Treatment of Malignant Pleural Effusions with Tunneled Long-term Drainage Catheters

doi:10.1016/S1051-0443(07)61826-0

Journal of Vascular and Interventional Radiology

Volume 12, Issue 2, February 2001, Pages 201-208

https://doi.org/10.1016/S1051-0443(07)61826-0 Get rights and content

PURPOSE

To assess the effectiveness of tunneled pleural catheters (TPCs) in the treatment of malignant pleural effusions (MPEs).

MATERIALS AND METHODS

Twenty-eight patients with symptomatic MPEs had 31 hemithoraces treated with TPCs placed under image guidance. Chemical sclerotherapy had failed in two patients and two had symptomatic locules. Drainage was accomplished by intermittent connection to vacuum bottles. Pleurodesis was considered achieved when three consecutive outputs were scant and imaging showed no residual fluid.

RESULTS

All catheters were successfully placed. Dyspnea improved in 94% (29 of 31 hemithoraces) at 48 hours and 91% (20 of 22 patients) at 30 days. Control of the MPE was achieved in 90% of hemithoraces (28/31), although five required ancillary procedures. Pleurodesis occurred in 42% (13 of 31) of hemithoraces, including both that underwent an earlier attempt at chemical sclerotherapy and one treated locule. Continued drainage without pleurodesis controlled the effusion in 48% (15 of 31). In only 7% was hospital time necessary for care related to the TPC. Early, transient catheter-related pain was common, but only three complications (in two patients) occurred. Neither of these altered patient care.

CONCLUSIONS

Regardless of whether pleurodesis is achieved, TPCs provide effective long-term outpatient palliation of MPEs.

Section snippets

Patients

Over the course of 53 months, 28 patients with symptomatic MPEs were referred to the interventional radiology department for management of fluid with a long-term TPC that would be intermittently drained. Three patients had bilateral effusions treated in this manner, for a total of 31 hemithoraces. There were 13 men and 15 women. The mean age was 60 years, with a range of 31–85 years. The etiologies for the effusions were lung cancer in 10 patients (10 hemithoraces), melanoma in four patients

Technical Results

All catheters were successfully placed with no procedural complications. Three asymptomatic pneumothoraces were noted after catheter placement, which were small and occurred in patients with free-flowing effusions. All three resolved with just the normal drainage routine for the TPC.

Clinical Results

Follow-up time after placement of the catheters ranged from 3 to 618 days, with a median of 51 days. Patient survival was 86% at 2 weeks, 79% at 30 days, 52% at 60 days, and 48% at 90 days.

Improvement in dyspnea was

DISCUSSION

The accumulation of pleural fluid in patients with cancer may be a result of overproduction from disease involving the pleura, lymphatic obstruction, or atelectasis (1, 2, 3). Malignant pleural effusions are associated with significant morbidity, with the most common complaint being dyspnea. Other symptoms include cough, chest discomfort, and diminished quality of life (6). Especially when considering the limited life expectancy in most patients with MPE, prompt evaluation and treatment is

