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ES19 - Recently Diagnosed Malignant Pleural Effusion (ID 22)
- Event: WCLC 2019
- Type: Educational Session
- Track: Interventional Diagnostics/Pulmonology
- Presentations: 5
- Now Available
- Moderators:Juan Carlos Trujillo-Reyes, Julius Janssen
- Coordinates: 9/09/2019, 14:00 - 15:30, Tokyo (1982)
ES19.01 - Benefits and Limitations of Systemic Therapy for Malignant Pleural Effusion (Now Available) (ID 3258)
14:00 - 15:30 | Presenting Author(s): Anne Tsao
Systemic therapy for metastatic non-small cell lung cancer is directed by molecular profiling. Ideally, genetic sequencing and PD-L1 immunohistochemistry should be performed on tumor cells obtained from malignant pleural effusions where the diagnosis of non-small cell lung cancer is evident. This discussion will review the recommended up to date testing practices and the subsequent systemic therapy decisions for patients with metastatic non-small cell lung cancer.
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ES19.02 - Best Endoscopic Tools for the Best Results (Now Available) (ID 3257)
14:00 - 15:30 | Presenting Author(s): Mohammed Munavvar
Best Endoscopic Tools for the Best Results
Dr M Munavvar
Lancashire Teaching Hospitals, Preston, UK
Undiagnosed pleural effusion is an increasingly common clinical problem and represents significant burden of disease both to patients and healthcare resources. With the increase in annual incidence of both primary and secondary pleural malignancies, better diagnostics and treatment options are very much needed.
Medical thoracoscopy, also known as local anaesthetic thoracoscopy , is a procedure where a rigid or semi-rigid scope is inserted into the pleural cavity via a port for direct visualisation of the pleura and biopsy of abnormal areas, besides completion of talc poudrage, where appropriate. It is usually performed under conscious sedation and local anaesthesia. This procedure avoids risks of general anaesthesia and single lung ventilation, required for video-assisted thoracoscopic surgery (VATS) and therefore can be performed in patients who are unfit for anaesthesia/surgery. The procedure of thoracoscopy is performed in a controlled environment such as in an operating theatre setting, endoscopy suite or treatment room with adequate staffing.
A significant number of cases of pleural effusion are undiagnosed after a single diagnostic pleural aspiration and the diagnostic yield of pleural fluid cytology is only approximately 60% . A second aspiration only modestly increases diagnostic yield by 15% and a third sample is non-contributory . A blind pleural biopsy (also known as closed pleural biopsy) increases the diagnostic yield above pleural fluid cytology by only 7-27% . In mesothelioma however, the diagnostic yield of pleural fluid cytology is even lower, at around 32% . A blind pleural biopsy only increases sensitivity to around 50% .
Medical thoracoscopy is substantially superior in diagnostic power compared to pleural fluid cytology and blind pleural biopsy. As it allows direct visual assessment of the pleura and subsequent biopsy of the abnormal areas, it maximises diagnostic yield to >90% in malignant pleural diseases [5,6]. Rigid thoracoscopy generates similar diagnostic yield compared to semirigid thoracoscopy in exudative pleural effusions but larger biopsy samples can be obtained during rigid thoracoscopy [5,6].The sensitivity of medical thoracoscopy in malignant mesothelioma appears to be equally good and the efficacy of rigid medical thoracoscopy in regards to diagnosis in pleural malignancy is as high as VATS .
With the increasing need to secure an accurate diagnosis and plan optimal treatment in possible pleural malignancy, medical thoracoscopy offers a high diagnostic yield earlier in the patient journey. Therefore, this is the preferred procedure where the option exists and helps to reduce the need for repeated diagnostic procedures and reduces the time taken to establish diagnosis and commence appropriate treatment.
Medical thoracoscopy as a therapeutic procedure
Another advantage of medical thoracoscopy is that it is a diagnostic and therapeutic procedure in the same setting. Complete drainage of pleural fluid can be achieved during the procedure and talc poudrage can also be performed during medical thoracoscopy. It is a highly effective method of pleurodesis with an efficacy of 84% at 1 month, which is at least equivalent to talc slurry via a seldinger chest drain, with possibly increased efficacy in the subgroup of patients who have breast or lung carcinoma and without trapped lung .
