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: [email protected] (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:

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