Hojjat Ahmadzadehfar
- Department of Nuclear Medicine, University Hospital Bonn, Sigmund-Freud-Strasse 25, 53127 Bonn, Germany.
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Janssen JP, Collier G, Astoul P, Tassi GF, Noppen M, Rodriguez-Panadero F, Loddenkemper R, Herth FJ, Gasparini S, Marquette CH, Becke B, Froudarakis ME, Driesen P, Bolliger CT, Tschopp JM. Safety of pleurodesis with talc poudrage in malignant pleural effusion: a prospective cohort study. Lancet 2007; 369:1535-1539. [PMID: 17482984 DOI: 10.1016/s0140-6736(07)60708-9] [Citation(s) in RCA: 223] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND Talc is the most effective chemical pleurodesis agent for patients with malignant pleural effusion. However, concerns have arisen about the safety of intrapleural application of talc, after reports of development of acute respiratory distress syndrome in 1-9% of treated patients. Our aim was to establish whether use of large-particle-size talc is safe in patients with malignant pleural effusion. METHODS We did a multicentre, open-label, prospective cohort study of 558 patients with malignant pleural effusion who underwent thoracoscopy and talc poudrage with 4 g of calibrated French large-particle talc in 13 European hospitals, and one in South Africa. The primary endpoint was the occurrence of acute respiratory distress syndrome after talc pleurodesis. FINDINGS No patients developed acute respiratory distress syndrome (frequency 0%, one-sided 95% CI 0-0.54%). 11 (2%) patients died within 30 days. Additionally, seven patients had non-fatal post-thoracoscopy complications (1.2%), including one case of respiratory failure due to unexplained bilateral pneumothorax. INTERPRETATION Use of large-particle talc for pleurodesis in malignant pleural effusion is safe, and not associated with the development of acute respiratory distress syndrome.
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Affiliation(s)
| | | | | | | | - Marc Noppen
- University Hospital UZ Brussels, Brussels, Belgium
| | | | | | - Felix Jf Herth
- Thoraxklinik, University of Heidelberg, Heidelberg, Germany
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Cardillo G, Carleo F, Carbone L, Di Martino M, Salvadori L, Ricci A, Petrella L, Martelli M. Long-term lung function following videothoracoscopic talc poudrage for primary spontaneous recurrent pneumothorax☆. Eur J Cardiothorac Surg 2007; 31:802-5. [PMID: 17336083 DOI: 10.1016/j.ejcts.2007.01.040] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2006] [Revised: 12/28/2006] [Accepted: 01/15/2007] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE Some concern still exists regarding long-term lung function following videothoracoscopic talc poudrage for primary spontaneous pneumothorax (PSP). We evaluated lung function at 5 years in a series of 100 patients surgically treated for PSP. METHODS Out of 1065 patients treated for PSP by means of videothoracoscopic talc poudrage from September 1995 to January 2006, we consecutively enrolled 50 patients (33 males, 17 females, mean age: 24.22 years, median age: 24 years; range: 13-40 years) (group A) with no recurrence for functional evaluation with measurement of static and dynamic volumes (FEV1-FVC-TLC-RV), and DLCO at 60 months after surgery. Fifty patients (35 males, 15 females, mean age: 23.56 years; median age: 22.5 years; range: 16-37 years) underwent same pulmonary function tests 5 years after simple drainage for recurrent PSP because of refusal of surgery (group B). RESULTS Pulmonary function tests showed (mean % value+/-SD for group A vs group B): FEV1 93+/-6.6 versus 95.4+/-6.4; FVC 98+/-6.5 versus 100.1+/-6.9; TLC 91.7+/-7.7 versus 94.36+/-5.8; RV 97+/-7 versus 99.2+/-4.9; DLCO 91.4+/-2.8 versus 91.98+/-4.2. No patient in both groups showed FEV1<80%. Analysis of mean difference of pulmonary function values was computed between group A and group B patients. CONCLUSIONS No statistically significant differences in long-term lung function have been found between patients treated with pleural drainage only versus patients treated with videothoracoscopic talc poudrage for PSP. Lung function is not impaired by videothoracoscopic talc poudrage.
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Affiliation(s)
- Giuseppe Cardillo
- Thoracic Surgery Unit, Carlo Forlanini Hospital, Azienda Ospedaliera San Camillo-Forlanini, Via Portuense 332, 00149 Rome, Italy.
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Györik S, Erni S, Studler U, Hodek-Wuerz R, Tamm M, Chhajed PN. Long-term follow-up of thoracoscopic talc pleurodesis for primary spontaneous pneumothorax. Eur Respir J 2007; 29:757-60. [PMID: 17182650 DOI: 10.1183/09031936.00122106] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The aim of the present study was to evaluate the long-term outcome of patients with primary spontaneous pneumothorax treated with talc pleurodesis. A follow-up study was undertaken in all patients with primary spontaneous pneumothorax who underwent talc pleurodesis for prolonged air leak or recurrence using thoracoscopy. In total, 112 patients underwent pleurodesis and follow-up data was obtained in 63 (56%) patients: 45 patients were available for clinical follow-up, 14 for telephone follow-up and four were dead. The causes of death were unrelated to the pleurodesis. There were no episodes of acute respiratory failure following pleurodesis. A total of 56 (95%) out of the cohort of 59 patients had a successful pleurodesis. Surgical pleurectomy was required in three (5%) patients for persistent air leak. Median duration of follow-up after talc pleurodesis was 118 months. Long-term success was observed in 53 (95%) out of 56 patients. Recurrent pneumothorax was observed in three (5%) out of 56 patients. Patients with successful talc pleurodesis had a median forced vital capacity (FVC) of 102% and median total lung capacity of 99% at follow-up. Comparing smokers and nonsmokers, the forced expiratory volume in one second (FEV(1)) was significantly lower in smokers and there was a tendency for the FEV(1)/FVC ratio to be lower in smokers. Talc pleurodesis in patients with primary spontaneous pneumothorax via thoracoscopy is an effective procedure associated with normal lung function in patients who do not smoke.
