EGFR Mutation is a Prognostic Factor in Lung Cancer Patients with Pleural Dissemination Detected During or After Surgery.

BACKGROUND: Primary lung tumors are sometimes resected when either pleural dissemination (PD) or malignant pleural effusion (MPE) exists. This study clarified the prognostic factors for non-small cell lung cancer (NSCLC) with either PD and MPE, or both, detected during or after surgery. PATIENTS AND METHODS: We examined patients with NSCLC from a multicenter database who had either PD, MPE, or both, detected during or after surgery between 2005 and 2015. Hazard ratios and 95% confidence intervals were estimated using the Cox proportional hazards model adjusted for potential confounding factors. RESULTS: Among 9463 registered patients, PD, MPE, or both, were found in 114 patients with NSCLC during or after surgery. Primary tumor resection and exploratory thoracotomy were performed in 65 and 49 patients, respectively. In univariate analysis, adenocarcinoma, clinically undetected lymph node metastasis (c-N0 or unknown), EGFR mutation, and combination of chemotherapy or tyrosine kinase inhibitors after surgery were better prognostic factors for overall survival (OS), whereas in the multivariate analysis, adenocarcinoma, clinically undetected lymph node metastasis, and EGFR mutation were favorable independent prognostic factors in OS. Additionally, limited to patients with EGFR mutation, patients with primary lung tumor resection showed a significantly better 5-year OS than those with exploratory thoracotomy (86.4 vs. 44.8%; p < 0.001). CONCLUSION: Our findings show that surgical resection of primary tumors could improve the prognosis of patients with PD, MPE, or both, detected during or after surgery when the tumors harbor an EGFR mutation.

Surgical intervention for non-small-cell lung cancer with minimal malignant pleural effusion.

PURPOSE: We assessed the clinical significance of minimal malignant pleural effusion (MPE) using liquid-based cytology (LBC) and immunocytochemistry and reviewed the postoperative outcomes of patients with non-small-cell lung cancer (NSCLC). METHODS: We reviewed 240 patients with cM0 NSCLC who underwent lobectomy. Carcinoembryonic antigen (CEA) immunocytochemistry was performed with LBC to aid in the diagnosis of minimal MPE. We assessed the efficacy of this diagnostic method, relevant clinical factors, and postoperative outcomes. RESULTS: LBC showed positive results in two patients and suspicious results in 21. Of the 21 patients, immunocytochemistry showed minimal MPE in 10 (47.6%); therefore, a total of 12 patients (5%) showed minimal MPE. Minimal MPE is associated with an older age, increased consolidation tumor ratio, and adenocarcinoma histology. The 12 patients with minimal MPE had a 3-year overall survival rate of 90%. Postoperative recurrence was observed in seven patients (58.3%), four of whom were treated with epidermal growth factor receptor-tyrosine kinase inhibitors or immune checkpoint inhibitors, while three are still undergoing treatment, with a survival of 2.2, 2.5 and 5.5 years. CONCLUSIONS: CEA immunocytochemistry offers high sensitivity for the diagnosis of minimal MPE. Surgical intervention may be considered for select patients with NSCLC showing minimal MPE.

Incidence and management of pleural effusions in patients with Wilms tumor: A Pediatric Surgical Oncology Research Collaborative study.

Wilms tumor (WT) is the most common renal malignancy in children. Children with favorable histology WT achieve survival rates of over 90%. Twelve percent of patients present with metastatic disease, most commonly to the lungs. The presence of a pleural effusion at the time of diagnosis of WT may be noted on staging imaging; however, minimal data exist regarding the significance and prognostic importance of this finding. The objectives of our study are to identify the incidence of pleural effusions in patients with WT, and to determine the potential impact on oncologic outcomes. A multi-institutional retrospective review was performed from January 2009 to December 2019, including children with WT and a pleural effusion on diagnostic imaging treated at Pediatric Surgical Oncology Research Collaborative (PSORC) participating institutions. Of 1259 children with a new WT diagnosis, 94 (7.5%) had a pleural effusion. Patients with a pleural effusion were older than those without (median 4.3 vs 3.5 years; P = .004), and advanced stages were more common (local stage III 85.9% vs 51.9%; P < .0001). Only 14 patients underwent a thoracentesis for fluid evaluation; 3 had cytopathologic evidence of malignant cells. Event-free and overall survival of all children with WT and pleural effusions was 86.2% and 91.5%, respectively. The rate and significance of malignant cells present in pleural fluid is unknown due to low incidence of cytopathologic analysis in our cohort; therefore, the presence of an effusion does not appear to necessitate a change in therapy. Excellent survival can be expected with current stage-specific treatment regimens.

