Q4Pacientes con cáncerIntroduction: Pleural effusion is a manifestation of advanced cancer that is associated with symptoms
whose control requires adopting different strategies. This study aimed to characterize the population of
patients with malignant pleural effusion who underwent placement (or insertion) of a tunnelled pleural
catheter to alleviate dyspnoea, describe the experience of its use and evaluate the 30-day hospitalization
rate for pleural effusion and the percentage of early and late complications.
Patients and methods: This study is a series of cases with cancer taken to implantation of a closed
pleural drainage system during the year 2020 in a third level hospital in Colombia.
Results: Eight patients underwent this procedure, in whom implantation was successful. Pleural effusion
due to breast cancer was the main indication. No late catheter complications were recorded given the high
30–day mortality, despite a low LENT (LDH, ECOG, neutrophilia and tumour type) score in some patients.
Conclusions: The indwelling tunnelled pleural catheter is useful in the palliative treatment of malignant
pleural effusion with few complications. It is necessary to evaluate the performance of the LENT scale in
the study population, given that despite a low score, the 30–day mortality rate was high.https://orcid.org/0000-0002-6925-3570https://orcid.org/0000-0002-3061-5212https://orcid.org/0000-0002-0311-2548https://orcid.org/0000-0002-3743-6268https://orcid.org/0000-0001-6461-2725Revista Internacional - IndexadaCN

Botero Bahamon, Juan David

Fernández Sánchez, Maria José

Lasso Apráez, Javier Iván

Serrano, Natalia

Torres, July Vianeth

Villaquirán-Torres, Claudio

Palliative Medicine in Practice

English

Juan David Botero

Javier Iván Lasso

María Natalia Serrano

Claudio Villaquiran

July Vianeth Torres

María José Fernández

Crossref

Use of tunnelled pleural catheter for palliative treatment of malignant pleural effusion: Experience of a third level hospital

