Thoracoscopy: general overview and place in the diagnosis and management of pleural effusion.
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History, 20th Century↗
Biomedical subjects
F Rodriguez-Panadero
Publications and source records attributed to F Rodriguez-Panadero.
The neutrophilic and fibrinolytic response to talc can predict the outcome of pleurodesis.
It was hypothesised that monitoring neutrophil and D-dimer (DD) levels into the pleural fluid, after talc instillation, could predict the outcome of pleurodesis. The current authors investigated a total of 168 patients with malignant pleural effusion, who were treated with talc poudrage. According to the outcome the patients were categorised into one of two groups, either successful or failed pleurodesis. In all cases, pleural fluid neutrophils and DDs were determined on serial measurements at 0, 3, 24 and 48 h after the procedure. The time course of these parameters was assessed in both groups and the time point at which they could better predict the outcome was further explored. Neutrophils rose rapidly after talc poudrage in both groups, reaching a plateau at 24 h, although in successful pleurodesis this response was significantly higher. DD dropped markedly at 24 h in the group with the successful outcome, but it did not show significant changes in the other group. A cut-off value of 61% for neutrophils and 61 mg.L-1 for the DD at 24 h yielded the best prognosis for successful pleurodesis. The current authors conclude that serial measurements of neutrophil and d-dimer values into the pleural fluid after talc poudrage could be used as predictors of the outcome of pleurodesis.
Adolescent↗
Malignant pleural diseases.
The incidence of malignant pleural effusions has been increasing over the last few decades (mainly due to the absolute increase in several types of cancers, especially those of lung and breast origin) and they account for up to 50% of the exudates in many clinical series. Although pleural malignancies are thought to present most frequently with a pleural effusion, several autopsy series, including the current one, found a pleural effusion present in little more than half of the cases of malignant pleural involvement (55% in this series). Thus, many pleural malignancies without effusion might pass unnoticed in clinical practice, especially in metastatic disease. Primary malignancies of the pleura (mesotheliomas) are associated with asbestos exposure in about two-thirds of cases, and they frequently present with chest pain, sometimes associated with a pleural effusion. Benign pleural plaques can coexist with malignant mesothelioma, and this association should be suspected when long-standing plaques change in shape or size over the years, and especially if chest pain develops in a previously asymptomatic patient. Metastatic pleural involvement is much more frequent than mesotheliomas, and its most frequent mechanism is the vascular spreading of tumour cells from distant organs to the lungs, and on to the visceral and parietal pleura. The visceral pleura was involved in up to 87% of the current metastatic cases, whereas the parietal zone in only 47% of the autopsy series. The diagnostic work-up lies in cytology, whose average yield is approximately 50%, and a biopsy technique (either by blind needle biopsy or thoracoscopy) is recommended when the effusion persists, for > 2 weeks, and the first cytology has been negative. Thoracoscopy has the additional advantage of allowing pleurodesis with talc poudrage if clear tumour lesions are found in the pleura. In cases of malignant effusion which are not sensitive to chemotherapy, pleurodesis is the treatment of choice for palliation of symptoms, and talc is the most effective agent. It can be used either in suspension ("slurry") or in dry aerosolized form ("talc poudrage"), but it seems that this last technique achieves the best effects. However, it requires thoracoscopy for a proper application, and this is its main drawback when that technique is not readily available.
Humans↗
Mycobacterium-mediated chemokine expression in pleural mesothelial cells: role of C-C chemokines in tuberculous pleurisy.
Pulmonary tuberculosis is characterized by granulomatous inflammation with an extensive infiltration of mononuclear phagocytes, but the mechanisms of phagocyte recruitment to the pleural space is unknown. In this study, pleural fluid from patients with tuberculosis contained significantly (P<.001) more biologically active MIP-1alpha and MCP-1 (C-C cytokines) than did effusions from patients with congestive heart failure. Antigenic MIP-1alpha and MCP-1 was detected by immunocytochemistry in pleural biopsy sections of patients with tuberculous pleurisy. In vitro, pleural mesothelial cells stimulated with bacille Calmette-Guérin (BCG) or interferon (IFN)-gamma produced MIP-1alpha and MCP-1. Reverse transcription-polymerase chain reaction studies confirmed that both BCG and IFN-gamma induced MIP-1alpha and MCP-1 expression in mesothelial cells, demonstrating that mesothelial cell-derived C-C chemokines play a biologically important role in the recruitment of mononuclear cells to the pleural space.
