Use of an Indwelling Pleural Catheter for the Management of Recurrent Chylothorax in Patients With Cancer

doi:10.1378/chest.06-2141

Chest

Volume 132, Issue 5, November 2007, Pages 1584-1590

https://doi.org/10.1378/chest.06-2141 Get rights and content

Background

Recurrent chylothorax is a debilitating condition. We describe the usefulness of an indwelling pleural catheter (IPC) in the palliative management of recurrent symptomatic chylothorax in patients with cancer relapse or progressive disease despite adequate treatment.

Methods

In 10 years, 5,594 patients underwent 8,498 pleural procedures at our institution. Pleural fluid triglycerides were measured in 1,343 patients; of these patients, 130 had a chylothorax. Their medical records were reviewed. In 19 patients, recurrent symptomatic chylothorax appeared in association with cancer relapse. Treating physicians decided to place an IPC in 10 patients, and 9 patients had other palliative interventions. Baseline and postintervention changes in weight, absolute lymphocyte counts, and albumin levels in both groups were statistically compared. Hazard ratio and Kaplan-Meier curves of time to second pleural intervention after index procedure were also evaluated.

Results

The risk of requiring a second pleural intervention after the index procedure during the following 500 days was lower in the IPC group compared to the other pleural interventions (p = 0.030), and Kaplan-Meier curves of time to second intervention were statistically different (p = 0.025). Albumin levels decrease in the IPC group (p = 0.007), but the decline was not worse than the decline observed in the control group (p = 0.329), and recovered rapidly after IPC removal.

Conclusions

Placement of an IPC may be considered as first-line palliative management for patients with symptomatic recurrent chylothorax poorly responsive to the treatment of the underlying malignancy.

Section snippets

Data Extraction

This is a case-control study in a group of patients with recurrent symptomatic chylothorax associated with cancer relapse or disease progression. The protocol and a waiver of informed consent were approved by The University of Texas M. D. Anderson Cancer Center Institutional Review Board.

Between November 1997 and November 2006, 5,594 patients underwent 8,498 pleural procedures at the University of Texas M. D. Anderson Cancer Center. Pleural fluid triglyceride levels were measured in 1,343

Results

Demographics, clinical characteristics, primary malignancies, and treatment modalities are shown in Table 1. Patients in the IPC group were older, but no statistical differences were found in gender proportions, ECOG performance status, follow-up after index procedure, patients alive at the end of follow-up, days to death after index procedure, or treatment modalities between IPC and control groups.

Table 2shows patient outcomes. Only one patient required 2 pleural interventions after the index

Discussion

Accumulation of chylous fluid in the pleural space of cancer patients is generally due to disruption of the thoracic duct or obstruction of lymphatic drainage of the pleural space. Obstruction can be caused by underlying malignancy or from mediastinal fibrosis, constrictive pericarditis, or superior vena cava obstruction as a result of prior therapy.⁹¹⁰¹¹ Treatment of the primary tumor often leads to resolution of the chylothorax,¹² with mediastinal radiation useful in controlling chylothorax