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Affiliation(s)
- S Györik
- Dept of Pulmonary Medicine, University Hospital Basel, Petersgraben 4, CH-4031, Basel, Switzerland
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Nasreen N, Najmunnisa N, Mohammed KA, Brown S, Su Y, Sriram PS, Moudgil B, Loddenkemper R, Antony VB. Talc mediates angiostasis in malignant pleural effusions via endostatin induction. Eur Respir J 2007; 29:761-9. [PMID: 17251235 DOI: 10.1183/09031936.00061606] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Talc remains the most effective sclerosing agent for pleurodesis. However, its mechanism of action in resolving pleural malignant disease remains unclear. The present study evaluated the angiogenic balance in the pleural space in patients with malignant pleural effusions (MPE) following talc insufflation. Patient pleural fluid samples were collected both before and after talc insufflation. The ability of pleural mesothelial cells (PMC) and malignant mesothelioma cells (MMC) to produce endostatin in vitro was compared. The biological effects of pleural fluids and conditioned media from talc-activated PMC on endothelial cells were evaluated by performing proliferation, invasion, tube formation and apoptosis assays. Pleural fluids from patients with MPE who received thoracoscopic talc insufflation contained significantly higher levels of endostatin (median 16.75 ng.mL(-1)) compared with pre-talc instillation (1.06 ng.mL(-1)). Talc-activated PMC released significantly greater amounts of endostatin (mean+/-SEM 1052.39+/-38.66 pg.mL(-1)) when compared with a MMC line (134.73+/-8.72 pg.mL(-1)). In conclusion, talc alters the angiogenic balance in the pleural space from a biologically active and angiogenic environment to an angiostatic milieu. Functional improvement following talc poudrage in patients with malignant pleural effusions may, in part, reflect these alterations in the pleural space.
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Affiliation(s)
- N Nasreen
- Division of Pulmonary and Critical Care Medicine, Dept of Medicine, University of Florida, Gainesville, FL, USA
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Debeljak A, Kecelj P, Triller N, Letonja S, Kern I, Debevec L, Rozman A. Talc pleurodesis: comparison of talc slurry instillation with thoracoscopic talc insufflation for malignant pleural effusions. J BUON 2006; 11:463-7. [PMID: 17309178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
PURPOSE Pleurodesis can relieve dyspnea in patients with malignant pleural effusions. We retrospectively compared the success rate of talc slurry instillation pleurodesis with thoracoscopic talc powder insufflation pleurodesis. PATIENTS AND METHODS From 2000 to 2005, two methods of talc pleurodesis were performed in 71 patients with symptomatic massive malignant pleural effusions: a) through the pleural drain (24F), 50 ml of a slurry containing 4-5 g of Luzenac talc in saline with 20 ml 1% lidocaine were instilled. The drain was clamped for 1 h; b) insufflation of 3-5 g of talc powder was performed via videothoracoscope using local anaesthesia. The drain was left in the pleural space until the daily secretion of pleural fluid was under 100 ml. Pleurodesis was considered successful when the patient was without dyspnea and did not need pleural fluid evacuation and the pleural fluid did not re-accumulate in the 1st month after pleurodesis. RESULTS The success rate of talc slurry pleurodesis was 78%(38/49). Excluding 8 patients who died in the first month, the success rate increased to 93% (38/41). Thoracoscopic pleurodesis was successful in 77% (17/22) of patients. Excluding one patient who died in the first month, the success rate increased to 81%(17/21) (intergroup difference non significant). Complications were observed in 41% (20/49). vs. 73% (16/22) of patients in the talc slurry group and thoracoscopic group, respectively (p=0.013). CONCLUSION Pleurodesis with instillation of talc slurry and with insufflation of talc during thoracoscopy were equally successful in patients with massive malignant pleural effusions. However, thoracoscopic pleurodesis is accompanied with considerably more complications, rather as a result of the thoracoscopy itself and not as a consequence of pleurodesis.
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Affiliation(s)
- A Debeljak
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia.
