Sioris T, Sihvo E, Salo J, Räsänen J, Knuuttila A.

Heart Center, Tampere University Hospital, P.O. Box 2000, FIN-33521 Tampere, Finland.

Abstract

Aims: Talc pleurodesis using talc slurry via chest tube is a primary option in malignant pleural effusion, since life expectancy is short and surgical decortication is hazardous. Incomplete lung expansion after fluid evacuation, and/or excessive fluid secretion predicts failure of pleurodesis. A mini-invasive alternative was investigated.

Methods: Between March 2004 and September 2005, 51 consecutive patients with malignant pleural effusion, and clinically considered unsuitable for talc pleurodesis, received an indwelling pleural catheter (Denver PleurX). In 47, implantation was done bedside using local anaesthesia. There were 24 men and 27 women, median age 63 (range 36–85) years, receiving 39 right side, 10 left side, and 2 bilateral catheters. There were 19 non-small cell lung cancer cases, 7 mesothelioma, and 25 with other malignancy. Chemotherapy was being given to 18 patients and was not interrupted.

Results: Discharge to home was possible in 71% (36 of 71 patients) on the following day. At 2 years follow-up in September 2007, one patient was alive. Mean survival was 3 months (range 5 days to 37+ months) for all patients, with best median survivals of 5.5–6 months in breast and ovarian cancer. Catheter was removed or replaced in 15% (8 of 51 patients) due to infection, air leak, or blockage. One patient requested decortication for excessive fluid secretion. None required surgery or died due to catheter-related complications. Pleural fusion with subsequent catheter removal was achieved in 21% (11 of 51 patients).

Conclusions: An indwelling pleural catheter is a safe alternative for patients with malignant pleural effusion unsuitable for talc pleurodesis. In some, pleural fusion may be achieved.

Keywords: Malignant pleural effusion; PleurX; Indwelling; Implantable; Catheter

Barone-Adesi F, Ferrante D, Bertolotti M, Todesco A, Mirabelli D, Terracini B, Magnani C.

Unit of Cancer Epidemiology, CeRMS and Center for Oncologic Prevention Piemonte, University of Turin, Turin, Italy.

Abstract

Models based on the multistage theory of carcinogenesis predict that the rate of mesothelioma increases monotonically as a function of time since first exposure (TSFE) to asbestos. Predictions of long-term mortality (TSFE >/= 40 years) are, however, still untested, because of the limited follow-up of most epidemiological studies. Some authors have suggested that the increase in mesothelioma rate with TSFE might be attenuated by clearance of asbestos from the lungs. We estimated mortality time trends from pleural and peritoneal cancer in a cohort of 3,443 asbestos-cement workers, followed for more than 50 years. The functional relation between mesothelioma rate and TSFE was evaluated with various regression models. The role of asbestos clearance was explored using the traditional mesothelioma multistage model, generalized to include a term representing elimination over time. We observed 139 deaths from pleural and 56 from peritoneal cancer during the period 1950-2003. The rate of pleural cancer increased during the first 40 years of TSFE and reached a plateau thereafter. In contrast, the rate of peritoneal cancer increased monotonically with TSFE. The model allowing for asbestos elimination fitted the data better than the traditional model for pleural (p = 0.02) but not for peritoneal cancer (p = 0.22). The risk for pleural cancer, rather than showing an indefinite increase, might reach a plateau when a sufficiently long time has elapsed since exposure. The different trends for pleural and peritoneal cancer might be related to clearance of the asbestos from the workers’ lungs.

Keywords: asbestos, mesothelioma, multi-stage model, latency, clearance

Qureshi RA, Collinson SL, Powell RJ, Froeschle PO, Berrisford RG.

Department of Thoracic Surgery,Exeter NHS Research and Development Support Unit Royal Devon & Exeter NHS Foundation Trust Exeter, United Kingdom. rizwanqureshi2@aol.com

Abstract

Management of recurrent malignant pleural effusion associated with trapped lung syndrome remains problematic. An alternative treatment using a pleural catheter has been advocated. Between August 1999 and August 2002, 127 patients underwent thoracoscopy for malignant pleural effusion. Of these, 52 (41%) with trapped lung were managed by insertion of a pleural catheter. Mean age was 66 years (range, 42–89 years). The most frequent diagnosis was breast cancer. Spontaneous pleurodesis (drainage < 10 mL) occurred in 25 (48%) patients whose catheter was removed after 30 to 255 days (mean, 93.8 days). Symptomatic relief was achieved in 49 (94%) patients. Mean dyspnea score improved significantly from 3.0 to 1.9. Complications comprised catheter blockage, surgical emphysema, cellulitis, and loculated effusion in 2 patients each. Mean length of hospital stay was 3 days (range, 1–16 days). Median survival was 126 days (range, 10–175 days). We conclude that long-term placement of a pleural catheter provides effective palliation for malignant pleural effusion associated with trapped lung syndrome.

Sam M. Janes, MBBS, PhD, MRCP; Najib M. Rahman, BM BCh, MA, MRCP; Robert J. O. Davies, DM, FRCP and Y. C. Gary Lee, MBChB, PhD, FCCP

^* From the Centre of Respiratory Research (Drs. Janes and Lee), University College London, UK; and Oxford Pleural Unit (Drs. Rahman and Davies), Oxford Centre for Respiratory Medicine and University of Oxford, Oxford, UK.

Correspondence to: Y. C. Gary Lee, MBChB, PhD, FCCP, Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford OX3 7LJ, UK; e-mail: ycgarylee@hotmail.com

Abstract

Indwelling pleural catheters are increasingly being used for ambulatory treatment of malignant pleural effusion, particularly for patients unsuitable for pleurodesis. These catheters are often left in situ for the rest of the patient’s life. Tumor metastasis along the tract between pleura and skin surface is a potential complication in patients with chronic indwelling pleural catheters that has seldom been reported. We describe four cases of catheter-tract metastasis that developed between 3 weeks and 9 months after catheter insertion. Catheter-tract metastasis occurred in two patients with mesothelioma despite prophylactic irradiation at time of insertion, and in two patients with metastatic adenocarcinoma. All cases were successfully treated using external-beam radiotherapy without necessitating catheter removal. A retrospective audit in our
center showed that catheter-tract metastasis occurred in 6.7% of 45 patients treated with indwelling pleural catheters for malignant pleural effusions. Both clinicians and patients should be aware of this potential complication.

Keywords: adenocarcinoma, indwelling catheter, mesothelioma, metastases, pleura