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74 Medical thoracoscopy and malignant pleural effusions (MPE) – 40 months on in the Cambridge pleural unit
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Poster abstracts, 11th Annual British Thoracic Oncology Group Conference, 2013: Diagnosis & Staging
trained nurse. Alfentanyl was used 1 minute before pleural biopsies were taken. Results: Thirty consecutive thoracoscopy patients were included over a period of 12 months. Mean (range) age was 68.7 (25, 86) years. The mean (range) dose of Midazolam was 2.25 (1 4) mg and of Alfentanyl 460 (0 1000) mcg. In 8 cases talc pleurodesis was not performed, the other 22 cases had 4 grams of sterile talc. Pleurodesis was not associated with increased discomfort apart from one. The mean (range) discomfort score was 1.3 (0 5, only 1 patient had a score of 5) in recovery and 1.2 at follow up. One third of patients had no discomfort at all and 70% had no or mild (score 0 or 1) discomfort. The nurse-perceived discomfort was none or minimal. Patient-perceived discomfort was described as pain (at biopsy) or uncomfortable position. Conclusion: Awake sedation thoracoscopy with Midazolam and Alfentanyl is well tolerated; patient-perceived discomfort is mild when assessed in recovery as well as 7 10 days later.
Our policy to give antibiotic intravenously 24 hours post-procedure results in a very low pleural infection rate, which is particularly important in patients who proceed to chemotherapy. 75 Unilateral small pleural effusions adjacent to primary lung tumours malignant or reactive? M. Evison1 *, M. Alaloul1 , N. Chaudhuri1 , J. Holme1 , A. Bentley1 . 1 University Hospital South Manchester Pleural Team, North West Lung Centre, University Hospital South Manchester, UK Introduction: Defining the nature of a small pleural effusion adjacent to a primary lung tumour is crucial for accurate staging and appropriate treatment. However small effusions can be difficult to aspirate and fluid cytology has poor sensitivity for detecting malignancy. We investigated a cohort of such patients exemplified by Figure 1.
74 Medical thoracoscopy and malignant pleural effusions (MPE) 40 months on in the Cambridge pleural unit S. Chatterji *, P. Sivasothy, E. Reid, T. Pulimood. Addenbrooke’s Hospital, University of Cambridge NHS Foundation Trust, UK Background: MPE is a marker of advanced cancer and frequently portends a poor prognosis. Diagnosis and management of MPE can be challenging due to low sensitivity of pleural fluid cytology, comorbidities and poor performance status. Medical thoracoscopy (MT) is performed with conscious sedation and local anaesthesia. It allows drainage, visualisation and targeted biopsies of the pleural space with talc poudrage (TP) if indicated. Aim: A descriptive study reviewing the case mix and procedurerelated outcomes of all MT cases performed for known or diagnosed MPE in our tertiary referral unit. Methods: Retrospective database analysis of all MT performed in the Cambridge Pleural Unit between April 2009 & October 2012 for known or MT-diagnosed MPE were included in this review. All cases were performed using a rigid scope single or dual port technique. Patient demographics, indication for procedure, length of stay, TP or indwelling pleural catheter (IPC) insertion and complications were recorded. Results: 179 out of 258 thoracoscopies were carried out for MPE. Female 93 (52%). Median age 72 yrs (45 93). MPE diagnoses (Table 1). 86 (48%) were carried out for diagnosis and the remainder for therapeutic management. 134 (75%) elective cases. Mean length of stay after elective procedure 3.1 days (range 1 22) and 9.4 days for emergency (range 1 51). TP >58% cases. IPC insertion in 18%. Complications failed pleurodesis (4), pleural infection (2; 1 needed VATS), pneumonia 1, unexpected trapped lung (18%). Table 1 Malignancy
Number
Lung Mesothelioma Breast Lymphoma Gynae Prostate Gastrointestinal Renal Sarcoma Others
36 (adeno 17; squamous 3; unknown 16) 47 (27 epithelioid; 6 biphasic; 2 sarcomatoid; 12 unknown) 28 14 11 1 12 8 2 17
Discussion: MT can be a safe, swift and effective method for diagnosing and managing MPE. TP is generally successful and an IPC can be inserted for suspected trapped lung in the same procedure thus reducing length of stay and need for repeat interventions.
Figure 1. A small (not visible on CXR) unilateral pleural effusion adjacent to a primary lung tumour.
Methods: We reviewed all patients referred for endoscopic mediastinal staging (EBUS-TBNA) to our centre from March 2010 to September 2012. We included those who had: 1. Confirmed primary lung cancer 2. Small (not visible on CXR) pleural effusion on CT or PET, ipsilateral to the primary tumour Initial radiology, cyto-histological results and serial radiology for a further 6 months were analysed. An effusion is considered malignant if: fluid cytology/pleural biopsy confirmed malignancy or follow-up radiology showed progressive effusion or malignant pleural changes. Lack of radiological progression over 6 months indicated benign effusions. Results: 27 patients fulfilled the criteria. In 24 the effusion was present on CT and in 3 the effusion was only apparent on subsequent PET. 3 patients had radiological features of malignant pleural disease (focal pleural nodularity or FDG avidity). In 1 malignancy was confirmed with a pleural biopsy. In the remaining two the effusion progressed in size on serial imaging. In the remaining 24, with no radiological features of pleural malignancy on initial CT/PET, there was no progression in the size of effusion over 6 months. 10 effusions spontaneously resolved. 9 patients underwent thoracic ultrasound with 4 having sufficient fluid for aspiration. Cytology was negative in all 4.
