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PubMed1998

Management of malignant pleural effusions.

Malignant pleural effusions (MPEs) represent a common complication of advanced malignancies. However, adequate palliation of this highly symptomatic accompaniment to cancer can be achieved in most patients by adopting the appropriate therapy. Several options are available for the treatment of MPE. Systemic therapy may control the effusion in patients whose underlying malignancy is sensitive to anti-cancer agents. Repeated thoracocentesis can be appropriate for patients with limited life expectancy or slowly recurrent effusions. In the majority of the remaining cases the treatment of choice is pleurodesis with sclerosing agents administered via tube thoracostomy. Controversy still exists as to which drug produces the best results: talc and bleomycin appear to be among the most cost-effective agents. The debate over the best agent to be used for pleurodesis refers to the difficulty in comparing results of studies using different eligibility criteria, response assessment and end-points. This article describes the various treatments which have been reported in the literature to play a role in the management of MPEs. It is also aimed at providing guidelines in allocating patients to appropriate treatments.

Anti-Bacterial Agents↗
PubMed1998

Thoracoscopic talc poudrage in malignant pleural effusions: effective pleurodesis despite low pleural pH.

STUDY OBJECTIVE: To determine the effectiveness of pleurodesis by thoracoscopic talc poudrage (TTP) in patients with low pH malignant pleural effusions. DESIGN: Review of prospectively collected data on all thoracoscopic procedures performed from 1982 to 1996. PATIENTS AND SETTING: Twenty-five members in a prepaid, closed-panel health maintenance organization, whose malignant pleural effusion pH was < or = 7.30. INTERVENTIONS: Pleural fluid pH was measured prior to diagnostic and therapeutic, single puncture, rigid thoracoscopy, under local anesthesia, in an operating room. MEASUREMENTS AND RESULTS: Success of pleurodesis was determined with serial radiographs at 10 days, 30 days, and frequent intervals until death or up to 1 year following the procedure. Failure was indicated by evidence of recurrent fluid or persistence of a space between the visceral and parietal pleura. Morbidity of the procedure, days of chest tube drainage, and days of hospitalization were recorded concurrently during hospitalization and outpatient follow-up. Fifty of the 76 patients found to have a pleural pH measurement had a pleural pH >7.30, averaging 7.37 (7.31 to 7.55). The other 26 patients (34%) with pH < or = 7.30 (low pH) are the subjects of this study, of whom 25 were evaluable. Pleurodesis was successful in 22 of 25 (88%), although 4 died prior to 30 days. The three failures all had trapped lung. Chest tube drainage averaged 3.2+/-1.3 days, which approximated the time of hospitalization (3.3+/-1.1 days). There were no thoracoscopy-related deaths; significant morbidity occurred only in one patient with trapped lung, who had prolonged chest tube drainage before and after TTP, and eventually developed empyema. CONCLUSIONS: TTP is an effective pleurodesis technique in malignant pleural effusions, even when the pleural pH is low. The short hospital stay and high success rate make this approach a good choice in palliating symptomatic malignant pleural effusions.

Adult↗
PubMed1997

[Massive pleural effusion secondary to pancreatic-pleural fistula as first manifestation of chronic pancreatitis. Report of three cases].

Patients with chronic pancreatitis develop massive pleural effusion in less than 1% and its frequency as the first clinical manifestation of the disease is unknown. Three patients with massive pleural effusion and dyspnea which led to the diagnosis of chronic pancreatitis are referred. The patients were 28, 37 and 41 years old, they were hard-drinking and they came to the hospital because of quick and progressive dyspnea, with hypoxemia and hypocapnia. Two patients had right and one left pleural effusion. The thoracothentesis gave 10, 9 and 3.5 l of serohematic liquid rich in pancreatic enzymes. All cases showed tomographic changes of chronic pancreatitis and pancreatic pseudocysts. Only in one of them the link between the pseudocyst and pleural effusion through a fistula in the right support of the diaphragm could be identified. The different therapeutic possibilities are discussed. Pancreatopleural fistula diagnosis should be considered in patients with massive fast pleural effusion and a history of high alcohol intake. High levels of pancreatic enzymes in the pleural liquid confirm the diagnosis.

Adult↗
PubMed1999

Useful tests on the pleural fluid in the management of patients with pleural effusions.

