Thoracoscopic Management of Malignant Pleural Effusions

of Management Thoracoscopic Malignant Pleural Effusions* P.C. Yim, MD, FCCP; Shiu Shek Chung, MB, BS; Anthony Tak Wai Lee, MB, BS; Chuen Kwong Lam, MB, BS; and Jonathan K.S. Ho, MD

Malignant pleural effusion is a common condition and often presents a challenge for treatment. We report our experience from a single institution with the use of video-assisted thoracoscopic surgery (VATS) in the management of malignant effusions. From September 1992 to April 1995,69 patients (31 men, 38 women; age range, 38 to 76 years) underwent diagnosis and/or treatment of malignant

effusions; these included 46 pleural biopsies, 34 talc insufflations, and 16 limited decortications. There was no mortality and there were no intraoperative complications. Postoperative complications occurred in seven patients (10%). Specific histologic diagnoses were obtained in all but 6 patients (87%). Malignant effusion was confirmed in 25 of 46 cases (54%). Thoracoscopic talc insufflation with or without additional decortication was successful in 32 of 34 cases (94%) in controlling recurrence of effusion after a mean follow-up of 6 months among the survivors (22 patients died during the follow-up period without effusion reaccumulation). We conclude that VATS not only provides an accurate diagnosis but also allows effective therapeutic procedures to be performed for malignant effusions that are associated with an acceptable morbidity. (CHEST 1996; 109:1234-38) Key words: malignant pleural effusion; thoracoscopic talc insufflation; video-assisted thoracoscopy surgery Abbreviation: VATS=video-assisted thoracoscopic surgery

of pleural disease remains the oldest Tk/Janagement indication of thoracoscopy. Jacobaeus,1 80 first used to

-L*-"-

over

years ago, thoracoscopy lyse pleural adhesions to collapse the lung in the treatment of tu¬ berculosis. For a long time since then, thoracoscopy has been used sporadically, mainly as a diagnostic modality,2 until its recent revival. There is now a wealth of literature on thoracoscopic management of pleural disease. Differences in the literature on patient selec¬ tions, results, and complications can be explained to an extent by differences in the techniques used and the operators who perform the procedures. Thoracoscopy is not a unified approach and can be performed using flexible3 or rigid scopes4 with or without5 the aid of a Hopkins rod lens, with or without video assistance6 under local,3 regional,' or general anesthesia with8,9 or without selective one-lung ventilation.10 Furthermore, there are few procedures like thoracoscopy that are *From the Cardiothoracic Unit, Department of Surgery, The Chi¬ nese University of Hong Kong, Prince of Wales Hospital, Shatin,

Hong Kong.

Presented in part at the Third International Symposium on Tho¬ racoscopy and Video-Assisted Thoracic Surgery, Luxembourg, June lL-13, 1995.funds from Supported by private donations to the Chinese Hong Kong (A/C 1635-23). University ofreceived Manuscript July 31, 1995; Revision accepted November Reprint requests: Dr. Yim, Dept of Surgery, Prince of Wales Hos¬

pital, Shatin, NT Hong Kong 1234

practiced by pulmonologists, general surgeons, pedi¬ atric surgeons, and thoracic surgeons. The author believes that these different techniques, in essence, represent different approaches altogether, and grouping two different techniques together in re¬ porting6,11 (for example with or without video assis¬ tance) makes interpretation of results difficult.12 This is a report on our experience with the use of videoassisted thoracoscopic surgery (VATS) in the manage¬ ment

of malignant pleural effusions from a single in¬ using a unified technique.

stitution

Methods From September 1992 to April 1995, 69 patients with suspected Materials

and

established malignant pleural effusions were referred to the Cardiothoracic Unit for treatment. There were 31 male and 38 fe¬ male patients with ages from 38 to 76 years. There were 46 patients with indeterminate pleural effusions despite thoracentesis with or without blind pleural biopsy for diagnosis; more than one third of the patients had a history of malignancy (17 cases). In addition, there were 23 patients with established symptomatic malignant effusions for VATS treatment. or

Indeterminate Pleural Effusions These patients had indeterminate pleural effusions despite prior thoracentesis with or without blind pleural biopsies. The procedure was performed under general anesthesia with selective one-lung ventilation with the patient in the lateral decubitus position and the table flexed at 30°.13 The skin was prepared and draped as for a thoracotomy.9 In adult patients, we routinely use a 10-mm operatClinical

