Malignant pleural effusions

Size: px
Start display at page:

Download "Malignant pleural effusions"

Transcription

1 Surg Clin N Am 82 (2002) Malignant pleural effusions Joe B. Putnam Jr, MD Department of Thoracic and Cardiovascular Surgery, The University of Texas, M.D. Anderson Cancer Center, 1515 Holcombe Boulevard, Box 445 Houston, TX , USA Pleural effusions are a significant public health problem. Diagnosis of over 1 million pleural effusions is estimated to occur yearly in the United States. Patients with pleural effusions are frequently symptomatic with dyspnea and loss of function. Treatment goals for these patients should focus on relief or elimination of dyspnea, restoration of normal activity and function, minimization or elimination of hospitalization, and efficient use of medical care resources [1,2]. Medical management, with treatment of the underlying cause, may be effective in some transudates. For exudates, management may be more difficult. Malignant pleural effusions (MPE; those effusions associated with primary, concurrent, or distant neoplasms) may be more complex, with frequent recurrence. The arbitrary view of requiring pleural symphysis, achieved by in-hospital drainage, with pleurodesis achieved by sclerosis with chemical or other agents, may subject the patient to a prolonged hospitalization or to other interventions that may significantly reduce quality of life and remaining survival outside the hospital. Pathophysiology Pleural effusions occur between two membranes: the visceral (inner) layer of the pleura attached to the lungs, and the parietal (outer) layer attached to the chest wall. The pleural space normally is nonexistent and is lubricated by a slight amount of pleural fluid (10 20 cc) that provides lubrication between the pleura. Fluid (sera) continuously moves from the parietal pleura through the pleural space to be absorbed by the visceral pleura. The fluid is then drained into the lymphatic system. The fluid in the pleural space is minimized by a balance of Starling forces, oncotic pressure in the circulation, and negative pressure in the lymphatics of the lungs. address: (J.B. Putman) /02/$ - see front matter Ó 2002, Elsevier Science (USA). All rights reserved. PII: S ( 0 2 )

2 868 J.B. Putnam Jr / Surg Clin N Am 82 (2002) In patients with primary malignancies, metastasis to the pleural space may cause significant shifts or fluid imbalance from derangements in the Starling forces that regulate the reabsorption of fluid within the pleural space. Movement of pleural fluid across the pleural space may involve over 5 to 10 L/d, and derangements in this movement may increase the normal amount of pleural fluid from 5 to 50 cc to a more significant amount. Other disease processes may also significantly affect the ability of the body to manage its intrapleural fluid. Pleural effusions may occur in patients with increased capillary permeability caused by inflammation, infection, or pleural metastasis increased hydrostatic pressure as results from congestive heart failure decreased oncotic pressure from hypoalbuminia increase in the normal negative pressure (more negative intrathoracic pressure) secondary to atelectasis impaired or decreased lymphatic drainage secondary to obstruction of the normal lymphatic channels by tumor, radiation, or chemotherapyinduced fibrosis Although multiple mechanisms may contribute to the development of MPE, the physician must consider the options available for diagnosis and to select the one that is most easily applied. Small effusions may occur in association with an intrathoracic neoplasm. If such effusions occur, the patient should have an ultrasound-directed aspiration for diagnosis. In patients with primary lung cancer, such small effusions must be evaluated. The presence of a cytologically positive effusion suggests that the patient is unresectable for cure (clinical stage IIIB) [3]. Patients with enormous pleural effusions have mediastinal shift, with impairment of venous return to the heart. With much the same mechanism as tension pneumothorax, this tension hydrothorax should be drained to prevent impending cardiac and respiratory collapse. Diagnosis Etiology Numerous benign, infectious, and malignant etiologies cause pleural effusions [4,5]. Twenty-five percent of all pleural effusions in a general hospital setting are secondary to cancer. Patients with cancers frequently develop recurrent MPE secondary to their disease. Thirty percent to 70% of all exudative effusions are secondary to cancer. Increased levels of vascular endothelial growth factor are present [6,7]. In patients with cancer, 50% to 60% of MPE are positive on first thoracentesis. In 25% of patients with cancer and a recurrent pleural effusion, malignant cells in the effusion may not be identified by pathologic examination [8]. Thoracoscopy is diagnostic in

3 J.B. Putnam Jr / Surg Clin N Am 82 (2002) greater than 90% of patients with MPE. The primary histologies for patients with MPE include non small cell lung cancer, breast cancer, lymphoma, or other malignancies such as ovarian cancer. Median life expectancy ranges from 3 to 9 months, depending on the primary pathology [8 10]. History and physical examination A thorough physical examination and careful history may reveal common causes of pleural effusion (see display boxes 1 and 2). These causes include congestive failure, parapneumonic effusions after or in association with pneumonia, primary or secondary malignancies of the lung or pleural cavity, or pulmonary emboli. Patients may be diagnosed with MPE by screening chest radiograph, as happens in patients with small asymptomatic effusions, or they may have underlying symptoms of cough, dyspnea, or chest pain. Pleuritic chest pain may suggest inflammation or pulmonary embolus. The physical examination demonstrates decreased breath sounds, dullness to percussion, or a pleural rub. Radiologic studies Standard chest roentgenograms (posterior anterior and lateral) may demonstrate blunting of the costophrenic angle suggestive of a small effusion. Patients with white-out of the chest may be identified by the subtle changes of widening of the intercostal spaces on the affected side. (This observation is in contrast to the expected findings of narrowed intercostal spaces, elevation of the hemidiaphragm, and shift of the mediastinum toward the affected side when the lung is completely collapsed). Lateral decubitus films or bilateral decubitus films may be considered in patients that have a MPE. This radiologic examination can demonstrate free-flowing effusions on one or both sides. Typically, when bilateral effusions are present, and bilateral decubitus films can assess the side that contains the largest amount of fluid for subsequent evaluation or initial treatment. In patients with significant bilateral pleural effusions, treatment of both effusions may be required. Box 1 Causes of transudates Congestive heart failure Cirrhosis Atelectasis Nephrotic syndrome Peritoneal dialysis Myxedema Constrictive pericarditis

4 870 J.B. Putnam Jr / Surg Clin N Am 82 (2002) Box 2 Causes of exudates Malignancy Carcinoma, lymphoma, mesothelioma, breast cancer, lung cancer, other Pulmonary embolism Collagen vascular disease (rheumatoid arthritis, lupus) Tuberculosis Asbestosis Pancreatitis Esophageal perforation Trauma Postcardiac injury syndrome Radiation pleuritis Drug-induced Drugs causing drug-induced lupus syndrome (procainamide, hydralazine, quinidine, isoniazid, penicillamine, and sulfonamide-related drugs) Nitrofurantoin Dantrolene Methysergide Procarbazine Methotrexate Chylothorax Meigs syndrome Sarcoidosis Yellow-nail syndrome Computed tomography (CT) may demonstrate a small asymptomatic effusion that is not seen well even on the posterior anterior and lateral chest radiograph. CT scan of the chest can assist in evaluation of parenchymal abnormalities (such as lung cancer), pleural abnormalities (eg, mesothelioma), and may be useful in the diagnosis of stable patients with pulmonary emboli. Loculated effusions can be identified and drained. Other studies In patients with loculated pleural effusions, as occur after multiple inadequate or unsuccessful attempts at thoracentesis, ultrasound-directed or CTdirected placement of drainage catheters may be required. Loculated pleural fluid must be distinguished from significant pleural thickening resulting from inflammation, infection, tumor, or primary neoplasms (such as mesothelioma).

5 J.B. Putnam Jr / Surg Clin N Am 82 (2002) Patients with primary lung neoplasms may have obstructive pneumonia. Parapneumonic effusions can occur. Parapneumonic effusions may be treated with observation or like symptomatic pleural effusions that occur in patients with a primary lung cancer, breast cancer, lymphoma, or other malignancies. Thoracentesis In patients in whom the diagnosis of pleural effusion is not clear, a thoracentesis should be performed. In patients who are symptomatic, a thoracentesis should be performed for both diagnosis and therapeutic intent. Complete drainage of the effusion must be performed. Pleural biopsy may be performed with minimal difficulties to obtain a diagnosis when the pleural fluid examination is nondiagnostic. Other diagnostic modalities must be tailored to the individual patient. Bronchoscopy, thoracoscopy, additional radiographic studies, and positron emission tomographic scans may be required to determine the presence or absence of malignancy causing pleural effusion. Complications of thoracentesis or pleural biopsy include pneumothorax, bleeding, hypotension (vasovagal-related), re-expansion pulmonary edema, or infection. Symptoms related to thoracentesis include paroxysmal cough (from rapid expansion of alveoli in the previously deflated lung) and pain when the visceral and parietal membranes make initial contact. The pain may commonly occur in the shoulder or upper back. Pleural fluid characteristics Evaluation of the fluid should include cytology, complete cell count, and culture and sensitivities. Pleural fluid and serum should be examined for total protein, glucose, LDH, and ph. Other chemistry evaluations may be performed when other diagnoses are of concern. Measurement of amylase in patients with pancreatitis, esophageal perforation, or esophageal malignancy, or elevation of triglycerides in patients with suspected chylothorax may be useful. Immunologic evaluation including antinuclear antibody and/or rheumatoid factor may be helpful in the diagnosis of autoimmune or collagen-vascular diseases. Pus or foul-smelling fluid represents empyema and should have complete and dependent drainage as soon as possible. Chylothorax presents as a milky-white to gray opalescent fluid, with a high triglyceride value. Chylothorax occurs with lymphatic obstruction or from thoracic duct injury. Bloody fluid may represent malignancy, trauma, or iatrogenic perforation of the intercostal artery, spleen, or liver, and so forth. Complete drainage with tube thoracoscopy may be required. A determination of the hematocrit of the fluid may be necessary. Management of infected pleural effusion and empyema will not be discussed here.

