Chemical Pleurodesis Using Mistletoe Extraction (ABNOVAviscum(®) Injection) for Malignant Pleural Effusion.

PURPOSE: Malignant pleural effusion (MPE) is common in patients with advanced cancer. Chemical pleurodesis can be considered for MPE that do not respond to chemotherapy, radiotherapy, or therapeutic thoracentesis. However, it is not yet clear which agent is more effective and safer in chemical pleurodesis. METHODS: This study was designed as a single arm, multicenter, and open-label phase III clinical trial to evaluate efficacy and safety of chemical pleurodesis using mistletoe extraction (ABNOVAviscum(®) Injection). References of other agents in chemical pleurodesis were investigated to compare efficacy and safety. Efficacy was evaluated by followed up chest X-ray and changes of clinical symptoms and Karnofsky performance scale. Safety was evaluated by serious adverse event (SAE) and changes of laboratory findings. A follow-up period was 4 weeks after last pleurodesis. RESULTS: Of 62 patients, 49 (79.0%) had complete response, 11 (17.7%) had partial response, and two had no response. Mean response rate was significantly different in this study comparing with reference response rate which was 64% (p <0.0001). There were two SAEs, but all were recovered without sequelas. CONCLUSION: The results of this study suggest that mistletoe extraction (ABNOVAviscum(®) Injection) could be an effective and safe agent of chemical pleurodesis in patients with MPE.

Talc pleurodesis through indwelling pleural catheters for malignant pleural effusions: retrospective case series of a novel clinical pathway.

Malignant pleural effusions cause significant morbidity, but there is no gold standard minimally invasive treatment. A new therapeutic approach combines talc pleurodesis and indwelling pleural catheters (IPCs) to enable outpatient management. This case series summarizes the safety and efficacy data of all patients (24) with a symptomatic malignant pleural effusion who underwent talc pleurodeses via IPCs between December 2010 and July 2013. Successful pleurodesis was achieved in 22 procedures (92%). There was one empyema, one hydropneumothorax, one recurrent effusion, and two minor complications: one drain site wound infection and one complaint of chest pain. Twenty-two procedures (92%) were performed in the outpatient setting. This report confirms the safety and efficacy of administering talc slurry through IPCs in an outpatient setting. Studies in a larger cohort are necessary to define the role of this novel approach in the treatment algorithm of patients with this condition.

Pleural MALT lymphoma diagnosed on thoracoscopic resection under local anesthesia using an insulation-tipped diathermic knife.

A 79-year-old man presented with back pain. Chest CT scan showed elevated nodular lesions in the right parietal pleurae with pleural effusion. There were no intrapulmonary or mediastinal abnormalities. Under local anesthesia, right thoracoscopy and subsequent thoracoscopic pleural resection were performed using an insulation-tipped diathermic knife (IT-knife). The resected pleura, 2.2 cm in diameter, had a rough granular surface. Lymphoid cells histologically infiltrated diffusely into the pleura. They were composed of centrocyte-like and monocytoid cells. On immunohistochemistry they were found to be positive for Bcl2, CD20, CD45RB and CD79a, but negative for CD3, CD5, CD10 and cyclin D1. EBV-encoded small RNA-1 (EBER-1) in situ hybridization was negative. A diagnosis of extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) arising in the pleura was therefore made. To the authors' knowledge this is the first case in which IT-knife was used for diagnosis of a pleural lesion. This large, single-piece, only slightly crushed pleural specimen, enabled study of histopathological findings (listed here) that could not have been obtained on conventional biopsy: (i) lack of apparent evidence of plasmacytic differentiation; (ii) no recognition of lymphoid follicles; (iii) mesothelial cells not infiltrated by lymphoma cell clusters; (iv) thin layer of hyperplastic mesothelial cells continuously covering the surface; and (v) no proliferation of fibroblast-like submesothelial cells.

[Videothoracoscopy in local anesthesia diagnosis and therapy of pleural effusions]. / Videotorakoskopie v lokální anestezii v diagnostice a lécbe pohrudnicních výpotku.

Videothoracoscopy (VTS) has been performed in the Department of Pneumology in Plzen since the year 2001. Up to-September 2005 there were realized 75 videothoracoscopies, all under local anaesthesia with analgosedation and during the spontaneous ventilation. The objective of the present work is to demonstrate that the so called "medical" videothoracoscopy is very well tolerated, quick and accurate miniinvasive method of examination of pleural pathological states, which has a high diagnostic effect and minimal complications. During the exploration it is possible to carry out, besides the collection of bioptic samples from parietal as well as visceral pleura, a whole range of therapeutical acts - evacuation of effusion, mechanical disruption of adhesions in case of empyema with its subsequent drainage or pleurodesis with talc in case of malignant exudates. As for the basic indication of the medica VTS, we consider it to be the differential diagnosis of a pleural effusion of unclear etiology, consisting mostly in the confirmation or exclusion of malignant exudates. The differential diagnosis with the help of VTS between the nonmalignant (mostly inflammatory) and malignant exudate was successful, in our group of patients, in 96 %. The operation was well tolerated by all patients and in none of them occurred significant complications or consequences.

[A case of malignant lymphoma diagnosed by thoracoscopy with local anesthesia].

