Intrapleural Streptokinase in the Management of Malignant Multiloculated Pleural Effusions

doi:10.1378/chest.115.3.729

Chest

Volume 115, Issue 3, March 1999, Pages 729-733

https://doi.org/10.1378/chest.115.3.729 Get rights and content

Objective

Pleural effusions are a frequent complication of malignancy and cause considerable morbidity from dyspnea. The drainage and control of malignant effusions relieve symptoms and maintain quality of life but these are difficult in patients with multiloculated effusions in whom drainage usually fails. This observational series reports the use of intrapleural streptokinase (IPSK) in the management of malignant multiloculated pleural effusions resistant to standard chest tube drainage.

Methods

Ten consecutive patients with malignant multiloculated pleural effusions, aged 39 to 89 years, were given 250,000-IU doses of IPSK twice daily after failure to drain the effusions with a standard chest tube because of multiloculation and multiseptation, as demonstrated by CT or ultrasound scanning. Outcome was assessed by radiographic improvement and symptom control.

Results

All 10 patients responded to between 500,000 and 1,500,000 IU of streptokinase. There was an increase in pleural fluid drained (mean volume ± SD; pre-IPSK, 843 ± 690 mL; post-IPSK, 2,368 ± 1,051 mL; p < 0.001, paired t test), and radiographic improvement was seen in all 10 patients. All subjects tolerated the instillation of streptokinase well. One subject required opiate analgesia for transient chest pain, and there were no hemorrhagic or allergic complications. One patient died of unrelated septicemia.

Conclusions

This series suggests that IPSK may be useful in the drainage of malignant multiloculated pleural effusions in patients who fail to drain adequately with a standard chest tube. Malignant pleural effusions should not be considered a contraindication to IPSK.

Section snippets

Materials and Methods

During a period of 1 year (September 1996 through August 1997), the records of 10 consecutive patients from one center who had malignant multiloculated or multiseptated pleural effusions and had been treated with IPSK were retrospectively reviewed. All patients had cytologically or histologically proven pleural malignancy (Table 1) and were admitted for palliation of their breathlessness.

In all patients, a 12F catheter was inserted under radiologic guidance into the most dependent large fluid

Results

Table 1 summarizes the clinical characteristics of the 10 patients who received IPSK. The age range was 39 to 89 years, with a mean of 64.7 years. Eight patients had received a previous thoracocentesis for the same pleural effusion, and patient 5 had undergone thoracoscopic pleurodesis with talc instillation 2 months previously with subsequent recurrence of multiloculated fluid. The remaining patient had not received any intervention for the effusion before this admission. No patients were

Discussion

This study reports the clinical effects of intrapleural fibrinolytics in the drainage of multiloculated malignant pleural effusions in 10 patients. When simple tube drainage had failed to completely drain effusions, the instillation of IPSK into the pleural cavity resulted in effective pleural drainage.

The use of intrapleural fibrinolytics as an adjunct to the drainage of the pleural space has been reported most commonly in pleural infection and in postoperative and traumatic hemothoraces.⁴^,7^,8

References (21)

TJ Lynch
Management of malignant pleural effusions
Chest
(1993)
SM Keller
Current and future therapy for malignant pleural effusion
Chest
(1993)
MF Muers
Streptokinase for empyema
Lancet
(1997)
JS Moulton et al.
Treatment of complicated pleural fluid collections with image-guided drainage and intracavity urokinase
Chest
(1995)
SK Willsie-Ediger et al.
Use of intrapleural streptokinase in the treatment of thoracic empyema
Am J Med Sci
(1990)
RT Temes et al.
Intrapleural fibrinolytics in management of empyema thoracis
Chest
(1996)
C Jerjes-Sanchez et al.
Intrapleural fibrinolysis with streptokinase as an adjunctive treatment in hemothorax and empyema
Chest
(1996)
LA Robinson et al.
Intrapleural fibrinolytic treatment of multiloculated thoracic empyemas
Ann Thorac Surg
(1994)
M Petrou et al.
Management of recurrent malignant pleural effusions: the complementary role of talc pleurodesis and pleuroperitoneal shunting
Cancer
(1995)
RJO Davies et al.
Randomized controlled trial of intrapleural streptokinase in community acquired complicated parapneumonic pleural effusion and empyema
Thorax
(1997)

There are more references available in the full text version of this article.

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A trial of intrapleural fibrinolytics, such as streptokinase, urokinase, and tissue plasminogen activator, may help in symptomatic multiloculated MPE that fails to drain adequately before attempting pleurodesis. This method has been reported to improve pleural drainage and lung expansion.61–63 Few complications were reported in these studies, and included hemothorax and infection.63
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Davies et al found that intrapleural streptokinase increased pleural fluid drainage and led to radiographic improvement and amelioration of symptoms in 10 patients with multiloculated or septated malignant effusions. Intrapleural streptokinase was well tolerated and no allergic or haemorrhagic complications were reported.120 Gilkeson et al121 preferred urokinase in their prospective but non-randomised study.

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Chest

Clinical InvestigationsLung CancerIntrapleural Streptokinase in the Management of Malignant Multiloculated Pleural Effusions

Objective

Methods

Results

Conclusions

Section snippets

Materials and Methods

Results

Discussion

Chest

Chest

Lancet

Chest

Am J Med Sci

Chest

Chest

Ann Thorac Surg

Management of recurrent malignant pleural effusions: the complementary role of talc pleurodesis and pleuroperitoneal shunting

Cancer

Randomized controlled trial of intrapleural streptokinase in community acquired complicated parapneumonic pleural effusion and empyema

Thorax

Clinical Investigations
Lung Cancer
Intrapleural Streptokinase in the Management of Malignant Multiloculated Pleural Effusions