Lung Cancer.pdf

230 J.B. Putnam, Jr.
Small-bore catheter drainage with bleomycin or talc sclerotherapy has
also been performed with success (Belani et al, 1998; Marom et al, 1999;
Parulekar et al, 2001).
Chronic Indwelling Pleural Catheter. Between 1994 and 1999, a prospective
randomized trial was conducted at M. D. Anderson and 10 other centers
to compare the effectiveness and safety of an indwelling pleural
catheter (Pleurx) (Figure 12–1) with the effectiveness and safety of a
chest tube and doxycycline sclerosis for treatment of cancer patients
with symptomatic recurrent malignant pleural effusions (Putnam et al,
1999). The potential benefits of catheter-based treatment were outpatient
management, improved quality of life, reduced medical costs, and improved
function.
A total of 144 patients were randomly assigned to either an indwelling
pleural catheter or a chest tube and doxycycline sclerosis. (Talc was not
available at all centers at the time of the study.) For every 2 patients treated
with a pleural catheter, 1 patient was stratified to treatment with a chest
tube and doxycycline sclerosis. Chest tubes were placed with a simple surgical
procedure (Figure 12–2). A modified Borg scale for dyspnea, the dyspnea
component of the Guyatt chronic respiratory questionnaire, and
Karnofsky performance status score were used to compare the 2 groups.
Outcomes measured included control of pleural effusion, length of hospitalization,
morbidity, and survival.
There was no difference between the 2 groups in performance status or
initial dyspnea scores. Median survival was 90 days in both the chest tube
and pleural catheter groups. Patients with lung or breast cancer had a 90day
survival rate of approximately 70%; patients with other cancer types
(as a group) had a 90-day survival rate of less than 40%. After treatment,
both the chest tube and pleural catheter groups showed similar significant
improvements in the Guyatt chronic respiratory questionnaire scores and
had similar morbidity. There were no treatment-related deaths.
Initial treatment success (pleurodesis achieved in the chest tube
group; drainage of effusion and relief of dyspnea in the pleural catheter
group) was achieved in 64% of the patients treated with a chest tube and
sclerosis, compared to 92% of those treated with a chronic indwelling
catheter. Seventy percent of patients treated with a pleural catheter experienced
spontaneous pleurodesis. Seventy-one percent of patients
with a chest tube had pleurodesis, although 28% of these patients developed
a recurrence of their pleural effusion after treatment. The mean
time of hospitalization was shorter in the pleural catheter patients: 1 day
versus 6.5 days.
The Pleurx catheter is ideal for patients with “trapped lung” and for patients
with a chronically recurring pleural effusion without a diagnosis of
malignancy (Figure 12–3). Use of the catheter allows the patient and/or
his or her family to relieve the dyspnea while draining the pleural fluid at