6 872 J.B. Putnam Jr / Surg Clin N Am 82 (2002) Pleural effusions are classified as transudate or exudate [4,11]. The patient with a transudate may have congestive heart failure, hypoalbuminemia, or cirrhosis. An exudate is diagnosed by a pleural fluid protein:serum protein ratio >0.5 pleural fluid LDH:serum LDH ratio >0.6 pleural fluid LDH value of greater than two thirds of the normal limit for serum Although multiple tests can be performed on pleural fluid for diagnosis and treatment, these simple studies provide significant information on presence of a transudate or exudate, infection, or malignancy. The amount of fluid drained during thoracentesis should be sufficient to obtain a diagnosis, relieve symptoms of dyspnea, and avoid re-expansion pulmonary edema or pneumothorax. General guidelines have suggested that the recommended limits are at 1000 to 1500 cc from one hemithorax during a single procedure. This recommendation must be placed in the context of the individual patient. The author suggests that the surgeon could drain up to 20 cc pleural fluid per kilogram of body weight as an outpatient procedure. On occasion, a transudative MPE will occur (up to 5% of patients) [12]. Pulmonary embolism can result in a transudative effusion in up to 30% of all cases. Therapeutic options In patients with transudates, the cause (ie, the patient s underlying medical condition or disease) should be identified and treated. The patient with an asymptomatic pleural effusion may be simply observed. If the patient is symptomatic, simple and complete drainage for diagnosis and relief of dyspnea may be accomplished as the initial intervention. This diagnostic and therapeutic thoracentesis provides excellent initial management. Should the fluid reoccur, the patient may be considered as having recurrent pleural effusion and be treated with several various methods. In patients with recalcitrant effusions that occur during or after treatment for a primary malignancy, management may be difficult. All treatment options require one or more of the following items: drainage of the pleural space, apposition of the visceral and pleural surfaces with complete expansion of the lung (usually), dispersion of a sclerosing agent throughout the pleural space, and maintenance of the pleural apposition until chemical or inflammatory pleuritis occurs and the pleural surfaces fuse. Treatment options include thoracentesis or repeat thoracentesis; tube thoracostomy; drainage and sclerosis with talc [13,14], bleomycin, or other material [15]; a chronic indwelling pleural catheter (Pleurx Ò, Denver Biomedical, Golden, CO) [8]; pleuroperitoneal shunt [16,17]; or thoracoscopy with drainage and talc insufflation [18 20].

7 J.B. Putnam Jr / Surg Clin N Am 82 (2002) Thoracoscopy Thoracoscopy may provide therapy by drainage and sclerosis with talc [21]. Thoracoscopy has high accuracy (greater than 90%) in diagnosis of pleural disease [22]. General anesthetic, thoracoscopy, and biopsy may be required for diagnosis; however, the benefit to end-stage patients may be very limited. In patients in whom a diagnosis must be obtained for treatment considerations, drainage, multiple pleural biopsies, and treatment may all be performed at one sitting. More simple strategies should be considered first. Surgical exploration and thoracoscopy are associated with risks of anesthetic and thoracic manipulation. As a result, thoracoscopy or open exploration is warranted only in highly selected patients. Patients with a parapneumonic effusion should be evaluated and treated rapidly. Patients who have a parapneumonic effusion with purulence, multiple loculations, a positive gram stain, or ph less than 7.2 should have urgent drainage. Trapped lung Patients with a trapped lung are another significant problem [23]. After drainage of pleural effusion, the underlying lung will remain collapsed (Fig. 1). To the inexperienced physician, this may mimic a pneumothorax. A chest tube may be placed; however, the trapped lung will not expand. Long-term use of the chest tube in an attempt to re-expand the lung may increase the risk of intrapleural infection and empyema. Standard techniques of thoracotomy and decortication may be considered to remove the pleural peel; however, this drastic and often unnecessary intervention in patients with extensive malignancy may be a disservice and pose a significant risk to the patient. Decortication is performed in patients with benign diseases in whom the pleural peel has been objectively demonstrated to cause restriction of ventilation, with progressive and refractory dyspnea. Expansion of the normal underlying lung can improve symptoms of dyspnea. Patients who have significant pleural disease may have significant dyspnea as a result of their pleural thickening. On the chest radiograph and CT scan, such a diagnosis may be difficult to distinguish from a MPE. Treatment of MPE The treatment of initial and recurrent MPE may be complex. Chest tube drainage, pleurodesis, pleural sclerosis, or drainage with a chronic indwelling pleural catheter is used most often for patients who have recurrent MPE. These patients have primary diagnoses of non small cell or small cell lung cancer, breast cancer, lymphoma, ovarian cancer, or other malignancies. The median life expectancy in these patients is 90 days. Given the limited survival in most patients, the goal of therapy must be to relieve

8 874 J.B. Putnam Jr / Surg Clin N Am 82 (2002) Fig. 1. Trapped lung. This patient had chronic pleural effusion and trapped lung after therapy for ovarian carcinoma. (A) September No malignancy was ever diagnosed. The patient did well with repeated thoracenteses until the lung became trapped and failed to expand after tube thoracostomy. (B) December A pleuroperitoneal shunt was placed with initial good results; however, the fluid became loculated around the limbs of the catheter in May 1994 (C), requiring replacement. symptoms, minimize hospitalization, enhance function, and to provide the patient with some control over their disease process. Although outpatient serial thoracenteses may be considered, the inconsistent application and drainage may result in loculations and further physical embarrassment to the patient. The pleural effusions can reaccumulate rapidly. In patients with a suspected MPE, a diagnostic and therapeutic thoracentesis should be performed. Evaluation of completeness of expansion of the lung within the hemithorax can be determined. In addition, an evaluation can be made to determine whether the pleural fluid was the cause of the

9 J.B. Putnam Jr / Surg Clin N Am 82 (2002) patient s dyspnea, pain, or other symptoms. In a small percentage of patients, the symptoms may be related to underlying pleural disease and not to the effusion in patients with mesothelioma or other chronic pleural thickening. After diagnostic and therapeutic thoracentesis, the patient should have follow-up to determine whether recurrent symptoms develop. If the pleural effusion recurs, the patient may be treated in an optimal fashion with a chronic indwelling pleural catheter. This technique provides good resolution of symptoms and is a cost-effective solution to expensive alternatives of general anesthesia, thoracoscopy or thoracotomy, and inpatient hospitalization [24]. Pleurodesis is performed to scar the visceral and parietal pleura together and obliterate the potential pleural space. A sclerosing agent is instilled within the hemithorax to induce an inflammatory reaction. With pleural symphysis, the pleural fluid cannot accumulate and compress the functioning lung or, at its extreme, the mediastinum. Sclerosing agents Almost all sclerosing agents [25] can produce fever, tachycardia, chest pain, and nausea. Because sclerosing agents may cause pain (talc, doxycycline, tetracycline, and so forth), the patient should be premedicated with pain medication (usually narcotics) prior to sclerosis instillation. Talc is the most effective sclerosing agent used, and is often administered as a slurry [26,27]. When administered as a slurry through a chest tube or pleural catheter, talc slurry may be as effective as direct insufflation of talc powder via thoracoscopy [28]. After drainage of the pleural fluid, the slurry (4 6 g of talc in a solution of 100 cc saline with or without lidocaine) is instilled. Injection of 0.5% lidocaine (20 50 cc) into the pleural cavity prior to instillation of a sclerosing agent may help alleviate pain. With complete expansion of the lung and apposition of the visceral and parietal pleura, pleural symphysis can occur. In one prospective study [29], 501 patients were randomized to receive talc (4 5 g) by chest tube or by video-assisted thoracic surgery with drainage and talc insufflation. Multiple confounding problems were noted in each group, including death prior to 30 days (chest tube 13%, video-assisted thoracic surgery 9.4%), talc not administered, lung not reexpanded more than 90%, or no follow-up data. In evaluable 30-day survivors, recurrent effusion free survival at 30 days was the same in both groups (chest tube 70%, 82/117; video-assisted thoracic surgery 79%, 103/131). Talc may cause adverse reactions such as microemboli and granulomatous tissue reactions [30]. Tetracycline has been commonly used in the past in association with tube thoracostomy [31]. Instillation of the tetracycline solution provides a faster pleurodesis and pleural symphysis than chest tube drainage alone; however, it may cause significant pain. Tetracyclinc is no longer commercially available for use as a sclerosant. Doxycycline is an available alternative to