Examination of the pleural fluid is useful in establishing the etiology of a pleural effusion. Transudative pleural effusions can be differentiated from exudative pleural effusions by measuring the levels of protein and lactic acid dehydrogenase in the pleural fluid and serum. If a patient clinically appears to have a transudative pleural effusion, but the pleural fluid meets exudative criteria, demonstration that the albumin levels is more than 1.2 gm/dl higher in the serum than in the pleural fluid provides evidence that the effusion is transudative. The gross appearance of the pleural fluid should always be noted. Other tests that routinely should be obtained on exudative pleural fluids are Gram stain and cultures, cell counts and differential, glucose, amylase, lactic acid dehydrogenase, cytology, and a marker for tuberculous pleuritis. The diagnosis of tuberculous pleuritis is strongly suggested by a pleural fluid adenosine deaminase level above 45 IU/L or a gamma interferon level above 3.7 U/ml.

Diagnosis, Differential↗
PubMed1998

Blind pleural biopsy using a Tru-cut needle in moderate to large pleural effusion--an experience.

BACKGROUND: Pleural biopsy is invaluable for the etiological diagnosis of pleural diseases in the presence of an exudative pleural effusion. Conventionally, pleural biopsy is either performed with the Cope's or the Abrams pleural biopsy needles. A few investigators have used the Tru-cut biopsy needle with or without ultrasound guidance. We report our experience in performing closed pleural biopsy using a Tru-cut needle without ultrasound guidance in moderate to large exudative pleural effusion. We used a perpendicular approach to biopsy the pleura instead of the tangential approach described earlier. METHODS: Closed Tru-cut biopsy was performed in 27 consecutive patients with exudative pleural effusion who volunteered to undergo the procedure. The biopsy specimen was sent for histopathology. Pleural fluid analysis and other relevant investigations required to obtain a specific diagnosis were carried out. RESULTS: A specific diagnosis of tuberculosis was obtained on histopathology of pleural tissue in 12 out of 16 patients (diagnostic yield 75%) and in 5 out of 7 patients with malignancy (diagnostic yield 71%). Among the other 4 patients, other causes of exudative pleural effusion were detected in 3 and in 1 patient, no specific diagnosis could be made, despite extensive investigation. CONCLUSION: Closed pleural biopsy using a Tru-cut needle is effective for the specific diagnosis of exudative pleural effusion. The use of a perpendicular approach to biopsy the pleura does not seem to increase the complication in moderate to large pleural effusion.

Biopsy, Needle↗
PubMed2002

Long-term follow-up of video-assisted talc pleurodesis in malignant recurrent pleural effusions.

OBJECTIVE: Recurrent pleural effusion is a common condition and often presents a challenge for treatment. The aim of this report is to evaluate the long-term follow-up of thoracoscopic management of malignant recurrent pleural effusions. METHODS: From July 1st, 1992 to February 28th, 2001, out of 2311 VATS procedures performed at our Institution, 690 patients (29.85%) underwent videothoracoscopy (VATS) for recurrent pleural effusion. Of these 611 (88.55%) were treated for a malignant pleural effusion. There were 374 male and 237 female, with a mean age of 61.2 years. In all patients VATS was performed under general anaesthesia. The pleural effusion was carefully aspirated; fibrinous adhesions were taken down while dense fibrous adhesions were selectively divided; some limited decortications were also performed. Multiple pleural biopsies were always performed. Pleurodesis was performed with 5 g of sterile purified talc insufflated through a talc atomizer. One chest tube was left in situ for 3-5 days. RESULTS: Operative mortality was 0.81% (five cases). Postoperative complications occurred in 19 cases (3.1%). Specific histologic diagnosis was obtained in all patients. Follow-up was available for 602 patients (98.5%). After a median follow-up of 64 months (range 5-105 months), talc pleurodesis was successful in controlling recurrence of effusion in 92.7% (558 out of 602) of patients. The success rate did not show any statistically significant difference between patients who underwent postoperative adjuvant therapy and patients who did not. In two patients with failure of talc pleurodesis a redo-VATS was performed. CONCLUSIONS: VATS represents the method of choice for both diagnosis and treatment of malignant recurrent pleural effusions. Talc poudrage is safe and effective in obtaining pleurodesis.