Medical thoracoscopy is also effective in the management of TB pleurisy and empyema. Septations and adhesions in complex infected effusions can be divided during thoracoscopy which can facilitate accurate chest tube placement and drainage.
Advanced Thoracoscopy Techniques
Narrow Band Imaging- using Semirigid Thoracoscope
Autofluorescence Rigid Thoracoscopy
Biopsy- with Insulated Tip Diathermy Knife
Cryobiopsy- using Semirigid Thoracoscope
Diacon AH, Van de Wal BW, Wyser C, et al. Diagnostic tools in tuberculous pleurisy: a direct comparative study. Eur Respir J 2003;22:589e91.
Rahman NM, Ali NJ, Brown G, Chapman SJ, O’Davies RJ, Downer NJ, Gleeson FV, Howes TQ, Treasure T, SinghS and Phillips GD Local anaesthetics thoracoscopy: British Thoracic Society pleural disease guideline 2010. Thorax 2010;65(Suppl 2):ii54-ii60
Mohan A, Chandra S, Agarwal D, Naik S and Munavvar M. Utility of semirigid thoracoscopy in the diagnosis of pleural effusions: a systematic review. Journal of Bronchology and Interventional Pulmonology 17 (3), 195-201
Munavvar M, Khan MAI, Edwards J, Waqaruddin Z and Mills J. The autoclavable semirigid thoracoscope: the way forward in pleural disease? Eur Respir J 2007; 29: 571-574
Dhooria S, Singh N, Agarwal AN, Gupta D and Agarwal R. A randomized trial comparing the diagnostic yield of rigid and semirigid thoracoscopy in undiagnosed pleural effusion. Respir Care 2014:59 (5), 756-764
Rozman A, Camlek L, Marc-Malovrh M, Triller N, Kern I. Rigid versus semi-rigid thoracoscopy for diagnosis of pleural disease: a randomized pilot study. Respirology, 2013 May;18(4):704-10.
Loddenkemper R, Lee P, Noppen M, Mathur PN. Medical thoracoscopy/pleuroscopy: step by step. Breathe. 2011;8(2):156-67.
ES19.03 - RCT's on Malignant Pleural Effusion Talc Pleurodesis Managment (Now Available) (ID 3260)
14:00 - 15:30 | Presenting Author(s): Nick Maskell
This talk will focus on 2 recently completed multicentre RCT's in talc pleurodesis for malignant pleural effusions; IPC plus trial (NEJM 2018) and the TAPPS trial (in submission). A summary of these 2 trials is below:
IPC Plus - Methods: Over a period of 4 years, we recruited patients with malignant pleural effusion at 18 centers in the United Kingdom. After the insertion of an indwelling pleural catheter, patients underwent drainage regularly on an outpatient basis. If there was no evi- dence of substantial lung entrapment (nonexpandable lung, in which lung expansion and pleural apposition are not possible because of visceral fibrosis or bronchial ob- struction) at 10 days, patients were randomly assigned to receive either 4 g of talc slurry or placebo through the indwelling pleural catheter on an outpatient basis. Talc or placebo was administered on a single-blind basis. Follow-up lasted for 70 days. The primary outcome was successful pleurodesis at day 35 after randomization. Results: The target of 154 patients undergoing randomization was reached after 584 patients were approached. At day 35, a total of 30 of 69 patients (43%) in the talc group had successful pleurodesis, as compared with 16 of 70 (23%) in the placebo group (haz- ard ratio, 2.20; 95% confidence interval, 1.23 to 3.92; P=0.008). No significant be- tween-group differences in effusion size and complexity, number of inpatient days, mortality, or number of adverse events were identified. No significant excess of blockages of the indwelling pleural catheter was noted in the talc group. Conclusions: Among patients without substantial lung entrapment, the outpatient administration of talc through an indwelling pleural catheter for the treatment of malignant pleural effusion resulted in a significantly higher chance of pleurodesis at 35 days than an indwelling catheter alone, with no deleterious effects. (Funded by Becton Dickinson; EudraCT number, 2012-000599-40.)
