Thornton, R.H., Miller, Z., Covey, A.M., Brody, L., Sofocleous, C.T., Solomon, S.B., & Getrajdman, G.I. (2010). Tunneled pleural catheters for treatment of recurrent malignant pleural effusion following failed pleurodesis. Journal of Vascular and Interventional Radiology: JVIR, 21(5), 696-700.

The objective of the study was to review the effectiveness of the use of single tunneled, valved pleural catheters in the treatment of symptomatic recurrent malignant pleural effusion following failed chemical pleurodesis.

Two hundred seventy patients who underwent placement of a tunneled pleural catheter between January 2002 and December 2006 were identified after reviewing interventional radiology billing records. After subsequent review of inpatient and outpatient medical reports for each case, 63 were reportedly treated for dyspnea associated with recurrent malignant pleural effusion following failed pleurodesis. In the incidence of suboptimal drainage post-procedure, fibrinolytic therapy with tissue-type plasminogen activator (tPA) dissolved in saline was administered into the catheter to dwell for two hours in the pleural space prior to drainage and was repeated at one- or two-day intervals, if clinically required for optimal drainage and symptom relief. Catheters were drained every other day until the volume decreased to 50 mL, in which case it was drained every three days. Catheters were subsequently removed from patients who achieved durable symptom relief on three consecutive drainages during the three-day intervals with less than 50 mL of drainage and who had no radiographic evidence of re-accumulation. For those with larger drainage volumes, however, catheters were left in place for continued use.

• Sixty-three of the 270 identified patients underwent pleural catheter placement for treatment of dyspnea associated with recurrent malignant pleural effusion (68 were documented hemithoraces).
• The mean age was 61 years, with a range of 30-85 years.
• Of the sample, 30.2% were males, and 69.8% were females.
• Of the 63 patients identified, malignancy was as followed: breast (22), lung (14), ovarian (7), pancreatic (4), primary peritoneal (4), mesothelioma (2), esophagus (2), carcinoid (2), chronic lymphocytic leukemia (1), colorectal (1), melanoma (1), cervical (1), squamous cell (1), and adenocarcinoma of unknown primary (1).
• Nine patients had pre-existing pigtail drainage catheters prior to placement of the tunneled catheter.
   

This single-site study was conducted in both inpatient and outpatient settings in Interventional Radiology.

• 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.

Dyspnea was measured, but the scale or instrument used was not defined.

• Sixty of 63 patients experienced “immediate clinical improvement in dyspnea” following catheter placement. No clear symptomatic improvement was noted in the remaining three.
• Fifty-seven of 63 patients (90%) were discharged from the hospital with a tunneled pleural drain after a median of three days (range 0-29 days).
• Twenty-one of the 68 hemithoraces (31%) required subsequent fibrinolytic therapy to promote drainage of complex pleural effusions.
• One patient had the pleural catheter removed prior to discharge, while five patients died before discharge.
• Twenty-seven patients (43%) were discharged in two days or less.
• Those with longer hospital stays were due to treatment of other disease-related medical conditions.
• Symptomatic recurrence of pleural effusion occurred in one patient 19 days after tunneled pleural catheter removal requiring catheter drainage.
• Median survival following catheter placement was 64 days (range 34-164 days).
• Mean follow-up for survivors was 746 days.

The large majority of patients (95%) experienced prompt symptom relief and clinical improvement following tunneled pleural catheter insertion. Parynchymal lung disease or rapid progression of disease was reported among the patients who did not improve from catheter placement.

• The study had a small sample size of less than 100.
• Authors did not describe how dyspnea was measured and evaluated pre- and post-catheter placement, making it hard to quantify/gauge the extent to which patients experienced symptomatic relief of dyspnea.
• Authors were unable to analyze the durability of symptom relief due to lack of “uniformity” of clinical follow-up and documentation (i.e., regarding patients' drainage schedule, drainage volumes, symptoms, imaging).
   

Use of tunneled pleural catheters for the treatment of recurrent malignant pleural effusion appears to be an appropriate and beneficial intervention for patients suffering from dyspnea following failed pleurodesis. The majority experienced immediate symptomatic relief of their dyspnea following catheter placement, although one-third of cases may necessitate transcatheter fibrinolytic therapy for adequate drainage. As noted by the authors, it is less invasive and more cost-effective than more successful, though high-risk interventions such as decortication (which is 100% effective but associated with high morbidity and mortality and not recommended for this population), thoracentesis (which offers immediate symptomatic relief but is associated with 98%-100% recurrence within 30 days), or thoracoscopy with talc poudrage (which has a high success rate but is more invasive and requires general anesthesia). It is also worth noting the short hospitalization period reported for 43% of the patient population, who were discharged within two days of catheter placement and symptom relief. However, effectiveness for patients with progressive disease remains questionable.