10 876 J.B. Putnam Jr / Surg Clin N Am 82 (2002) tetracycline and is felt to have roughly equal effectiveness [15,32,33]. Bleomycin (60 units) has been used as an alternative sclerosing agent and may have equivalent effectiveness to tetracycline. It is expensive, however, and can have systemic toxicity [34,35]. After placement of the chemical agent, the chest tube should be clamped for a period of 2 to 4 hours. During this time, the patient should lie in the following positions: supine, right lateral decubitus position, problem, left lateral decubitus position and, for period of time, in the Trendelenburg and reverse Trendelenburg positions. Afterward, the chest tube should be unclamped and the residual fluid allowed to drain. This may be repeated a day or two later if high volume chest tube output continues after the initial sclerosis. When the drainage is less than 200 to 300 cc per day, the chest tube may be removed. Although some physicians and surgeons wish to follow the results of treatment radiographically, no additional treatment would be recommended unless the patient becomes symptomatic. For that reason, a follow-up chest radiograph as a baseline study is recommended, and any additional chest radiographs should be obtained only when symptoms recur. Other techniques Thoracoscopy may also be considered as a therapeutic option. A small incision (or incisions) is made in the skin, and a small thoracoscope is passed through the incision to visualize the pleura. After drainage and biopsy, the sclerosing agent is placed under direct visualization onto the pleural surface. Several agents can be used for pleurodesis, including talc, bleomycin, and doxycycline [21,36]. Complications with this procedure include requirements for intubation and general anesthesia, and a small risk of bleeding and infection. Pneumothorax is uniformly present and requires a chest tube for a short time after the procedure. Proponents of this procedure believe the sclerosing agent can be more efficiently applied to the pleura; however, there are no studies showing one method to be superior to the other. Surgical techniques (such as thoracoscopy, drainage, and talc poudrage) may not carry any objective advantages over simple drainage and instillation of a talc slurry. Mechanical abrasion of the parietal pleura (using gauze) or other techniques such as laser or argon beam coagulator can be applied by thoracoscopic or open techniques. Pleurectomy carries excessive risk of mortality and cannot be generally recommended. Pleurodesis or palliation? In the past, successful treatment of MPE required hospitalization for chest tube, drainage, sclerosis and, it was hoped, pleural symphysis obliteration of the pleural space, with removal of drainage catheters. If pleurodesis could not be achieved during the patient s hospitalization, the treatment was designated as failed, and the patient then was treated with the best avail-

11 J.B. Putnam Jr / Surg Clin N Am 82 (2002) able means. Pleural symphysis was required for discharge. In contrast, patient-centered treatment focuses on relief of the patient s symptoms and restoration of normal function. Pleurodesis (pleural symphysis) or hospitalization is not required in order to achieve these goals. Palliation Various temporary and semipermanent catheters have been applied to patients in an attempt to palliate symptoms of MPE [37 39]. Drainage by gravity of the pleural fluid can be accomplished and pleurodesis can be achieved with sclerosis using several agents. Small studies have been performed, with early success [13,24,40 42]. The pleuroperitoneal shunt (Denver Biomedical, Golden, CO) has been used in selected patients. The catheter is placed intracorporeally via a subcutaneous tunnel, with fenestrated limbs placed into the pleural cavity and into the peritoneal cavity. A one-way valve within a subcutaneous pumping chamber allows the patient to pump and self-drain the fluid on a daily basis (from the pleural cavity to the peritoneal cavity). The average pumping volume per compression is 1 to 2 cc. The disadvantage of this approach is that the patient must pump or press the subcutaneous pumping chamber up to several hundred times daily to drain the fluid (see Fig. 1). The Pleurx Ò catheter is a soft silastic chronic indwelling catheter (Fig. 2). The patient or caregiver drains the pleural fluid periodically by connecting the tubing to a disposable vacuum container to provide relief of dyspnea and potentially achieve spontaneous pleurodesis. Technique of catheter insertion A local anesthetic is administered, and the pleural fluid is located with a needle. After placing a flexible wire into the thorax (directed in a posteriorlateral direction), a counter incision is made inferiorly and medially to the wire, and a tunnel is created for the pleural catheter. The catheter is drawn through the tunnel and the Teflon cuff placed 1 cm within the tunnel, away from the skin edge. A peel-away sheath over a removable stylet is inserted over the wire and placed into the thorax. The stylet is withdrawn, and the catheter is threaded through the sheath into the thorax. The peel-away sheath is withdrawn. The two skin incisions are closed and the catheter secured to the skin. Immediate drainage of 1500 cc or more has been accomplished in 38.4% of patients, 1000 to 1499 cc in 40.4% of patients, and less than 1000 cc in 21% of patients [8]. A chest roentgenogram is obtained to confirm position of the catheter in the chest, drainage of the fluid, and absence of pneumothorax (Fig. 3). Patients and caregivers are instructed on self-drainage of their MPE. Typically, patients drain their effusion at home every other day. When scant or no fluid was obtained on three consecutive attempts, the patient comes to

12 878 J.B. Putnam Jr / Surg Clin N Am 82 (2002) Fig. 2. Insertion of the Pleurx Ò catheter. (A) The Pleurx Ò catheter. The catheter is a soft silastic catheter with multiple fenestrations within the pleural component of the catheter. A Teflon sheath provides a biologic-mechanical barrier to minimize the potential for infection. The oneway valve is accessed with a sterile plastic catheter for drainage. (B) The catheter is placed using a Seldinger technique. After adequate local anesthesia, confirmation of free-flowing pleural fluid, and determination of optimal placement position for the catheter, a larger bore needle is placed into the pleural fluid and a wire is advanced. The catheter is tunneled. A dilator covered with a peel-away sheath is placed over the wire. After removal of the dilator, the tunneled catheter is placed through the peel-away sheath into the chest. the clinic for removal of the catheter. Patients are routinely evaluated in the clinic at 1-month intervals while the catheter is in place. After removal of the catheter, the patient is discharged to the care of their regular physician. Evaluation of the Pleurx Ò catheter To evaluate this alternative method of treatment of MPE, a prospective multi-institutional randomized trial was conducted to compare the effectiveness and safety of an indwelling pleural catheter (Pleurx Ò ) with chest tube and doxycycline sclerosis for treatment of cancer patients with symptomatic recurrent MPE [8]. The possible benefits of such treatment include primary outpatient management, improved quality of life, reduced medical costs, improved function, and spontaneous pleurodesis (pleural symphysis). One hundred forty-four patients were randomized to either pleural catheter drainage or to chest tube and doxycycline sclerosis (randomization ratio of 2:1, respectively). A modified Borg scale for dyspnea, the dyspnea component

13 J.B. Putnam Jr / Surg Clin N Am 82 (2002) of the Guyatt chronic respiratory questionnaire, and Karnofsky performance status score were used to compare the two groups. There was no difference between the two groups in performance status or initial dyspnea scores. Outcomes measured included control of pleural effusion, hospitalization, morbidity, and survival. Overall survival was approximately 50% at 90 days. Lung and breast cancer histologies had a 90-day survival of approximately 70%; other histologies (as a group) had a 90-day survival of less than 40%. After treatment, both groups showed similar improvements in the Guyatt chronic respiratory questionnaire scores and showed similar morbidity. Fig. 3. (A) Chest roentgenograms (posterior anterior and lateral). A significant free-flowing recurrent MPE is identified. (B) CT demonstrates a significant effusion, with compression of the right lower lobe. Some mediastinal and cardiac shift is noted. (C) Placement of the Pleurx Ò catheter is accomplished with initial drainage of the recurrent MPE. Good placement along the posterior medial aspect of the hemithorax is accomplished. This is the initial chest roentgenogram immediately after placement of the catheter.

14 880 J.B. Putnam Jr / Surg Clin N Am 82 (2002) Fig. 3 (continued) There was no treatment-related mortality, emergency operations, or major bleeding. Initial hospital treatment success was achieved in 64% of patients with a chest tube and sclerosis versus 92% of those with a chronic indwelling catheter. Spontaneous pleurodesis occurred in 70% of pleural catheter patients. Seventy-one percent of patients with a chest tube achieved pleural symphysis, although 28% of these patients developed recurrence of their pleural effusion after treatment. Median survival was the same in both groups: 50% at 90 days. Chronic indwelling pleural catheter and chest tube and sclerosis significantly improved dyspnea from recurrent MPE. The pleural catheter had safety and efficacy equivalent to chest tube and sclerosis. The hospitalization was shorter in the pleural catheter patients: 1 day versus 6.5 days. Outpatient management of MPE using the Pleurx Ò catheter Based on this experience, the outpatient management of patients with MPE with this indwelling pleural catheter was explored [43]. In this study, the author and colleagues hoped to identify significant cost savings. Hospitalization and early charges with the pleural catheter versus the chest tube drainage and sclerosis were compared. Similar outcomes of pleural effusion control, hospitalization, morbidity, and survival were evaluated. One hundred consecutive patients treated with the pleural catheter (40 inpatient, 60 outpatient) and 100 consecutive patients treated with chest tube, sclerosis, and drainage (all inpatients) were evaluated. No difference was found in Zubrod performance scores or symptoms in the two groups. Mean hospitalization was 8 days for inpatients whether treated with a chest tube or pleural catheter. Overall, survival was 50% at 90 days. Survival did not differ by

