Home-management of malignant pleural effusion with an indwelling pleural catheter: Ten years experience

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Abstract

Background

More than one half of patients with cancer have a malignant pleural effusion (MPE) at some time during their life span. Recurrent malignant pleural effusions impair respiratory functions and worsen the quality of life. Once a patient develops MPE, only fluid drainage relieves pulmonary compression and dyspnea. Optimal treatment is however, still controversial. In patients not suitable for pleurodesis, or with recurrent MPE after pleurodesis, or with trapped lung, the outpatient intermittent drainage through a subcutaneous tunneled indwelling pleural catheter (IPC) is a possible choice.

Methods

In ten years, we treated 90 patients by outpatient insertion of IPC. Eligibility for IPC required previous thoracentesis with histological confirmation of malignancy and chest roentgenogram evidence of effusion. All patients treated were made aware of their malignancy and positive cytology in the pleural effusion.

Results

Mean survival was 197 days (range 23–296 days). Median time of draining interval was 7.0 days with maximum amount of effusion drained off being 1000 ml. Pleurodesis occurred in 37 (41.1%) patients with a mean time of pleurodesis of 51 days (range 34–78 days). No major complication was recorded.

Conclusions

The IPC is a useful device in the management of recurrent MPE. Treatment can be entirely accomplished at home and the complication rate is low.

Introduction

Malignant pleural effusion (MPE) is a well-known sign of end-stage cancer and reduced expectancy of life (median range: 3–12 months).1 Moreover, MPE seriously affects the quality of end-of-life of cancer patients. Therefore, several methods have been proposed to relieve dyspnea. Repetitive thoracentesis is the most widely used method; however, its effect is of short duration.2 Pleurodesis with talc slurry via chest tube or talc insufflation by single port thoracoscopy are both effective.3, 4 However, if the lung remains trapped after fluid evacuation or there is >300 ml/day fluid drainage after chest tube insertion, talc pleurodesis fails.5 In patients not suitable for pleurodesis (low performance status or comorbidity), or with recurrent MPE after pleurodesis, or with trapped lung, the outpatient intermittent drainage through a subcutaneous tunneled indwelling pleural catheter (IPC) relieved dyspnea effectively without complications.6 This study was carried out to investigate the effectiveness of IPC for the outpatient treatment of MPE in these subgroups of patients with MPE. We retrospectively reviewed the results of prospectively collected data on patients who underwent IPC placement.

Section snippets

Patients and methods

From January 2001 to December 2011, 90 consecutive patients were referred to us for IPC (PleurX; Denver Biomaterials, Golden, Co., USA) (Fig. 1). Implantation for an MPE considered unsuitable for talc pleurodesis or for recurrent MPE after pleurodesis or for a trapped lung. Patients' characteristics are described in Table 1. Unilateral implantation was performed in 83 patients, simultaneous bilateral in 2 patients, and sequentially bilateral in 5 patients. There were 58 male and 32 female

Results

All patients considered the catheter effective and reported a reduction in the grade of dyspnea and improvement of well-being. All patients were discharged home the day of implantation. Minor complications occurred in 10/90 (11.1%) patients. Early complications were observed in 7 patients (7.7%): in two patients subcutaneous emphysema occurred and five experienced pain during evacuation. Local infection was seen in two patients (2.2%); none of them needed hospitalization or to remove the IPC.

Discussion

Talc slurry instillation via chest tube or thoracoscopic insufflation of talc is the method of choice to achieve pleurodesis, with over 90% success rates, provided that the lung can expand.7 Sterile asbestos free talc is readily available and inexpensive, but other agents such as doxycycline are preferred in the United States due to concerns about talc-associated ARDS. The IPC is an effective method for controlling recurrent and symptomatic MPE patients. The presence of foreign material within

Conflict of interest statement

All authors not disclose any financial and personal relationships with other people or organizations that could inappropriately influence (bias) their work.

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