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Antonangelo L, Vargas FS, Teixeira LR, Acencio MMP, Vaz MAC, Filho MT, Marchi E. Pleurodesis induced by talc or silver nitrate: evaluation of collagen and elastic fibers in pleural remodeling. Lung 2006; 184:105-11. [PMID: 16622780 DOI: 10.1007/s00408-005-2569-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2005] [Indexed: 11/26/2022]
Abstract
This study evaluated the extracellular matrix (collagen and elastic fibers) in pleurodesis induced by intrapleural talc (TL) or silver nitrate (SN). Study subjects were 420 rabbits divided into two groups and sacrificed from 15 min to 12 months after the injection of the sclerosing agents at intervals previously defined. Pleural adhesions and fibrosis were graded (0-4), and the collagen and elastin were quantified. The maximum score of the pleural adhesions was observed two months after TL (2.80 +/- 0.99) and 15 days after SN (3.75 +/- 0.25). More intense pleural adhesions were observed in the SN group from day 5 (p < 0.05). Pleural thickness and pleural fibrosis were, in general, significantly higher after SN (p < 0.05). Increased deposition of collagen and elastin was observed in both groups but was more evident in the SN group. In the TL group, a linear correlation was observed between pleural adhesions and fibrosis (r = 0.775), between pleural adhesions and collagen (r = 0.779), and between fibrosis and collagen (r = 0.709). In the SN group, these correlations were acceptable (r = 0.605, 0.665, and 0.663). The elastin presented a correlation of 0.707 (p < 0.001) in the TL group and of 0.564 (p < 0.001) in the SN group. In conclusion, intrapleural 0.5% silver nitrate and talc (400 mg/kg) are effective in the induction of pleurodesis. However, the intensity of adhesions and the richness of collagen after SN, in combination with the early onset of tissue remodeling, demonstrate the local superiority of this agent. Considering the easy availability and instillation, the low cost, and the absence of important side effects, silver nitrate might be considered as a sclerosing agent to induce pleurodesis in humans.
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Affiliation(s)
- Leila Antonangelo
- Laboratory of Pleura-Pulmonary Division and Division of Applied Physiology, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
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Luria S, Applbaum Y, Yaakov A, Weil Y, Yoram W, Liebergall M, Meir L, Peyser A. Talc sclerodhesis of persistent Morel-Lavallée lesions (posttraumatic pseudocysts): case report of 4 patients. J Orthop Trauma 2006; 20:435-8. [PMID: 16825972 DOI: 10.1097/00005131-200607000-00013] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Large posttraumatic pseudocysts are infamous for their tendency to recur despite repeated aspiration. The standard practice has been repeated extensive surgical debridement. To avoid the need for such treatment, talc was used to sclerose the lesion in 4 patients treated between 2000 and 2003. The patients were between the ages of 20 and 73 and had thigh and buttock pseudocysts that persisted for an average of 3 months. Talc was administered under fluoroscopic guidance and suction drainage (wall suction followed by a bulb vacuum drainage system) was applied for an average of 12 days. The patients were followed for an average period of 27 months after talc sclerodhesis. All persistent pseudocysts showed an immediate cessation of fluid accumulation in the treated space without reccurence. One case which was complicated by infection, had to be treated twice with talc to cease the accumulation. In this case, the infection recurred, although fluid accumulation did not recur. Talc sclerodhesis proved to be a simple and rapid method of treatment in posttraumatic cases classically treated by repeated and aggressive surgical methods.
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Affiliation(s)
- Shai Luria
- Department of Orthopedic Surgery, The Hadassah-Hebrew University Medical School, Jerusalem 91120, Israel
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Aelony Y, Yao JF, King RR. Prognostic Value of Pleural Fluid pH in Malignant Epithelial Mesothelioma after Talc Poudrage. Respiration 2006; 73:334-9. [PMID: 16679752 DOI: 10.1159/000092085] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2005] [Accepted: 12/22/2005] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Current staging schemes for malignant mesothelioma are inadequate. The most accurate staging may require pneumonectomy - a procedure associated with many complications. The pH of pleural fluid (ppH) predicts survival in non-mesotheliomatous malignant pleural effusions, suggesting that this noninvasive test might be useful for prognostication in malignant mesothelioma. OBJECTIVE It was the aim of this study to determine whether baseline ppH correlates with survival in malignant epithelial pleural mesothelioma. METHODS We reviewed survival data in patients treated with thoracoscopic talc pleurodesis whose final diagnosis was epithelial malignant pleural mesothelioma and whose chart recorded a ppH determination performed just before thoracoscopy. We monitored 26 patients until April 2002 (25 of these patients died), identifying cutoff ppH values that discriminate best for survival; Cox proportional hazards models were recursively run by increasing the ppH cutoff value by 0.02 each time. RESULTS The mean follow-up time was 19+/-14 months. Mean ppH was 7.30+/-0.09, and median ppH was 7.32. Several cutoff points correlated with a statistically significant difference in survival, but ppH 7.32 was associated with the greatest value for the area under the curve. Patients with ppH>.32 lived a median of 21.2 months (95% confidence interval 16.5-30.0 months) after diagnosis compared with patients who had ppH <or=7.32 and lived a median of 13.4 months (95% confidence interval 4.5-16.2 months; p=0.0194). CONCLUSIONS Baseline ppH correlates with survival in epithelial mesothelioma patients treated palliatively with pleurodesis by thoracoscopic talc poudrage. This noninvasive test - ppH - should be included when staging patients with malignant mesothelioma.
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Affiliation(s)
- Yossef Aelony
- Department of Internal Medicine, Kaiser Permanente Medical Center, Harbor City, Calif. 90275, USA.
