Methods for Treatment of Malignant Pleural Effusion

International Journal of Biomedicine 10(1) (2020) 16-19 http://dx.doi.org/10.21103/Article10(1)_RA2 REVIEW ARTICLE INTERNATIONAL JOURNAL OF BIOMEDICINE Methods for Treatment of Malignant Pleural Effusion Alexei L. Charyshkin, PhD, ScD1*; Ekaterina A. Kuzmina²; Bulat I. Khusnutdinov1,3; Evgeniy A.Toneev1,3; Vladimir I. Midlenko, PhD, ScD1 Ulyanovsk State University, Ulyanovsk, Russia Pirogov Russian National Research Medical University, Moscow, Russia 3 Regional Clinical Oncology Center, Ulyanovsk, Russia 1 2 Abstract This brief review provides up-to-date information on the management of malignant pleural effusions (MPE). In general, selection of the most appropriate treatment approach should be individualized. Management of MPE relies on tumor type, pulmonary re-expansion, performance status, symptoms, and life expectancy. Pleurodesis and IPC placement are two effective treatments recommended for recurrent MPE, both of which can effectively improve dyspnea and quality of life of patients. Other options such as intrapleural therapies, radiation therapy, and pleuroperitoneal shunting are alternative treatments. However, most of these treatments are temporary, and MPE would recur soon. Hence, further palliative treatments to effectively control pleural effusions and relieve symptoms are necessary. (International Journal of Biomedicine. 2020;10(1)16-19.) Key Words: malignant pleural effusions • thoracentesis • pleurodesis • indwelling pleural catheters M ore than 300,000 patients in the Russian Federation die every year from malignant neoplasms, which thus occupy the third place in the mortality structure of the country’s population and remain the most important medical and social problem. One of the most common complications of tumor diseases is malignant pleural effusions (MPE). In the structure of the general incidence, the proportion of pleurisy reaches 4%, while the oncological etiology accounts for 63% of all exudative pleurisy. The majority of MPE is caused by metastatic disease: most commonly lung cancer in men and breast cancer in women.(1) These two cancers combined account for 50%–65% of all MPE.(2-5) Mesothelioma is the most common type of primary pleural tumor and is associated with MPE in more than 90% of cases.(3) In 12% of patients with MPE, it is not possible to establish the nature of the primary tumor. The presence of MPE indicates an advanced stage of the disease with a median life expectancy of 3 to 12 months, depending on the stage and type of underlying malignancy.(6) There are more than 100,000 new cases of MPE yearly in Russia. *Corresponding author: Prof. Alexei L. Charyshkin, PhD, ScD, Head of the Faculty Surgery Department, Institute of Medicine, Ecology and Physical Education, Ulyanovsk State University. Ulyanovsk, Russia. E-mail: Although the first randomized trial for MPE treatment methods was performed in 1977,(7) the optimum management of the disease remains under debate and research. In MPE patients, dyspnea is the most common presenting symptom followed by chest discomfort and cough.(3,8,9) The quality of life is improved by local treatment methods, which not only help reduce the symptoms of pleurisy, but also extend the life of patients from several months to 1-3 years. Prior to considering any definitive treatment intervention, all patients with MPE should undergo a therapeutic aspiration to assess symptomatic improvement and rate of fluid reaccumulation. During the past two decades, there has been a change in direction in MPE research and management.(1) Historically, studies were focused on halting pleural fluid accumulation and often employed aggressive surgical methods (pleurectomy);(10-12) and most clinical trials(13,14) aimed at identifying the best agent that would achieve obliteration of the pleural space (pleurodesis). The most common end-point of these early studies was radiological improvement at 1-3 months post-pleurodesis, without consideration of the patients’ symptoms.(15) Currently, the treatment approach for patients with MPE is mainly aimed at alleviating their symptoms and improving quality of life indicators, which is a key goal of treatment.(16) In general, selection of the most appropriate treatment approach should be individualized. Management of MPE relies on tumor type, pulmonary re-expansion, performance A. L. Charyshkin et al. / International Journal of Biomedicine 10(1) (2020) 16-19 status, symptoms, and life expectancy. Asymptomatic patients with a known tumor type who are responding well to systemic therapies should be under observation.(3) Some cancers, such as small cell lung cancer, lymphoma, breast cancer, prostate, and ovarian cancer, may respond well to chemotherapy.(3,17-19) Patients who have a life expectancy of more than 3 months or are resistant to chemotherapy should be given palliative treatments,(20) such as observation, thoracentesis, indwelling pleural catheters (IPCs), pleurodesis, intrapleural therapies, radiation therapy, and pleuroperitoneal shunting (PPS).(3,20-22) Thoracentesis is generally safe, especially if it is performed with ultrasound guidance.(23) Thoracentesis is a good choice for patients with advanced disease and a short life expectancy (1-3 months), slow pleural fluid reaccumulation, or poor performance status that precludes the patient from other interventional therapies.(21,24) The amount of fluid evacuated by pleural aspiration will be guided by patient symptoms and should be limited to 1.5L on a single occasion. (3,25) Pneumothorax is one of the most common complications associated with thoracentesis, with an incidence rate as high as 20%-39%.(26) Re-expansion pulmonary edema occurs rapidly if the removed fluid is more than 1.5L.(27,28) As known, almost all patients experience recurrence of symptoms and effusions within 1 month.(3,29) Although thoracentesis does not improve survival, it can significantly improve the patient’s condition and avoid hospitalization. Pleurodesis refers to the process of chemically or mechanically inducing pleural inflammation to the visceral and parietal pleura to obliterate the area and prevent the accumulation of air or liquid in the pleural space. Instillation of the sclerosing agent is thereafter followed by a profound inflammatory response between the layers, which, in turn, result in fibrin accumulation and pleural fibrosis. Pleurodesis is a better option for recurrent MPE than thoracocentesis unless the patient has a very poor performance status, a short life expectancy, or a trapped lung.(27) A variety of different chemicals (e.g. talc, bleomycin, tetracycline, iodopovide) and bacterial products (Corynobactum parvum, Streptococcus pyogenes, Staphylococcus aureus, and others) have been used in clinical studies to achieve pleurodesis.(30-33) The profound inflammatory response they may result in adverse events, such as pain and fever, but it is believed that the level of inflammation correlates with the likelihood of successf (...truncated)