15 J.B. Putnam Jr / Surg Clin N Am 82 (2002) treatment for any group. There were no pleural catheter related deaths, no emergency operations, and no major bleeding. Eighty-one percent of patients having pleural catheter had no morbidity. The economic impact was significant. For patients treated in-hospital, mean charges ranged from $7000 to $11,000. Patients treated as outpatients (all pleural catheter patients) had mean charges of $3400. Outpatient pleural catheter drainage was safe, cost efficient, and successful, with minimal morbidity. No hospitalization was required for patients initially evaluated as outpatients. Cost of supplies and reimbursement has been a concern for a minority of patients who may live for months after placement of these catheters. In these patients, sclerosis has been applied successfully. Outpatient management of MPE with a Pleurx Ò catheter has become the author s standard of care. Summary The management of pleural effusions and, in particular, recurrent MPE require an accurate assessment of the characteristics of the pleural fluid and the relief of the patient s symptoms. Although a common problem, treatment of pleural effusions and MPE is highly variable. Selection of optimal treatment for the individual patient (or population of patients) requires a careful assessment of the benefits and associated risks of the therapy. Pleurodesis is an artificial measure of success that is hospital centered, not patient centered. Because patients with MPE have limited life expectancy, efforts to palliate or eliminate dyspnea, optimize function, eliminate hospitalization, and reduce excessive end-of-life medical care costs may be best achieved with a chronic indwelling pleural catheter. The need for expensive supplies may temper the use of such outpatient management. Alternative techniques of tube thoracostomy, drainage, and sclerosis or thoracoscopy with drainage and talc poudrage also have benefits but are associated with variable hospitalization and increased medical costs. References [1] American Thoracic Society. Management of malignant pleural effusions. Am J Respir Crit Care Med 2000;162: [2] Antunes G, Neville E. Management of malignant pleural effusions. Thorax 2000;55: [3] Mountain CF. Revisions in the International System for Staging Lung Cancer. Chest 1997;111: [4] Light RW. Useful tests on the pleural fluid in the management of patients with pleural effusions. Curr Opin Pulm Med 1999;5: [5] Light RW. Management of pleural effusions. J Formos Med Assoc 2000;99: [6] Cheng D, Rodriguez RM, Perkett EA, et al. Vascular endothelial growth factor in pleural fluid. Chest 1999;116: [7] Zebrowski BK, Yano S, Liu W, et al. Vascular endothelial growth factor levels and induction of permeability in malignant pleural effusions. Clin Cancer Res 1999;5:

16 882 J.B. Putnam Jr / Surg Clin N Am 82 (2002) [8] Putnam JB Jr, Light RW, Rodriguez RM, et al. A randomized comparison of indwelling pleural catheter and doxycycline pleurodesis in the management of malignant pleural effusions. Cancer 1999;86: [9] Sanchez-Armengol A, Rodriguez-Panadero F. Survival and talc pleurodesis in metastatic pleural carcinoma, revisited. Report of 125 cases. Chest 1993;104: [10] Burrows CM, Mathews WC, Colt HG. Predicting survival in patients with recurrent symptomatic malignant pleural effusions: an assessment of the prognostic values of physiologic, morphologic, and quality of life measures of extent of disease. Chest 2000;117:73 8. [11] Gazquez I, Porcel JM, Vives M, et al. Comparative analysis of Light s criteria and other biochemical parameters for distinguishing transudates from exudates. Respir Med 1998;92: [12] Ashchi M, Golish J, Eng P, et al. Transudative malignant pleural effusions: prevalence and mechanisms. South Med J 1998;91:23 6. [13] Marom EM, Patz EF Jr, Erasmus JJ, et al. Malignant pleural effusions: treatment with small-bore-catheter thoracostomy and talc pleurodesis. Radiology 1999;210: [14] Patz EF Jr. Malignant pleural effusions: recent advances and ambulatory sclerotherapy. Chest 1998;113:74S 7S. [15] Patz EF Jr, McAdams HP, Erasmus JJ, et al. Sclerotherapy for malignant pleural effusions: a prospective randomized trial of bleomycin vs doxycycline with small-bore catheter drainage. Chest 1998;113: [16] Lee KA, Harvey JC, Reich H, et al. Management of malignant pleural effusions with pleuroperitoneal shunting. J Am Coll Surg 1994;178: [17] Ponn RB, Blancaflor J, D Agostino RS, et al. Pleuroperitoneal shunting for intractable pleural effusions. Ann Thorac Surg 1991;51: [18] Aelony Y, King RR, Boutin C. Thoracoscopic talc poudrage in malignant pleural effusions: effective pleurodesis despite low pleural ph. Chest 1998;113: [19] Danby CA, Adebonojo SA, Moritz DM. Video-assisted talc pleurodesis for malignant pleural effusions utilizing local anesthesia and IV sedation. Chest 1998;113: [20] Jacobi CA, Wenger FA, Schmitz-Rixen T, et al. Talc pleurodesis in recurrent pleural effusions. Langenbecks Arch Surg 1998;383: [21] de Campos JR, Vargas FS, de Campos WE, et al. Thoracoscopy talc poudrage: a 15-year experience. Chest 2001;119: [22] Petrakis I, Katsamouris A, Drossitis I, et al. Usefulness of thoracoscopic surgery in the diagnosis and management of thoracic diseases. J Cardiovasc Surg (Torino) 2000;41: [23] Pien GW, Gant MJ, Washam CL, et al. Use of an implantable pleural catheter for trapped lung syndrome in patients with malignant pleural effusion. Chest 2001;119: [24] Belani CP, Pajeau TS, Bennett CL. Treating malignant pleural effusions cost consciously. Chest 1998;113:78S 85S. [25] Schafers SJ, Dresler CM. Update on talc, bleomycin, and the tetracyclines in the treatment of malignant pleural effusions. Pharmacotherapy 1995;15: [26] Zimmer PW, Hill M, Casey K, et al. Prospective randomized trial of talc slurry vs bleomycin in pleurodesis for symptomatic malignant pleural effusions. Chest 1997;112: [27] Antony VB. Pathogenesis of malignant pleural effusions and talc pleurodesis. Pneumologie 1999;53: [28] Hartman DL, Gaither JM, Kesler KA, et al. Comparison of insufflated talc under thoracoscopic guidance with standard tetracycline and bleomycin pleurodesis for control of malignant pleural effusions. J Thorac Cardiovasc Surg 1993;105: [29] Olak J, Dresler CM. Sclerosis of pleural effusions by talc thoracoscopy versus talc slurry: A Phase III study. Cancer and Leukemia Group B (CALGB #9334) [30] Kennedy L, Rusch VW, Strange C, et al. Pleurodesis using talc slurry. Chest 1994;106: [31] Martinez Moragon E, Aparicio Urtasun J, Sanchis Aldas J, et al. Pleurodesis con tetraciclinas en el tratamiento del derrame pleural maligno. Estudio retrospectivo de 91

17 J.B. Putnam Jr / Surg Clin N Am 82 (2002) casos [Tetracycline pleurodesis for treatment of malignant pleural effusions. Retrospective study of 91 cases]. Med Clin 1993;101: [32] Herrington JD, Gora-Harper ML, Salley RK. Chemical pleurodesis with doxycycline 1 g. Pharmacotherapy 1996;16: [33] Prevost A, Nazeyrollas P, Milosevic D, et al. Malignant pleural effusions treated with high dose intrapleural doxycycline: clinical efficacy and tolerance. Oncol Rep 1998;5: [34] Noppen M, Degreve J, Mignolet M, et al. A prospective, randomised study comparing the efficacy of talc slurry and bleomycin in the treatment of malignant pleural effusions. Acta Clin Belg 1997;52: [35] Ong KC, Indumathi V, Raghuram J, et al. A comparative study of pleurodesis using talc slurry and bleomycin in the management of malignant pleural effusions. Respirology 2000;5: [36] Schulze M, Boehle AS, Kurdow R, et al. Effective treatment of malignant pleural effusion by minimal invasive thoracic surgery: thoracoscopic talc pleurodesis and pleuroperitoneal shunts in 101 patients. Ann Thorac Surg 2001;71: [37] Pollak JS, Burdge CM, Rosenblatt M, et al. Treatment of malignant pleural effusions with tunneled long-term drainage catheters. J Vasc Interv Radiol 2001;12: [38] Saffran L, Ost DE, Fein AM, et al. Outpatient pleurodesis of malignant pleural effusions using a small-bore pigtail catheter. Chest 2000;118: [39] Smart JM, Tung KT. Initial experiences with a long-term indwelling tunnelled pleural catheter for the management of malignant pleural effusion. Clin Radiol 2000;55: [40] Goff BA, Mueller PR, Muntz HG, et al. Small chest-tube drainage followed by bleomycin sclerosis for malignant pleural effusions. Obstet Gynecol 1993;81: [41] Hsu WH, Chiang CD, Chen CY, et al. Ultrasound-guided small-bore Elecath tube insertion for the rapid sclerotherapy of malignant pleural effusion. Jpn J Clin Oncol 1998;28: [42] Parulekar W, Di Primio G, Matzinger F, et al. Use of small-bore vs large-bore chest tubes for treatment of malignant pleural effusions. Chest 2001;120: [43] Putnam JB Jr, Walsh GL, Swisher SG, et al. Outpatient management of malignant pleural effusion by a chronic indwelling pleural catheter. Ann Thorac Surg 2000;69:

Therapy of pleural effusions Modern techniques

Therapy of pleural effusions Modern techniques Therapy of pleural effusions Modern techniques Dr. Melanie Toffel Sugery of the chest Pleural effusion Ethiology In the normal pleural space there is a steady state in which there is a roughly equal rate

More information

Surgeons Role in Symptom Management. A/Prof Cliff K. C. Choong Consultant Thoracic Surgeon Latrobe Regional Hospital GIPPSLAND

Surgeons Role in Symptom Management. A/Prof Cliff K. C. Choong Consultant Thoracic Surgeon Latrobe Regional Hospital GIPPSLAND Surgeons Role in Symptom Management A/Prof Cliff K. C. Choong Consultant Thoracic Surgeon Latrobe Regional Hospital GIPPSLAND Conditions PLEURAL Pleural effusion Pneumothorax ENDOBRONCHIAL Haemoptysis

More information

EPEC -O. Education In Palliative And End-Of-Life Care For Oncology. Self-Study Module 3m: Symptoms; Malignant Pleural Effusions

EPEC -O. Education In Palliative And End-Of-Life Care For Oncology. Self-Study Module 3m: Symptoms; Malignant Pleural Effusions EPEC -O Education In Palliative And End-Of-Life Care For Oncology Self-Study Module 3m: Symptoms; Malignant Pleural Effusions Module 3m: Symptoms; Malignant Pleural Effusions Abstract... 3 Introduction...