Repositorio Institucional - Pontificia Universidad Javeriana

www.journals.viamedica.pl/palliative_medicine_in_practice 103Original articleAddress for correspondence:Javier Iván LassoHospital Universitario San Ignacio, Bogota, ColumbiaCarrera 7 40 62, Bogota, Columbiae-mail: jilasso@husi.org.co  Palliative Medicine in Practice 2022; 16, 2, 103–107  Copyright © Via Medica, ISSN 2545–0425, e-ISSN: 2545–1359  DOI: 10.5603/PMPI.2022.0005 This article is available in open access under Creative Common Attribution-Non-Commercial-No Derivatives 4.0 International  (CC BY-NC-ND 4.0) license, allowing to download articles and share them with others as long as they credit the authors and the publisher, but without permission to change them in any way or use them commercially.Juan David Botero1, 2 , Javier Iván Lasso1, 2, María Natalia Serrano1, 2,  Claudio Villaquiran1, 2, July Vianeth Torres3, María José Fernández1, 21Hospital Universitario San Ignacio, Bogota, Columbia 2Department of Internal Medicine, Pontificia Universidad Javeriana, Bogotá, Colombia 3Hospital Universitario Nacional, Bogota, ColumbiaUse of tunnelled pleural catheter  for palliative treatment of malignant pleural effusion: Experience  of a third level hospitalAbstractIntroduction: Pleural effusion is a manifestation of advanced cancer that is associated with symptoms whose control requires adopting different strategies. This study aimed to characterize the population of patients with malignant pleural effusion who underwent placement (or insertion) of a tunnelled pleural catheter to alleviate dyspnoea, describe the experience of its use and evaluate the 30-day hospitalization rate for pleural effusion and the percentage of early and late complications.Patients and methods: This study is a series of cases with cancer taken to implantation of a closed pleural drainage system during the year 2020 in a third level hospital in Colombia.Results: Eight patients underwent this procedure, in whom implantation was successful. Pleural effusion due to breast cancer was the main indication. No late catheter complications were recorded given the high 30–day mortality, despite a low LENT (LDH, ECOG, neutrophilia and tumour type) score in some patients.Conclusions: The indwelling tunnelled pleural catheter is useful in the palliative treatment of malignant pleural effusion with few complications. It is necessary to evaluate the performance of the LENT scale in the study population, given that despite a low score, the 30–day mortality rate was high.Palliat Med Pract 2022; 16, 2: 103–107Key words: indwelling pleural catheter, malignant pleural effusion, metastatic cancer, palliative carePalliative Medicine in Practice 2022, vol. 16, no. 2www.journals.viamedica.pl/palliative_medicine_in_practice104IntroductionMalignant pleural effusion is a sign of advanced cancer associated with difficult to control symptoms, which occurs in 15% of patients [1]. The main associa-ted malignant neoplasms are lung and breast cancer, which account for approximately 65% of cases [2]. Dyspnoea is one of the most common symptoms, is difficult to control and is often refractory to phar-macological management. It increases disability and functional limitation and is related to worse survival and deterioration of quality of life [3].The initial approach is ultrasound-guided evacu-ative thoracentesis, by which large volumes of fluid can be removed, allowing lung re-expansion and symptom improvement. However, the only way to prevent the fluid from continuing to accumulate is to control cancer. Because of this, this procedure is only palliative and should be repeated each time patients have symptoms that limit their functionality. The most frequent complications of this procedure are pneumothorax (in 6% of cases), haemothorax (2%), and less frequent, such as re-expansion pulmonary oedema [4].There are other options, such as a pleural catheter, pleurodesis, and pleurectomy [5]. The choice depends on pre-surgical risk, functional status as measured by ECOG (Eastern Collaborative Oncology Group) and life expectancy [6].The pleural catheter is preferred in patients with a life expectancy greater than one month and less than 6 months since in this survival range the catheter is associated with fewer hospitalization days and less need for subsequent thoracentesis when compared to pleurodesis [7]. With a safety profile similar to that of thoracentesis, its main complications are pneumotho-rax, subcutaneous emphysema, bleeding, and infec-tions, which occur in 2.8–6% of cases [8]. One of its main advantages is that it can generate spontaneous pleurodesis in up to half of the patients [9].There is experience with its use in the United Sta-tes, where an adequate safety profile [10] and good cost-effectiveness have been reported. European