TAPPS - Methods We recruited patients with malignant pleural effusion from 17 United Kingdom hospitals over 5 years. On an open-label basis, patients were randomly assigned to receive either 4g talc poudrage at thoracoscopy under conscious sedation, or chest tube insertion under local anesthetic followed by 4g talc slurry. Follow-up lasted for six months. The primary outcome was pleurodesis failure rate three months after randomization, defined as the need for further pleural intervention during follow-up. Secondary outcomes including mortality and cost-effectiveness were also assessed. Results The target of 330 patients was reached after 583 were approached. At three months, pleurodesis failure rate was 36/161 (22%) with poudrage and 38/159 (24%) with slurry (adjusted odds ratio (OR) 0.91, 95% confidence interval (CI) 0.54-1.55, p=0.74). No statistically significant differences were noted in any secondary outcome. Numbers of adverse events were similar between groups. Using a standard threshold, poudrage had a 36% probability of being cost-effective. Conclusions In patients with malignant pleural effusion, there appears to be no additional clinical or cost-effectiveness benefit to choosing talc poudrage at physician-led thoracoscopy over talc slurry through chest tube. (Funded by the United Kingdom National Institute for Health Research).
ES19.04 - How to Deal with a Trapped Lung (Now Available) (ID 3259)
14:00 - 15:30 | Presenting Author(s): Y C Gary Lee
TRAPPED LUNG AND MALIGNANT PLEURAL EFFUSIONS
Y C Gary Lee MBChB PhD FRACP FRCP FCCP
Professor of Respiratory Medicine, University of Western Australia
Trapped lung, now also called nonexpandable lung, refers to the observation when an underlying lung fails to fully expand upon removal of pleural fluid or air . It occurs in ~30% of patients with malignant pleural effusions (MPEs) and may arise from thickened visceral pleura (inhibiting lung expansion) or from endobronchial tumor obstruction. The pleural space in patients with nonexpandable lung is usually under high negative pressure. This can lead to transudative fluid accumulation by Starling’s equation, in addition to the underlying MPE formation. This condition is often difficult to manage as fluid often keep recurring to fill up the trapped lung space.
Patients with MPE and trapped lung often present with breathlessness. It is important to recognize that removal of the fluid can still provide symptom relief despite the nonexpendable underlying lung . A trial of fluid drainage to determine if the patient has symptoms benefits is worthwhile. The current belief is that breathlessness from MPE is a result of altered respiratory mechanics when the hemithorax expands to accommodate the volume of the effusion (see our review  for details).
Patients with nonexpandable lungs usually do not benefit from pleurodesis due to the lack of apposition of the visceral and parietal pleura. Indwelling pleural catheter (IPC) is now a recognized first choice management of MPE in patients with a nonexpendable lung, as recommended in the latest American thoracic Society MPE guidelines (2018) . Several large randomized studies in recent years have testified to the benefits of IPC management of MPEs. The TIME-2 study  showed that IPC offered benefits to breathlessness and chest pain similar to conventional talc slurry pleurodesis. The AMPLE trial  showed that patients with MPE managed with IPC spent fewer days in hospital and required fewer pleural invasive procedures in their remaining life while enjoying the same level of symptom and quality-of-life improvements as those patients treated with talc pleurodesis. The recently published AMPLE-2 study  compared daily catheter drainage vs symptom-guided drainage in patients with MPEs and an IPC. Interestingly 50% of those with initial trapped lung who underwent daily drainage eventually developed spontaneous pleurodesis that allow removal of the catheter. The numbers however were small and the results require verification.