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Multidisciplinary Management of Chylothorax
2022, Chest
Citation Excerpt :
The use of IPCs has also been described for ambulatory management of chylothorax related to malignancies such as lymphoma while awaiting oncological treatment to take effect.69 Compared with palliative measures, IPC use in patients with recurrent chylothorax related to malignancy reduced the risk of requiring a second pleural procedure.70 Initial management of traumatic chylothorax (Fig 1) includes pleural drainage for management of symptoms as well as assessment of output.
Chylothorax, the accumulation of chyle in the pleural space, is usually caused by the disruption of the thoracic duct or its tributaries. Etiologies are broadly divided into traumatic, including postsurgical, and nontraumatic, most commonly in the setting of malignancy. The management of chylothorax largely depends on the cause and includes dietary modification and drainage of the pleural space. A definitive intervention, whether surgical or a percutaneous lymphatic intervention, should be considered in patients with a persistently high volume of chylous output and in those with a prolonged leak, before complications such as malnutrition ensue. No methodologically robust clinical trials guiding management are currently available. In this article, we review the current literature and propose a stepwise, evidence-based multidisciplinary approach to the management of patients with both traumatic and nontraumatic chylothorax.
Indwelling Pleural Catheters
2021, Clinics in Chest Medicine
Citation Excerpt :
No cases of empyema or other serious complications were reported. Small retrospective case series describing the use of IPC for refractory chylothorax report pleurodesis rates up to 64% with no significant infectious or nutritional complications reported.49,50 Because the use of IPCs for NMPEs may continue to increase over time, well-designed RCTs will be necessary to determine how suitable they are for long-term use in specific patient populations.
Transudative chylothorax in a patient with liver cirrhosis: A rare association
2015, Heart and Lung: Journal of Acute and Critical Care
Citation Excerpt :
Use of the tunneled indwelling pleural catheters (TIPCs) in the management of chylothoraces is theoretically contraindicated due to the risk of significant lymphocyte, protein, fat and immunoglobulin loss in the chyle. However some authors have recently reported successful utilization of TIPCs for both benign as well as malignant chylothoraces without significant complications.9,10 While there may be a role of TIPCs in the management of chylothoraces, at this stage their use should be considered experimental only pending more prospective studies.
Chylothorax is an unusual type of pleural effusion which results from the accumulation of chyle in the pleural cavity. High triglyceride content and presence of chylomicrons in the chyle give this fluid a characteristic milky appearance. Chylothorax most commonly results from the obstruction of the thoracic duct by a malignant lesion or from its traumatic disruption. Liver cirrhosis is an uncommon and frequently underappreciated cause of chylothorax. Pleural effusion in chylothorax is typically described as a lymphocytic predominant, exudative type and it is exceedingly rare to encounter a transudative type of chylothorax. To date, very few cases of transudative chylothoraces have been described in the literature, most commonly in association with liver cirrhosis. Only a limited range of other clinical settings have been linked to transudative chylothorax and timely recognition of these associations can prevent unnecessary, expensive and sometimes invasive workup in this patient population.
Vandetanib and indwelling pleural catheter for non-small-cell lung cancer with recurrent malignant pleural effusion
2014, Clinical Lung Cancer
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Therefore, at our institution in recent years, IPC placement has become common practice as a first-line option in all patients with a recurrent and symptomatic MPE. Published data show that pleurodesis can be achieved in 40% to 70% of patients, with times to catheter removal ranging from 8 to 283 days, depending on the characteristics of the population studied and the strategy used to drain the pleural fluid.3,5-8 Several studies have examined the utility of intrapleural drug administration for management of MPE, however, none of the studied drugs so far have reached clinical approval.9,10
Non–small-cell lung cancer patients with malignant pleural effusion have a poor overall median survival (4.3 months). VEGF is a key regulator of pleural effusion production. It is unknown if pharmacological inhibition of VEGF signaling modifies the disease course of non–small-cell lung cancer patients with recurrent malignant pleural effusion. We report the final results of a single-arm phase II clinical trial of the VEGF receptor inhibitor, vandetanib, combined with intrapleural catheter placement in patients with non–small-cell lung cancer and recurrent malignant pleural effusion, to determine whether vandetanib reduces time to pleurodesis.
Non–small-cell lung cancer patients with proven metastatic disease to the pleural space using pleural fluid cytology or pleural biopsy who required intrapleural catheter placement were eligible for enrollment. On the same day of the intrapleural catheter insertion, the patients were started on a daily oral dose of 300 mg vandetanib, for a maximum of 10 weeks. The primary end point was time to pleurodesis, with response rate as the secondary end point. Exploratory analyses included measurement of pleural fluid cytokines and angiogenic factors before and during therapy.
Twenty eligible patients were included in the trial. Eleven patients completed 10 weeks of treatment. Median time to pleurodesis was 35 days (95% confidence interval, 15-not applicable). Median time to pleurodesis in the historical cohort was 63 days (95% confidence interval, 45-86) when adjusted for Eastern Cooperative Oncology Group performance status ≤ 2.
Vandetanib therapy was well tolerated; however, it did not significantly reduce time to pleurodesis.
Chylothorax: pathophysiology, diagnosis, and management —a comprehensive review
2024, Journal of Thoracic Disease
Management strategies for recurrent pleural effusion: a clinical practice review
2023, AME Medical Journal

View all citing articles on Scopus

The Department of Pulmonary Medicine of the University of Texas M.D. Anderson Cancer Center received an unrestricted educational grant from Denver Biomedical Inc., Denver, CO.

The authors have no conflicts of interest to disclose.

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Original ResearchINTERVENTIONAL PULMONOLOGYUse of an Indwelling Pleural Catheter for the Management of Recurrent Chylothorax in Patients With Cancer

Background

Methods

Results

Conclusions

Section snippets

Data Extraction

Results

Discussion

Chest

Chest

J Thorac Cardiovasc Surg

Ann Oncol

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Chest

Chest

Chylothorax and pseudochylothorax

Chylothorax causing reversible T-cell depletion

J Trauma

Clinical and immunological alterations observed in patients undergoing long-term thoracic duct drainage

Surgery

Original Research
INTERVENTIONAL PULMONOLOGY
Use of an Indwelling Pleural Catheter for the Management of Recurrent Chylothorax in Patients With Cancer