stu-dies have shown that it is an outpatient procedure that reduces hospitalizations and re-interventions [11]. However, in Latin America, there is little expe-rience with the use of the catheter for the palliative management of pleural effusion [12, 13]. This study aimed to describe a case series of patients with mali-gnant pleural effusion from a referral centre who were taken to insertion of an indwelling tunnelled pleural catheter. Specifically, to describe 30-day survival after implantation, the need for recurrent thoracentesis, and early and late complications associated with the procedure.Patients and methodsThe present study is a case series of cancer patients who underwent implantation of a closed indwelling pleural catheter system between January 2020 and December 2020 in a third level hospital in Colombia. All adult patients who underwent catheter implanta-tion with a diagnosis of malignant pleural effusion (positive cytology for malignancy or pleural biopsy with tumour infiltration) to palliate dyspnoea me-asured with the mMRC (modified Medical Research Council) scale, who had an ECOG and LENT score (LDH, ECOG, Neutrophilia and Tumour type) with dyspnoea measured with the mMRC (modified Medical Research Council) scale were included. Patients in whom 30-day follow-up by medical records could not be guaranteed were excluded. This study was evaluated and accepted by the Institutional Ethics Committee. Medical devices were paid for by patient insurance.Sociodemographic characteristics, type of cancer, anticancer and palliative treatment were collected. The catheter was implanted using the ultrasound-guided Seldinger technique. The first drainage was done in a collector and thereafter patients or family members, previously trained, did the drainage at home using the disposable closed collection systems supplied with the catheter. After catheter implantation, chest radiogra-phy was routinely performed to assess positioning and immediate complications.Emergency room visits and outpatient controls were reviewed to verify late complications or the generation of spontaneous pleurodesis. A telephone follow-up was performed 30 days after the procedure to evaluate complications, symptom control, rehospi-talizations and catheter status.Statistical analysisCategorical variables are described as absolute values and percentages, continuous variables are described as means and standard deviations. No hy-pothesis tests were performed for group comparison, due to the descriptive characteristics of the group.ResultsEight patients with an indication for pleural catheter placement were included in the case se-ries. Table 1 shows the clinical characteristics of the pa-tients. The majority were female (62.5%) with primary breast tumours (50%). Fifty per cent of the patients were underweight and malnourished. All patients had a high comorbidity index, measured by the Charlson index, greater than 6. It is important to highlight that 66.7% of patients were receiving chemotherapy and, www.journals.viamedica.pl/palliative_medicine_in_practice 105Juan David Botero et al., Use of tunnelled pleural catheter for palliative treatment of malignant pleural effusiondespite this, persisted with recurrent pleural effusion. Fifty per cent of patients required triple multimodal analgesic management for cancer pain.Analysing patient outcomes, there was only one complication during the first week, due to pain at the insertion site, which required in-hospi-tal analgesic management six days after catheter placement (Table 2). The patient died 14 days after catheter insertion, due to acute pulmonary throm-boembolism.Twenty-five per cent (n = 2) required hospitaliza-tions related to underlying disease and associated Table 1. General characteristics of the patientsPa­tient Sex Age BMI Loca­tionPrimary tumour Charlson Chemo­therapyType of CHEMOAnalge­sia LENT(years) [kg/m2] Right *Location U Yes1 F 54 32.7 B Breast adenocarci-noma 7 x A T 42 M 78 24.2 R Follicular thyroid carcinoma 9 x TKI O 63 F 71 18 B Breast adenocarci-noma 9 x A T 34 M 87 19.05 R Non-Hodgkin’s man-tle-cell lymphoma9 T 25 F 42 17.78 R Breast adenocarci-noma 6 x A T 46 F 69 27 R Melanoma 8 Ac 67 M 53 20.8 R Lung adenocarci-noma8 x 58 F 61 17.9 B Ovarian adenocarci-noma7 x A T T 4M — male; F — female; R — right; B — bilateral; A — anthracyclines; T — taxanes; TKI — tyrosine kinase inhibitor; Tr — triple analgesia with acetami-nophen; opioid and pregabalin; Ac — acetaminophen; O — opioid; HR — hormone receptors; CHEMO — chemotherapyTable 2. Catheter­associated complications and survivalPatient Complications Re­hospitalization Time to re­hospitali­zationSurvival days Spontaneous pleurodesisType Yes Days1 No > 30 No2 No x 4 7 days No3 No 18 days No4 No Unknown No5 No 25 days6 Yes Pain x 7 14 days No7 No > 30 No8 No > 30 Yescomplications not related to catheter placement. The first patient required hospitalization for symptomatic hypocalcaemia and oedematous syndrome, and the second for pain and pulmonary thromboembolism. No late complications were documented after 30 days, such as catheter dislodgement or fracture, haemotho-rax, bleeding from the insertion site, or local infection. 