Investigations

Table 1.VATS Management of Pleural Effusions.Patient Profile and Results

Table 3.Correlation ofMalignancy History With Pathologic Outcome in the 46 Cases of Indeterminate Effusions

Pleural Effusion No. of patients Procedures

46

Malignancy History

Malignant

Indeterminate

I-1 Present Absent

23

performed

Pleural biopsy (46) Talc insufflation* (11)

Talc insufflation (23)

chest tube duration, d* Hospital stay, d*

2.9+0.9

6.2±2.7

Postoperative

*

Values

are

1.0±0.3

Decortication* (16)

mean±SD.

patient already came with a chest drain, we would use the drain site for the introduction of the telescope. Otherwise, needle aspiration

undertaken to determine the location of the fluid. We normally prefer to introduce the telescope low down in the chest (usually between the sixth and seventh intercostal spaces unless the diaphragm was shown or suspected to be elevated) between the mid to posterior axillary line. The pleural fluid was drained, the pleural cavity inspected, and guided biopsy specimens taken. In 11 cases of confirmed pleural metastases by frozen section, talc insufflation was performed (see below) even though we did not routinely perform frozen sections due to our tight operating schedule. During the same study period, three patients with markedly di¬ minished pulmonary reserve (FEVi <0-4 L/s) underwent flexible pleuroscopy under local anesthesia for diagnosis. They were excluded from this study. Symptomatic Malignant Pleural Effusions Patients with recurrent symptomatic malignant pleural effusions were considered for video-assisted thoracoscopic talc insufflation. Selection criteria include established malignant pleural effusion, recurrent dyspnea that was improved after chest tube drainage or 30%,14 and the large-volume thoracentesis, Karnofsky score abovemore than a 25% absence of severely trapped lung (giving rise to fixed pneumothorax after chest tube drainage or thoracentesis). We were careful in excluding patients whose dyspnea was due to tumor replacement of lung parenchyma rather than effusion. We modified the technique previously described using local an¬ esthesia.15 VATS was performed under general anesthesia as described above. Any residual pleural fluid was aspirated. Loculawas

were

broken down. Fibrinous adhesions

were

taken down

Table 2.Final Histologic Diagnosis of Indeterminate Pleural Effusions

Diagnosis Total No. of cases

Malignancy

No. 46

Adenocarcinoma Squamous cell carcinoma Poorly differentiated carcinoma

11 8 6

Tuberculosis

15 6

Benign

Nonspecific inflammation* *No clinical evidence of malignancy after a mean follow-up months.

17

Benign

5.1±3.4

*These were performed with another procedure during the same anes¬ thesia setting. ing telescope (K. Storz; Germany) that carries a 5-mm instrument channel and hence minimizes the number of ports made. If the

tions

Pathologic diagnosis Malignant

of 11

0

21

while dense fibrous adhesions were selectively divided. In 16 cases, limited decortication to remove the encasing visceral pleura was with or without additional performed. By performing adhesiolysis decortication, complete reexpansion of the lung was achieved in all cases. Some air leak was inevitable but we found as long as the lung could fully reexpand, air leak was seldom a lasting problem. Five

grams of purified talc (Halewood Chemicals; Middlesex, UK) ster¬ ilized by dry heat was then insufflated into the chest to evenly cover the entire visceral and parietal surfaces. Initially we used a special talc atomizer (K. Storz; Culver City, Calif), but we now prefer us¬ ing a mucus extractor (UnoPlast; Hundested, Denmark) connected to a 50-mL syringe. The latter set-up is simple and is readily avail¬ able in most hospitals. Two 28F chest tubes were left in situ of which was visually guided) and connected to 15-cm (placement H2O suction. The lung was confirmed thoracoscopically to be fully reexpanded prior to withdrawal of the scope. The drains were re¬ moved when the total output was less than 50 mL in 24 h. Patients were followed-up radiologically in the outpatient clinic and by telephone at monthly intervals.

