The Inflammatory Cytokine Profile of Patients with Malignant Pleural Effusion Treated with Pleurodesis.

Patients with malignant pleural effusion (MPE) who underwent successful pleurodesis survive longer than those for whom it fails. We hypothesize that the therapy-induced inflammatory responses inhibit the cancer progression, and thereby lead to a longer survival. Thirty-three consecutive patients with MPE that were eligible for bleomycin pleurodesis between September 2015 and December 2017 were recruited prospectively. Nineteen patients (57.6%) achieved fully or partially successful pleurodesis, while 14 patients either failed or survived less than 30 days after pleurodesis. Two patients without successful pleurodesis were excluded because of missing data. Interleukin (IL)-1 beta, IL-6, IL-10, transforming growth factor beta, tumor necrosis factor alpha (TNF-α), and vascular endothelial growth factor in the pleural fluid were measured before, and after 3 and 24 h of pleurodesis. Their pleurodesis outcome and survival were monitored and analyzed. Patients who underwent successful pleurodesis had a longer survival rate. Patients without successful pleurodesis had significantly higher TNF-α and IL-10 levels in their pleural fluid than in the successful patients before pleurodesis. Following pleurodesis, there was a significant increment of IL-10 in the first three hours in the successful patients. In contrast, significant increments of TNF-α and IL-10 were found in the unsuccessful patients between 3 and 24 h after pleurodesis. The ability to produce specific cytokines in the pleural space following pleurodesis may be decisive for the patient's outcome and survival. Serial measurement of cytokines can help allocate the patients to adequate treatment strategies. Further study of the underlying mechanism may shed light on cytokine therapies as novel approaches.

Clinical outcomes of chemical pleurodesis using a minocycline.

BACKGROUND: Pleurodesis is often used to prevent the re-accumulation of a malignant pleural effusion (MPE). Intrapleural urokinase (IPUK) therapy facilitates lung re-expansion for patients with loculated MPE or a trapped lung that allows subsequent pleurodesis. MPE management has been traditionally regarded as a symptomatic treatment. We tried to evaluate their impact on patient survival. METHODS: There were 314 consecutive patients with symptomatic MPE that underwent minocycline pleurodesis with ( n = 109) and without ( n = 205) the antecedent IPUK therapy between September 2005 and August 2015, who were recruited for the pleurodesis outcome and survival analysis. RESULTS: The rate of successful pleurodesis was similar between the simple pleurodesis group and the IPUK therapy group followed by the pleurodesis group (69.0% versus 70.5%; p = 0.804). The patients who succeeded pleurodesis had a longer survival rate than those who failed in either the simple pleurodesis group (median, 414 versus 100 days; p < 0.001) or the IPUK therapy followed by pleurodesis group (259 versus 102 days; p < 0.001). The survival differences remained when the lung and breast cancer patients were studied separately. CONCLUSION: Successful pleurodesis translated into a better survival rate that promotes performing pleurodesis on lung re-expansion. The apparent shorter survival of the patients with loculated MPE or trapped lung, and those that did not respond to the IPUK therapy, lowered the probability of the survival benefit through the simple physical barrier by the fibrin formation to prevent the tumor spreading. The successfully induced inflammatory response by minocycline is supposed to prohibit the tumor invasion and metastasis. Further studies are warranted to clarify the mechanism and provide opportunities to develop novel therapeutic strategies.

Increasing Receipt of High-Tech/High-Cost Imaging and Its Determinants in the Last Month of Taiwanese Patients With Metastatic Cancer, 2001-2010: A Retrospective Cohort Study.

