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

Wednesday, August 6, 2008

Source: European Journal of Surgical Oncology

A pleural effusion is a build-up of fluid in the pleural cavity that restricts proper lung expansion, causing chest pain and breathing troubles in affected patients. Effusions are the most common symptom of pleural mesothelioma and are often indicative of late-stage disease in patients suffering from other cancers. Effective palliation for pleural effusions is possible by undergoing a procedure, known as a pleurodesis, that removes the space where fluid builds-up by fusing together the parietal and the visceral pleura. However, not all patients are eligible for pleurodesis, so alternative treatments are required to ease the burden of disease for these patients. One such procedure involves the implantation of a long-term, indwelling pleural catheter, a thin, hollow tube that draws the fluid out of the pleural cavity and drains it from the body.

Pleural catheters have been used for the palliative treatment of pleural effusions due to mesothelioma, lung cancer and other malignancies for many years, but few studies have examined their overall efficacy for this purpose. Researchers from Finland have recently released the results of a study they conducted which did look at this topic and they found long-term use of pleural catheters to be an effective remedy for many of the symptoms commonly associated with pleural effusions.

Overview of the Study

As we said above, pleurodesis is the preferred procedure for most patients with pleural effusions, but not everyone is eligible for it. The two most common indications against pleurodesis are the following: restricted lung expansion that does not allow contact between the pleurae and the secretion of greater than 250 ml/day of fluid. Patients who present with either or both of these symptoms are likely to fail a pleurodesis, so alternative procedures will be substituted.

To analyze the efficacy of pleural catheters for symptom palliation of pleural effusions, the authors of the article under discussion analyzed the treatment courses of 51 patients treated for a malignant effusion at their institution between March 2004 and July 2005. All patients presented with a disease status that made pleurodesis a difficult or unworkable procedure and each received a PleurX® brand, indwelling pleural catheter for the palliative management of the effusion. The patients underwent monthly follow-ups and their progress was tracked until their deaths.

Results

Of the 51 patients who received the catheter implantation, 24 were male and 27 were female, while the average age for the study population was 63 years-old. At 19 diagnoses, non-small cell lung cancer was the most common malignancy of this patient cohort, closely followed by ovarian cancer (8 diagnoses), mesothelioma (7 diagnoses) and breast cancer (also 7 diagnoses).

39 patients received a right-sided catheter, 10 received a left side catheter and 2 patients had bilateral implantations. 36 patients were discharged back home within a day of the operation, while 10 were transferred to another hospital or to full-time nursing care. Five patients died during the hospital stay in which they received the catheter. These deaths were not directly related to the implant procedure, but were likely the cause of advanced disease.

11 patients experienced some type of complication, but the majority of the cohort were relatively side effect-free. Mean survival was only three months for the entire group, but there were great variations in this figure when individual cancers were accounted for. Mean survival for patients with non-small cell lung cancer—the most common of the diagnoses in the patient cohort—was 2.5 months, while mean survival in mesothelioma patients was 11 months. The breast cancer patients and the ovarian cancer patients demonstrated mean survival times of 6 months and 5.5 months, respectively.

Conclusion

The authors conclude that pleurodesis should still remain the treatment of choice for those who are eligible for it, but they definitively state that indwelling pleural catheters are an effective means of symptom palliation for patients with malignant pleural effusions who are not eligible for pleurodesis. In their study, the overall complications were low and there were no treatment-related deaths. The patients who died within two weeks of the procedure were already quite ill and cause of death was considered more likely from concomitant morbidities than catheter implantation. The authors state that the successful results of this study have led them to change their institutional policy regarding catheter use and they now consider the standard of care for patients who are not eligible for pleurodesis.

Labels: cancer, mesothelioma, treatments

posted by Belluck & Fox at 4:34 PM
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