Results

The patient profile and results

are

shown in Table

1. There was no mortality and there were no intraop¬ erative complications. For the indeterminate pleural

effusion group, histologic diagnosis was obtained in all Malignancy was the most common cause andIn represented just over half of the cases (Table 2). those with newly diagnosed pleural metastases, 8 (32%) had no other clinical features of malignancy. However, a history of malignancy is a strong predictor for a malignant effusion (Table 3). Of the 34 cases of malignant pleural effusions treated by talc insufflation, postoperative low-grade fever attributable to talc was observed in less than half of the patients (14 cases). Limited decortication was in 16 patients to achieve full lung reexpan¬ performed sion. Relief was obtained in all patients who presented with symptomatic effusions. Twenty-two patients died the follow-up period without evidence of fluid during reaccumulation. Recurrence of effusion was observed in 2 patients among the survivors after a mean of 6 months (range, 1 to 13 months): 1 was follow-up at 1 month and the other at 2 months after the proce¬ dure. In both cases, the effusions were only moderate and the patient remained asymptomatic, so no further cases.

treatment was given. One patient

subsequently died; 8

months postoperatively, the other patient is without further evidence of increasing fluid accumulation. Complications occurred in 7 of 69 patients (10%) CHEST /109 / 5 / MAY, 1996

1235

and consisted of persistent air leak over 7 days and wound infection in the same patient, bleeding requir¬ ing transfusion (2), reexpension pulmonary edema (1), deep vein thrombosis (1), cerebrovascular accident (1), and port site recurrence (l).16 Both persistent air leak and bleeding from decortications stopped spontane¬ ously without the need for reoperation. The port site recurrence occurred in an elderly patient with meta¬ static adenocarcinoma and symptomatic malignant effusion who underwent successful thoraco¬ pleural talc scopic insufflation for control. She was noted to have an asymptomatic 2.5-cm subcutaneous nodule over the instrument port scar 3 months after the pro¬ cedure. As she remained asymptomatic, no specific treatment was offered17 and she died 3 months later. Discussion

There are few procedures like thoracoscopy that have been practiced for so long using so many differ¬ ent techniques by so many different medical special¬ ists. VATS using general anesthesia with selective ventilation is the authors' preferred tech¬ one-lungwhich has several distinct advantages over the nique, others. Firstly, a magnified panoramic view of the hemithorax with high resolution for details is obtained. Secondly, collapse of the ipsilateral lung gives rise to of room for maneuverability of the telescope plenty and instruments. This not only allows adequate biopsy specimens for histologic, and possibly immunocytoand electron microscopic study,14 but also gives logic the option for therapeutic procedures to be performed like decortication, pleurectomy, mechanical pleuro¬ desis, talc insufflation, and last but not least, visual di¬ rected placement of chest drains. Thirdly, the nursing and anesthetic staff can now observe the operation as it goes and the assistant can take up a more active role. Fourthly, general anesthesia is certainly more com¬ fortable for the patients and in this era, the overall risk of general anesthesia is small. Therapeutic maneuvers under local anesthesia are at best, difficult, and at worst, dangerous in a sedated patient who could move without warning and whose lungs are ventilating.18 There is little consensus in the literature regarding when thoracoscopy should be undertaken for indeter¬ minate effusions. From various reports, positive cytol¬ ogy can be identified on thoracentesis from 45 to 80% ofall malignant effusions even though the yield is much lower (20%) with mesothelioma.19 Repeated thora¬ centesis will only marginally increase the yield.20 Likewise, Prakash21 reported that the addition of a closed pleural biopsy will not significantly increase the yield for malignancy and again especially for lymphoma or mesothelioma. This is not surprising as Canto et al22 out that a significant portion of the pleural pointed metastases are located at sites (like the costophrenic 1236

