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Catheter-Tract Metastases Associated With Chronic Indwelling Pleural Catheters
CHEST Catheter-Tract Metastases Associated With Chronic Indwelling Pleural Catheters* Sam M. Janes, MBBS, PhD, MRCP; Najib M. Rahman, BM BCh, MA, MRCP; Robert J. O. Davies, DM, FRCP; and Y. C. Gary Lee, MBChB, PhD, FCCP
Indwelling pleural catheters are increasingly being used for ambulatory treatment of malignant pleural effusion, particularly for patients unsuitable for pleurodesis. These catheters are often left in situ for the rest of the patient’s life. Tumor metastasis along the tract between pleura and skin surface is a potential complication in patients with chronic indwelling pleural catheters that has seldom been reported. We describe four cases of catheter-tract metastasis that developed between 3 weeks and 9 months after catheter insertion. Catheter-tract metastasis occurred in two patients with mesothelioma despite prophylactic irradiation at time of insertion, and in two patients with metastatic adenocarcinoma. All cases were successfully treated using external-beam radiotherapy without necessitating catheter removal. A retrospective audit in our center showed that catheter-tract metastasis occurred in 6.7% of 45 patients treated with indwelling pleural catheters for *From the Centre of Respiratory Research (Drs. Janes and Lee), University College London, UK; and Oxford Pleural Unit (Drs. Rahman and Davies), Oxford Centre for Respiratory Medicine and University of Oxford, Oxford, UK. Dr. Janes is supported by a Medical Research Council Clinician Scientist Fellowship, Dr. Lee is supported by a Wellcome Advanced Fellowship, and Dr. Rahman is supported by a Medical Research Council Training Fellowship. Drs. Janes and Rahman do not have any conflict of interests or involvement with organizations with financial interests in the subject matter. Drs. Davies and Lee have been awarded a project grant from the British Lung Foundation to compare conventional pleurodesis with chronic indwelling pleural catheters in patients with malignant pleural effusions. The investigators of the trial have accepted an arrangement to use pleural catheters provided for free by Rocket Med plc (UK), since the acceptance of this manuscript for publication. None of the investigators received any funding from the company. Manuscript received September 24, 2006; revision accepted November 10, 2006. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Y. C. Gary Lee, MBChB, PhD, FCCP, Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford OX3 7LJ, UK; e-mail: [email protected] DOI: 10.1378/chest.06-2353 1232
Selected Reports
malignant pleural effusions. Both clinicians and patients should be aware of this potential complication. (CHEST 2007; 131:1232–1234) Key words: adenocarcinoma; indwelling catheter; mesothelioma; metastases; pleura
pleural effusions are common in clinical M alignant practice. Indwelling pleural catheters have increas1
ingly been advocated for management of recurrent effusions, especially in patients unsuitable for pleurodesis, or in whom pleurodesis has failed.1–5 These catheters are often left in situ for the rest of the patient’s life. Tumor metastases from the parietal pleura to the skin surface following tracts from pleural procedures (eg, thoracoscopy) are known complications of mesothelioma but are rare with other malignancies.1 Patients with chronic indwelling pleural catheters are at continual risks of tumor spread along catheter tracts. Catheter-tract metastasis has seldom been reported, and its incidence is unclear. We report a series of four patients with catheter-tract metastasis from indwelling pleural catheters: two patients with adenocarcinoma, and two patients with mesothelioma.
Case Report A large left pleural effusion developed in a 61-year-old woman (Fig 1, 2) 4 months after a left pneumonectomy and chest wall
Figure 1. Chest radiograph from the initial presentation showing a large left pleural effusion in the postpneumonectomy space. Selected Reports
Retrospective Audit The above case prompted a retrospective audit of the incidence of catheter-tract metastases from indwelling PleurX catheters in the Oxford Pleural Unit. Between June 2002 and February 2006, 45 PleurX catheters were inserted for drainage of malignant pleural effusions. All patients were followed up by the unit, and any cathetertract metastases were recorded. Catheter-tract metastasis developed in 3 of 45 patients (6.7%) [Table 1]. The incidence appeared higher in mesothelioma patients (2 of 15 patients, 13.3%) than in those with metastatic carcinomas (1 of 30 patients, 3.3%). Both of the patients with mesothelioma had such metastases despite prophylactic irradiation within 2 weeks of catheter placement. Tract metastasis developed after 6 months in two patients and 9 months in the third patient. All three patients were successfully treated with radiotherapy with the drain in situ, and the indwelling catheters continued to function well.