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Arapis K, Caliandro R, Stern JB, Girard P, Debrosse D, Gossot D. Thoracoscopic palliative treatment of malignant pleural effusions. Surg Endosc 2006; 20:919-23. [PMID: 16738983 DOI: 10.1007/s00464-005-0534-6] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2005] [Accepted: 12/05/2005] [Indexed: 11/30/2022]
Abstract
BACKGROUND The aim of this study was to analyze the results of pleurodesis for malignant pleural effusion performed by surgeons. PATIENTS AND METHODS A series of 273 patients with malignant pleural effusion underwent thoracoscopy with the aim of performing a palliative pleurodesis. There were 94 males (34.4%) and 175 females (64.1%), ranging in age from 15 to 94 years (mean age: 60.6 years). The effusion was on the right side in 136 patients (49.8%), on the left side in 110 (40.3%), and bilateral in 27 (9.9%). Thoracoscopy was performed under general anaesthesia in all patients. Pleural biopsy was performed in two thirds of the patients (70.7%). Pleurodesis was produced by instillation of 5g of sterile asbestos-free talc; the chest tube was left in place a minimum of 3 days. It was removed when fluid drainage was less than 200 ml/24 h. Patients were usually discharged the day after chest tube removal. RESULTS There was no intraoperative mortality. Two patients (0.7%) had intraoperative complications; 17 (6.2%) underwent a bilateral pleurodesis, and 10 (3.7%) had a pericardiopleural window. In 32 patients (11.7%) no pleurodesis was done, either because the lung did not properly re-expand (5.2%), or because of suspected infection, e.g., false membranes (1.9%), or because of multiple adhesions (4.6%). Finally, only 241 patients (88.3%) had a talc poudrage at the time of thoracoscopy. Duration of postoperative pleural drainage ranged between 1 and 11 days (mean: 3.64 days). The postoperative hospital stay ranged from 2 to 21 days (mean: 7.1 days). Pleural empyema occurred in 4 patients (1.5%) and was lethal in one patient. The mean follow-up period was 8.39 (7.2 months, and 172 patients had regular follow up. In this group, there were 24 recurrences (14%), 12 of which were treated by repeat pleurodesis. The results were very good in 133 patients (77.3%), acceptable in 35 patients (20.3%), and there was a failure in 4 patients (2.4%). CONCLUSIONS Results of surgical thoracoscopy for malignant pleural effusion are good, with low morbidity. However, in debilitated patients, bedside talc slurry may be preferable.
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Affiliation(s)
- K Arapis
- Thoracic Department, Institut Mutualiste Montsouris, 42 Bd Jourdan, F-75014, Paris, France
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Lin DJ, Zhang M, Gao GX, Li B, Wang MF, Zhu L, Xue LF. Thoracoscopy for diagnosis and management of refractory hepatic hydrothorax. Chin Med J (Engl) 2006; 119:430-4. [PMID: 16542590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023] Open
Affiliation(s)
- Dian-jie Lin
- Department of Respiratory Diseases, Shandong University Shandong Provincial Hospital, Jinan 250002, China.
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Marrazzo A, Noto A, Casà L, Taormina P, Lo Gerfo D, David M, Mercadante S. Video-thoracoscopic surgical pleurodesis in the management of malignant pleural effusion: the importance of an early intervention. J Pain Symptom Manage 2005; 30:75-9. [PMID: 16043010 DOI: 10.1016/j.jpainsymman.2005.01.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/29/2005] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
- Antonio Marrazzo
- Department of Experimental Oncology and Clinical Application, University of Palermo, Italy
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Gravino E, Griffo S, Gentile M, Storti M, Grossi N, Gily B. Comparison of two protocols of conscious analgosedation in video-assisted talc pleurodesis. Minerva Anestesiol 2005; 71:157-65. [PMID: 15756156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
AIM Video-assisted thoracoscopy surgery (VATS) is classically performed using general anesthesia with a double-lumen endotracheal tube to allow collapse of the operated lung. However, according to our opinion, the risks of general anesthesia with one-lung ventilation could be accepted when major thoracic operation is planned, but it should be avoided or kept at minimum when performing less invasive procedures such as video-assisted talc pleurodesis. In this paper, 2 different protocols are described in order to demonstrate the effectiveness and safety of Monitored Anesthesia Care (MAC) for performing VATS talc pleurodesis. METHODS We studied 65 neoplastic patients ASA III-IV who underwent video-assisted pleurodesis with talc nebulization. They were randomized into 2 homogenous groups: Group 1, received midazolam (0.015-0.030 mg/kg) and sufentanil (0.15-0.20 microg/kg); Group 2, received midazolam (0.15-0.2 mg/kg) and continuous remifentanil infusion 0.5-1 microg/kg/min in the first minute, followed by 0.05 microg/kg/min. Local anesthesia with 0.2% ropivacaine was employed before the thoracoscopic trocar was inserted in both groups. Intraoperative standard monitoring required ECG, heart rate, non-invasive blood pressure, transcutaneous carbon dioxide and oxygen saturation. Consciousness status has been evaluated by Ramsey scale, while pain intensity by VAS scale. RESULTS No statistically significant fluctuations were observed for mean arterial pressure, heart rate, SpO(2), tCO(2), VAS and Ramsey score. No postoperative complications and hospital mortality occurred. CONCLUSIONS Both the protocols offer an efficient control of analgosedation with a minimum incidence of intraoperative and postoperative side effects. Anyway, the titration of the drug is very important.