Adult↗
PubMed2001

Management of malignant pleural effusion.

Malignant pleural effusion, an abnormal accumulation of fluid in the intrapleural space, is a common complication of cancer resulting in debilitating symptoms including dyspnea, pain, and fatigue. The goal of treatment is aimed at symptomatic control, relief and control of dyspnea, and obliteration of the intrapleural space to prevent reaccumulation of pleural fluid. Treatment options include chemotherapy, radiation, intrapleural instillation of sclerosing agents, indwelling pleural catheters with intermittent drainage, pleuroperitoneal shunts, and pleurectomy. Therapeutic approaches used in the management of malignant effusions must be directed at maintaining or improving the quality of life for the individual.

Catheters, Indwelling↗
PubMedDate not supplied

Pleural lavage: a novel diagnostic approach for diagnosing exudative pleural effusion.

Patients with pleural effusions frequently present a diagnostic and therapeutic challenge. The diagnosis is based on the interpretation of the results of thoracentesis or pleural biopsy. When a malignant tumor metastasizes to the pleura, tumor cells can be seeded over the mesothelial surface or in the subserous layer. In the former situation, tumor cells are abundant in pleural fluid, but in the latter, few malignant cells are exfoliated into the pleural cavity, and microscopic deposits may not be visualized at thoracoscopy. Pleural lavage cytologic study at the time of thoracoscopy has not been studied. The purpose of this study was to assess the value of thoracoscopic pleural lavage as an adjuvant in the diagnostic workup of patients with exudative pleural effusions. Fifty patients with exudative pleural effusions were investigated by pleural fluid cytologic findings, Abram's pleural biopsy, thoracoscopy, and pleural lavage cytologic findings. After aspiration of all pleural fluid, 300 mL saline was instilled into the pleural cavity and then recovered for cytologic analysis. The final diagnoses were 32 malignant (64%), 15 tuberculous (30%), and 3 idiopathic (6%) effusions. In the malignant group, thoracoscopic biopsy had the highest yield (94%) followed by lavage cytologic analysis (84%), fluid cytologic analysis (62%), and biopsy with Abram's needle (50%). The sensitivity of combined thoracoscopy and lavage cytologic analysis was 96%. In the patients with tuberculous pleuritis, the yield from the pathologic examination of the biopsy specimen was 93% with thoracoscopy and 60% with the Abrams needle. The diagnostic yield with cytologic analysis on pleural lavage fluid is significantly higher than that on pleural fluid. This is probably because the cells in the lavage fluid are fresher and better preserved than those in the regular pleural fluid, which may have undergone degenerative changes, yielding false-negative results. Pleural lavage cytologic analysis should be performed in patients with suspected malignant pleural effusion who are subjected to diagnostic thoracoscopy, because it may provide additional information to thoracoscopic biopsy.

Adult↗
PubMed2005

Management of recurrent malignant pleural effusions with a chronic indwelling pleural catheter.

Many patients with various forms of cancer develop sooner or later malignant pleural effusions, resulting in feelings of discomfort and reduced quality of life. Several palliative options exist, including repeated thoracocentesis and pleurodesis with a sclerosing agent. However, these "therapeutic" possibilities are not always successful and sometimes even contraindicated. Also, patients need to visit the hospital regularly or have to stay hospitalised for several days. A chronic indwelling pleural catheter could provide a simple, completely outpatient way to provide respiratory relief and improvement in quality of life in patients with malignant pleural effusions. We evaluated retrospectively the course of 17 patients with malignant pleural effusions who were treated with a chronic indwelling pleural catheter (PleurX). Eligible patients were selected in the years 2001-2003 from a single institution. In 70-80% of patients, catheter use was uncomplicated and provided significant symptom relief. Mean duration of catheter use was 2.3 (range 1-6) months. Mean fluid removal was 360 (range 150-1000 cc) per 24 h in the first weeks of treatment. Infection was seen in two (12%) patients, dislocation of the catheter in three (18%). In the final analysis, catheter use was unsatisfactory in two patients (12%). We conclude that a chronic indwelling catheter is a very useful tool in the management of recurrent malignant pleural effusions. Treatment can be accomplished completely at home, whereas complications are rare.

