Thoracic Imaging 2003 - Society of Thoracic Radiology
Thoracic Imaging 2003 - Society of Thoracic Radiology
Thoracic Imaging 2003 - Society of Thoracic Radiology
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SUNDAY<br />
86<br />
Image-Guided Therapy <strong>of</strong> Malignant Pleural Effusions<br />
H. Page McAdams, M.D.<br />
Learning Objectives:<br />
At completion <strong>of</strong> this lecture, the attendee will be able to:<br />
1. Describe indications for image-guided treatment <strong>of</strong><br />
malignant pleural effusions.<br />
2. Explain image-guided treatment <strong>of</strong> malignant pleural<br />
effusions.<br />
3. Discuss the use <strong>of</strong> fibrinolytic and sclerosing agents<br />
for management <strong>of</strong> malignant pleural effusions.<br />
Definition:<br />
Malignant pleural effusions are common in cancer patients<br />
with advanced disease. Approximately 50% <strong>of</strong> patients with<br />
breast carcinoma, 25% <strong>of</strong> patients with lung carcinoma and 35%<br />
<strong>of</strong> patients with lymphoma develop a malignant effusion during<br />
the course <strong>of</strong> their disease. Patients with malignant effusions<br />
present with progressive dyspnea, cough, and chest pain that<br />
compromises their quality <strong>of</strong> life.<br />
Treatment Options:<br />
Treatment options depend on the extent <strong>of</strong> disease, effectiveness<br />
<strong>of</strong> systemic therapy, and patient performance status.<br />
Pleural effusions in patients with lymphoma, small cell lung<br />
cancer or germ cell malignancies may be controlled by systemic<br />
treatment alone. Patients with pleural metastatic disease refractory<br />
to systemic therapy may require palliative treatment to<br />
improve their quality <strong>of</strong> life. Therapeutic options include thoracentesis,<br />
large bore tube thoracostomy and sclerotherapy, and<br />
thoracoscopic instillation <strong>of</strong> sclerosing agents such as talc.<br />
Numerous studies have now shown that malignant effusions can<br />
be effectively managed by image-guided small bore catheter<br />
drainage and sclerotherapy. <strong>Imaging</strong> guidance is particularly<br />
useful in these patients both for localizing pleural abnormalities<br />
and for avoiding unnecessary procedures in patients with central<br />
obstructing masses, a thick pleural peel, or multiple loculated<br />
fluid pockets.<br />
Tube Placement:<br />
We typically place our catheters in the mid-axillary line at<br />
the sixth or seventh interspace using either US or fluoroscopic<br />
guidance and adequate conscious sedation. The skin entrance<br />
site is marked and prepped using aseptic technique. The skin is<br />
anesthetized with 1% topical lidocaine and an 18 gauge trocar<br />
needle is placed directly into the pleural space. Fluid is aspirated<br />
to confirm the intrapleural location <strong>of</strong> the needle. A 0.38,<br />
100 cm floppy-tip guidewire is then fed through the needle to<br />
guide tube placement and to mechanically break up pleural<br />
adhesions. With the guidewire in position, progressive dilation<br />
<strong>of</strong> the drainage tract is performed and a 14 French pig tail<br />
catheter is inserted. The chest tube is then secured by a catheter<br />
retention device and up to 1 liter <strong>of</strong> fluid is immediately aspirated.<br />
If the patient begins to cough or complain <strong>of</strong> increased<br />
shortness <strong>of</strong> breath during aspiration, we discontinue further<br />
aspiration.<br />
A post tube placement radiograph is obtained to assure proper<br />
placement <strong>of</strong> the tube. Up to 30% <strong>of</strong> patients will have a<br />
pneumothorax on the post tube placement films. This is usually<br />
due to an ‘ex vacuo’ phenomenon and will resolve over the next<br />
few days. When the patient is returned to the ward, the tube is<br />
connected to a Pleur-evac with continuous wall suction at 20 to<br />
25 cm H 2 O. Daily tube outputs are recorded and tubes are<br />