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Affiliation(s)
- E Gravino
- Department of Surgical, Anesthesiological, Resuscitation and Emergency Sciences, Federico II University, 80134 Naples, Italy
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Abstract
AIMS To describe iatrogenic pathological lesions in malignant pleural mesothelioma. METHODS AND RESULTS All cases of malignant pleural mesothelioma confirmed by antemortem pleural biopsy and undergoing post mortem examination over a 7-year period (1995-2001) formed the study group. This comprised 48 malignant pleural mesotheliomas [epithelioid (n = 21), biphasic (n = 14) and sarcomatoid (n = 13)]. Twenty-eight of 48 (58%) had received chemical (talc) pleurodesis, 30/48 (63%) palliative localized radiotherapy, 6/48 (13%) chemotherapy, and 14/48 (30%) surgery [12/48 (26%) pleural decortication and 2/48 (4%) pleuropneumonectomy]. CONCLUSIONS Talc pleurodesis induces a marked pseudosarcomatous fibroblastic proliferation which may impart a biphasic pattern to the neoplasm. In more chronic cases, paucicellular fibrosis with a foreign body giant cell reaction is noted. The talc is polarizable and deposited in linear fashion within the tumour. In 2/28 (7%) pleurodesis cases platyform ferruginous bodies were seen in the peripheral alveolated lung parenchyma and these mimicked asbestos bodies. An awareness of this is important to prevent false attribution to asbestos. Talc could be identified by transmission electron microscopic mineral analysis in 5/15 (33%) cases examined. Tumour nodules developing subjacent to iatrogenic wound sites were noted in 8/48 (17%) cases. In 6/8 (75%) of these cases, comparative assessment of the locally irradiated subcutaneous chest wall tumour, with background pleural mesothelioma, showed no morphological difference in architectural tumour growth pattern, extent of necrosis, cytological or nuclear pleomorphism, mitotic activity or tumour immunophenotype. In 2/8 (25%) cases the locally irradiated tumour showed prominent bizarre multinucleated tumour giant cells and intense mixed inflammation, a feature not seen in the background (non-irradiated) tumour. All six malignant pleural mesotheliomas receiving chemotherapy appeared refractory to treatment in that chemotherapy did not appear to have any significant effect on the tumour morphology, cytonuclear pleomorphism, mitotic activity, extent of necrosis or immunophenotype. In the 12 decortication specimens and two pleuropneumonectomy resections, post mortem examination identified evidence of residual malignant mesothelioma of similar morphological subtype and immunophenotype to the resected tumour.
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Affiliation(s)
- R L Attanoos
- Department of Histopathology, Cardiff and Vale NHS Trust, Llandough Hospital, Cardiff, UK
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Abstract
Previous analyses of pleural effusions of different origin revealed high levels of matrix metalloproteinase-9 proenzyme (proMMP-9), predominantly in parainfectious exudates. To confirm the etiological association with inflammation and to explore time course of release of proMMP-9 under conditions of a local inflammatory reaction, the authors estimated proMMP-9 in pleural fluids of patients undergoing therapeutic talc pleurodesis (n = 20) and explorative thoracoscopy (n = 4), before, and at different time intervals after the intervention. The authors also compared proMMP-9 values with proinflammatory markers, such as interleukin-6 (IL-6), C-reactive protein (CRP), and leukocyte count. As revealed through scanning substrate electrophoresis, proMMP-9 levels increased within the first hours a!nd culminated 16 to 48 hours after intervention, amounting to 1.5- to 102 -fold of initial concentration (mean = 14.8 -fold). MMP-9 proenzyme values significantly correlated with the levels of proinflammatory cytokine IL-6 (r =.79, n = 47, p <.01) and with neutrophil counts (r =.75, n = 45, p <.01). In conclusion, the results present proMMP-9 as a novel early indicator of acute host-response in pleural space that complements traditional proinflammatory markers and might be useful in monitoring pleural inflammatory processes.
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Affiliation(s)
- Jaromír Kotyza
- Institute of Biochemistry, Medical Faculty in Pilsen, Charles University, The Czech Republic.
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Haddad FJ, Younes RN, Gross JL, Deheinzelin D. Pleurodesis in Patients with Malignant Pleural Effusions: Talc Slurry or Bleomycin? Results of a Prospective Randomized Trial. World J Surg 2004; 28:749-53; discussion 753-4. [PMID: 15457352 DOI: 10.1007/s00268-004-7269-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The purpose of this study was to evaluate the efficacy, safety, and cost of bedside pleurodesis for malignant pleural effusions using talc slurry (TS) or bleomycin (BL) in a prospective randomized trial, and to determine prognosticators for procedure failure. From June 1997 to June 1999 a series of 71 patients entered this trial. They underwent 37 procedures with TS (4 g) and 34 with BL (60 units) via tube thoracostomy. Success was defined as no recurrence of pleural effusion or asymptomatic recurrence of a small amount of effusion. Pleural effusion-free survival curves were used to analyze the success rates and the prognosticators of failure. Follow-up ranged from 3 days to 26 months (median 2.5 months). No difference in success rates was detected between TS or BL (log-rank test: p = 0.724). There were no major complications related to the procedure. The independent prognosticators of failed pleurodesis were the use of steroids ( p = 0.004) and the volume of pleural fluid drained during the first thoracentesis when it was more than 900 ml ( p = 0.029). The average cost of intervention per patient was significantly lower for TS ( p < 0.001). There was no significant difference between the success rates for TS and BL as agents of bedside pleurodesis for malignant pleural effusions. Because of its significantly lower cost, TS should be considered the agent of choice. The use of steroids and the volume drained during the first thoracentesis (if more than 900 ml) were independent prognosticators of pleurodesis failure. The role of this latter finding as a marker of pleurodesis failure awaits more data.