Inter-observer variation in image interpretation and the prognostic importance of non-expansile lung in malignant pleural effusion.

BACKGROUND AND OBJECTIVE: Non-expansile lung (NEL) frequently complicates management of malignant pleural effusion (MPE) and is an important factor in clinical practice and trials. NEL is frequently diagnosed on a single radiographic observation, but neither the inter-observer agreement of this approach nor the prognostic importance of NEL in MPE has been reported. METHODS: A multicentre retrospective cohort study was performed in two UK pleural centres. NEL was defined as <50% pleural re-apposition on post-drainage radiographs by primary and secondary assessors at each site. Inter-observer agreement was assessed by Cohen's kappa (κ). Kaplan-Meier methodology and multivariate Cox models were used to assess the prognostic impact of NEL versus no NEL and 'complete NEL' versus 'complete expansion', based on a single assessor's results from each site. RESULTS: NEL was identified by the primary assessor in 33 of 97 (34%) in Cohort 1 and 15 of 86 (17%) in Cohort 2. Inter-observer agreement between assessors was only fair-to-moderate (Cohort 1 κ: 0.38 (95% CI: 0.21-0.55), Cohort 2 κ: 0.51 (95% CI: 0.30-0.72)). In both cohorts, NEL was associated with shorter median overall survival (Cohort 1: 188 vs 371 days, Cohort 2: 192 vs 412 days). This prognostic association was independent in Cohort 1 (hazard ratio (HR): 2.19, 95% CI: 1.31-3.66) but not in Cohort 2 (HR: 1.42, 95% CI: 0.71-2.87). Survival was inferior in both cohorts in cases of complete NEL versus complete expansion. CONCLUSION: Radiographic NEL is common but inter-observer agreement is only fair-to-moderate. NEL is associated with adverse survival. These data do not support the use of single radiographic assessments to classify NEL.

Pleural effusions in hematologic malignancies and their management with indwelling pleural catheters.

PURPOSE OF REVIEW: Pleural effusions in patients with hematologic malignancy may represent malignant pleural effusion (MPE) or occur secondary to infection, treatment effects, and other common causes. The impact of MPE on prognosis in this cohort remains unclear. Indwelling pleural catheters (IPCs) are routinely placed for palliation of recurrent symptomatic MPEs, but perceived concerns over infection and bleeding may limit their use in patients with hematologic malignancies. However, recent evidence suggests IPCs are both well tolerated and effective in this cohort. In this review, the evaluation of pleural effusions in hematologic malignancies and their management with an IPC are outlined. RECENT FINDINGS: Two retrospective studies have been published regarding the use of IPCs in hematologic malignancies. Lymphomatous effusions are the most common cause of MPE in this cohort. The rates of complications and pleurodesis with IPC in hematologic malignancies are similar to those with solid organ tumors. SUMMARY: Pleural effusions in patients with hematologic malignancies may be managed safely with an IPC. Sterile technique, barrier protection, standardized algorithms for placement and removal, and quality assurance initiatives are crucial to centers that place IPCs for all patients. The safety of IPC in hematologic malignancies warrants a paradigm shift in the management of pleural disease for this cohort.

Conventional versus pigtail chest tube-are they similar for treatment of malignant pleural effusions?