More information

Malignant pleural effusions: treatment with tunneled long-term drainage catheters Jeffrey S. Pollak, MD

Malignant pleural effusions: treatment with tunneled long-term drainage catheters Jeffrey S. Pollak, MD Malignant pleural effusions: treatment with tunneled long-term drainage catheters Jeffrey S. Pollak, MD Malignant pleural effusion is a significant cause of morbidity and a poor prognostic indicator. Traditional

More information

Diseases. Inflammations Non-inflammatory pleural effusions Pneumothorax Tumours

Diseases. Inflammations Non-inflammatory pleural effusions Pneumothorax Tumours Pleura Visceral pleura covers lungs and extends into fissures Parietal pleura limits mediastinum and covers dome of diaphragm and inner aspect of chest wall. Two layers between them (pleural cavity) contains

More information

Management of mesothelioma

Management of mesothelioma Management of mesothelioma Jan.vanmeerbeeck@ugent.be Amsterdam, March 6, 2010 1 management Palliation Symptomatic care Pain Breathlessness Radiotherapy Chemotherapy Surgery Radical (intention to cure)

More information

Malignant Pleural Effusions. Introduction. Further Reading. Etiology. Abstract

Malignant Pleural Effusions. Introduction. Further Reading. Etiology. Abstract 372 PLEURAL EFFUSIONS / Malignant Pleural Effusions Further Reading Antony VB and Mohammed KA (1999) Pathophysiology of pleural space infections. Seminars in Respiratory Infections 14(1): 9 17. Colice

More information

Management of the patient with a symptomatic malignant pleural

Management of the patient with a symptomatic malignant pleural 1992 A Randomized Comparison of Indwelling Pleural Catheter and Doxycycline Pleurodesis in the Management of Malignant Pleural Effusions Joe B. Putnam, Jr., M.D. 1 Richard W. Light, M.D. 2 R. Michael Rodriguez,

More information

Pleural Diseases. Pleural Diseases. Director, Pulmonary Vascular Program Respiratory Institute Cleveland Clinic FACP, FRCP(C), FCCP, FCCM, FAHA

Pleural Diseases. Pleural Diseases. Director, Pulmonary Vascular Program Respiratory Institute Cleveland Clinic FACP, FRCP(C), FCCP, FCCM, FAHA Pleural Diseases Raed A. Dweik, M.D. FACP, FRCP(C), FCCP, FCCM, FAHA Director, Pulmonary Vascular Program Respiratory Institute Cleveland Clinic Cleveland, OH Effusions: Fluid Transudates Exudates Pus

More information

D iseases of the pleura and pleural space are

D iseases of the pleura and pleural space are ii1 BTS GUIDELINES Introduction to the methods used in the generation of the British Thoracic Society guidelines for the management of pleural diseases R J O Davies, F V Gleeson... Thorax 2003;58(Suppl

More information

INFLAMMATORY PLEURAL EFFUSION

INFLAMMATORY PLEURAL EFFUSION PLEURA- LESIONS LESIONS OF PLEURA Primary Intra pleural bacterial infections Neoplasm (mesothelioma) Secondary A complication of some underlying disease PLEURAL EFFUSION Common manifestation of both primary

More information

Disease/Illness GUIDE TO ASBESTOS LUNG CANCER. What Is Asbestos Lung Cancer? www.simpsonmillar.co.uk Telephone 0844 858 3200

Disease/Illness GUIDE TO ASBESTOS LUNG CANCER. What Is Asbestos Lung Cancer? www.simpsonmillar.co.uk Telephone 0844 858 3200 GUIDE TO ASBESTOS LUNG CANCER What Is Asbestos Lung Cancer? Like tobacco smoking, exposure to asbestos can result in the development of lung cancer. Similarly, the risk of developing asbestos induced lung

More information

PET POSITIVE PLEURAL PLAQUES DECADES AFTER PLEURODESIS: MESOLTHELIOMA? Ellen A. Middleton 1. Jonathan C. Daniel 2. Kenneth S.

PET POSITIVE PLEURAL PLAQUES DECADES AFTER PLEURODESIS: MESOLTHELIOMA? Ellen A. Middleton 1. Jonathan C. Daniel 2. Kenneth S. PET POSITIVE PLEURAL PLAQUES DECADES AFTER PLEURODESIS: MESOLTHELIOMA? Ellen A. Middleton 1 Jonathan C. Daniel 2 Kenneth S. Knox 1 Kathleen Williams 1 Departments of Medicine 1 and Surgery 2, University

More information

American Thoracic Society

American Thoracic Society American Thoracic Society Management of Malignant Pleural Effusions THIS OFFICIAL STATEMENT OF THE AMERICAN THORACIC SOCIETY WAS ADOPTED BY THE ATS BOARD OF DIRECTORS, MARCH 2000 CONTENTS Incidence Etiology

More information

Objectives. Mylene T. Truong, MD. Malignant Pleural Mesothelioma Background

Objectives. Mylene T. Truong, MD. Malignant Pleural Mesothelioma Background Imaging of Pleural Tumors Mylene T. Truong, MD Imaging of Pleural Tumours Mylene T. Truong, M. D. University of Texas M.D. Anderson Cancer Center, Houston, TX Objectives To review tumors involving the

More information

Anatomy Pleura Visceral Layer outer surface of lung Separates lobes of lung from each other Parietal Layer inner surface chest wall Pleural linings Co

Anatomy Pleura Visceral Layer outer surface of lung Separates lobes of lung from each other Parietal Layer inner surface chest wall Pleural linings Co Pleural diseases Dr. JM Nel Department of Pulmonology Pleural diseases Anatomy Empyema Physiology Pleurisy Pleural effusion Spontaneous Pneumothorax Asbestos- related pleural disease 1 Anatomy Pleura Visceral

More information

Differential Diagnosis of Pleural Effusions

Differential Diagnosis of Pleural Effusions Review Article Differential Diagnosis of Pleural Effusions JMAJ 49(9 10): 315 319, 2006 Tetsuo Sato* 1 Abstract A variety of disease states are associated with the development of pleural effusions, which

More information

CHEST IMAGING RADIOLOGY FUNDAMENTALS: UNDERSTANDING THE CHEST X- RAY RADIOGRAPHIC DENSITIES. Hounsfield Units 10/15/2013

CHEST IMAGING RADIOLOGY FUNDAMENTALS: UNDERSTANDING THE CHEST X- RAY RADIOGRAPHIC DENSITIES. Hounsfield Units 10/15/2013 CHEST IMAGING RADIOLOGY FUNDAMENTALS: UNDERSTANDING THE CHEST X- RAY RADIOGRAPHIC DENSITIES What are the different basic radiographic densities? Density Characteristics 1. Metal 2. Bone 3. Soft Tissue

More information

Management of Chest Tubes and Air Leaks after Lung Resection

Management of Chest Tubes and Air Leaks after Lung Resection Management of Chest Tubes and Air Leaks after Lung Resection Emily Kluck PA-C The Johns Hopkins Hospital Baltimore, MD AATS 2014, Toronto, CAN April 2014 Management of Chest Tubes 1 Overview Review the

More information

Pleural controversy: Pleurodesis versus indwelling pleural catheters for malignant effusionsresp_1986 747..754

Pleural controversy: Pleurodesis versus indwelling pleural catheters for malignant effusionsresp_1986 747..754 INVITED REVIEW SERIES: PLEURAL DISEASE SERIES EDITORS: JOSÉ M. PORCEL AND Y.C. GARY LEE Pleural controversy: Pleurodesis versus indwelling pleural catheters for malignant effusionsresp_1986 747..754 PAUL

More information

Aspira* Pleural Drainage Catheter

Aspira* Pleural Drainage Catheter Aspira* Pleural Drainage Catheter Instructions For Use Access Systems Product Description: The Aspira* Pleural Drainage Catheter is a tunneled, long-term catheter used to drain accumulated fluid from the

More information

Small cell lung cancer

Small cell lung cancer Small cell lung cancer Small cell lung cancer is a disease in which malignant (cancer) cells form in the tissues of the lung. The lungs are a pair of cone-shaped breathing organs that are found within

More information

N26 Chest Tubes 5/9/2012

N26 Chest Tubes 5/9/2012 Thoracic cavity, pleural space 1 Conditions requiring chest drainage_1 Air between the pleurae is a pneumothorax Occurs when there is an opening on the surface of the lung or in the airways, y, in the

