Long-term indwelling pleural catheter (PleurX) for malignant pleural effusion unsuitable for talc pleurodesis

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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.

Introduction

The discovery of a malignant pleural effusion is a known sign of end-stage cancer. Median life expectancy is short, ranging from 3 to 12 months depending on the type and stage of cancer, and is shortest in lung cancer.1 In symptomatic patients with a very short life expectancy, pleural aspiration is recommended.1, 2 In the rest, chemical pleurodesis via chest tube can prevent the inevitable recurrence,2 and talc slurry appears to be the best agent.1, 3, 4 Thoracoscopic talc insufflation requires general anaesthesia and has not been proven to be superior primarily,5 but may help in cases unsuitable for pleurodesis via chest tube.1 Surgical decortication has excessive mortality and morbidity, and should be considered only in exceptional cases or in treatment trials.1,6, 7, 8

If the lung does not expand to contact with the pleural walls after fluid evacuation or there is >250 ml/day fluid secretion after chest tube insertion, talc pleurodesis may fail.1, 9 A standard chest tube left in place can lead to infection of the pleural space, and tube dislodgement can occur: it is not recommended for use without plerodesis.1 This retrospective study was carried out to investigate the suitability of an indwelling catheter as an option for palliating malignant pleural effusion in patients clinically deemed unsuitable for chest tube pleurodesis using talc slurry, or with an increased procedural risk for thoracoscopic talc insufflation under general anaesthesia.

Section snippets

Patients

Between March 2004 and July 2005, 51 consecutive patients were referred from the Department of Pulmonary Medicine for thoracic surgical consultation. All had a malignant pleural effusion clinically considered unsuitable for talc pleurodesis because of an average fluid secretion exceeding 300 ml/24 h and or incomplete lung expansion after needle thoracocentesis, or at excessively high risk for general anaesthesia due to chronic lung disease or poor general condition. All had an exudative pleural

Immediate results

Seventy-one percent (36 of 51 patients) were discharged home the day after implantation, 20% (10 of 51 patients) were discharged home with daily professional nursing care provided or to a hospice or regional hospital, and 9% (5 of 51 patients) died during the same hospital stay from progression of the malignancy. Outpatient implantations were not done during this study, which is presently our routine. The results are summarised in Table 2.

Early complications

Early complications were observed in 8% (4 of 51

Benefits of implantable catheter

We investigated the indwelling pleural catheter as an alternative to surgical procedures for patients unlikely to benefit from talc pleurodesis, since encouraging results have been published.3, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 Assumed benefits were to avoid a high-risk general anaesthesia necessary for thoracoscopic talc insufflation and postoperative chest tube treatment. Our concerns were with the intolerability of one-lung ventilation in patients with chronic lung disease, high risk of

Conflict of interest

None of the authors have any financial conflicts of interest to declare regarding any part of this study.

Acknowledgement

This study was supported by a grant from the Tampere University Hospital Heart Centre Research Fund.

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