One strategy for controlling the skyrocketing costs of cancer care may be to target high-tech/high-cost imaging at the end of life (EOL). This population-based study investigated receipt of high-tech/high-cost imaging and its determinants for Taiwanese patients with metastatic cancer in their last month of life.Individual patient-level data were linked with encrypted identification numbers from computerized administrative data in Taiwan, that is, the National Register of Deaths Database, Cancer Registration System database, and National Health Insurance claims datasets, Database of Medical Care Institutions Status, and national census statistics (population/household income). We identified receipt of computerized tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), and radionuclide bone scans (BSs) for 236,911 Taiwanese cancer decedents with metastatic disease, 2001 to 2010. Associations of patient, physician, hospital, and regional factors with receiving CT, MRI, and bone scan in the last month of life were evaluated by multilevel generalized linear-mixed models.Over one-third (average [range]: 36.11% [33.07%-37.31%]) of patients with metastatic cancer received at least 1 high-tech/high-cost imaging modality in their last month (usage rates for CT, MRI, PET, and BS were 31.05%, 5.81%, 0.25%, and 8.15%, respectively). In 2001 to 2010, trends of receipt increased for CT (27.96-32.22%), MRI (4.34-6.70%), and PET (0.00-0.62%), but decreased for BS (9.47-6.57%). Facilitative determinants with consistent trends for at least 2 high-tech/high-cost imaging modalities were male gender, younger age, married, rural residence, lung cancer diagnosis, dying within 1 to 2 years of diagnosis, not under medical oncology care, and receiving care at a teaching hospital with a larger volume of terminally ill cancer patients and greater EOL care intensity. Undergoing high-tech/high-cost imaging at EOL generally was not associated with regional characteristics, healthcare resources, and EOL care intensity.To more effectively use high-tech/high-cost imaging at EOL, clinical and financial interventions should target nonmedical oncologists/hematologists affiliated with teaching hospitals that tend to aggressively treat high volumes of terminally ill cancer patients, thereby avoiding unnecessary EOL care spending and transforming healthcare systems into affordable high-quality cancer care delivery systems.

Intrapleural urokinase for the treatment of loculated malignant pleural effusions and trapped lungs in medically inoperable cancer patients.

BACKGROUND: Pleural fluid loculations or trapped lungs frequently render patients with symptomatic malignant pleural effusions (MPEs) unsuitable for pleurodesis. Thoracoscopic surgery or thoracotomy with decortication is generally not feasible for patients with a poor performance status. MPEs have augmented procoagulant and depressed fibrinolytic activity that contributes to fibrin deposition within the pleural space. The authors conducted an observational prospective cohort study to investigate the use of intrapleural urokinase (IPUK) for such patients and made a comparison with a historical control group. METHODS: Between March of 2000 and August of 2005, 48 consecutive patients with symptomatic MPEs with an average Karnofsky performance scale score of 46.7% were recruited. Dyspnea persisted with the presence of substantial residual loculated MPEs in 36 patients and trapped lungs in 12 patients, when the effectiveness of 8-French intrapleural catheter drainage had decreased despite regular saline flushes. Urokinase was instilled daily through the catheter at a dose of 100,000 IU diluted in 100 ml of normal saline for 3 days. Additional IPUK instillation was required upon partial improvement. The records and chest radiographs of another 52 patients with symptomatic MPEs had met these eligibility criteria between January of 1995 and February of 2000 and received saline flushes only were also reviewed. RESULTS: Immediate lung reexpansion and resolution of dyspnea was achieved in 29 of the 48 patients who underwent IPUK therapy (60.4%). The mean dose of urokinase instillations per patient was 360,000 IU. There were no major complications. A significant association of earlier intervention with the success of IPUK therapy was noted. Responders also had a significantly increased drainage within the 24 hours after the first dose of IPUK. Minocycline pleurodesis was subsequently performed for the 29 IPUK responders. Eighteen patients were followed up until death, with a median survival of 6.5 months. The other remained alive at the time of analysis with a median follow-up of 5 months. Two patients had an immediate failure of pleurodesis at 1 month. Three relapses occurred at 3, 4, and 7 months from pleurodesis, respectively. Twenty-three patients (79.3%) had lifelong pleural symphysis, including 21 having loculated MPEs and two having trapped lungs, respectively. Compared with the historical control group, the IPUK study group had significantly greater improvement on chest radiography and a shorter duration of pleural drainage. CONCLUSION: These results suggest that IPUK is a safe and useful nonsurgical adjunct therapy for loculated MPEs or trapped lungs in medically inoperable cancer patients.

Xanthogranulomatous appendicitis.

Xanthogranulomatous inflammation is an uncommon, though well-recognized entity that has been described in various organs but mostly commonly in the kidney and gallbladder. There have been few reports of its occurrence in the appendix. We report a 39-year-old man who presented with fever, right lower quadrant abdominal pain and mass. Abdominal computed tomography (CT) revealed diffuse wall thickening over the terminal ileum and cecum with involvement of the mesentery. CT-guided biopsy showed colitis with infiltration of lymphocytes, neutrophils and eosinophils. The patient's illness responded to intravenous antibiotics, but relapsed after switching to oral antibiotics. After the second course of intravenous antibiotics was given without resolution of symptoms, exploratory laparotomy was performed. Although operative findings favored colitis of the cecum, cancer of the cecum could not be completely ruled out. Right hemicolectomy was done and pathology confirmed the diagnosis of xanthogranulomatous appendicitis. This case illustrates that xanthogranulomatous appendicitis may mimic a locally advanced cancer, has a benign course, and can be cured by surgical resection.