A 67-year-old woman was hospitalized with right pleural effusion on chest radiography. Chest CT showed a thickened parietal pleura and pleural effusion in the right thorax. Cytological examination of pleural effusion showed atypical plasma cells. We performed thoracoscopy with local anesthesia for diagnosis and observed an about 5 x 5 cm seized red soft tumor on the parietal pleura. Pathological and immunohistochemical examination of the pleural tumor revealed that it was marginal zone B-cell malignant lymphoma. In this case, we could not reach a diagnosis only by cytological examination of the pleural effusion. Thoracoscopy with local anesthesia was safe and useful for diagnosis of malignant lymphoma with pleural effusion. Most cases of primary pleural malignant lymphoma have a history of chronic pyothorax. This case is thought to be a very rare case of primary pleural malignant lymphoma with no history of pyothorax.

[Negative pleural cytology after intrapleural perfusion hyperthermo-chemotherapy for malignant pleural effusion].

We gave intrapleural perfusion hyperthermo-chemotherapy to a 72-year-old woman in whom malignant pleural effusion developed after surgery for primary cancer. This procedure involved irrigating the pleural space for 2 hours with a water solution at 42-43 degrees containing 240 mg cisplatin using specially devised extracorporeal circuits. Thoracoscopy was used to examine the intrapleural cavity and to place the catheters for perfusion. The patient had an uneventful postoperative course and was discharged for hospital on the second postoperative day. Thereafter, she experienced good quality of life with negative pleural cytology. Unfortunately, the patient died 3 months after the therapy, but the cause of death was unknown and there was no cancer recurrence. This technique may be safe and feasible for controlling malignant effusion to preserve quality of life, although the survival benefit has not yet been clarified.

[Clinical utility and safety of diagnostic thoracoscopy].

The increasing use of thoracoscopy performed under local anesthesia has made contributions to the diagnosis of pleural disease with effusion. During the past 7 years, we have performed 100 such thoracoscopy procedures using a flexible fiberoptic bronchoscope. On the basis of our clinical findings, we are able to discuss the utility and safety of this procedure. The causes of pleural effusion were carcinomatous pleurisy in 72 cases, tuberculosis pleurisy in 15 cases, infection without tuberculosis in 4 cases, malignant pleural mesothelioma in 8 cases and one case of asbestosis. The success rate of thoracoscopic pleural biopsies were 97% for carcinomatous pleurisy, 100% for malignant pleural mesothelioma and 86% for tuberculosis pleurisy. This procedure was performed with no serious effect on blood pressure, oxygen saturation, monitored ECG or BGA data, and with no serious complications. Therefore, we concluded that this method is very useful for the diagnosis of pleural effusions and has few complications.

[Chemotherapy in combination with whole-body hyperthermia in advanced malignant pleural mesothelioma]. / Chemotherapie in Kombination mit Ganzkörperhyperthermie bei fortgeschrittenem malignem Pleuramesotheliom.

HISTORY AND CLINICAL FINDINGS: A 57-year-old man presented with dyspnoea, cough, fatigue and weight loss. He had been exposed to asbestos 30 years ago. Physical examination was unremarkable apart from a suspected pleural effusion. INVESTIGATIONS: Computed tomography (CT) of the thorax showed multiple pleural masses with pleural effusion on the left side. CT of the abdomen and bronchoscopy were normal. The patient underwent explorative thoracoscopy; biopsies were taken, and diffuse malignant pleural mesothelioma was demonstrated. TREATMENT AND COURSE: The patient was evaluated at the University Hospital Lübeck for Phase II experimental therapy with whole-body hyperthermia (WBH). The pretreatment evaluation revealed normal cardiorespiratory function and a normal contrast-enhanced CT of the brain. The patient's haematologic profile and electrolytes were normal. The WBH-radiant heat device (RHD) used for therapy was Aquatherm provided by the Cancer Research Institute (CRI, New York, USA). The patient received ifosfamide (5 g/m2, day 1), carboplatin (300 mg/m2, day 1), etoposide (150 mg/m2, days 2-3) combined with WBH at 41.8 degrees C (for 60 minutes). Two cycles were applied without complications and a partial remission of the disease was observed. CONCLUSION: Radiant heat whole body hyperthermia, in conjunction with a defined anticancer treatment and pharmacological approach to sedation, was a safe and effective palliative treatment in this patient.

[Thoracoscopic pleural biopsy under local anesthesia using a 2 mm laparoscope].

Thoracoscopy is indicated in patients with undiagnosed effusion after conventional methods. It has been usually performed under general anesthesia or using a thoracoscope with a thoracoscope with a diameter over 5 mm. However, it is an invasive diagnostic technique. We evaluated the feasibility of thoracoscopic pleural biopsy under local anesthesia using a 2 mm laparoscope. Six patients with a pleural effusion of unknown etiology after conventional methods, underwent thoracoscopy under local anesthesia. A 2 mm laparoscope and biopsy forceps (2 mm Minisite, United States Surgical Corp., USA) was used in all patients. Pleural fluid was removed, and the thoracic cavity was inspected. Thoracoscopic intercostal blocks were performed with 1% lidocaine, and then a biopsy was performed. The biopsy specimen was sent for histopathology. Three patients were shown to have carcinomatous pleurisy, two of them with localized lesions less than 10 mm. In the remaining three patients, non-specific diagnoses were made, but long-term follow-up revealed no malignant pleural disease. Although the pictures obtained using a 2 mm laparoscope were inferior in quality, they were adequate for the detection of malignant lesions in the pleural cavity. There were no procedure-related complications. These findings suggest that thoracoscopy using a 2 mm laparoscope is (1) a useful diagnostic tool in cases of pleural malignancy; (2) a minimally invasive method with the advantage of being easily performed under local anesthesia. Thus, thoracoscopic pleural biopsy using a 2 mm laparoscope appears to be useful for undiagnosed pleural effusion.