62.5% of patients had a survival of fewer than 30 days after catheter placement. In this case series, only one patient had spontaneous catheter-associated pleurodesis, after which the catheter was removed without complications.Palliative Medicine in Practice 2022, vol. 16, no. 2www.journals.viamedica.pl/palliative_medicine_in_practice106DiscussionExperience with the use of pleural catheters in Latin America is scarce, with few case series published in Mexico and Brazil [12, 13]. This is the first series describing the intervention in the Colombian popu-lation. LENT is a validated scale for assessing survival in patients who are to undergo pleural procedures; a higher score indicates worse survival [14]. The results obtained in this series show high 30-day mortality, even in patients with low LENT scores predictive of good survival. This finding could be attributed to the low nutritional component.When making a comparison with the results of other series, similar findings were found concerning sociodemographic characteristics. In Pakistan [15] it was found that the majority of patients with malig-nant pleural effusion were women with breast cancer, up to 52%, a finding similar to ours. However, a very small percentage were receiving chemotherapy (39%). Mortality during follow-up was 85%, whereas in the present study series it was 62%. In the United Kingdom [16] most malignant strokes occurred in women, but the main related tumour is of pulmonary origin, with only 13% of cases secondary to breast cancer. The mean survival was 141 days, much better than that of the present series, in which only 37% were alive 30 days after catheter insertion. In Germany [14], 67% of the patients were women, 30.6% of the cancers were represented by primary ovarian tumour, which also differs from this series, in which only one case corresponded to a primary ovarian tumour, and 49% of the effusions were of right laterality, similar to the present series. The pleurodesis rate reported in the series ranges from 16–50% [12–14], but in this series, only one patient presented spontaneous pleurodesis (12.5%).There was a low complication rate in the series. The complications described differ depending on the series reviewed. Abrão et al. [12] reported 49% complica-tions, mainly infections (52%), followed by catheter tamponade (18%). According to Páez-Codeso et al. [13], complication rate was 4.4%, and Frost et al. [17] it was 13.4%: infections (5.6%), empyema (2.5%), outflow tract, and tunnelitis (0.9%). The present se-ries showed few complications, possibly due to the short survival.This is one of the few Latin American series and the first Colombian series on the use of pleural cathe-ters. However, it is necessary to emphasize the descrip-tive nature of the study, with multiple uncontrolled variables that can lead to erroneous conclusions. For this reason, the findings of this series should be only considered for the generation of exploratory hypoth-eses on the use of pleural catheters. In addition, this study shows another limitation in the patient expe-rience, at the time of insertion, patient follow-ups were based on medical records; follow-up protocol had just been submitted due to the recent implemen-tation of this technique, and useful questionnaires in this scenario could be EORTC QLQ-C30 and EORT QLQ-C15 [15, 16]. The importance of this paper lies in the availability of this resource for the palliative man-agement of patients with tumorous pleural effusion. It is a reference to evaluate the survival of patients with tumour pleural effusion by applying the LENT score.ConclusionsTo conclude, it is important to mention that the use of the indwelling pleural catheter is a palliative intervention that is safe in several series. It requires proper patient selection, especially the estimation of expected survival. In the present series, there was little relationship between the LENT score and sur-vival, an assessment that needs to be evaluated in another study.Declaration of conflict of interestsThe authors declare that there is no conflict of in-terest.FundingNone declared.References1. Asciak R, Rahman N. Malignant Pleural Effusion. Clin Chest Med. 2018; 39(1): 181–193, doi: 10.1016/j.ccm.2017.11.004.2. Psallidas I, Kalomenidis I, Porcel JM, et al. Malignant pleural effusion: from bench to bedside. Eur Respir Rev. 2016; 25(140): 189–198, doi: 10.1183/16000617.0019-2016, indexed in Pubmed: 27246596.3. McKenzie E, Hwang MK, Chan S, et al. Predictors of dysp-nea in patients with advanced cancer. Ann Palliat Med. 2018; 7(4): 427–436, doi: 10.21037/apm.2018.06.09, indexed in Pubmed: 30180735.4. Cantey EP, Walter JM, Corbridge T, et al. Complications of thoracentesis: incidence, risk factors, and strategies for prevention. Curr Opin Pulm Med. 2016; 22(4): 378–385, doi: 10.1097/MCP.0000000000000285, indexed in Pub-med: 27093476.5. Skok K, Hladnik G, Grm A, et al. Malignant Pleural Effusion and Its Current Management: A Review. Medicina. 