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Affiliation(s)
- Fabio José Haddad
- Department of Thoracic Surgery, Hospital do Cancer A. C. Camargo, University of São Paulo, Rua Professor Antonio Prudente 211, LIM-62, 01509-900, UNIP, São Paulo, Brazil.
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Abstract
BACKGROUND Talc pleurodesis is widely performed for the management of persistent pneumothorax or pleural effusion, particularly malignant effusions. However, there are very few data characterizing fluorodeoxyglucose (FDG)-positron emission tomography (PET) and CT findings after treatment. METHODS We retrospectively evaluated the FDG-PET and CT studies of nine patients who underwent talc pleurodesis for the treatment of malignant pleural effusions or persistent air leak. RESULTS FDG-PET studies were performed on average 22 months after talc pleurodesis, and the mean CT follow-up period was 25 months. There was moderate-to-intense plaque-like or focal nodular-increased FDG uptake in the pleura on PET with mean standardized uptake value of 5.4 (SEM, 1.2; range, 2.0 to 16.3). The FDG uptake was either diffuse (two patients) or focal (seven patients), and most commonly occurred in the posterior costophrenic angles (five patients), followed by the apical regions (three patients), anterior costophrenic angle (one patient), and the anterior chest wall (one patient). On CT, high-density areas of pleural thickening or nodularity (mean, 230 Hounsfield units [HU]; SEM, 23 HU; range, 140 to 380 HU) corresponded to regions of increased FDG uptake. These pleural foci had an average thickness of 1.2 cm and measured up to 8.2 cm (mean, 7.1 cm) in length. Rounded pleural nodules were as large as 3.1 cm (mean, 1.5 cm). CONCLUSIONS Talc pleurodesis produces increased FDG uptake on PET and high-density areas of pleural thickening on CT that remain unchanged on serial imaging. When PET detects increased uptake in the pleural space, correlation with CT is recommended to detect the presence of pleural thickening of increased attenuation that suggests talc deposits rather than tumor.
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Affiliation(s)
- Boon Han Kwek
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
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De Weerdt S, Noppen M, Everaert H, Vincken W. Positron emission tomography scintigraphy after thoracoscopic talcage. Respiration 2004; 71:284. [PMID: 15133349 DOI: 10.1159/000077427] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2003] [Accepted: 04/09/2003] [Indexed: 11/19/2022] Open
Affiliation(s)
- S De Weerdt
- Respiratory Division, University Hospital AZ-VUB, Brussels, Belgium.
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Kuzdzał J, Zieliński M. Re: Thoracoscopic talc pleurodesis for recurrent, symptomatic pleural effusion following cardiac operations. Surg Lap Endosc Percut Tech. Surg Laparosc Endosc Percutan Tech 2004; 14:102; author reply 102-3. [PMID: 15287613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
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Keller CA. Lasers, staples, bovine pericardium, talc, glue and...suction cylinders? Tools of the trade to avoid air leaks in lung volume reduction surgery. Chest 2004; 125:361-3. [PMID: 14769708 DOI: 10.1378/chest.125.2.361] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Paull DE, Delahanty TJ, Weber FJ, Harostock MD. Thoracoscopic talc pleurodesis for recurrent, symptomatic pleural effusion following cardiac operations. Surg Laparosc Endosc Percutan Tech 2004; 13:339-44. [PMID: 14571172 DOI: 10.1097/00129689-200310000-00011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Seventeen patients who underwent a cardiac operation developed a recurrent, symptomatic pleural effusion ultimately requiring video-assisted thoracic surgery (VATS) and talc pleurodesis. These patients represented 0.4% of all patients undergoing a cardiac operation over the same time period. Compared with an age- and sex-matched control group of cardiac surgery patients, patients requiring VATS for recurrent pleural effusion were more obese with higher body mass index (31.9 +/- 1.2 versus 28.3 +/- 1.4 kg/M2, P = 0.03), were more likely to have undergone a complex cardiac operation (8/17 versus 1/17, P =.01) and were more frequently on anticoagulation and antiplatelet agents besides aspirin (8/17 versus 2/17, P =.02). Patients underwent 1.86 +/- 0.34 thoracenteses with drainage of 846 +/- 166 mL/thoracentesis prior to referral for VATS. On average, patients underwent VATS 4.83 +/- 1.49 months after their cardiac operation. There were 3 VATS-related complications (17.6%) and no deaths. VATS talc pleurodesis led to symptomatic and radiologic improvement in all patients with a mean follow-up of 8.2 +/- 1.5 months. VATS talc pleurodesis effectively and safely treats the unusual postcardiac surgery patient with refractory pleural effusion.