Poster abstracts, 11th Annual British Thoracic Oncology Group Conference, 2013: Diagnosis & Staging
trained nurse. Alfentanyl was used 1 minute before pleural biopsies were taken. Results: Thirty consecutive thoracoscopy patients were included over a period of 12 months. Mean (range) age was 68.7 (25, 86) years. The mean (range) dose of Midazolam was 2.25 (1 4) mg and of Alfentanyl 460 (0 1000) mcg. In 8 cases talc pleurodesis was not performed, the other 22 cases had 4 grams of sterile talc. Pleurodesis was not associated with increased discomfort apart from one. The mean (range) discomfort score was 1.3 (0 5, only 1 patient had a score of 5) in recovery and 1.2 at follow up. One third of patients had no discomfort at all and 70% had no or mild (score 0 or 1) discomfort. The nurse-perceived discomfort was none or minimal. Patient-perceived discomfort was described as pain (at biopsy) or uncomfortable position. Conclusion: Awake sedation thoracoscopy with Midazolam and Alfentanyl is well tolerated; patient-perceived discomfort is mild when assessed in recovery as well as 7 10 days later.
Our policy to give antibiotic intravenously 24 hours post-procedure results in a very low pleural infection rate, which is particularly important in patients who proceed to chemotherapy. 75 Unilateral small pleural effusions adjacent to primary lung tumours malignant or reactive? M. Evison1 *, M. Alaloul1 , N. Chaudhuri1 , J. Holme1 , A. Bentley1 . 1 University Hospital South Manchester Pleural Team, North West Lung Centre, University Hospital South Manchester, UK Introduction: Defining the nature of a small pleural effusion adjacent to a primary lung tumour is crucial for accurate staging and appropriate treatment. However small effusions can be difficult to aspirate and fluid cytology has poor sensitivity for detecting malignancy. We investigated a cohort of such patients exemplified by Figure 1.
74 Medical thoracoscopy and malignant pleural effusions (MPE) 40 months on in the Cambridge pleural unit S. Chatterji *, P. Sivasothy, E. Reid, T. Pulimood. Addenbrooke’s Hospital, University of Cambridge NHS Foundation Trust, UK Background: MPE is a marker of advanced cancer and frequently portends a poor prognosis. Diagnosis and management of MPE can be challenging due to low sensitivity of pleural fluid cytology, comorbidities and poor performance status. Medical thoracoscopy (MT) is performed with conscious sedation and local anaesthesia. It allows drainage, visualisation and targeted biopsies of the pleural space with talc poudrage (TP) if indicated. Aim: A descriptive study reviewing the case mix and procedurerelated outcomes of all MT cases performed for known or diagnosed MPE in our tertiary referral unit. Methods: Retrospective database analysis of all MT performed in the Cambridge Pleural Unit between April 2009 & October 2012 for known or MT-diagnosed MPE were included in this review. All cases were performed using a rigid scope single or dual port technique. Patient demographics, indication for procedure, length of stay, TP or indwelling pleural catheter (IPC) insertion and complications were recorded. Results: 179 out of 258 thoracoscopies were carried out for MPE. Female 93 (52%). Median age 72 yrs (45 93). MPE diagnoses (Table 1). 86 (48%) were carried out for diagnosis and the remainder for therapeutic management. 134 (75%) elective cases. Mean length of stay after elective procedure 3.1 days (range 1 22) and 9.4 days for emergency (range 1 51). TP >58% cases. IPC insertion in 18%. Complications failed pleurodesis (4), pleural infection (2; 1 needed VATS), pneumonia 1, unexpected trapped lung (18%). Table 1 Malignancy
Number
Lung Mesothelioma Breast Lymphoma Gynae Prostate Gastrointestinal Renal Sarcoma Others
36 (adeno 17; squamous 3; unknown 16) 47 (27 epithelioid; 6 biphasic; 2 sarcomatoid; 12 unknown) 28 14 11 1 12 8 2 17
Discussion: MT can be a safe, swift and effective method for diagnosing and managing MPE. TP is generally successful and an IPC can be inserted for suspected trapped lung in the same procedure thus reducing length of stay and need for repeat interventions.
Figure 1. A small (not visible on CXR) unilateral pleural effusion adjacent to a primary lung tumour.
Methods: We reviewed all patients referred for endoscopic mediastinal staging (EBUS-TBNA) to our centre from March 2010 to September 2012. We included those who had: 1. Confirmed primary lung cancer 2. Small (not visible on CXR) pleural effusion on CT or PET, ipsilateral to the primary tumour Initial radiology, cyto-histological results and serial radiology for a further 6 months were analysed. An effusion is considered malignant if: fluid cytology/pleural biopsy confirmed malignancy or follow-up radiology showed progressive effusion or malignant pleural changes. Lack of radiological progression over 6 months indicated benign effusions. Results: 27 patients fulfilled the criteria. In 24 the effusion was present on CT and in 3 the effusion was only apparent on subsequent PET. 3 patients had radiological features of malignant pleural disease (focal pleural nodularity or FDG avidity). In 1 malignancy was confirmed with a pleural biopsy. In the remaining two the effusion progressed in size on serial imaging. In the remaining 24, with no radiological features of pleural malignancy on initial CT/PET, there was no progression in the size of effusion over 6 months. 10 effusions spontaneously resolved. 9 patients underwent thoracic ultrasound with 4 having sufficient fluid for aspiration. Cytology was negative in all 4.