Biopsy↗
Pleurodesis: state of the art.
Pleurodesis aims to achieve a symphysis between parietal and visceral pleural surfaces, in order to prevent accumulation of fluid or air in the pleural space. Its major indications are malignant effusions and pneumothorax, and a re-expandable lung is essential for the success of the technique. Moreover, expectation of a reasonably long survival is important before attempting pleurodesis. A successful lung re-expansion is unlikely if the pleural pressure falls more than 20 cmH2O x L(-1) of fluid removed, because there is a central bronchial obstruction or the lung is trapped by tumour and/or fibrin. Pleural fluid pH (<7.20) is a good indicator of the presence of trapped lung; moreover, a successful pleurodesis is less likely when pH is low, and this parameter is also a good predictor for survival of the patients. Among the many sclerosing agents that have been used for pleurodesis, talc has achieved the best results, with an average success rate of approximately 90%. The cellular and biochemical mechanisms involved in pleurodesis may be specific to the agent used, however, they may all follow a common final pathway leading to activation of the pleural coagulation cascade, the appearance of fibrin networks, and the proliferation of fibroblasts. The details of these mechanisms are still unclear and need to be further elaborated.
Humans↗
Current trends in pleurodesis.
Pleurodesis is intended to prevent the accumulation of fluid or air in the pleural space by creating symphysis between the visceral and parietal pleura. The main indications for this procedure are malignant effusions and pneumothorax. A reexpandable lung and reasonably long expected survival are criteria that must be met before pleurodesis is attempted in a patient with malignant pleural effusion. A low pleural fluid pH (less than 7.20) is a good predictor for both the presence of a trapped lung and short expected survival. Talc appears to be the sclerosing agent of choice in cases of cancer, whereas video-assisted thoracic surgery techniques are preferable for the treatment of pneumothorax, especially in young patients. To improve results and prevent complications, application of the right technique is crucial, especially with regard to size of drainage and rate of suction. In addition, recent research suggests that prevention of a systemic activation of coagulation with prophylactic heparin should be taken into account in patients who are undergoing pleurodesis for palliative treatment of malignant effusion.
Humans↗
Failure of talc pleurodesis is associated with increased pleural fibrinolysis.
Diffuse pleural inflammation and fibrin deposition following the instillation of the sclerosing agent is considered necessary for a successful pleural symphysis. We hypothesized that an impairment in fibrin formation or an increased endopleural fibrinolysis would lead to failure of pleurodesis. To investigate changes in the pleural coagulation/fibrinolysis balance, we studied 75 consecutive patients who underwent thoracoscopy. Fifty-four of these patients with malignant pleural effusions and four with a benign recurrent effusion underwent thoracoscopic talc pleurodesis. Another four patients with malignancy and 13 with benign effusions had no talc poudrage performed and were included as a control group. Serial determinations of thrombin-antithrombin III complex (TAT), plasminogen activator inhibitor (PAI), and D-dimer were made in pleural fluid samples taken at the beginning of thoracoscopy (baseline), immediately after thoracoscopic biopsies had been done (postbiopsy), 3 h after thoracoscopy--either with talc poudrage or without--and 24 and 48 h after the procedure, as well as in cases of recurrence of effusions (farline). Successful pleurodesis was obtained in 42 of 52 patients who could be evaluated (81%), and failure was seen in 10. Strong activation of coagulation and production of PAI was observed in all groups, including the control (no talc) group. Fibrinolytic activity (as expressed by D-dimer levels) showed a clear decline 24 h after talc poudrage in patients with a good outcome of pleurodesis, as oppossed to those with bad results and to the control group, and returned to the baseline by 15 d. We conclude that increased pleural fibrinolytic activity is associated with failure of pleurodesis, despite significant inhibitory activity of PAI in all groups.
Antithrombin III↗
Talc pleurodesis for treating malignant pleural effusions.
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Humans↗
Survival and talc pleurodesis in metastatic pleural carcinoma, revisited. Report of 125 cases.
