Video-Assisted Thoracoscopic Pleurectomy in the Management of Malignant Pleural Effusion

doi:10.1378/chest.107.5.1454

Chest

Volume 107, Issue 5, May 1995, Pages 1454-1456

https://doi.org/10.1378/chest.107.5.1454 Get rights and content

Study objective

To evaluate the outcome of pleurectomy using video-assisted thoracic surgery (VATS) for pleurodesis in patients with malignant pleural effusion.

Design

Cohort prospective study. Follow-up of patients from referral for thoracoscopy to death.

Setting

Regional Cardiothoracic Surgical Centre.

Patients

Nineteen patients (median age 63 years, range 51 to 84 years) with malignant pleural effusion, secondary to mesothelioma in 13 and metastatic adenocarcinoma in 6.

Intervention

Video-assisted parietal pleurectomy.

Measurements and results

Median operating time was 35 min (range 15 to 60 min). The median fall in hemoglobin concentration in the first 24 h postsurgery was 1.1 g/dL (0.3-2.5 g/dL). The median postoperative morphine requirement was 1.25 mg/h (0-6.2 mg/h) in the first 12 h postoperatively. All patients were successfully extubated in the operating room, without the need for reventilation, and all patients were successfully discharged from the hospital with a median postoperative stay of 5 days (range 2 to 20 days). At current median follow-up of 12 months (range 4 to 17 mon) 6 patients died of their underlying disease. In the remaining 13 patients, two have developed recurrent effusions.

Conclusions

Using VATS to perform parietal pleurectomy is a safe, effective method of obtaining palliative pleurodesis in patients with malignant effusions.

Section snippets

Patients

All patients were referred to us for surgical intervention by respiratory physicians. The referral population is about 3 million people with a large number of ex-shipyard workers. The indications for surgery were either a persistent pleural effusion of unknown cause or a malignant effusion, which had recurred after tube drainage and chemical pleurodesis.

Operative Technique

All procedures were performed with the patients receiving general anesthesia. Before surgery, a paravertebral regional anesthetic block between

Patient Characteristics

Pleurectomy was performed in 19 patients (13 men and 6 women), with a median age of 63 years (range, 51 to 84 years). Respiratory function was impaired; the median FEV₁ was 51% of predicted (range, 25 to 97%), and the median forced vital capacity was 56% of predicted (range, 34 to 83%). In all patients, pleural fluid had previously been aspirated for cytologic examination; ten patients also had had a closed pleural biopsy using the Abrams needle and seven patients had undergone thoracic

Discussion

Surgical intervention in patients with malignant pleural effusions is unlikely to affect the course of the underlying disease. Many of these patients either die from the effects of the effusion, rather than the tumor itself, or suffer significant morbidity. Effective pleurodesis in these patients can improve their quality of life in the terminal stages of their disease.

Chemical pleurodesis via tube thoracostomy using tetracycline⁷ or talc⁸ has been used in this group of patients. This

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Cited by (83)

