Suzuki, K., Servais, E.L., Rizk, N.P., Solomon, S.B., Sima, C.S., Park, B.J., . . . Adusumilli, P.S. (2011). Palliation and pleurodesis in malignant pleural effusion: The role for tunneled pleural catheters. Journal of Thoracic Oncology: Official Publication of the International Association for the Study of Lung Cancer, 6(4), 762-767.

The objective of the study was to evaluate tunneled pleural catheters for efficacy of palliation and the rate and predictors for spontaneous pleurodesis.

The study was a retrospective review of all patients (no matter who or where inserted) with at least tunneled pleural catheter inserted at a single institution from September 2007 to September 2009. Catheters were placed by pulmonologists, interventional radiologists, and thoracic surgeons in interventional radiology or bedside. All catheters were placed by Seldinger technique, unless during a video-assisted thoracoscopic procedure (VATs).

A total of 418 tunneled pleural catheters were placed. Forty-two patients had additional contralateral pleural catheters, 13 patients had an additional ipsilateral pleural catheter, and 4 patients had both a contralateral and secondary ipsilateral catheter.

• The study reported on a sample of 355 patients.
• The median age was 63 years, with a range of 16-90 years.
• Of the sample, 42% were males and 58% were females.
• Of the sample, 106 patients (30%) had lung cancer, 62 (17%) had breast cancer, 36 (10%) had gynecologic cancer, 24 (7%) had urologic cancer, 21 (6%) had upper gastrointestinal cancer, 18 (5%) had sarcoma, 18 (5%) had lower gastrointestinal cancer, 18 (5%) had hepatobiliary, and 52 (15%) had other disease.
• Two hundred fifty-three patients (61%) had right effusions, and 165 patients (39%) had left effusions.
• Sixty-nine patients (17%) had undergone previous procedures, and 349 patients (83%) had undergone no previous procedures.
• One hundred and ten patients (26%) had loculated pleural effusions, and 308 patients (74%) had simple, non-loculated pleural effusions.

The single-site study was conducted in both the inpatient and outpatient settings. Two hundred sixty-one patients (62%) were treated in interventional radiology, 107 patients (26%) were treating in the operating room, 37 patients (9%) were treated at the bedside, and 13 patients (3%) were treated in a clinic.

• Patients were undergoing long-term follow-up care.
• The study has clinical applicability for end-of-life and palliative care.
   

The study was a retrospective review.

• Radiographic evaluation of effusions pre- and post-catheter placement
• Computed tomography (CT) scan preferred; chest x-ray when CT not available
• Measured presence/absence of pleural fluid and presence/absence of spontaneous pleurodesis     
• Dyspnea was measured as “absence of symptoms” and “no need for subsequent effusion-directed drainage,” but the exact instrument or method of measurement was not described.
   

Median survival in this series from the time of the first catheter insertion was 3.7 months (range 2.9-4.5 months, confidence interval 95%). Median follow-up was 2.4 months, with a range of 1.0-6.4 months. Three hundred eighty of 418 catheters inserted (91%) did NOT need additional effusions-directed therapies. The successful palliation rate in patients who lived longer than 30 days was 89% (28 of 322 insertions). Spontaneous pleurodesis was achieved in 110 catheters (26%), and accounting for those who died, the probability of successful pleurodesis during the study time was 34%. The catheter complication rate was 4.8% (20 catheters; 5 grade II, 15 grade III).

• Tunneled pleural catheters were considered more cost-effective than talc pleurodesis for patients living less than six weeks. They had complication rates of 4.8% and were less severe than with talc pleurodesis (severe respiratory distress in 1%-9%).
• High rate of palliation (91%) was evidenced by no need for additional interventions for relief of symptomatic pleural effusions.
• The spontaneous pleurodesis rate of 26% is lower than other tunneled catheter studies.

•  No appropriate control group
•  Lack of a definitive symptom assessment scale
•  Lack of control for insertion operator, location, indication, or phase of disease.
   

Tunneled pleural catheters offer an alternative method of pleural drainage and may even induce spontaneous pleurodesis in patients with symptomatic malignant pleural effusions. The process of placing the catheter is minimally invasive, is associated with a low complication rate, and allows for rapid recovery of patients with limited life expectancy. More than 90% of patients receiving this therapy experienced symptomatic relief that did not require additional interventions for treatment of pleural effusions. This therapy option for management of symptomatic pleural effusions may be suggested by nurses familiar with the management of malignant pleural effusions. Studies addressing specific symptom relief would be valuable to validate the effectiveness of this intervention.