INTRODUCTION: The optimal chest tube type and size for drainage and chemical pleurodesis of malignant pleural effusions remains controversial. This retrospective study was conducted to compare the efficacy of conventional versus pigtail chest tube in the treatment of malignant pleural effusions. METHODS: Patients submitted to chest tube drainage and slurry talc pleurodesis due to malignant pleural effusion in our pulmonology ward from 2012 to 2016 were eligible. According to the type of chest tube, they were divided into two groups: group I-conventional chest tube and group II-pigtail chest tube. Number of deaths, recurrence of malignant pleural effusion, and timelines associated with the procedures were reviewed and compared between groups. RESULTS: Out of the 61 included patients, 46 (75.4%) were included in group I and 15 (24.6%) in group II. Only one patient had pigtail chest tube obstruction, with posterior insertion of conventional chest tube. Death during hospital stay and up to 3 months, recurrence at 4 weeks, total duration of hospital stay, time from chest tube insertion to pleurodesis, and time from chest tube insertion to removal were not significantly different between the two groups (all p > 0.05). DISCUSSION: These findings suggest that pigtail chest tube can be an alternative on palliation, with no compromise in pleurodesis performance.

Thoracoscopy: Advances and Increasing Role for Interventional Pulmonologists.

Thoracoscopy is an increasingly common procedure that provides significant clinical information and therapeutic applications. The procedure allows the physician to biopsy the parietal pleura under direct visualization with high accuracy. In addition, one can drain pleural fluid, place a chest tube in a precise location, and perform poudrage pleurodesis. Medical thoracoscopy (MT) is carried out in the operating room or procedure suite under moderate sedation with spontaneous ventilation. In comparison, video-assisted thoracoscopic surgery (VATS) is performed under general anesthesia with single lung ventilation and through multiple ports in the operating room. MT is less invasive, has a comparable diagnostic yield, and may be better tolerated in high-risk patients. The indications, complications, and advances in thoracoscopy will be discussed in this article. In the era of rapidly evolving therapeutics for lung cancer, immune-modulation and ever-increasing risks of immunosuppression, MT will evolve and continue to play a pivotal role in the evaluation and research of pleuropulmonary diseases.

Sarcomatoid Carcinoma of the Prostate Presenting in a 44 Year Old

We present the case of a 44-year-old man diagnosed with metastatic sarcomatoid carcinoma of the prostate. The pathogenesis and optimal treatment of this rare and aggressive subtype of prostate cancer are not fully clear. The patient was managed using a multimodality approach of chemotherapy, hormonal blockade and radiation therapy, with palliative intent.

[Efficacy and Safety of Indwelling Pleural Catheters]. / Effektivität und Sicherheit von getunnelten pleuralen Dauerkathetern.

In symptomatic malignant pleural effusions, mostly in a palliative situation, therapeutic procedures should be chosen to improve dyspnoea and the concomitant impairment of quality of life. Indwelling pleural catheters (IPC) have played an increasing role in recent years. The efficacy and safety of this method have not been adequately clarified under real-life clinical conditions. 94 patients, in whom IPC had been implanted because of a clinical indication, were analysed retrospectively with respect to efficacy and safety, together with patient characteristics, peri- and postinterventional complications, e.g. infections or pneumothorax, and long-term follow-up - with special emphasis on the occurrence of a pleurodesis. Overall, 89.5% (n = 85) of the patients received an IPC due to a recurrent pleural effusion caused by a malignant primary disease. The average duration of hospitalisation for patients did not decease as a result of their incurable condition and was 3.29 days. In 21.2% (n = 20) of the patients, pleurodesis occurred. Method-related complications arose for 33.2% (n = 32) of the patients, although further treatment was only needed in 8 patients. Late complications developed for 9 of the patients observed. The average survival period after implantation was 88.72 days. The results show that IPC is a technically straightforward, minimally invasive alternative to recurrent punctures or other methods of pleurodesis. A major benefit is the possibility of outpatient care.

1000 cases of tubeless video-assisted thoracic surgery at the Rome Tor Vergata University.

In the early 2000s, the 'Awake Thoracic Surgery Research Group' at Tor Vergata University began a program of thoracic operations in awake nonintubated patients. To our knowledge this was the first program created with this specific purpose. Since then over 1000 tubeless operations have been carried out successfully, making this series one of the widest in the world. Both nononcologic and oncologic conditions were successively approached and major operations for lung cancer are now being performed. Uniportal access was progressively adopted with significant positive outcomes in postoperative recovery, patient acceptance and economical costs. Failure rates due to patient's intolerance and open surgery conversion are progressively reducing. Tubeless thoracic surgery can be accomplished in a safe manner with effective results.