2019; 55(8): 490, doi: 10.3390/medicina55080490.6. Koegelenberg CFN, Shaw JA, Irusen EM, et al. Contempora-ry best practice in the management of malignant pleural ef-fusion. Ther Adv Respir Dis. 2018; 12: 1753466618785098, doi: 10.1177/1753466618785098, indexed in Pubmed: 29952251.7. Thomas R, Fysh ETH, Smith NA, et al. Effect of an Indwel-ling Pleural Catheter vs Talc Pleurodesis on Hospitalization Days in Patients With Malignant Pleural Effusion: The AMPLE Randomized Clinical Trial. JAMA. 2017; 318(19): www.journals.viamedica.pl/palliative_medicine_in_practice 107Juan David Botero et al., Use of tunnelled pleural catheter for palliative treatment of malignant pleural effusion1903–1912, doi: 10.1001/jama.2017.17426, indexed in Pubmed: 29164255.8. Chalhoub M, Saqib A, Castellano M. Indwelling pleu-ral catheters: complications and management stra-tegies. J Thorac Dis. 2018; 10(7): 4659–4666, doi: 10.21037/jtd.2018.04.160, indexed in Pubmed: 30174919.9. Department of Medicine, Queen Mary Hospital, The Uni-versity of Hong Kong, Pokfulam, Hong Kong, Wong W, Tam TC, Wong MK, Lui MM, Ip MS, et al. Managing mali-gnant pleural effusion with an indwelling pleural catheter: factors associated with spontaneous pleurodesis. Hong Kong Med J [Internet]. 2016 . http://www.hkmj.org/abs-tracts/v22n4/334.htm (17 Oct 2021).10. Chalhoub M, Ali Z, Sasso L, et al. Experience with indwel-ling pleural catheters in the treatment of recurrent pleural effusions. Ther Adv Respir Dis. 2016; 10(6): 566–572, doi: 10.1177/1753465816667649, indexed in Pubmed: 27655919.11. Botana-Rial M, Ramos-Hernández C, Lojo-Rodríguez I, et al. Cost Effectiveness of Malignant Pleural Effusion with Indwelling Catheter: Systematic Review. J Palliat Med. 2021; 24(8): 1206–1212, doi: 10.1089/jpm.2020.0695, indexed in Pubmed: 33395352.12. Abrão FC, Abreu IR, Cavalcanti MG, et al. Use of indwelling pleural catheters for the definitive treatment of malignant pleural effusion. J Bras Pneumol. 2017; 43(1): 14–17, doi: 10.1590/S1806-37562016000000021, indexed in Pubmed: 28125148.13. Páez-Codeso F, Dorado-Galindo A, Jiménez-Fernández D, et al. Tratamiento paliativo ambulatorio de disnea con catéter pleural tunelizado en derrame pleural maligno. Estudio descriptivo. NCT Neumología y Cirugía de Tórax. 2017; 76(4): 308–314, doi: 10.35366/77192.14. Clive AO, Kahan BC, Hooper CE, et al. Predicting survival in malignant pleural effusion: development and valida-tion of the LENT prognostic score. Thorax. 2014; 69(12): 1098–1104, doi: 10.1136/thoraxjnl-2014-205285, indexed in Pubmed: 25100651.15. Petrella F, Maisonneuve P, Borri A, et al. Pleural cathe-ters after thoracoscopic treatment of malignant pleu-ral effusion: a randomized comparative study on qu-ality of life. J Thorac Dis. 2018; 10(5): 2999–3004, doi: 10.21037/jtd.2018.05.49, indexed in Pubmed: 29997967.16. Sivakumar P, Douiri A, West A, et al. OPTIMUM: a protocol for a multicentre randomised controlled trial compa-ring Out Patient Talc slurry via Indwelling pleural cathe-ter for Malignant pleural effusion vs Usual inpatient Management. BMJ Open. 2016; 6(10): e012795, doi: 10.1136/bmjopen-2016-012795, indexed in Pubmed: 27798020.17. Akram MJ, Khalid U, Bakar MA, et al. Indications and cli-nical outcomes of indwelling pleural catheter placement in patients with malignant pleural effusion in a cancer setting hospital. Clin Respir J. 2020; 14(11): 1040–1049, doi: 10.1111/crj.13239, indexed in Pubmed: 32750225.18. Messeder SJ, Thomson MC, Hu MK, et al. Indwelling pleural catheters: an overview and real-life experience. QJM. 2019; 112(8): 599–604, doi: 10.1093/qjmed/hcz116, indexed in Pubmed: 31120124.19. Frost N, Brünger M, Ruwwe-Glösenkamp C, et al. Indwel-ling pleural catheters for malignancy-associated pleural effusion: report on a single centre’s ten years of experience. BMC Pulm Med. 2019; 19(1): 232, doi: 10.1186/s12890-019-1002-8, indexed in Pubmed: 31791305.

Use of tunnelled pleural catheter for palliative treatment of malignant pleural effusion : experience of a third level hospital

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Use of tunnelled pleural catheter for palliative treatment of malignant pleural effusion : experience of a third level hospital

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