Figure 2. Contrast-enhanced thoracic CT scan demonstrating diffuse tumor involvement of the pleural surface.
resection for lung adenocarcinoma and preoperative chemotherapy. She had significant symptomatic relief after drainage of pleural fluid, which tested positive for malignant cells. Despite second-line chemotherapy with docetaxel, the effusion reaccumulated rapidly and required frequent drainage. Given the prior pneumonectomy, pleurodesis was regarded as inappropriate. Instead, a small-bore indwelling pleural catheter (PleurX; Denver Biomedical; Golden, CO) was inserted for ambulatory fluid drainage, with good symptomatic effect. Three weeks later, a tumor nodule developed (Fig 3) at the catheter insertion site. This was treated with external-beam radiotherapy (21Gy in three fractions) administered while the catheter remained in situ. Radiotherapy did not affect the function of the catheter. The nodule resolved and was replaced by scar tissue 2 weeks after irradiation. No new nodules developed in the subsequent 3 months of follow-up.
Figure 3. Tumor nodule growing through the chest wall at the indwelling catheter site. www.chestjournal.org
Discussion We report four cases of catheter-tract metastasis in patients with pleural malignancies managed with indwelling pleural catheters. Our series include two cases of tract metastasis from adenocarcinomas: a complication seldom reported with cancers other than mesothelioma. In addition, we have shown that catheter-tract metastasis can be treated with external-beam irradiation with the catheter in situ. Prophylactic radiotherapy to the insertion site did not prevent metastasis from indwelling catheters in the two patients with mesothelioma. Ambulatory drainage of recurrent malignant effusions using small-bore indwelling pleural catheters is increasingly used worldwide for the management of malignant pleural effusions, especially in patients who failed pleurodesis, have trapped lungs, or have a limited life expectancy.1 The use of these catheters is generally safe, but the full spectrum of potential side effects has not been established. The parietal pleura is often affected in malignant pleural diseases.1 Needle tract metastasis along previous pleural puncture sites is well established with mesothelioma, and occurs in up to 40% of patients.5 However, metastasis from adenocarcinomas along pleural puncture sites are uncommon. Catheter-tract metastasis with indwelling pleural catheters has rarely been reported. In three large series of a combined 374 patients,2– 4 only two cases were described. In our population, catheter-tract metastasis occurred in 6.7% of patients who received PleurX catheters. Prophylactic irradiation of the pleural puncture sites is effective in preventing needle tract metastases from mesothelioma following “one-off” pleural procedures (eg, thoracostomy or thoracoscopy). However, radiotherapy may offer limited protection against ongoing risks of malignant invasion in patients with long-term indwelling pleural catheters. This may explain the development of catheter-tract metastases despite prophylactic radiotherapy in our two mesothelioma patients. External-beam radiotherapy was effective in treating CHEST / 131 / 4 / APRIL, 2007
1233
Table 1—Details of the Three Patients With Catheter-Tract Metastasis From the Retrospective Audit Patient No.
Histologic Tumor Type
Insertion of PleurX Catheter After Diagnosis, mo
Tract Metastasis After Insertion, mo
Prophylactic Radiotherapy
1
Mesothelioma
1.5
10 d after PleurX insertion
7
2
Epithelioid mesothelioma
1
9
3
Poorly differentiated adenocarcinoma of unknown primary
5 d after PleurX insertion Not given
11
the catheter-tract metastases. Irradiation was performed with the catheter in situ without impairing the catheter drainage. In summary, catheter-tract metastasis can develop with both metastatic carcinomas and mesothelioma. The incidence is frequent enough that patients should be warned of this potential complication. Larger series are required to establish the incidence and risk factors for cathetertract metastasis.