Insert: Surgical Operative Procedures Suggested by an Expert
2019, Malignant Pleural Mesothelioma: A Guide for Clinicians
The surgical treatment of malignant pleural mesothelioma is complex and should be discussed by a multidisciplinary team. Radical surgery is limited to patients with early stage of disease and good clinical status and should be a part of multimodality approach. There are two types of surgery, lung-sacrificing (extrapleural pneumonectomy) and lung-sparing (pleurectomy/decortication). The current data does not conclusively support one operation over the other. Thus, the choice of the approach depends on the patient’s clinical condition and institutional expertise and experience. In patients with advanced stage of disease, surgery has a limited role. Palliative care and symptoms management are essential while debulking surgery should be considered in very select cases or to obtain an adequate specimen for diagnosis.
Surgery in Malignant Pleural Mesothelioma
2018, Journal of Thoracic Oncology
Citation Excerpt :
Parenchyma-sparing debulking P/D or partial pleurectomy should be considered in symptomatic patients who decline or are not eligible for MCR due to stage or status, and have not responded to thoracentesis or catheter drainage, as freeing an entrapped lung may improve respiratory function.84 This palliative surgical approach can also be performed by video-assisted thoracic surgery (VATS) with the intention to improve the QoL of these patients.85-88 Alternatively, indwelling pleural catheters, which can be placed in an outpatient setting and are easy to handle, are a very good alternative for a rapid palliation of recurring pleural effusions.89,90
Surgical intervention plays an important role in the diagnosis, staging, and treatment of malignant pleural mesothelioma (MPM) and can be applied with curative or palliative intent. The overall aim of surgery should be, as in any oncologic surgery, the macroscopic complete resection (MCR) of the tumor. Most importantly, the majority of patients with the diagnosis of MPM should be appropriately staged and initially evaluated in a multidisciplinary setting, including medical oncology, radiation oncology, and surgery after histologic diagnosis. Surgical staging, including determination of the histologic subtype and lymph node status, as well as clinical staging with positron-emission tomography–computer tomography scan and determination of cardiopulmonary reserve are crucial. Herein, we summarize the role of surgical resection, specifically macroscopic complete resection, performed as extrapleural pneumonectomy or extended pleurectomy/decortication in multimodality treatment settings and advocate for optimal patient selection for one or the other procedure. In addition, the roles of surgery in diagnosis of MPM and in palliative care are discussed.
Pleural mesothelioma: Is the surgeon still there?
2018, Annals of Oncology
Citation Excerpt :
Palliative surgical procedures should be primarily minimally invasive, to reduce the potential harmful effects of a thoracotomy [7]. After demonstration of the feasibility of pleurectomy by VATS [8], there were reports of symptomatic improvement [9] and even possible survival benefit [7]. The particular advantage of this procedure is the option to free entrapped lungs by peeling off the tumor-thickened visceral pleura resulting in re-expansion of the lungs with a regained contact to the chest wall and hence successful pleurodesis.
Malignant pleural mesothelioma (MPM) is a rare malignancy with some unique characteristics. Tumor biology is aggressive and prognosis is poor. Despite more knowledge on histology, tumor biology and staging, there is still a relevant discrepancy between clinical and pathologic staging resulting in difficult prediction of prognosis and treatment outcome, making treatment allocation more challenging than in most other malignancies. After years of nihilism in the late 80s, a period of activism started evaluating different treatment protocols combined with research driven mainly by academic centers; at the time, selection was based on histology and stage only. This period was important to gain knowledge about the disease. However, the interpretation of data was difficult since selection criteria and definitions varied substantially. Not surprisingly, until now there is no common agreement on best treatment even among specialists. Hence, a review of our current concepts is indicated and personalized treatment should become applicable in the future. Surgery was and still is an issue of debate. In principle, surgery is an effective approach as it allows macroscopic complete elimination of a tumor, which is relatively resistant to medical treatment. It helps to set the clock back and other therapies that have also just a limited effect can be applied sequentially before or after surgery. Furthermore, to date best long-term outcome is reported from surgical series in combination with other modalities. However, part of the community considers surgery associated with too high morbidity and mortality when balanced to the limited life expectancy. This criticism is understandable, since poor results after surgery are reported. The present article will review the indication for surgery and discuss the different procedures available for macroscopic complete resection—such as lung-preserving (extended) pleurectomy/decortication as well as extrapleural pneumonectomy to illustrate that ‘The surgeon is still there!’
Malignant Mesothelioma
2018, IASLC Thoracic Oncology
The Third Italian Consensus Conference for Malignant Pleural Mesothelioma: State of the art and recommendations
2016, Critical Reviews in Oncology/Hematology
Malignant Pleural Mesothelioma (MPM) remains a relevant public health issue, and asbestos exposure is the most relevant risk factor. The incidence has considerably and constantly increased over the past two decades in the industrialized countries and is expected to peak in 2020–2025. In Italy, a standardized-rate incidence in 2011 among men was 3.5 and 1.25 per 100,000 in men and women, respectively, and wide differences are noted among different geographic areas. The disease remains challenging in terms of diagnosis, staging and treatment and an optimal strategy has not yet been clearly defined. The Third Italian Multidisciplinary Consensus Conference on Malignant Pleural Mesothelioma was held in Bari (Italy) in January 30–31, 2015. This Consensus has provided updated recommendations on the MPM management for health institutions, clinicians and patients.
Surgery for malignant pleural mesothelioma: Why, when and what?
2014, Lung Cancer
Citation Excerpt :
Patients with trapped-lung could not receive talc and had to be treated by pleurectomy or placement of a long-term drain. In the mid-90s Ritchie and his group and Waller and his group promoted the use of VATS pleurectomy in mesothelioma patients with trapped lung [71–74]. This approached allowed for a full lung expansion and possibly better quality of life, with acceptable mortality and morbidity [71–74].
Malignant pleural mesothelioma is a fatal cancer developing in the pleural cavity, linked to asbestos exposure. Various therapies have been tried in the past 50 years including surgery, radiotherapy, chemotherapy, immunotherapy and more recently, targeted therapy. Radical surgery remains controversial in malignant pleural mesothelioma and two procedures have been offered in the past to obtain maximal cytoreduction: extrapleural pneumonectomy (EPP) and pleurectomy/decortication (P/D). Despite growing evidence that EPP might be detrimental, many believe that radical surgery should still be part of multimodality therapy in patients with malignant pleural mesothelioma. Recent evidence suggests that P/D is well tolerated and produces low mortality and morbidity. The role of adjuvant intrapleural therapies remains to be determined and evaluated in large prospective trials. Pleurectomy/decortication does not jeopardize the chance of having chemotherapy, or chemoradiotherapy either. Many now believe that it should be the default procedure in multimodality regimens. However, this remains to be proven in a large randomized trial. Palliative surgery still has an important role to play in mesothelioma, in establishing or refining diagnosis and in controlling symptoms and improving quality of life in many patients whose life expectancy is limited. Recent progress in molecular analyses and biomarkers should help with patient selection for surgery, immunotherapy and systemic therapies in the near future.

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Chest

Minimally Invasive TechniquesVideo-Assisted Thoracoscopic Pleurectomy in the Management of Malignant Pleural Effusion

Study objective

Design

Setting

Patients

Intervention

Measurements and results

Conclusions

Section snippets

Patients

Operative Technique

Patient Characteristics

Discussion

Chest

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Chest

Minimally Invasive Techniques
Video-Assisted Thoracoscopic Pleurectomy in the Management of Malignant Pleural Effusion