More information

Sternotomy and removal of the tumor

Sternotomy and removal of the tumor Sternotomy and removal of the tumor All thymomas originate from epithelial thymic cells 4% of them consist of a pure population of epithelial cells Most have mixed populations of lymphoid cells to a

More information

CHEST TUBES AND CHEST DRAINAGE SYSTEMS

CHEST TUBES AND CHEST DRAINAGE SYSTEMS CHEST TUBES AND CHEST DRAINAGE SYSTEMS Central Nursing Orientation April 2008 Revised September 2011 OBJECTIVES Describe common tubes and indications for use at LHSC Review indications and contraindications,

More information

General Information About Non-Small Cell Lung Cancer

General Information About Non-Small Cell Lung Cancer General Information About Non-Small Cell Lung Cancer Non-small cell lung cancer is a disease in which malignant (cancer) cells form in the tissues of the lung. The lungs are a pair of cone-shaped breathing

More information

بسم هللا الرحمن الرحيم

بسم هللا الرحمن الرحيم بسم هللا الرحمن الرحيم Updates in Mesothelioma By Samieh Amer, MD Professor of Cardiothoracic Surgery Faculty of Medicine, Cairo University History Wagner and his colleagues (1960) 33 cases of mesothelioma

More information

Understanding Pleural Mesothelioma

Understanding Pleural Mesothelioma Understanding Pleural Mesothelioma UHN Information for patients and families Read this booklet to learn about: What is pleural mesothelioma? What causes it? What are the symptoms? What tests are done to

More information

Diseases of peritoneum Lect. Al Qassim University, Faculty of Medicine Phase II Year III, CMD 332 Pathology Department 31-32

Diseases of peritoneum Lect. Al Qassim University, Faculty of Medicine Phase II Year III, CMD 332 Pathology Department 31-32 Diseases of peritoneum Lect Al Qassim University, Faculty of Medicine Phase II Year III, CMD 332 Pathology Department 31-32 Describe the etiology, pathogenesis and types of peritonitis Define ascites and

More information

Pleural Disease Chapter 14

Pleural Disease Chapter 14 14 Pleural Disease The pleura is a thin tissue covered by a layer of cells (mesothelial cells) that surrounds the lungs and lines the inside of the chest wall. The pleural space is the area between the

More information

Round Table with Drs. Anne Tsao and Alex Farivar, Case 2: Mesothelioma

Round Table with Drs. Anne Tsao and Alex Farivar, Case 2: Mesothelioma Round Table with Drs. Anne Tsao and Alex Farivar, Case 2: Mesothelioma I d like to welcome everyone, thanks for coming out to our lunch with experts. The faculty today are great people in the thoracic

More information

Instructions for Use

Instructions for Use Pleural Effusion Shunt with External Pump Chamber Catalog No. 42-9005 Instructions for Use Denver Biomedical, Inc. Table of Contents Description 2 Indications 2 Contraindications 2 Warnings 4 Cautions

More information

International Journal of Case Reports in Medicine

International Journal of Case Reports in Medicine International Journal of Case Reports in Medicine Vol. 2013 (2013), Article ID 409830, 15 minipages. DOI:10.5171/2013.409830 www.ibimapublishing.com Copyright 2013 Andrew Thomas Low, Iain Smith and Simon

More information

Malignant Mesothelioma

Malignant Mesothelioma Malignant Malignant mesothelioma is a tumour originating from mesothelial cells. 85 95% of mesotheliomas are caused by asbestos exposure. It occurs much more commonly in the chest (malignant pleural mesothelioma)

More information

Malignant Mesothelioma

Malignant Mesothelioma Malignant mesothelioma is a tumour originating from mesothelial cells. 85 95% of mesotheliomas are caused by asbestos exposure. It occurs much more commonly in the chest (malignant pleural mesothelioma)

More information

TUBERCULOSIS PLEURAL EFFUSION - MANAGEMENT

TUBERCULOSIS PLEURAL EFFUSION - MANAGEMENT TUBERCULOSIS PLEURAL EFFUSION - MANAGEMENT Introduction : ETB 15-20% Pleural effusion 20% in non HIV Under reporting because of AFB negative in fluid In HIV patients: EPTB 20% PTB + EPTB 50% Pleural Effusion

More information

Mesothelioma. Malignant Pleural Mesothelioma

Mesothelioma. Malignant Pleural Mesothelioma Mesothelioma William G. Richards, PhD Brigham and Women s Hospital Malignant Pleural Mesothelioma 2,000-3,000 cases per year (USA) Increasing incidence Asbestos (50-80%, decreasing) 30-40 year latency

More information

GUIDELINES FOR THE MANAGEMENT OF LUNG CANCER

GUIDELINES FOR THE MANAGEMENT OF LUNG CANCER GUIDELINES FOR THE MANAGEMENT OF LUNG CANCER BY Ali Shamseddine, MD (Coordinator); as04@aub.edu.lb Fady Geara, MD Bassem Shabb, MD Ghassan Jamaleddine, MD CLINICAL PRACTICE GUIDELINES FOR THE TREATMENT

More information

Extrapleural Pneumonectomy for Malignant Mesothelioma: Pro. Joon H. Lee 9/17/2012

Extrapleural Pneumonectomy for Malignant Mesothelioma: Pro. Joon H. Lee 9/17/2012 Extrapleural Pneumonectomy for Malignant Mesothelioma: Pro Joon H. Lee 9/17/2012 Malignant Pleural Mesothelioma (Epidemiology) Incidence: 7/mil (Japan) to 40/mil (Australia) Attributed secondary to asbestos

More information

MANAGEMENT OF MALIGNANT PLEURAL EFFUSION

MANAGEMENT OF MALIGNANT PLEURAL EFFUSION MANAGEMENT OF MALIGNANT PLEURAL EFFUSION Effective Date: October, 2014 The recommendations contained in this guideline are a consensus of the Alberta Provincial Lung Tumour Team and are a synthesis of

More information

Pre-workshop exercise

Pre-workshop exercise Setting research priorities for mesothelioma workshop 10 th November 2014 Pre-workshop exercise Your individual ranking of unanswered questions about the diagnosis, treatment and care of mesothelioma Please

More information

PERCUTANOUS TUBE THORACOSTOMY

PERCUTANOUS TUBE THORACOSTOMY PERCUTANOUS TUBE THORACOSTOMY Suveer Singh BSc MBBS FRCP PhD EDIC BDICM Consultant Pulmonary and Critical Care Chelsea and Westminster Hospital London, UK Suveer.singh@imperial.ac.uk September 2007 Anatomy

More information

Gallbladder cancer is a disease in which malignant (cancer) cells form in the tissues of the gallbladder.

Gallbladder cancer is a disease in which malignant (cancer) cells form in the tissues of the gallbladder. Gallbladder cancer Gallbladder cancer is a disease in which malignant (cancer) cells form in the tissues of the gallbladder. Gallbladder cancer is a rare disease in which malignant (cancer) cells are found

More information

Simple Thoracostomy Avoids Chest Drain Insertion in Prehospital Trauma

Simple Thoracostomy Avoids Chest Drain Insertion in Prehospital Trauma Simple Thoracostomy Avoids Chest Drain Insertion in Prehospital Trauma Deakin, C. D. MA, MRCP, FRCA; Davies, G. MRCP; Wilson, A. FRCS Author Information From the Helicopter Emergency Medical Service, Royal

More information

The diagnostic usefulness of tumour markers CEA and CA-125 in pleural effusion

The diagnostic usefulness of tumour markers CEA and CA-125 in pleural effusion Malaysian J Path01 2002; 24(1) : 53-58 The diagnostic usefulness of tumour markers CEA and CA-125 in pleural effusion Pavai STHANESHWAR MD, Sook-Fan YAP FRCPath, FRCPA and Gita JAYARAM MDPath, MRCPath

More information

Thymus Cancer. This reference summary will help you better understand what thymus cancer is and what treatment options are available.

Thymus Cancer. This reference summary will help you better understand what thymus cancer is and what treatment options are available. Thymus Cancer Introduction Thymus cancer is a rare cancer. It starts in the small organ that lies in the upper chest under the breastbone. The thymus makes white blood cells that protect the body against

More information

Principal Investigator: Valerie W. Rusch, MD, FACS, Chief, Thoracic Surgery Memorial Sloan-Kettering Cancer Center

Principal Investigator: Valerie W. Rusch, MD, FACS, Chief, Thoracic Surgery Memorial Sloan-Kettering Cancer Center Protocol 1101-1088 Phase I study of intra-pleural administration of GL-ONC1 in patients with malignant pleural effusion: primary, metastases and mesothelioma Principal Investigator: Valerie W. Rusch, MD,

More information

There are a number of other carcinogens (cancer causing agents) that are believed to be associated with lung cancer, and are reviewed elsewhere.

There are a number of other carcinogens (cancer causing agents) that are believed to be associated with lung cancer, and are reviewed elsewhere. Lung Cancer What is cancer? First, some background on the way the body is built. Organs, like the heart, liver, and lung, are made up of tissues, such as blood vessels and muscle. Tissues, in turn, are

More information

Surgery. Wedge resection only part of the lung, not. not a lobe, is removed. Cancer Council NSW

Surgery. Wedge resection only part of the lung, not. not a lobe, is removed. Cancer Council NSW The treatment you receive will depend on your lung cancer type, for example, whether you have a non-small cell lung cancer Adenocarcinoma or Squamous cell carcinoma, and if this is a sub-type with a mutation.