References 1 Lee YCG, Light RW. Management of malignant pleural effusions. Respirology 2004; 9:148 –156 2 Tremblay A, Michaud G. Single-center experience with 250 tunnelled pleural catheter insertions for malignant pleural effusion. Chest 2006; 129:362–368 3 Putnam JB Jr, Walsh GL, Swisher SG, et al. Outpatient management of malignant pleural effusion by a chronic indwelling pleural catheter. Ann Thorac Surg 2000; 69:369 – 375 4 Musani AI, Haas AR, Seijo L, et al. Outpatient management of malignant pleural effusions with small-bore, tunneled pleural catheters. Respiration 2004; 71:559 –566 5 Boutin C, Rey F, Viallat JR. Prevention of malignant seeding after invasive diagnostic procedures in patients with pleural mesothelioma: a randomized trial of local radiotherapy. Chest 1995; 108:754 –758
8
Treatment for Tract Metastasis
Time of Death After Insertion, mo
Radiotherapy at 30 Gy in six fractions (2 mo after initial metastasis) Low-dose palliative radiotherapy Radiotherapy (30 Gy in six fractions) and catheter removal 2 mo after initial metastasis
17
12 22
pneumonia-like symptoms that did not respond to treatment with antibiotics. Their chest radiographs revealed bilateral diffuse infiltrates. The diagnosis of AEP was established based on the clinical picture, BAL that revealed an average eosinophil count > 45%, and immediate clinical improvement after introducing corticosteroids. All other possible causes were excluded during the initial workup. (CHEST 2007; 131:1234 –1237) Key words: eosinophils; pneumonia; smoking Abbreviation: AEP ⫽ acute eeosinophilic pneumonia
eosinophilic pneumonia (AEP) is characterized A cute by eosinophilic infiltration in the lungs, respiratory
distress, a rapid therapeutic response to corticosteroids, and the absence of relapse.1 Cigarette smoking has been recognized to cause AEP, and a report2 from Japan has demonstrated an association of cigarette smoking-induced AEP with menthol-flavored cigarettes. Based on review of two cases of AEP following flavored cigar smoking, we believe that the flavoring component may have a major rule in precipitating the illness.
Case Reports Case 1
Flavored Cigar Smoking Induces Acute Eosinophilic Pneumonia* Nawar Al-Saieg, MD; Ousama Moammar, MD; and Ritha Kartan, MD, FCCP
Two cases of acute eosinophilic pneumonia (AEP) following smoking of flavored cigars were analyzed for characteristic features. None of our patients had a history of smoking flavored cigars/cigarettes in the past. One of them had never smoked, and the second patient was an ex-smoker who quit 17 years ago. Both patients presented with community-acquired 1234
A previously healthy 23-year-old man presented to the emergency department with a 5-day history of shortness of breath and exercise intolerance. The patient reported a relatively sudden onset of a *From the Department of Internal Medicine, Western Reserve Care System/Northeastern Ohio Universities College of Medicine, Youngstown, OH. This work was performed at Western Reserve Care System, Youngstown, OH. The authors have no conflicts of interest to disclose. Manuscript received October 27, 2006; revision accepted November 21, 2006. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Nawar Al-Saieg, MD, Department of Internal Medicine, Western Reserve Care System, 500 Gypsy Ln, Youngstown, OH 44501; e-mail: [email protected] DOI: 10.1378/chest.06-2623 Selected Reports
Indwelling pleural catheters are increasingly being used for ambulatory treatment of malignant pleural effusion, particularly for patients unsuitable for pleurodesis. These catheters are often left in situ for the rest of the patient’s life. Tumor metastasis along the tract between pleura and skin surface is a potential complication in patients with chronic indwelling pleural catheters that has seldom been reported. We describe four cases of catheter-tract metastasis that developed between 3 weeks and 9 months after catheter insertion. Catheter-tract metastasis occurred in two patients with mesothelioma despite prophylactic irradiation at time of insertion, and in two patients with metastatic adenocarcinoma. All cases were successfully treated using external-beam radiotherapy without necessitating catheter removal. A retrospective audit in our center showed that catheter-tract metastasis occurred in 6.7% of 45 patients treated with indwelling pleural catheters for *From the Centre of Respiratory Research (Drs. Janes and Lee), University College London, UK; and Oxford Pleural Unit (Drs. Rahman and Davies), Oxford Centre for Respiratory Medicine and University of Oxford, Oxford, UK. Dr. Janes is supported by a Medical Research Council Clinician Scientist Fellowship, Dr. Lee is supported by a Wellcome Advanced Fellowship, and Dr. Rahman is supported by a Medical Research Council Training Fellowship. Drs. Janes and Rahman do not have any conflict of interests or involvement with organizations with financial interests in the subject matter. Drs. Davies and Lee have been awarded a project grant from the British Lung Foundation to compare conventional pleurodesis with chronic indwelling pleural catheters in patients with malignant pleural effusions. The investigators of the trial have accepted an arrangement to use pleural catheters provided for free by Rocket Med plc (UK), since the acceptance of this manuscript for publication. None of the investigators received any funding from the company. Manuscript received September 24, 2006; revision accepted November 10, 2006. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Y. C. Gary Lee, MBChB, PhD, FCCP, Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford OX3 7LJ, UK; e-mail: [email protected] DOI: 10.1378/chest.06-2353 1232
Selected Reports
malignant pleural effusions. Both clinicians and patients should be aware of this potential complication. (CHEST 2007; 131:1232–1234) Key words: adenocarcinoma; indwelling catheter; mesothelioma; metastases; pleura
pleural effusions are common in clinical M alignant practice. Indwelling pleural catheters have increas1
ingly been advocated for management of recurrent effusions, especially in patients unsuitable for pleurodesis, or in whom pleurodesis has failed.1–5 These catheters are often left in situ for the rest of the patient’s life. Tumor metastases from the parietal pleura to the skin surface following tracts from pleural procedures (eg, thoracoscopy) are known complications of mesothelioma but are rare with other malignancies.1 Patients with chronic indwelling pleural catheters are at continual risks of tumor spread along catheter tracts. Catheter-tract metastasis has seldom been reported, and its incidence is unclear. We report a series of four patients with catheter-tract metastasis from indwelling pleural catheters: two patients with adenocarcinoma, and two patients with mesothelioma.