Histopathology of removed indwelling pleural catheters from patients with malignant pleural diseases.

BACKGROUND AND OBJECTIVE: Indwelling pleural catheters (IPC), used for management of malignant pleural effusions, are often left in situ for a long duration. This study reports for the first time the histological findings of IPCs removed from patients with underlying pleural malignancy. METHODS: Forty-one IPCs (in situ for median 126 days, interquartile range 43-226) that were removed over a 54-month period from a single centre were examined. RESULTS: Mesothelioma (n = 18) was the predominant underlying malignancy followed by breast, tubo-ovarian and lung carcinomas. The catheter tubing was fully intact macroscopically in all IPCs. There was no evidence of direct tumour invasion or cancer cell growth on the catheter surfaces in none of the 29 IPCs that were histologically examined. Malignant cells were seen within organizing fibrinous tissues in the lumen of 11 IPCs (27%). A foreign body giant cell reaction was present at the cuff site in all the 29 IPC in which the subcutaneous cuff was examined. Acute (n = 10) and/or chronic inflammatory changes were seen in the luminal contents in all 41 IPCs. CONCLUSION: Our study provides reassuring evidence that the IPC material does not support direct tumour growth or invasion even in the setting of high mesothelioma prevalence. See Editorial, page 787.

Extralobar Pulmonary Sequestration Presenting with Recurring Massive Pleural Effusion in a Young Woman: A Challenging Case.

We report a case of extralobar pulmonary sequestration (ELS) in a young woman, presenting with right recurring massive pleural effusion. The patient initially underwent a diagnostic Video Assisted Thoracic Surgery (VATS) for a suspected diffuse malignancy. After the aspiration of the pleural effusion we observed a highly vascularised cystic mass, with its origin from the right lower lobe. As we tried to retract the right lower lobe, the mass broke with massive bleeding requiring emergency right lateral thoracotomy. The mass was succesfully excised, resembling an extra-lobar pulmonary sequestration. The patient was discharged on post-operative day 5.

The impact of pleural disease on the management of advanced ovarian cancer.

Malignant pleural effusion is the most common site of stage IV ovarian cancer. A positive cytology is required for a stage IVA diagnosis. Unfortunately, the accuracy rate of pleural cytology remains low. A number of factors have been identified as prognostic for clinical outcomes in patients with epithelial ovarian cancer (EOC), the International Federation of Gynaecology and Obstetrics (FIGO) stage and residual tumor after debulking surgery being the most widely reported. Thereby careful selection of patients is crucially important, yet no preoperative predictor has proven sufficiently reliable to predict surgical outcome. The authors present a review of the literature on stage IV ovarian cancer specifically focusing on prognostic value of FIGO stage, preoperative workup, role of video-assisted thoracic surgery and maximal cytoreductive surgery.

Role of surgery in multi-modality treatment for carcinomatous pleuritis in patients with non-small cell lung cancer.

OBJECTIVE: To evaluate the role of surgery in the treatment of the patients with non-small cell lung cancer with pleural dissemination. METHODS: The clinical records of 25 patients (mean age 69 years) diagnosed with carcinomatous pleuritis during a thoracotomy by pathological examination and followed by surgery between 1994 and 2012 were reviewed. The treatment modality, including surgery, the clinicopathologic characteristics and 5-year survival were analyzed. RESULTS: There were 16 adenocarcinomas, 6 squamous cell carcinomas and 3 large cell carcinomas. Surgery included resection of the main tumor by partial resection in 10 cases, segmentectomy in 2 cases, lobar resection in 12 cases and bilobectomy in 1 case. Intrathoracic irrigation was performed in 20 cases. The pathological N status was N0/N1/N2/Nx: 10/6/7/2. Fifteen patients received adjuvant therapy. The overall 5-year survival rate was 22.2 %. The 5-year survival rates of the N0, N1 and N2 groups were 36.0, 16.7 and 14.3 %, respectively (p = 0.0068). Nine patients lived more than 3 years including 5 in N0, 3 in N1 and 1 in N2. CONCLUSIONS: Surgery should not be excluded from the multi-modality treatment of patients with carcinomatous pleuritis because there are some patients who could benefit from surgery especially if they are in N0 status.

