impact of repeated thoracentesis on the outcome of chemical pleurodesis in malignant pleural effusion

Repeated thoracentesis may cause pleural inflammation and induce local release of proinfammatory cytokine as tumor necrosis factor-alpha [TNF-alpha] which may subsequently enhance the release of plasminogen activator inhibitor-1 [PAI-1] and lead to fibrin formation in malignant effusion. The presence of fibrin strands after repeated thoracentesis may be of considerable value in predicting the success of subsequent pleurodesis in patients with malignant pleural effusions [MPEs]. So, the aim of this work is to study the impact of repeated thoracentesis on the outcome of chemical pleurodesis in MPE. This is a retrospective study included 116 patients with MPE, they were diagnosed finally by pleural fluid [PF] cytology and/or either computed tomography [CT]-guided biopsy or tissue biopsy [Abram's or thoracoscopic biopsy]. These patients were admitted and subjected to the following: a] Pleural tapping and the aspirated fluid was sent for chemical, cytological and bacteriological examinations for determination of the inclusion criteria, [b] Tube thoracostomy insertion, [c] Pleurodesis, and assessment of the response to pleurodesis was done once after 30 days and another after 60 days. Regarding pleurodesis success or failure in this work, there was statistically highly significant decrease in the duration of chest tube before pleurodesis in patients with successful pleurodesis than that in patients with failed one. But, statistically non-significant decrease was observed in the duration of chest tube after pleurodesis in patients with successful pleurodesis than that in patients with failed one. There was statistically significant negative correlation between the number of pleural fluid [PF] aspiration and the duration of chest tube after pleurodesis and statistically nonsignificant negative correlation between the number of PF aspiration and the duration of chest tube before pleurodesis. Also, to predict the success of the pleurodesis, after 30 days of pleurodesis with cut-point of PF aspiration number >7 times, sensitivity and specificity were 75.3% and 65.7% respectively and after 60 days of pleurodesis, also, at cut-point of PF aspiration number >7 times, sensitivity of 80.3% was higher than that after 30 days of pleurodesis and specificity of 64.4% which was near that after 30 days of pleurodesis. Repeated thoracentesis may be of considerable value in predicting the success of subsequent chemical pleurodesis in MPE. Repeated thoracentesis of MPE >7 times has good sensitivity, but low specificity in predicting success of subsequent chemical pleurodesis. Measurement of PF glucose levels and PF cytology provide information about the outcome of chemical pleurodesis in MPE

Effectiveness and safety of outpatient pleurodesis in patients with recurrent malignant pleural effusion and low performance status

OBJECTIVES: To evaluate the effectiveness and safety of pleurodesis carried out entirely on an outpatient basis in patients with recurrent malignant pleural effusions and Karnofsky Performance Status scores <70. METHODS: This study was a prospective trial comprising patients with symptomatic recurrent malignant pleural effusion and Karnofsky Performance Status scores <70 but >30. All selected patients underwent pleural catheter placement (14 Fr) in an outpatient facility. When chest radiography revealed post-drainage lung expansion of >90 percent, pleurodesis (3 g of talc) was performed. Catheters were maintained until the daily output was ,100 mL/day. The patients were evaluated in the first month and every three months thereafter for fluid recurrence, the need for additional procedures, and complications. RESULTS: During the study period (January 2005 to July 2007), 64 patients (24 men, 40 women), with an average age of 61.4 years, underwent elective chest tube drainage. Primary sites of the underlying malignancy were breast (27), lung (22), and others (15). Sixty-six pleural catheters were placed (bilaterally in 2 patients), and 52 talc pleurodesis procedures were performed. Fourteen patients had a trapped lung and were excluded from the trial. No complications were observed during catheter placement or pleurodesis. Post-pleurodesis complications included catheter obstruction (4 patients) and empyema (1). The average drainage time was 9.9 days. The recurrence rate observed in patients that were alive 30 days after pleurodesis was 13.9 percent (5/36 patients). Six patients required additional procedures after the pleurodesis. The average survival time was 101 days. CONCLUSION: In this study, talc pleurodesis was safely performed in an outpatient setting with good efficacy and a reasonable complication rate, thereby avoiding hospital admission.

Pleurodese nos derrames pleurais malignos: um inquérito entre médicos em países da América do Sul e Central / Pleurodesis for malignant pleural effusions: a survey of physicians in South and Central America