Conventionally it is believed that surgical decortication of the lung in MPE patients with visceral pleural thickening may allow the lung to re-expand and thus permit successful pleurodesis. Limited objective data exist to support this belief (see our recent review ). In the VATS-Meso trial  and other observational series, patient who underwent VATS pleurodesis +/- pleurectomy have higher risks of complications especially prolonged post-operative air-leak and thus hospitalization. The planned AMPLE-3 randomized trial will compare IPC treatment with surgical pleurodesis for MPE.
Patients with MPEs and underlying nonexpandable lung are often excluded in clinical trials and thus their optimal management remains unclear. They represent a sizeable subset of MPE patients and deserve specific attention in future research.
1. Light RW, Lee YCG. Textbook of Pleural Dieaseas. 3rd ed. USA: Taylor & Francis; 2016.
2. Thomas R, Jenkins S, Eastwood PR, et al. Physiology of breathlessness associated with pleural effusions. Curr Opin Pulm Med. 2015;21(4):338-45.
3. Feller-Kopman DJ, Reddy CB, DeCamp MM, et al. Management of Malignant Pleural Effusions. An Official ATS/STS/STR Clinical Practice Guideline. Am J Respir Crit Care Med. 2018;198(7):839-49.
4. Davies HE, Mishra EK, Kahan BC, et al. Effect of an indwelling pleural catheter vs chest tube and talc pleurodesis for relieving dyspnea in patients with malignant pleural effusion: the TIME2 randomized controlled trial. JAMA. 2012;307(22):2383-9.
5. Thomas R, Fysh ETH, Smith NA, et al. Effect of an Indwelling Pleural Catheter vs Talc Pleurodesis on Hospitalization Days in Patients With Malignant Pleural Effusion: The AMPLE Randomized Clinical Trial. JAMA. 2017;318(19):1903-12.
6. Muruganandan S, Azzopardi M, Fitzgerald DB, et al. Aggressive versus symptom-guided drainage of malignant pleural effusion via indwelling pleural catheters (AMPLE-2): an open-label randomised trial. Lancet Respir Med. 2018;6(9):671-80.
7. Fitzgerald DB, Koegelenberg CFN, Yasufuku K, et al. Surgical and non-surgical management of malignant pleural effusions. Expert Rev Respir Med. 2018;12(1):15-26.
8. Rintoul RC, Ritchie AJ, Edwards JG, et al. Efficacy and cost of video-assisted thoracoscopic partial pleurectomy versus talc pleurodesis in patients with malignant pleural mesothelioma (MesoVATS): an open-label, randomised, controlled trial. Lancet. 2014;384(9948):1118-27.
ES19.05 - Surgical Management of Malignant Pleural Effusion (Now Available) (ID 3261)
14:00 - 15:30 | Presenting Author(s): Alan D Sihoe
At first glance, it would seem that the thoracic surgeon has little role to play nowadays in the management of malignant pleural effusion (MPE). Substantial advances have been made in the understanding of the pathophysiology of MPE and its diagnosis. There is broad consensus that pleurodesis should generally be given at the bedside rather than in the operating theatre, while intractable cases can be managed with indwelling catheters. Even where interventions into the chest are required, the advent of ‘medical’ thoracoscopy appears to have diminished the role of surgeons in managing MPE.
However, it would be wrong to presume that thoracic surgeons may be completely excluded from the MPE scene. There remain situations were surgery is still required for a definitive diagnosis or effective palliation. Surgeons continue to have more extensive experience with biopsy, drainage, and ‘rapid pleurodesis’ – yielding high rates of success. More importantly, minimally invasive Video-Assisted Thoracic Surgery (VATS) has evolved significantly in recent years. Uniportal VATS is becoming increasingly utilized, and is often complemented by technological advances such as non-intubated anesthesia. The latest advances in minimally invasive thoracic surgery have ensured that the high success rate of surgery is now coupled with surprisingly little – if any – functional or physiological ‘cost’ to the patient with MPE. The ‘VATS’ available today is not the same VATS from even a few years ago.
This presentation provides an overview of the current surgical options available in the management of MPE. The modern thoracic surgeon remains fully equipped and prepared to contribute to the multi-disciplinary care of patients with this complication.