Aged↗
PubMed2000

Isolated massive pleural effusion caused by pancreatico-pleural fistula.

BACKGROUND: Massive pleural effusions are uncommon but well-documented complications of chronic pancreatitis, usually caused by the development of a pancreaticopleural fistula. The mechanism of the fistula formation is thought to be rupture of the pancreatic duct or pseudocyst. MATERIAL AND METHODS: In the past 7 years we have treated 5 patients with massive pleural effusion of pancreatic origin in the Surgical Department of Semmelweis University Medical School. 4 patients were males; the average age was 52 years (range: 46-59 years). RESULTS: All 5 patients had a history of alcohol abuse and were admitted to the pulmonary department because of respiratory distress. Other symptoms such as abdominal pain, chest pain, or weight loss were not always present. The diagnosis was confirmed by a markedly elevated amylase level in the aspirated pleural fluid. Abdominal ultrasound, CT scan, and ERCP examinations were carried out in order to determine the cause of the pancreaticopleural fistula. Conservative (nonsurgical) treatment was effective within 3 weeks in only one case. The other 4 patients required surgical management. In 3 cases distal pancreatic resection with splenectomy and cholecystectomy was done. In one case cystojejunostomy was performed. All 5 patients have been cured with complete resolution of their pleural effusions. CONCLUSIONS: Patients with large pleural effusions may have underlying pancreatitis with a pancreaticopleural fistula. It is important to establish this diagnosis because treatment may require operative interventions.

Acute Disease↗
PubMed2004

The significance of thoracoscopic mechanical pleurodesis for the treatment of malignant pleural effusions.

BACKGROUND: Malignant pleural effusion (MPE) is a frequent and serious complication of numerous malignant tumors in the human organism. The patients are suffering from the primary disease, and the pleural effusion causes dyspnea, thus reducing the quality of their survival time. In our study we wished to establish the significance of thoracoscopic mechanical pleurodesis (TMP) as a new method for the resolution of this pathology, by comparing the results with those of thoracotomy with pleurectomy (TP) and thoracic drainage (TD). The main criterion for the effectiveness of each method was the absence of pleural effusion in a certain time interval. PATIENTS AND METHODS: 84 patients with recurrent MPE and primary tumors at various locations were divided into three groups according to the type of palliative intervention. The patients were classified according to the indication guidelines for individual procedures and their general condition. Group 1 consisted of 44 patients in whom TMP was performed, group 2 consisted of 17 patients with primary tumors in the thoracic region in whom thoracotomy with pleurectomy (TP) was performed, and in group 3 there were 26 patients with TD. We compared the effectiveness of individual palliative methods by periodical X-ray checks, numbers of complications, length of TD and hospitalization, and changes in spirometric values after individual procedures. The t-test was used in statistic processing of the data. RESULTS: After six months, radiological investigation revealed recurrence of pleural effusion in three patients in group 1 (93.2% efficacy), no recurrence in group 2 (100% efficacy), and recurrence in 18 patients in group 3 (25.0% efficacy). There were fewer postoperative complications in group 1, the duration of TD and hospitalization was significantly shorter, and spirometric values increased. CONCLUSION: TMP is an effective palliative method for the treatment of recurrent pleural effusions, with a minimum number of complications and a short period of hospitalization. After TMP there is significant improvement in respiratory functions, and for the patient it represents a relatively simple surgical procedure. TP is indicated in the treatment of tumors and subsequent MPE in the thoracic region, and TD is indicated in patients who are not suitable candidates for one of the palliative pleurodesis procedures, because of either their poor general condition or a trapped lung.

Adult↗
PubMed1986

T-cell differentiation antigens and antigenic lymphocyte reactivity in pleural effusions.

Blood and pleural effusion mononuclear cells from thirteen patients were examined for the expression of T lymphocyte differentiation antigens as well as in vitro thymidine incorporation. The ratio of T4 to T8 cells was significantly greater among pleural effusion lymphocytes than among blood lymphocytes. Effusion lymphocyte responses to phytohaemagglutinin were less than those of blood lymphocytes. Unstimulated thymidine incorporation was greater in pleural effusion lymphocytes. Antigen-stimulated lymphocyte reactivity was not consistently greater in either blood or effusion lymphocytes. Lymphocytes from tuberculous effusions all reacted to tuberculin. Pleural effusion lymphocytes, regardless of the etiology of the effusion, possessed the same range of antigenic specificities as did blood lymphocytes. Therefore, effusion lymphocyte responsiveness to tuberculin does not prove the presence of tuberculous pleurisy but does indicate sensitisation to tuberculin.