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Effusions either in the chest or abdomen are a known complication of cancer. Diagnosis of malignant fluid in the abdomen, thorax, and pericardium includes cytopathologic evaluation of the fluid. Evaluation of the extent of physiologic compromise caused by the effusion is key to evaluation of the need for intervention. Asymptomatic effusions typically don’t need therapy. Symptomatic effusions typically require intervention. In addition to successful treatment of the causative malignancy, palliation of symptoms from the fluid accumulation occurs by drainage procedures such as therapeutic thoracentesis, pericardiocentesis, or paracentesis. Rapid accumulation of fluid in the face of cancer treatment can be ameliorated through semi-permanent catheter placement so that the patient is able to drain fluid to palliate symptoms caused by ascites or pleural effusions. Other more invasive procedures can also be used to prevent fluid re-accumulation but typically are only used in the chest such as pleurodesis or pericardial window. Symptoms (Mild to severe), responsiveness of the malignancy to systemic treatment, and prognosis of the patient help determine which therapeutic approaches are used in the management of effusions.
Phase I Study of Intrapleural Gene-Mediated Cytotoxic Immunotherapy in Patients with Malignant Pleural Effusion
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Gene-mediated cytotoxic immunotherapy (GMCI) is an immune strategy implemented through local delivery of an adenovirus-based vector expressing the thymidine kinase gene (aglatimagene besadenovec, AdV-tk) followed by anti-herpetic prodrug valacyclovir. A phase I dose escalation trial of GMCI followed by chemotherapy was conducted in patients with malignant pleural effusion (MPE). AdV-tk was administered intrapleurally (IP) in three cohorts at a dose of 1 × 10¹² to 10¹³ vector particles. Primary endpoint was safety; secondary endpoints included response rate, progression-free survival, and overall survival. Nineteen patients were enrolled: median age 67 years; 14 with malignant mesothelioma, 4 non-small-cell lung cancer (NSCLC), and 1 breast cancer. There were no dose limiting toxicities. All 3 patients in cohort 2 experienced transient cytokine release syndrome (CRS). Addition of celecoxib in cohort 3 reduced the incidence and severity of CRS (none > grade 2). Three patients are alive (23–33 months after GMCI), and 3 of 4 NSCLC patients had prolonged disease stabilization; one is alive 29 months after GMCI, 3.6 years after initial diagnosis. GMCI was safe and well tolerated in combination with chemotherapy in patients with MPE and showed encouraging response. Further studies are warranted to determine efficacy.
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Pleural metastases and malignant pleural effusion may occur with metastatic breast cancer. Presentation can vary widely from an incidental finding on imaging to a large effusion with severe dyspnea. Any pleural effusion in a breast cancer patient can be suspected to be a malignant effusion until proven otherwise. The focus of the clinician should be to provide the most efficient, accurate diagnosis with the least risk of complication and pain for the patient. This chapter reviews diagnosis and management of malignant pleural and pericardial effusions.
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Citation Excerpt :
Again, their design is very similar to that of the PleurX catheter, with a 16F soft silicone catheter, 40 cm in length with side holes over the distal 24 cm. Placement of IPCs is routinely an outpatient procedure,22 unless the patient is already admitted for another reason. The authors provide patients with teaching videos developed by the catheter manufacturer prior to their IPC placement so they can be more familiar and better prepared for handling these catheters.
Ambulatory treatment of malignant pleural effusion: A case report
2012, Medicina Paliativa
El derrame pleural maligno es una patología frecuente en los pacientes con cáncer, y por tanto en los servicios de cuidados paliativos. Esta complicación se asocia tanto a los tumores pulmonares primarios como a los metastásicos, y suele plantear problemas relevantes a la hora de tomar decisiones terapéuticas.
Presentamos un caso clínico de un enfermo diagnosticado de carcinoma epidermoide de pulmón y derrame pleural secundario, en quien se realizó tratamiento domiciliario por expreso deseo del paciente. Tras valorar las distintas opciones, se decidió la colocación de un tubo tunelado permanente para drenaje pleural, cuyo manejo domiciliario resultó sencillo y eficaz. El paciente mantuvo el dispositivo funcionante hasta su fallecimiento, con buen control de los síntomas.
El derrame pleural maligno requiere un manejo individualizado y una adecuada gestión de las diversas modalidades terapéuticas disponibles. En determinados casos, el empleo de un tubo tunelado permanente puede aportar claros beneficios terapéuticos y mejorar la calidad de vida de los enfermos.
Malignant pleural effusion (MPE) is a frequent disorder in patients with cancer and thus often seen in Palliative Care Units. MPE is associated with both primary lung cancer and metastatic tumours and will be a significant complication in making decisions about patients.
We report a case of a patient with squamous cell lung cancer associated with a newly diagnosed malignant pleural effusion. At the express wish of the patient on regular at-home-treatment and assessing the therapeutic options for treatment, it was decided to place permanent tunnelled pleural drainage catheter, which was easily performed by the palliative care team at home. The patient had a functionally operating pleural drainage with good control of symptoms until his death at home.
MPE requires an individualised approach and a suitable management of the available therapeutic possibilities. In selected patients, like ours, the use of a permanent tunnelled drainage catheter can bring clear therapeutic advantages and an increase in patient quality of life

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¹: Current address: Department of Diagnostic Imaging, Newport Hospital, Newport, Rhode Island.

²: Current address: Clinical Immunology Service, Memorial Sloan-Kettering Cancer Center, New York, New York.

View full text

Treatment of Malignant Pleural Effusions with Tunneled Long-term Drainage Catheters

PURPOSE

MATERIALS AND METHODS

RESULTS

CONCLUSIONS

Section snippets

Patients

Technical Results

Clinical Results

DISCUSSION

Clin Chest Med

Chest

Chest

Chest

Chest

Ann Thorac Surg

Management of malignant pleural effusions

Drugs

Management of malignant pleural effusion

AustNZJMed

Pleural effusions

A randomized comparison of indwelling pleural catheter and doxycycline pleurodesis in the management of malignant pleural effusions

Cancer

Pleural effusion in cancer patients: a prospective randomized study of pleural drainage with the addition of radioactive phosphorous to the pleural space vs. pleural drainage alone

Cancer