Malignant Pleural Effusions: Treatment with Indwelling Pleural Catheter

1. Malignant Pleural Effusions:Treatment with Indwelling Pleural Catheter Luca Bertolaccini 1, Alessandro Berra 2, Emilpaolo Manno 2, Ferdinando Massaglia 1 Division of Thoracic and General Surgery, Department of Emergency, Maria Vittoria Hospital, Turin, Italy Intensive Care Unit, Department of Emergency, Maria Vittoria Hospital, Turin, Italy

2. Introduction • More than half of patients with malignancy present with a pleural effusion at some time in their course. • Recurrent malignant pleural effusions (MPE) impair functions and worsen the quality of life. • Once a patient develops MPE, only mechanical drainage relieves pulmonary compression and dyspnea. • Optimal treatment is, however, still controversial.

3. Patients & Methods • During January 2001 to January 2007, we treated 62 patients with outpatient insertion of chronic indwelling pleural catheter (IPC), PleurX (PleurX™, Surgimedics, Denver Biomaterials, Denver, CO, USA). • Primary malignancy included: 37 lung cancers, 13 mesotheliomas, 7 breast cancers, 2 colon cancers, 2 pancreas cancers and 1 ovarian cancer. • Eligibility for IPC required prior thoracentesis with histological confirmation of malignancy and chest roentgenogram evidence of effusion. • All patients treated were made aware of their prior malignancy and positive cytology for MPE. PleurX™– 15.5 F Silicone Catheter One – way valve and cap Multiple fenestrations Polyester cuff

4. Catheter Placement • Prep, drape and inject local anesthesia. • Insert 18 G needle and aspirate fluid; remove syringe; insert guide wire; tunnel PleurX from inferior and medial incision site to guide wire. • Insert 16 F peel-away introducer over guide wire; advance peel-away just into pleural space. • Remove dilator; insert PleurX into peel-away • Remove peel-away; be certain that polyester cuff is at least 1 cm under the skin. 2 1 4 3 5

5. Results • The permanence mean time of IPC was 78 days. In 1 patient with advanced stage breast cancer, catheter remained inserted for 290 days until death. Two patients died within 10 days after the application of the technique for the primary disease. • The median time of draining interval was 7.0 days with maximum amount of effusion drained off being 1000 ml. • An improvement in respiratory performance status was immediately registered in all treated patients. Seventeen patients who underwent procedure were able to continue life at home and receive home-care. • Cumulative proportion of survival, was 50% in 210 days. Median survival time of patients was 80 days. The effective survival was 290 days in one patient with breast cancer. • Major complications, as systemic or pleural infections, were not registered. • We registered 72.3% of pleurodesis with a mean time for pleurodesis of 48 days.

6. Discussion & Conclusions • Discussion • The aim of our study was to evaluate the effectiveness and safety of this new device in the treatment of MPE. • IPC allows an ambulatory treatment with a safe and effective drainage of MPE. • Our patients reported good, symptomatic relief following IPC placement without major and few minor complications. • Conclusions • IPC is an effective alternative treatment to the procedures currently in use. • Randomized studies are necessary to compare if the quality of life of patients with IPC is better than patients who undergo VATS and to compare this technique with the other most common pleurodesis procedures.

7. Corresponding Author • Luca Bertolaccini, MD, PhD Maria Vittoria Hospital Department of Emergency Division of Thoracic Surgery 72, Cibrario Street – 10149 Turin (Italy) Phone: +39-011-4393480 Fax: +39-011-4393403 E-mail: l.bertolaccini@vodafone.it