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Affiliation(s)
- Douglas E Paull
- Departments of Cardioghoracic Surgery, Wilkes-Barres General Hospital, Wilke-Barre, PA, USA.
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Lee YCG, Baumann MH, Maskell NA, Waterer GW, Eaton TE, Davies RJO, Heffner JE, Light RW. Pleurodesis practice for malignant pleural effusions in five English-speaking countries: survey of pulmonologists. Chest 2004; 124:2229-38. [PMID: 14665505 DOI: 10.1378/chest.124.6.2229] [Citation(s) in RCA: 131] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Pleurodesis is important in the management of malignant pleural effusions, but no consensus exists on the optimal agent or methods of pleurodesis. How pleurodesis is practiced worldwide has not been studied. OBJECTIVES To identify variations in the clinical practice of pleurodesis in major English-speaking countries, and to quantify the experience of pulmonologists on the effectiveness and adverse effects of different pleurodesis agents worldwide. METHODS Eight hundred fifty-nine pulmonologists practicing in the United States, United Kingdom, Canada, Australia, and New Zealand participated in a Web-based survey. RESULTS The respondents collectively perform > 8,300 pleurodesis annually. Talc was the preferred agent by most respondents (slurry, 56%; poudrage, 12%), followed by tetracycline derivatives (26%), and bleomycin (7%). Differences were seen in pleurodesis practice patterns among practitioners among and within the surveyed countries. Physicians' overall satisfaction with the available pleurodesis agents was modest (5.0 out of 8), and the reported success rate averaged only 66%. Talc (both poudrage and slurry) was perceived as significantly more effective, but was associated with significantly more pain, nausea, and fever (p < 0.05). Respiratory failure occurred more commonly with talc poudrage than with other agents (p < 0.05), and had been observed by 70% and 54% of physicians who used talc poudrage and slurry, respectively. CONCLUSIONS Significant variations exist in how pleurodesis is performed worldwide. Pleurodesis agents currently available are perceived as suboptimal. Talc poudrage and slurry were perceived to be more effective, but were associated with more complications, including respiratory failure.
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Affiliation(s)
- Y C Gary Lee
- University of Oxford and Osler Chest Unit, Churchill Hospital, Oxford OX3 7BN, UK.
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Kuzdzał J, Sładek K, Wasowski D, Soja J, Szlubowski A, Reifland A, Zieliński M, Szczeklik A. Talc powder vs doxycycline in the control of malignant pleural effusion: a prospective, randomized trial. Med Sci Monit 2003; 9:PI54-9. [PMID: 12824959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Malignant pleural effusion is a common problem in advanced cancers, contributing to the poor quality of life in this group of patients. The aim of the study was to assess the efficiency of talc powder and doxycycline in pleurodesis in patients with malignant pleural effusion in comparable conditions. MATERIAL/METHODS Of 52 patients screened, 33 entered the trial. They were randomized to the talc group (n=18) and the doxycycline group (n=15). Both groups were comparable with regard to age, sex and the most important variables influencing effectiveness of the procedure, i.e. primary malignancy and stage of metastatic involvement of the pleura. Efficiency of pleurodesis was prospectively assessed. RESULTS The analysis of short-term effectiveness of pleurodesis in the first 33 patients has shown a highly significant difference in favor of talc powder (p=0.009); this difference was the reason for terminating the randomization. Further observation has revealed in the doxycycline group an increasing number of patients with fluid reaccumulation, as time went by; this was not observed in the talc group. A statistical analysis of the long-term effectiveness of both agents studied has shown a more significant difference in favor of the talc powder (p=0.00003). CONCLUSIONS Talc powder is superior to doxycycline in achieving pleurodesis in patients with malignant pleural effusion, in both short- and long-term observations.
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Affiliation(s)
- Jarosław Kuzdzał
- Department of Thoracic Surgery, Specialized Hospital of Pulmonary Medicine, Zakopane, Poland.
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Ferrante D, Arguedas MR, Cerfolio RJ, Collins BG, van Leeuwen DJ. Video-assisted thoracoscopic surgery with talc pleurodesis in the management of symptomatic hepatic hydrothorax. Am J Gastroenterol 2002; 97:3172-5. [PMID: 12492206 DOI: 10.1111/j.1572-0241.2002.07126.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Video-assisted thoracoscopic surgery with talc pleurodesis is a therapeutic option for patients with hepatic hydrothorax that is refractory to medical therapy. We report the outcomes of 15 patients who underwent this procedure for significantly symptomatic disease. METHODS Data on 15 consecutive patients presenting to our institution between November, 1996, and June, 2000, with refractory hepatic hydrothorax was retrospectively collected. Baseline demographical and clinical characteristics and outcomes after the procedure were analyzed. RESULTS The mean age of our cohort was 51.5 yr, and eight (53%) of the 15 patients were male. The etiologies of liver disease were hepatitis C virus and/or alcohol (n = 12) and cryptogenic cirrhosis (n = 3). Nine patients were Child-Pugh class C and six class B. Success defined as control of symptomatic hydrothorax in the first 30 days after the procedure was achieved in 11 of 15 patients (73%). Eight of these patients remained asymptomatic at a median follow-up of 5.5 months after the procedure, but three patients experienced symptomatic fluid reaccumulation 45, 61, and 62 days after the initial procedure. After a second VATS procedure, control was achieved in two of these three patients. Complications included pain around the chest tube site, low grade fever with leukocytosis, pleurocutaneous fistula and empyema, all of which responded to medical therapy. Four patients did not respond to the procedure. There were no procedure-related deaths. Overall mortality and baseline clinical characteristics were similar between responders and nonresponders to VATS with pleurodesis. CONCLUSIONS Symptomatic hepatic hydrothorax can be controlled with a single VATS with pleurodesis in as many as 53% of patients and with two procedures in 73% with no procedure-related mortality. The procedure may be considered as a palliative alternative in patients needing frequent thoracocentesis. It also provides an alternative to transjugular intrahepatic portosystemic shunts and is a bridge toward liver transplantation.