Adult↗
PubMed2005

Evaluation of interferon-gamma, interferon-gamma-inducing cytokines, and interferon-gamma-inducible chemokines in tuberculous pleural effusions.

Tuberculous and malignant pleural effusions are representative of lymphocytic pleural effusions. In tuberculous pleurisy, especially, T-helper type 1 (Th1) cytokines are dominant, containing, for example, high concentrations of interferon (IFN)-gamma. We focused on cytokines that induce expression of IFN-gamma and Th1 cell-specific CXC chemokines induced by IFN-gamma. We also evaluated the diagnostic utility of these markers in tuberculous pleural effusions. Forty-three patients with pleural effusions (11 with tuberculous pleuritis, 32 with malignant pleuritis) were studied. We measured the pleural concentrations of IFN-gamma, IFN-gamma-inducing cytokines (interleukin IL-12 and IL-18), and IFN-gamma-inducible chemokines (interferon-gamma-inducible protein of 10-kD [IP-10], monokine induced by interferon-gamma [Mig], and interferon-inducible T-cell alpha chemoattractant [I-TAC]). Our results demonstrate that the concentrations of IFN-gamma, IFN-gamma-inducing cytokines, and IFN-gamma-inducible chemokines were all higher in tuberculous pleural effusions than in malignant pleural effusions. Also, IFN-gamma was significantly correlated with IL-12, Mig, and I-TAC. Moreover, receiver-operator-characteristic (ROC) analysis demonstrated that IFN-gamma produced a greater area under the ROC curve than any other factor. We conclude that the concentrations of IFN-gamma, cytokines that induce expression of IFN-gamma, and chemokines induced by IFN-gamma in tuberculous pleural effusion were all increased. The Th1 chemokines we examined, especially IP-10, are comparable to IFN-gamma as diagnostic markers of tuberculous and malignant pleural effusions, although IFN-gamma is the most valuable.

Aged↗
PubMed1989

[Pleuroperitoneal shunt for malignant pleural effusions].

The malignant pleural effusion was introduced into the abdominal cavity by the manual compression of a pleuroperitoneal shunt tube, which was indwelt in the subcutaneous tissue of the lateral chest under local anesthesia. Seven patients having malignant pleural effusion, due to lung cancer in 4 and breast cancer in 3, were used as subjects. This technique caused no serious complications. Retention of pleural effusion was markedly reduced in all of the 7 patients. Three patients, whose performance status (P.S.) was preoperatively determined to be 3 or 2, could be discharged during early periods. This technique seemed to be highly feasible in these patients, but not in those having P.S. of 4. Since peritoneal dissemination of the tumor was seen in 1 of 3 patients examined by autopsy, there is a possibility that this technique might have contributed to spread and scattering of tumor cells in the peritoneal cavity. These results suggested that this technique is useful therapeutic means for the treatment of patients in whom hospitalization is necessary due to the presence of malignant pleural effusion, while this technique involves the risk of artificial induction of peritoneal dissemination of tumor cells. Therefore, the application of this technique should be decided based on the prognosis of each patient.

Aged↗
PubMed1976

Acute coccidioidal pleural effusion.

Acute coccidioidal pleural effusions were studied in 28 patients. Coccidioidal pleural effusion appeared to be secondary to direct spread of contigous parenchymal infection, rather than to hematogenous dissemination, in more than 90 per cent of these patients. Only 2 of 28 patients had the concomitant development of disseminated infection, and both patients possessed factors known to predispose to dissemination. Because of the excellent prognosis in most patients, therapy in patients with coccidioidal pleural effusion should be expectant. This is true even when substantial increases occur in complement fixation titers; such elevations were frequent in this series. Cultures of pleural biopsy specimens were the most rewarding cultural source in this series, being positive in all 8 patients in whom such biopsy specimens were cultured. Dermal hypersensitivity, including erythema nodosum and erythema multiforme, was commin in patients whose clinical course was uncomplicated.

Adolescent↗