Outcome of indwelling tunneled PleurX® catheter placement in pediatric and young adult patients with malignant effusions.

Malignant effusions may cause significant morbidity and mortality for cancer patients. Indwelling tunneled PleurX® catheter placement for intermittent drainage of malignant effusions has been shown to be efficacious in adults but has not been studied in children. We performed a retrospective review of nine children and young adults who underwent PleurX® catheter placement for the palliation of symptoms associated with malignant effusions. Eight of nine demonstrated symptomatic improvement and seven of nine were discharged from the hospital after catheter placement. No patients experienced catheter-associated complications. PleurX® catheter placement should be considered for palliation of symptoms due to malignant effusions in pediatric oncology patients.

Successful use of indwelling tunneled catheters for the management of effusions in children with advanced cancer.

BACKGROUND: Malignant pleural effusion (MPE) and ascites (MA) negatively impact quality of life of palliative patients. Treatment options are limited. This study's purpose is to examine the experience with indwelling tunneled catheters (ITCs) for management of MPE/MA in children with advanced cancer. METHODS: Children with MPE/MA who underwent ITC insertion (2007-2012) were retrospectively reviewed. Clinical, procedural, complication and outcome details were analyzed. RESULTS: PleurX® ITCs (n = 12) were inserted in eight patients (5-18 years) with sarcoma (11 MPE, 1 MA), achieving symptom relief and facilitating discharge home post ITC (median 2 days). Median survival following ITC was 51 days. There were two major complications: pain (n = 1), late site infection (n = 1), and five minor complications. Drainage ceased in four patients (pleurodesis/tumor progression). At time of death, six ITCs (five patients) were still in situ. CONCLUSIONS: ITC appears to be a safe, effective treatment for MPE/MA in advanced pediatric cancer, achieving symptomatic relief and discharge home.

Indwelling pleural catheters.

Indwelling pleural catheters (IPC) are now established as one of the major tools for the management of recurrent pleural effusions. Their traditional role, which saw them only as second line treatment for malignant effusions, has now expanded. Recent evidence has not only suggested that they may be effectively employed as first-line therapy in some malignant cases, but that there is a wider spectrum of diseases which may be managed by their use. The majority of patients are likely to experience symptomatic benefit and some may also go on to achieve pleurodesis. IPCs are relatively simple to insert and maintain, and theoretically allow patients to be managed entirely as an outpatient, meaning that they are likely to be cost-effective in the longer term. They can also dramatically improve the quality of life in patients who have typically needed lengthy hospital admissions or who have terminal malignant disease.

Ultrasound guidance reduces pneumothorax rate and improves safety of thoracentesis in malignant pleural effusion: report on 445 consecutive patients with advanced cancer.

BACKGROUND: Malignant pleural effusion (MPE) is an extremely common problem affecting cancer patients, and thoracentesis is an essential procedure in an attempt to delineate the etiology of the fluid collections and to relieve symptoms in affected patients. One of the most common complications of thoracentesis is pneumothorax, which has been reported to occur in 20% to 39% of thoracenteses, with 15% to 50% of patients with pneumothorax requiring tube thoracostomy.The present study was carried out to assess whether thoracenteses in cancer patients performed with ultrasound (US) guidance are associated with a lower rates of pneumothorax and tube thoracostomy than those performed without US guidance. METHODS: A total of 445 patients were recruited in this retrospective study. The medical records of 445 consecutive patients with cancer and MPE evaluable for this study, undergoing thoracentesis at the Oncology-Hematology and Internal Medicine Departments, Piacenza Hospital (Italy) were reviewed. RESULTS: From January 2005 to December 2011, in 310 patients (69.66%) thoracentesis was performed with US guidance and in 135 (30.34%) without it. On post-thoracentesis imaging performed in all these cases, 15 pneumothoraces (3.37%) were found; three of them (20%) required tube thoracostomy. Pneumothorax occurred in three out of 310 procedures (0.97%) performed with US guidance and in 12 of 135 procedures (8.89%) performed without it (P<0.0001). It must be emphasized that in all three patients with pneumothorax requiring tube thoracostomy, thoracentesis was performed without US guidance. CONCLUSIONS: The routine use of US guidance during thoracentesis drastically reduces the rate of pneumothorax and tube thoracostomy in oncological patients, thus improving safety as demonstrated in this study.