angle and the diaphragmatic surface) that are inacces¬ sible to the blind percutaneous approach. In our insti¬ tution, we therefore recommend to proceed directly to video-assisted thoracoscopic biopsy for diagnosis if the initial cytologic study and culture are negative, the patient is not clinically suspected of having tuberculo¬ sis,21'23 and the patient can tolerate general anesthesia. In practice, the main goal of diagnostic thoracoscopy is to identify patients with pleural metastasis (or tuberculosis) for further management. Our data are in agreement with others that malignancy is by far the most common cause accounting for approximately one half of the indeterminate effusions.19,20 We have not encountered mesothelioma in our series compared to others that showed it to be the most common malig¬ nant diagnosis.24 The reason for this is unclear and it may truly reflect a low incidence in our locality (or underdiagnosis by our pathologists). Besides diagnosis, VATS offers an option for treatment once pleural me¬ tastasis is confirmed. We have encountered no recur¬ rence in our 11 patients in whom talc insufflation was administered after pleural metastasis had been con¬ firmed on frozen section. VATS is therefore our pre¬ ferred approach and we reserve flexible pleuroscopic for those patients who cannot otherwise toler¬ biopsy ate general anesthesia. Malignant pleural effusion is a common clinical condition that is often disabling and could be very dif¬ ficult to treat. It represents a terminal condition with short median survival (in terms of months) and the goal of treatment is palliation.25 Systemic chemotherapy is occasionally useful for breast and small cell lung car¬ cinoma, but local therapy remains the mainstay of treatment. Options include repeated therapeutic tho¬ racentesis, tube thoracostomy and sclerotherapy, tho¬ racoscopic talc insufflation, mechanical pleurodesis, shunt, and pleurectomy.26 We re¬ pleuroperitoneal serve repeated thoracentesis only for those who are severely disabled and require continuous hospitaliza¬ tion (Karnofsky score below 30% )14 as rapid reaccumulation, protein depletion, and risk of empyema oc¬ cur with this treatment. However, pleurectomy carries with it substantial morbidity and mortality27 and is hard to justify for a palliative procedure. Pleuroperitoneal shunt has been shown to be effective28 but it requires a very compliant patient who needs to manually pump 400 times a day. Moreover, there is a risk of shunt oc¬ clusion by blood clots or fibrin debris.29 We therefore have reserved this approach for patients with severely (>25% pneumothorax) trapped lung.11 Of all the sclerosants available, talc is considered the agent of choice because of its good track record (>90% success rate), wide availability, and low cost.30 The possible harmful long-term effects of talc,31 if any, seem academic in this group of patients with limited survival. Acute respiraClinical

Investigations

tory failure32 and death33 have been anecdotally re¬ ported with talc "slurry"32 or insufflation.33 The exact

underlying mechanism remains unclear even though it may be dose-related. Kennedy and Sahn30 recom¬ mended a 5-g dose, which is what we use, and so far we have not experienced any talc-related respiratory complications with VATS insufflation. Patients with diffuse pleural metastasis are at risk of developing tu¬ seeding at thoracoscopy port sites. Fortunately, this is uncommon: 6 of 215 patients described by Boutin et al,20 2 of 30 patients described by Davidson et al,4 and 1 patient described by us.17 We recommend mor

observation if the port site recurrence is asymptomatic in view ofthe patient's short life expectancy; otherwise, local irradiation has been shown to

liation.4

provide good pal¬

The preferred route of administration of talc to achieve pleurodesis ("dusting,"34 "slurry" through a chest tube,35 "poudrage" or insufflation through chest drains,36 or thoracoscopy915) remains unclear. Recent laboratory study showed that talc insufflation is as ef¬ fective as mechanical techniques and superior to laser,

cautery, or tetracycline pleurodesis.37 We report our experience with video-assisted tho¬

racoscopic talc insufflation, which is effective in con¬ and associated with an ac¬ trolling malignant effusion We believe the important ceptable morbidity. for with success ingredient sclerotherapy is to achieve full lung reexpansion to allow close approximation be¬

tween the lung and the chest wall. Inability to achieve this has been shown to be associated with treatment failures.24 We suspect the two failures we have in our series were due to inadequate decortication in our

early experience. In conclusion, we have shown that VATS is a safe and effective approach in the management of malig¬ nant effusions. Recent advances in video camera refined instrumentation, and improved technology, anesthetic techniques have allowed therapeutic ma¬ neuvers like limited decortication or talc insufflation to be safely and effectively carried out. Three areas deserve further investigation. Firstly, talc insufflation is effective, definite improve¬ although ment in a patient's quality of life has not been scien¬ documented. We have encountered problems tifically in using standard questionnaires for our patients: they require translation into Chinese; self-evaluation and visual linear analogue pose difficulties to those with a low level of education and/or low performance status;38 functional status is closely influenced by social and factors that are difficult to quantify; and psychological the questionnaires have not been externally validated. Secondly, although we believe that talc insufflation at the time of thoracoscopic diagnosis carries a high chance of success with little additional surgical ma¬

neuvering, the efficacy and cost effectiveness of this

approach remain to be documented.18 Thirdly, talc insufflation vs other approaches like talc slurry35 in the management of malignant effusions remains to be evaluated in a prospective randomized trial. These is¬ sues are currently under study. ACKNOWLEDGMENTS: The authors are grateful to Alex Fung,

BA, for his editorial assistance.

References

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Clinical

Investigations