Case Report A large left pleural effusion developed in a 61-year-old woman (Fig 1, 2) 4 months after a left pneumonectomy and chest wall
Figure 1. Chest radiograph from the initial presentation showing a large left pleural effusion in the postpneumonectomy space. Selected Reports
Retrospective Audit The above case prompted a retrospective audit of the incidence of catheter-tract metastases from indwelling PleurX catheters in the Oxford Pleural Unit. Between June 2002 and February 2006, 45 PleurX catheters were inserted for drainage of malignant pleural effusions. All patients were followed up by the unit, and any cathetertract metastases were recorded. Catheter-tract metastasis developed in 3 of 45 patients (6.7%) [Table 1]. The incidence appeared higher in mesothelioma patients (2 of 15 patients, 13.3%) than in those with metastatic carcinomas (1 of 30 patients, 3.3%). Both of the patients with mesothelioma had such metastases despite prophylactic irradiation within 2 weeks of catheter placement. Tract metastasis developed after 6 months in two patients and 9 months in the third patient. All three patients were successfully treated with radiotherapy with the drain in situ, and the indwelling catheters continued to function well.
Figure 2. Contrast-enhanced thoracic CT scan demonstrating diffuse tumor involvement of the pleural surface.
resection for lung adenocarcinoma and preoperative chemotherapy. She had significant symptomatic relief after drainage of pleural fluid, which tested positive for malignant cells. Despite second-line chemotherapy with docetaxel, the effusion reaccumulated rapidly and required frequent drainage. Given the prior pneumonectomy, pleurodesis was regarded as inappropriate. Instead, a small-bore indwelling pleural catheter (PleurX; Denver Biomedical; Golden, CO) was inserted for ambulatory fluid drainage, with good symptomatic effect. Three weeks later, a tumor nodule developed (Fig 3) at the catheter insertion site. This was treated with external-beam radiotherapy (21Gy in three fractions) administered while the catheter remained in situ. Radiotherapy did not affect the function of the catheter. The nodule resolved and was replaced by scar tissue 2 weeks after irradiation. No new nodules developed in the subsequent 3 months of follow-up.
Figure 3. Tumor nodule growing through the chest wall at the indwelling catheter site. www.chestjournal.org
Discussion We report four cases of catheter-tract metastasis in patients with pleural malignancies managed with indwelling pleural catheters. Our series include two cases of tract metastasis from adenocarcinomas: a complication seldom reported with cancers other than mesothelioma. In addition, we have shown that catheter-tract metastasis can be treated with external-beam irradiation with the catheter in situ. Prophylactic radiotherapy to the insertion site did not prevent metastasis from indwelling catheters in the two patients with mesothelioma. Ambulatory drainage of recurrent malignant effusions using small-bore indwelling pleural catheters is increasingly used worldwide for the management of malignant pleural effusions, especially in patients who failed pleurodesis, have trapped lungs, or have a limited life expectancy.1 The use of these catheters is generally safe, but the full spectrum of potential side effects has not been established. The parietal pleura is often affected in malignant pleural diseases.1 Needle tract metastasis along previous pleural puncture sites is well established with mesothelioma, and occurs in up to 40% of patients.5 However, metastasis from adenocarcinomas along pleural puncture sites are uncommon. Catheter-tract metastasis with indwelling pleural catheters has rarely been reported. In three large series of a combined 374 patients,2– 4 only two cases were described. In our population, catheter-tract metastasis occurred in 6.7% of patients who received PleurX catheters. Prophylactic irradiation of the pleural puncture sites is effective in preventing needle tract metastases from mesothelioma following “one-off” pleural procedures (eg, thoracostomy or thoracoscopy). However, radiotherapy may offer limited protection against ongoing risks of malignant invasion in patients with long-term indwelling pleural catheters. This may explain the development of catheter-tract metastases despite prophylactic radiotherapy in our two mesothelioma patients. External-beam radiotherapy was effective in treating CHEST / 131 / 4 / APRIL, 2007
1233
Table 1—Details of the Three Patients With Catheter-Tract Metastasis From the Retrospective Audit Patient No.