More information

Thoracentesis and Pleural Effusions

Thoracentesis and Pleural Effusions Thoracentesis and Pleural Effusions Fletcher T. Penney, MD, FHM Medical University of South Carolina Department of Medicine June 6, 2013 / Hospital Medicine Curriculum 1 / 44 Outline Introduction Indications

More information

INTERNATIONAL TRAUMA LIFE SUPPORT

INTERNATIONAL TRAUMA LIFE SUPPORT INTERNATIONAL TRAUMA LIFE SUPPORT NEEDLE DECOMPRESSION OF TENSION PNEUMOTHORAX Roy Alson, MD, PhD, FACEP, FAAEM and Sabina Braithwaite, MD, MPH, FACEP INTRODUCTION The purpose of this document is to update

More information

Thoracoscopy in Pleural Malignant Mesothelioma

Thoracoscopy in Pleural Malignant Mesothelioma Diagnostic and Therapeutic Endoscopy, 1997, Vol. 3, pp. 147-151 Reprints available directly from the publisher Photocopying permitted by license only (C) 1997 OPA (Overseas Publishers Association) Amsterdam

More information

NEEDLE THORACENTESIS Pneumothorax / Hemothorax

NEEDLE THORACENTESIS Pneumothorax / Hemothorax NEEDLE THORACENTESIS Pneumothorax / Hemothorax By: Steven Jones, NREMT-P Pneumothorax Pneumothorax is a collection of air or gas in the pleural space of the lung, causing the lung to collapse. Pneumothorax

More information

A Practical Guide to Advances in Staging and Treatment of NSCLC

A Practical Guide to Advances in Staging and Treatment of NSCLC A Practical Guide to Advances in Staging and Treatment of NSCLC Robert J. Korst, M.D. Director, Thoracic Surgery Medical Director, The Blumenthal Cancer Center The Valley Hospital Objectives Revised staging

More information

Lung Cancer Understanding your diagnosis

Lung Cancer Understanding your diagnosis Lung Cancer Understanding your diagnosis Lung Cancer Understanding your diagnosis When you first hear that you have cancer you may feel alone and afraid. You may be overwhelmed by the large amount of information

More information

CERVICAL MEDIASTINOSCOPY WITH BIOPSY

CERVICAL MEDIASTINOSCOPY WITH BIOPSY INFORMED CONSENT INFORMATION ADDRESSOGRAPH DATA CERVICAL MEDIASTINOSCOPY WITH BIOPSY You have decided to have an important procedure and we appreciate your selection of UCLA Healthcare to meet your needs.

More information

Aspira* Peritoneal Drainage Catheter

Aspira* Peritoneal Drainage Catheter Aspira* Peritoneal Drainage Catheter Instructions For Use Access Systems Product Description: The Aspira* Peritoneal Drainage Catheter is a tunneled, long-term catheter used to drain accumulated fluid

More information

Screening, early referral and treatment for asbestos related cancer

Screening, early referral and treatment for asbestos related cancer Screening, early referral and treatment for asbestos related cancer Marc de Perrot, MD, MSc, FRCSC Toronto Mesothelioma Research Program University of Toronto Asbestos related diseases Mesothelioma Lung

More information

Chest X-rays: Author Dr R Katz. Chest X-rays: Programme 3

Chest X-rays: Author Dr R Katz. Chest X-rays: Programme 3 Chest X-rays: Programme 3 In the previous tutorial we looked at the different causes and appearances of increased shadowing in the lungs. I will start this tutorial by briefly looking at the causes of

More information

Lung Cancer: Diagnosis, Staging and Treatment

Lung Cancer: Diagnosis, Staging and Treatment PATIENT EDUCATION patienteducation.osumc.edu Lung Cancer: Diagnosis, Staging and Treatment Cancer begins in our cells. Cells are the building blocks of our tissues. Tissues make up the organs of the body.

More information

New Cardiothoracic Surgery CPT Codes for 2013

New Cardiothoracic Surgery CPT Codes for 2013 New Cardiothoracic Surgery CPT Codes for 2013 There were several changes to the cardiothoracic surgery CPT codes for 2013. There are five new codes in the general thoracic surgery section, with one revised

More information

Lung Cancer: Diagnosis, Staging and Treatment

Lung Cancer: Diagnosis, Staging and Treatment PATIENT EDUCATION patienteducation.osumc.edu Lung Cancer: Diagnosis, Staging and Treatment Cancer starts in our cells. Cells are the building blocks of our tissues. Tissues make up the organs of the body.

More information

BTS Pleural Disease Guideline 2010

BTS Pleural Disease Guideline 2010 ISSN 2040-2023 August 2010 BTS Pleural Disease Guideline 2010 A Quick Reference Guide British Thoracic Society www.brit-thoracic.org.uk BTS PLEURAL DISEASE GUIDELINE 2010 A QUICK REFERENCE GUIDE British

More information

catheter system catalog PleurX PleurX

catheter system catalog PleurX PleurX PleurX catheter system catalog New indication: The PleurX pleural catheter can be used in place of a chest tube to deliver talc slurry or bleomycin, giving you an additional treatment option. Help your

More information

Neoplasms of the LUNG and PLEURA

Neoplasms of the LUNG and PLEURA Neoplasms of the LUNG and PLEURA 2015-2016 FCDS Educational Webcast Series Steven Peace, BS, CTR September 19, 2015 2015 Focus o Anatomy o SSS 2000 o MPH Rules o AJCC TNM 1 Case 1 Case Vignette HISTORY:

More information

Dr. Peters has declared no conflicts of interest related to the content of his presentation.

Dr. Peters has declared no conflicts of interest related to the content of his presentation. Steve G. Peters, MD Dr. Peters has declared no conflicts of interest related to the content of his presentation. Disclosure No financial disclosure I serve on Advisory Committee to the AMA CPT Panel from

More information

X-Plain Subclavian Inserted Central Catheter (SICC Line) Reference Summary

X-Plain Subclavian Inserted Central Catheter (SICC Line) Reference Summary X-Plain Subclavian Inserted Central Catheter (SICC Line) Reference Summary Introduction A Subclavian Inserted Central Catheter, or subclavian line, is a long thin hollow tube inserted in a vein under the

More information

Mesothelioma: Questions and Answers

Mesothelioma: Questions and Answers CANCER FACTS N a t i o n a l C a n c e r I n s t i t u t e N a t i o n a l I n s t i t u t e s o f H e a l t h D e p a r t m e n t o f H e a l t h a n d H u m a n S e r v i c e s Mesothelioma: Questions

More information

INTRAPERITONEAL HYPERTHERMIC CHEMOTHERAPY (IPHC) FOR PERITONEAL CARCINOMATOSIS AND MALIGNANT ASCITES. INFORMATION FOR PATIENTS AND FAMILY MEMBERS

INTRAPERITONEAL HYPERTHERMIC CHEMOTHERAPY (IPHC) FOR PERITONEAL CARCINOMATOSIS AND MALIGNANT ASCITES. INFORMATION FOR PATIENTS AND FAMILY MEMBERS INTRAPERITONEAL HYPERTHERMIC CHEMOTHERAPY (IPHC) FOR PERITONEAL CARCINOMATOSIS AND MALIGNANT ASCITES. INFORMATION FOR PATIENTS AND FAMILY MEMBERS Description of Treatment A major difficulty in treating

More information

Lung Cancer. This reference summary will help you better understand lung cancer and the treatment options that are available.

Lung Cancer. This reference summary will help you better understand lung cancer and the treatment options that are available. Lung Cancer Introduction Lung cancer is the number one cancer killer of men and women. Over 165,000 people die of lung cancer every year in the United States. Most cases of lung cancer are related to cigarette

More information

Mesothelioma. 1995-2013, The Patient Education Institute, Inc. www.x-plain.com ocft0101 Last reviewed: 03/21/2013 1

Mesothelioma. 1995-2013, The Patient Education Institute, Inc. www.x-plain.com ocft0101 Last reviewed: 03/21/2013 1 Mesothelioma Introduction Mesothelioma is a type of cancer. It starts in the tissue that lines your lungs, stomach, heart, and other organs. This tissue is called mesothelium. Most people who get this

More information

A 53-year-old woman presented in September 1991 to Adiyaman State Hospital with pain on the left side of the chest, dyspnoea, and dry cough.

A 53-year-old woman presented in September 1991 to Adiyaman State Hospital with pain on the left side of the chest, dyspnoea, and dry cough. Mesotelioma de pulmão - DR H. Ziya Ozel - Nerium oleander Nerium oleander Usou ANVIRZEL extrato da planta CASE REPORT Diagnosis: Mesothelioma - HD A 53-year-old woman presented in September 1991 to Adiyaman

More information

PERIPHERAL STEM CELL TRANSPLANT INTRODUCTION

PERIPHERAL STEM CELL TRANSPLANT INTRODUCTION PERIPHERAL STEM CELL TRANSPLANT INTRODUCTION This booklet was designed to help you and the important people in your life understand the treatment of high dose chemotherapy with stem cell support: a procedure

More information

Malignant Mesothelioma Current Approaches to a Difficult Problem. Raja M Flores, MD Thoracic Surgery Memorial Sloan-Kettering Cancer Center

Malignant Mesothelioma Current Approaches to a Difficult Problem. Raja M Flores, MD Thoracic Surgery Memorial Sloan-Kettering Cancer Center Malignant Mesothelioma Current Approaches to a Difficult Problem Raja M Flores, MD Thoracic Surgery Memorial Sloan-Kettering Cancer Center Malignant Pleural Mesothelioma Clinical Presentation Insidious

More information

Smoking and misuse of certain pain medicines can affect the risk of developing renal cell cancer.