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Affiliation(s)
- Dino Ferrante
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama 35294-005, USA
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Erickson KV, Yost M, Bynoe R, Almond C, Nottingham J. Primary treatment of malignant pleural effusions: video-assisted thoracoscopic surgery poudrage versus tube thoracostomy. Am Surg 2002; 68:955-9; discussion 959-60. [PMID: 12455787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2023]
Abstract
The objective of this study is to show that primary treatment of malignant pleural effusions secondary to ovarian carcinoma with video-assisted thoracoscopic surgery (VATS)-assisted talc poudrage (VATS-ATP) results in shorter hospital stays and reduced time with a chest tube than primary treatment with a chest tube and chemical pleurodesis. We conducted a retrospective chart review of all patients with a symptomatic pleural effusion secondary to primary ovarian carcinoma receiving intervention from January 1996 to December 2000. Patients either received tube thoracostomy with pleurodesis (n = 22) or VATS-ATP (n = 12). Of the patients treated with tube thoracostomy 18 per cent (4/21) died in the hospital before pleurodesis, 77 per cent (14/19) had successful pleurodesis, and 22 per cent (4/18) failed pleurodesis requiring VATS-ATP. In the group treated primarily with tube thoracostomy the chest tube was in place 8.36 +/- 2.61 days with a hospital stay of 12.64 +/- 5.80 days after the procedure. In the group treated with VATS-ATP there was 100 per cent successful pleurodesis. There were no mortalities. There was one prolonged intubation of 3 days and one incomplete lung reexpansion. The chest tube was in place for 4.58 +/- 1.78 days and a hospital stay of 7.50 +/- 4.12 days postprocedure. Groups treated by tube thoracostomy and VATS were statistically different; P < 0.001 for days with a chest tube and P = 0.011 for hospital days. We conclude that both tube thoracostomy with chemical pleurodesis and VATS-ATP provide adequate treatment of ovarian carcinoma-associated malignant pleural effusions. VATS-ATP provides a shorter duration of chest tube placement and postprocedure hospital stay.
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Affiliation(s)
- Kurt V Erickson
- Department of Surgery, School of Medicine, University of South Carolina, Columbia, South Carolina 29203, USA
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Lee YCG, Yasay JR, Johnson JE, Parker RE, Thompson PJ, Lane KB, Light RW. Comparing transforming growth factor-beta2, talc and bleomycin as pleurodesing agents in sheep. Respirology 2002; 7:209-16. [PMID: 12153686 DOI: 10.1046/j.1440-1843.2002.00397.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Transforming growth factor (TGF)-beta2 can produce effective pleurodesis in animals, but its efficacy has not been compared with commonly used pleurodesing agents in sheep, which have a thick pleura resembling that of humans. The acute physiological effects and the level of systemic TGF-beta absorption after its intrapleural administration have not been studied. The aims of the present study were to compare: (i) the effectiveness of TGF-beta2, talc and bleomycin in producing pleurodesis in sheep; (ii) the acute side-effects and systemic TGF-beta levels following the intrapleural administration of these agents; and (iii) histological changes after intrapleural injections of these agents. METHODOLOGY Twelve sheep were divided into three groups and were given a single intrapleural dose of TGF-beta2 (0.25 microg/kg), talc slurry (5 g) or bleomycin (60 IU) via a chest tube. Saline or buffer was injected into the contralateral side, which served as the control. Arterial blood gases and respiratory and heart rates were monitored for the first 24 h. Plasma levels of TGF-beta1 and TGF-beta2 were measured. Pleurodesis was graded macroscopically from 1 (none) to 8 (symphysis > 50% of hemithorax) at day 14. RESULTS At day 14, the pleurodesis score of the TGF-beta2 group (7.7+/-0.6) was similar to that of the talc (7.0+/-1.7) group and significantly higher than that of the bleomycin group (3.3+/-2.3; P < 0.05). No significant differences were seen in arterial blood gas analysis, vital signs and plasma TGF-beta1 and TGF-beta2 concentrations among the three groups. CONCLUSIONS Transforming growth factor-beta2 was as effective as talc and more so than bleomycin in inducing pleurodesis in sheep. Intrapleural administration of TGF-beta2 appeared safe. No acute changes in gaseous exchange or macroscopic abnormalities were seen following intrapleural TGF-beta2. Importantly, there was no evidence of an increase in systemic TGF-beta levels following its intrapleural administration.
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Affiliation(s)
- Y C Gary Lee
- Department of Pulmonary Medicine, St Thomas Hospital, Nashville, Tennessee, USA.
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