OBJETIVO: A pleurodese é uma alternativa eficaz no controle dos derrames pleurais malignos, mas existem controvérsias a respeito de sua indicação e técnica. O objetivo deste estudo foi avaliar como é realizada a pleurodese em países da América do Sul e Central. MÉTODOS: Profissionais que realizam pleurodese responderam um questionário sobre critérios de indicação para pleurodese, técnicas utilizadas e desfechos. RESULTADOS: Nossa amostra envolveu 147 profissionais no Brasil, 49 em outros países da América do Sul e 36 em países da América Central. Mais de 50 por cento dos participantes realizavam pleurodese somente se confirmada a malignidade no derrame pleural. Entretanto, escalas de dispneia e de status de performance eram raramente utilizadas para indicar o procedimento. Aproximadamente 75 por cento dos participantes no Brasil e na América Central preferiam realizar a pleurodese somente no caso de recidiva do derrame, e a expansão pulmonar deveria variar de 90 por cento a 100 por cento. O talco slurry foi o agente mais utilizado, instilado via drenos de calibre intermediário. A toracoscopia foi realizada em menos de 25 por cento dos casos. Febre e dor torácica foram os efeitos adversos mais comuns, e empiema ocorreu em < 14 por cento dos casos. A média de sobrevida após o procedimento variou entre 6 e 12 meses. CONCLUSÕES: Há variações consideráveis quanto aos critérios de indicação para pleurodese, técnicas utilizadas e desfechos entre os países. Talco slurry é o agente mais frequentemente utilizado, e a toracoscopia é a primeira escolha no Brasil. Os baixos índices de complicações e o tempo de sobrevida elevado indicam que a pleurodese é efetiva e causa poucos efeitos adversos.

OBJECTIVE: Pleurodesis is an effective alternative for the control of malignant pleural effusions. However, there is as yet no consensus regarding the indications for the procedure and the techniques employed therein. The objective of this study was to evaluate how pleurodesis is performed in South and Central America. METHODS: Professionals who perform pleurodesis completed a questionnaire regarding the indications for the procedure, the techniques used therein, and the outcomes obtained. RESULTS: Our sample comprised 147 respondents in Brazil, 49 in other South American countries, and 36 in Central America. More than 50 percent of the respondents reported performing pleurodesis only if pleural malignancy had been confirmed. However, scores on dyspnea and performance status scales were rarely used as indications for the procedure. Nearly 75 percent of the respondents in Brazil and in Central America preferred to perform pleurodesis only for recurrent effusions and stated that lung expansion should be 90-100 percent. Talc slurry, instilled via medium-sized chest tubes, was the agent most often employed. Thoracoscopy was performed in less than 25 percent of cases. Fever and chest pain were the most common side effects, and empyema occurred in < 14 percent of cases. The mean survival time after the procedure was most often reported to be 6-12 months. CONCLUSIONS: There was considerable variation among the countries evaluated in terms of the indications for pleurodesis, techniques used, and outcomes. Talc slurry is the agent most commonly used, and thoracoscopy is the technique of choice in Brazil. Pleurodesis is an effective procedure that has few side effects, as evidenced by the low complication rates and high survival times.

Inflammation and clinical repercussions of pleurodesis induced by intrapleural talc administration

Although reports on pleurodesis date back to the beginning of the 20th century, the search for the ideal sclerosing agent is ongoing. Several agents have been studied and used, but talc continues to be the most popular. However, potentially harmful systemic side effects have been associated with talc pleurodesis. In this article we discuss the likely mechanisms of pleural inflammation and pleurodesis with emphasis on the systemic response due to the instillation of talc into the pleural space.

Apesar dos relatos sobre pleurodese remontarem ao início do século XX, ainda hoje se busca o agente esclerosante ideal. Diversos agentes foram estudados e utilizados, mas o talco é considerado o mais popular. No entanto, efeitos sistêmicos potencialmente tóxicos tem sido associados à pleurodese pelo talco. Neste artigo discutimos os prováveis mecanismos de inflamação pleural e pleurodese, com ênfase na resposta sistêmica produzida pela instilação intrapleural de talco.

Importancia del pH del derrame pleural maligno en la efectividad de la pleurodesis química con Bleomycina

Con el objeto de averiguar si el pH del Líquido Pleural del paciente con Derrame Pleural Maligno (DPM) altera la eficiencia de la Preurodesis Química con Bleomycyna, se realizó este procedimiento con dosis de 1mg/k, a 33 pacientes del Hospital Santa Clara de Bogotá entre los meses de febrero de 1991 y enero de 1993. Para ingresar al estudio los pacientes debían cumplir los siguientes requisitos: 1) No haber recibido tratamiento previo para su enfermedad neoplásica (radio, quimioterapia, drenajes previos, etc.). 2) Reexpansión completa del pulmón y drenaje total del derrame pleural Post-toracostomía cerrada. 3. Puntaje de Karnofsky mayor de 60. 4) Medición del pH del líquido pleural. 5) Comprobación por biopsia pleural de compromiso metastásico de la pleura. Se realizó control clínico y radiológico de los pacientes a los 30 días de realizada la Pleurodesis Química. 3 pacientes no ingresaron a este análisis: Uno por fallecer antes del plazo descrito y dos por haber presentado Empiema como complicación. Se comparó la efectividad de la Pleurodesis con Bleomycina en los pacientes que tenían pH del líquido pleural menor a 7.3 con el grupo de pacientes que tenían cifras mayores e iguales a esa cifra: se encontró que la efectividad del procedimiento era del 30 por ciento en el primer grupo y del 85 por ciento en el segundo. (p = 0.01). La "respuesta parcial" se consideró como efectividad en ambos grupos. Así se sugiere, por primera vez en la literatura disponible, que la efectividad de la pleurodesis con Bleomycina, del mismo modo que ocurre con la Tetraciclina, varía de acuerdo al pH previo del líquido pleural.