STUDY OBJECTIVE: To find out whether patients with different types of metastatic pleural carcinomas have significant differences in survival, as related to pleural fluid glucose and pH. A second objective was to evaluate the outcome of talc poudrage for pleurodesis. DESIGN: Cohort analytic prospective study; follow-up of patients from thoracoscopic diagnosis and evaluation to death. SETTING: Pulmonary department at a referral medical center. PATIENTS: One hundred twenty-five patients with metastatic pleural carcinoma diagnosed by thoracoscopy were evaluated prospectively. One patient was lost to follow-up. INTERVENTIONS: Thoracoscopy was performed in every patient, with talc pleurodesis performed at the end of each procedure. MEASUREMENTS AND RESULTS: On the same day as thoracoscopy or the previous day, glucose levels and pH of both the blood and pleural fluid were determined. The outcome of talc poudrage was that pleural effusions were controlled in 104 out of 119 patients (87 percent). Pleurodesis failed in 43 percent (6/14) of the patients with a pleural fluid pH lower than 7.20, as opposed to 9 percent (8/92) of failures in patients with a pH above this limit (p < 0.01). Average survival was as follows: nonsmall cell lung cancer (n = 40), 4.3 months (range, 1 to 15 months); small cell lung cancer (n = 8), 3.7 months (1 to 12 months); breast carcinoma (n = 30), 7.4 months (1 to 29 months); and ovarian carcinoma (n = 8), 9.4 months (1 to 29 months). There was a significant difference in survival between patients with breast carcinoma and patients with cancer not sensitive to chemotherapy (7.4 vs 4.7 months; p < 0.02), although the pleural tumor lesion rating was even greater in the first group. We found no significant differences between lung carcinomas and those from other origins. Patients with a low pleural fluid glucose level and low pH had significantly shorter survival than the group with high glucose and high pH levels (1.9 vs 5.7 months, respectively; p < 0.005). CONCLUSIONS: We confirmed our previous data demonstrating poor survival in patients with pleural effusions with low glucose and pH levels. The outcome of talc pleurodesis correlated to these same parameters. These results apply to all kinds of metastatic pleural carcinomas.
Adult↗
Validity of enlarged mediastinal nodes as markers of involvement by non-small cell lung cancer.
To assess the validity of enlarged mediastinal nodes as markers of involvement for staging in non-small cell lung cancer, we studied the records of 167 consecutive patients who underwent thoracotomy for this disease in the last 4 yr in our center. Careful search for both hilar (N1) and ipsilateral mediastinal nodes (N2) was done in every case. All nodes found at thoracotomy (regardless of their size) were either removed or sampled and then sent to the pathology department for examination. We found enlarged nodes (larger than 10 mm) in 131 of the 167 patients included in the study (72%). Of these patients, 58 had enlarged nodes at the hilar level (presumably N1 disease, 38%), and 73 were considered as presumably N2 at thoracotomy, before pathologic examination (62%). Only 12 of 58 patients with presumably N1 disease had true neoplastic involvement at this level (21%), whereas there was true N2 disease in only 18 of 73 patients with enlarged mediastinal nodes (25%). The positive predictive value for N2 in epidermoid carcinoma was 23%, and it was even lower with adenocarcinoma (18%). We conclude that open surgery with careful sampling is the method of choice for evaluation of mediastinal nodes in non-small cell lung cancer if evidence of malignant involvement cannot be proven histologically before thoracotomy.
Carcinoma, Non-Small-Cell Lung↗
Survival time of patients with pleural metastatic carcinoma predicted by glucose and pH studies.
STUDY OBJECTIVE: To determine the survival time of patients with pleural metastatic carcinoma diagnosed by thoracoscopy, as related to the pleural glucose and pH levels, and to the extension of pleural neoplastic lesions. DESIGN: Cohort analytic prospective study. Follow-up of the patients from diagnostic thoracoscopy to death (range: one to 29 months). SETTING: Referral Pneumology Service at a Tertiary Care Center. PATIENTS: Consecutive sample of 50 patients with pleural metastatic carcinoma diagnosed by thoracoscopy. Three patients were lost in the follow-up. INTERVENTIONS: Talc pleurodesis was performed after diagnosis and with the same technique in every case. MEASUREMENTS AND RESULTS: In all the cases, the extension of the tumorous lesions was determined by thoracoscopy (classified on a scale from 0 to 9) and the survival time was studied from the time that thoracoscopic diagnosis was made. On the same or the previous day as the exploration, blood and pleural fluid glucose levels as well as arterial and pleural pH and gas tensions were determined.
Follow-Up Studies↗