flushed with 10 cc <strong>of</strong> normal saline every 8 -12 hours. Patients<br />
are seen each day to assure that the tube is functioning properly.<br />
Daily chest radiographs are not obtained when drainage continues<br />
without difficulty. When drainage decreases to 150-200 cc<br />
in a 24-hour period, a chest radiograph is performed to exclude<br />
loculated fluid and to assure complete lung re-expansion. It is<br />
important that the pleural fluid is completely drained and that<br />
the lung is completely re-expanded prior to instillation <strong>of</strong> the<br />
sclerosing agent.<br />
Sclerotherapy:<br />
Once the pleural space has been drained (usually 2 to 5<br />
days), a sclerosing agent is infused. The most common agents<br />
are doxycycline, bleomycin or a sterile talc slurry. The dosage<br />
for doxycycline is 500 mg in 100 cc <strong>of</strong> normal saline. The<br />
dosage for Bleomycin is 60 units in 100 cc <strong>of</strong> D5W. The<br />
dosage for talc is 5 grams in 100 cc saline. Although no single<br />
sclerosant has been shown to have a clear advantage over the<br />
others, we are currently using talc because it is both effective<br />
and inexpensive. We usually add 10 cc <strong>of</strong> a one percent lidocaine<br />
solution to the talc slurry for pain control. Most patients<br />
require some degree <strong>of</strong> pain control and sedation during instillation<br />
<strong>of</strong> either talc or doxycycline. Pain is the most common<br />
complication <strong>of</strong> sclerotherapy. A small percentage <strong>of</strong> patients<br />
develop systemic complaints such as fever after bleomycin or<br />
talc instillation. There are rare reports <strong>of</strong> serious reactions,<br />
including ARDS and death, following instillation <strong>of</strong> large<br />
amounts <strong>of</strong> talc, usually 10 grams or greater.<br />
After the sclerosing agent is instilled, the tube is closed to<br />
suction and the patient is instructed to change positions every 15<br />
minutes for 2 hours in order to evenly distribute the sclerosant<br />
throughout the pleural space. The tube is then reopened to suction<br />
until the following day when the tube is removed if<br />
overnight drainage is less than 200 cc. Repeat sclerosis is recommended<br />
if the overnight drainage is greater than 200 cc.<br />
Complications:<br />
Complications are unusual and include tube malfunction<br />
(e.g., clotting or kinking) or malposition, infection, loculation,<br />
pneumothorax and re-expansion pulmonary edema (see below).<br />
Tubes with decreased drainage are flushed with saline, heparin<br />
or streptokinase to determine patency; guide wire insertion is<br />
occasionally required to re-establish tube patency. If the tube is<br />
severely kinked or clotted, it may have to be replaced.<br />
If the pleural fluid is loculated, multiple drainage catheters<br />
may be required. We have also found that fibrinolytic agents<br />
such as streptokinase are quite useful for managing complex or<br />
loculated collections. We typically instill 250,000 U <strong>of</strong> streptokinase<br />
mixed in 100 cc <strong>of</strong> normal saline directly into the pleural<br />
space. The tube is then closed for 2 hours to allow the fibrinolytic<br />
agent to distribute throughout the pleural space and is<br />
thereafter reopened to continuous suction. We repeat instillation<br />
on a daily basis as needed. The choice <strong>of</strong> fibrinolytic agent is<br />
controversial. While streptokinase is less expensive than either<br />
urokinase or tPA, it is antigenic and can cause fever in up to<br />
28% <strong>of</strong> treated patients. Urokinase is non-antigenic, does not<br />
cause fever, and may be slightly more effective than streptokinase.<br />
The dosage for Urokinase is 100,000 units in 100 cc <strong>of</strong><br />
normal saline. Unfortunately, Urokinase is not currently available<br />
for intrapleural injection in the United States. Experience<br />
with tPA in the pleural space is limited.