Smoking and misuse of certain pain medicines can affect the risk of developing renal cell cancer. Renal cell cancer Renal cell cancer is a disease in which malignant (cancer) cells form in tubules of the kidney. Renal cell cancer (also called kidney cancer or renal adenocarcinoma) is a disease in which

More information

Introduction Breast cancer is cancer that starts in the cells of the breast. Breast cancer happens mainly in women. But men can get it too.

Introduction Breast cancer is cancer that starts in the cells of the breast. Breast cancer happens mainly in women. But men can get it too. Male Breast Cancer Introduction Breast cancer is cancer that starts in the cells of the breast. Breast cancer happens mainly in women. But men can get it too. Many people do not know that men can get breast

More information

September 2008 [KT 168] Sub. Code: 2063 M.D. DEGREE EXAMINATION Branch XVII Tuberculosis and Respiratory Diseases NON-TUBERCULOSIS CHEST DISEASES Common to Part II Paper II - (Old /New/Revised Regulations)

More information

The Need for Accurate Lung Cancer Staging

The Need for Accurate Lung Cancer Staging The Need for Accurate Lung Cancer Staging Peter Baik, DO Thoracic Surgery Cancer Treatment Centers of America Oklahoma Osteopathic Association 115th Annual Convention Financial Disclosures: None 2 Objectives

More information

Recent Advances in the Diagnosis and Management of Malignant Pleural Effusions

Recent Advances in the Diagnosis and Management of Malignant Pleural Effusions SYMPOSIUM MALIGNANT ON SOLID PLEURAL TUMORS EFFUSIONS Recent Advances in the Diagnosis and Management of Malignant Pleural Effusions JOHN E. HEFFNER, MD, AND JEFFREY S. KLEIN, MD Malignant pleural effusions

More information

Diagnosis and Treatment of Pleural Effusion

Diagnosis and Treatment of Pleural Effusion RECOMMENDATIONS OF THE SPANISH SOCIETY OF PULMONOLOGY AND THORACIC SURGERY (SEPAR) Diagnosis and Treatment of Pleural Effusion 143.719 Victoria Villena Garrido (coordinator), a Jaime Ferrer Sancho, b Hernández

More information

Post-operative intrapleural chemotherapy for mesothelioma

Post-operative intrapleural chemotherapy for mesothelioma Post-operative intrapleural chemotherapy for mesothelioma Robert Kratzke, MD John Skoglund Chair for Lung Cancer Research Section of Heme-Onc-Transplant University of Minnesota Medical School Efficacy

More information

Thoracic Cavity. Photo: This normal canine lung collapsed when the thorax was opened and the negative pressure was lost in the thorax.

Thoracic Cavity. Photo: This normal canine lung collapsed when the thorax was opened and the negative pressure was lost in the thorax. Thoracic Cavity There are significant anatomical differences in the mediastinum of domestic animals. For instance, bovines, like humans, have well-developed mediastinal separation between the left and

More information

Breast Cancer. Sometimes cells keep dividing and growing without normal controls, causing an abnormal growth called a tumor.

Breast Cancer. Sometimes cells keep dividing and growing without normal controls, causing an abnormal growth called a tumor. Breast Cancer Introduction Cancer of the breast is the most common form of cancer that affects women but is no longer the leading cause of cancer deaths. About 1 out of 8 women are diagnosed with breast

More information

Mesothelioma is almost always caused by exposure to asbestos and can develop decades after the exposure.

Mesothelioma is almost always caused by exposure to asbestos and can develop decades after the exposure. Mesothelioma Summary Mesothelioma is a rare type of cancer that can develop decades after exposure to asbestos. Mesothelioma usually targets the outer membrane of the lungs (pleura), but can also occur

More information

Management of Bile Duct Problems Treatment Overview

Management of Bile Duct Problems Treatment Overview Management of Bile Duct Problems Treatment Overview Bile Duct Obstruction Bile duct (or biliary) obstruction occurs for numerous reasons. Causes can include cancerous and non-cancerous processes as well

More information

2011 Radiology Diagnosis Coding Update Questions and Answers

2011 Radiology Diagnosis Coding Update Questions and Answers 2011 Radiology Diagnosis Coding Update Questions and Answers How can we subscribe to the Coding Clinic for ICD-9 guidelines and updates? The American Hospital Association publishes this quarterly newsletter.

More information

PET/CT in Lung Cancer

PET/CT in Lung Cancer PET/CT in Lung Cancer Rodolfo Núñez Miller, M.D. Nuclear Medicine and Diagnostic Imaging Section Division of Human Health International Atomic Energy Agency Vienna, Austria GLOBOCAN 2012 #1 #3 FDG-PET/CT

More information

Non-Small Cell Lung Cancer

Non-Small Cell Lung Cancer Non-Small Cell Lung Cancer About Your Lungs and Lung Cancer How do your lungs work? To understand lung cancer it is helpful to understand your lungs. Your lungs put oxygen into the blood, which the heart

More information

SMALL CELL LUNG CANCER

SMALL CELL LUNG CANCER Protocol for Planning and Treatment The process to be followed in the management of: SMALL CELL LUNG CANCER Patient information given at each stage following agreed information pathway 1. DIAGNOSIS New

More information

UNIVERSITA' DEGLI STUDI DI ROMA TOR VERGATA

UNIVERSITA' DEGLI STUDI DI ROMA TOR VERGATA SYSTEMATIC PATHOLOGY I IIIYear Scientific Field DISCIPLINE TUTOR Systematic Pathology I MED/21 MED/10 Thoracic Surgery Respiratory Diseases Tommaso Claudio Mineo Paola Rogliani MED/10 Respiratory Diseases

More information

FELINE PLEURAL DISEASE Diagnosis and Treatment

FELINE PLEURAL DISEASE Diagnosis and Treatment FELINE PLEURAL DISEASE Diagnosis and Treatment Philip Padrid, DVM Southwest Regional Medical Director Veterinary Centers of America Associate Professor of Medicine University of Chicago (adjunct) The Ohio

More information

Preoperative Laboratory and Diagnostic Studies

Preoperative Laboratory and Diagnostic Studies Preoperative Laboratory and Diagnostic Studies Preoperative Labratorey and Diagnostic Studies The concept of standardized testing in all presurgical patients regardless of age or medical condition is no

More information

Avastin: Glossary of key terms

Avastin: Glossary of key terms Avastin: Glossary of key terms Adenocarcinoma Adenoma Adjuvant therapy Angiogenesis Anti-angiogenics Antibody Antigen Avastin (bevacizumab) Benign A form of carcinoma that originates in glandular tissue.

More information

Effusions of the Serous Cavities

Effusions of the Serous Cavities Effusions of the Serous Cavities Annika Dejmek Professor/Consultant in Cytopathology Clinical Pathology; Department of Laboratory Medicine, Malmö, Lund University 5th EFCS Tutorial Trondheim 2012 Pleura

More information

Radiation Therapy in the Treatment of

Radiation Therapy in the Treatment of Lung Cancer Radiation Therapy in the Treatment of Lung Cancer JMAJ 46(12): 537 541, 2003 Kazushige HAYAKAWA Professor and Chairman, Department of Radiology, Kitasato University School of Medicine Abstract:

More information

Suffering from varicose veins? Patient Information. ELVeS Radial Minimally invasive laser therapy of venous insufficiency

Suffering from varicose veins? Patient Information. ELVeS Radial Minimally invasive laser therapy of venous insufficiency Suffering from varicose veins? Patient Information ELVeS Radial Minimally invasive laser therapy of venous insufficiency Do you suffer from heavy legs or visible veins? This makes diseases of the veins

More information

Mesothelioma Understanding your diagnosis

Mesothelioma Understanding your diagnosis Mesothelioma Understanding your diagnosis Mesothelioma Understanding your diagnosis When you first hear that you have cancer, you may feel alone and afraid. You may be overwhelmed by the large amount of

More information

Empyema: An Uncommon Complication of Common Pneumonia

Empyema: An Uncommon Complication of Common Pneumonia March 2011 Empyema: An Uncommon Complication of Common Pneumonia Heather Hsu, HMS III Overview Patient presentation History of present illness and other relevant information Menu of appropriate radiologic

More information

CHAPTER 2. Neoplasms (C00-D49) March 2014. 2014 MVP Health Care, Inc.

CHAPTER 2. Neoplasms (C00-D49) March 2014. 2014 MVP Health Care, Inc. Neoplasms (C00-D49) March 2014 2014 MVP Health Care, Inc. CHAPTER SPECIFIC CATEGORY CODE BLOCKS C00-C14 Malignant neoplasms of lip, oral cavity and pharynx C15-C26 Malignant neoplasms of digestive organs

More information

Cardiac Masses and Tumors

Cardiac Masses and Tumors Cardiac Masses and Tumors Question: What is the diagnosis? A. Aortic valve myxoma B. Papillary fibroelastoma C. Vegetation from Infective endocarditis D. Thrombus in transit E. None of the above Answer:

More information