Histologic Tumor Type
Insertion of PleurX Catheter After Diagnosis, mo
Tract Metastasis After Insertion, mo
Prophylactic Radiotherapy
1
Mesothelioma
1.5
10 d after PleurX insertion
7
2
Epithelioid mesothelioma
1
9
3
Poorly differentiated adenocarcinoma of unknown primary
5 d after PleurX insertion Not given
11
the catheter-tract metastases. Irradiation was performed with the catheter in situ without impairing the catheter drainage. In summary, catheter-tract metastasis can develop with both metastatic carcinomas and mesothelioma. The incidence is frequent enough that patients should be warned of this potential complication. Larger series are required to establish the incidence and risk factors for cathetertract metastasis.
References 1 Lee YCG, Light RW. Management of malignant pleural effusions. Respirology 2004; 9:148 –156 2 Tremblay A, Michaud G. Single-center experience with 250 tunnelled pleural catheter insertions for malignant pleural effusion. Chest 2006; 129:362–368 3 Putnam JB Jr, Walsh GL, Swisher SG, et al. Outpatient management of malignant pleural effusion by a chronic indwelling pleural catheter. Ann Thorac Surg 2000; 69:369 – 375 4 Musani AI, Haas AR, Seijo L, et al. Outpatient management of malignant pleural effusions with small-bore, tunneled pleural catheters. Respiration 2004; 71:559 –566 5 Boutin C, Rey F, Viallat JR. Prevention of malignant seeding after invasive diagnostic procedures in patients with pleural mesothelioma: a randomized trial of local radiotherapy. Chest 1995; 108:754 –758
8
Treatment for Tract Metastasis
Time of Death After Insertion, mo
Radiotherapy at 30 Gy in six fractions (2 mo after initial metastasis) Low-dose palliative radiotherapy Radiotherapy (30 Gy in six fractions) and catheter removal 2 mo after initial metastasis
17
12 22
pneumonia-like symptoms that did not respond to treatment with antibiotics. Their chest radiographs revealed bilateral diffuse infiltrates. The diagnosis of AEP was established based on the clinical picture, BAL that revealed an average eosinophil count > 45%, and immediate clinical improvement after introducing corticosteroids. All other possible causes were excluded during the initial workup. (CHEST 2007; 131:1234 –1237) Key words: eosinophils; pneumonia; smoking Abbreviation: AEP ⫽ acute eeosinophilic pneumonia
eosinophilic pneumonia (AEP) is characterized A cute by eosinophilic infiltration in the lungs, respiratory
distress, a rapid therapeutic response to corticosteroids, and the absence of relapse.1 Cigarette smoking has been recognized to cause AEP, and a report2 from Japan has demonstrated an association of cigarette smoking-induced AEP with menthol-flavored cigarettes. Based on review of two cases of AEP following flavored cigar smoking, we believe that the flavoring component may have a major rule in precipitating the illness.
Case Reports Case 1
Flavored Cigar Smoking Induces Acute Eosinophilic Pneumonia* Nawar Al-Saieg, MD; Ousama Moammar, MD; and Ritha Kartan, MD, FCCP
Two cases of acute eosinophilic pneumonia (AEP) following smoking of flavored cigars were analyzed for characteristic features. None of our patients had a history of smoking flavored cigars/cigarettes in the past. One of them had never smoked, and the second patient was an ex-smoker who quit 17 years ago. Both patients presented with community-acquired 1234
A previously healthy 23-year-old man presented to the emergency department with a 5-day history of shortness of breath and exercise intolerance. The patient reported a relatively sudden onset of a *From the Department of Internal Medicine, Western Reserve Care System/Northeastern Ohio Universities College of Medicine, Youngstown, OH. This work was performed at Western Reserve Care System, Youngstown, OH. The authors have no conflicts of interest to disclose. Manuscript received October 27, 2006; revision accepted November 21, 2006. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Nawar Al-Saieg, MD, Department of Internal Medicine, Western Reserve Care System, 500 Gypsy Ln, Youngstown, OH 44501; e-mail: [email protected] DOI: 10.1378/chest.06-2623 Selected Reports