Abdominopelvic cytoreduction rates and recurrence sites in stage IV ovarian cancer: is there a case for thoracic cytoreduction?

OBJECTIVE: We report the rates of optimal abdominopelvic cytoreduction and the sites of recurrence in stage IV ovarian cancer patients, with particular attention to the potential impact of thoracic cytoreduction on treatment results in patients with intra-thoracic spread. METHODS: A historic cohort study of all stage IV ovarian cancer patients diagnosed between 1994 and 2010 and underwent abdominopelvic cytoreductive surgery. Controls were stage IIIc patients. Statistical analyses included χ(2) test, Cox proportional hazards regression models and Kaplan-Meier curves with log-rank tests. RESULTS: Group 1 included 76 stage IV patients, 55% with thoracic spread. Group 2 included 142 stage IIIc patients. Age, histology, primary peritoneal tumor and ascites rates were similar for the two groups. Respective rates of optimal abdominopelvic cytoreduction were 68% vs. 83.5% (p<0.05), median time to progression 5.3 vs. 12.3 months (p<0.01) and overall survival 27.2 vs. 46.1 months (p<0.01). Optimal cytoreduction and survival rates were similar for all group 1 patients regardless of spread location. Sites of recurrence in stage IV were abdomen (59.3%), thorax (6.8%), both (28.8%) or other (5.1%). The four patients with thoracic recurrence alone were all initially diagnosed with malignant pleural effusion. Three of them developed abdominal recurrence within 15‒6 months. CONCLUSIONS: Optimal abdominopelvic cytoreduction was achievable in stage IV patients, although in significantly fewer patients than in stage IIIc. Sites of recurrence were rarely thorax alone, implying that thoracic debulking is likely to change the course of disease in only few patients and thus should be carefully individualized.

Single-incision thoracoscopic surgery of pleural effusions for diagnosis and treatment.

BACKGROUND: Several procedures such as video-assisted thoracoscopic surgery (VATS) are used to make a definite diagnosis in recurrent pleural effusions so that appropriate treatment can be arranged. Single-incision thoracoscopic surgery (SITS) is the most appropriate procedure that can be used for this purpose. The contribution of SITS to diagnosis and treatment is evaluated in this study that we conducted using a single thoracoport in patients with pleural effusion. METHODS: Nineteen consecutive patients with pleural effusion that was recurrent or refractory to medical treatment were included in the study to be diagnosed and treated with SITS. Thoracentesis was performed and pleural fluid samples obtained in all patients before the procedure. Pleural effusion drainage was performed from the 11-mm single skin incision by using a 10.5-mm single thoracoport, and biopsy or talc pleurodesis was performed in the same session when needed. RESULTS: The median age of the patients was 56.68 ± 3.05 years and there were 11 males and 8 females. The total amount of fluid drained by SITS was 1,436 ± 227 mL and the surgery lasted 81.05 ± 5.36 min. In addition, partial decortication and/or deloculation were performed in six patients and talc pleurodesis in nine patients. Fifteen patients were diagnosed with benign and four patients with malignant pleural effusion by thoracentesis, while nine patients were diagnosed with benign and ten patients with malignant pleural effusion by SITS. We therefore had six cases diagnosed as benign with thoracentesis who were diagnosed with malignant disease after SITS. CONCLUSIONS: SITS presents both diagnosis and treatment options together for pleural effusions. We believe SITS should be preferred to conventional three-port VATS to minimize the spread of infection and tumor cells to the chest wall in infectious and malignant diseases.