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        Clinical analysis of 25 cases of malignant pleural effusion treated with thoracoscope and hyperthermic perfusion

        Date:2014年2月26日 10:55

        Clinical analysis of 25 cases of malignant pleural effusion treated with thoracoscope and hyperthermic perfusion
        • Clinical Research •
        Zuotao Li1, Qizheng Han1, Changcheng Hao 1, Yimin Song 2

        (1 Department of thoracic surgery, the Second People's Hospital of Shandong Weifang 261041; 2 Department of pharmaceutical engineering,Qingdao University of Science and Technology, Shandong Qingdao 266042)

        [Abstract] Objectives explore the short-term therapeutic effect of thoracoscopy combined with hyperthermic perfusion for malignant pleural effusion treatment caused by lung cancer. Method All the 25 cases with malignant pleural effusion caused by lung cancer were treated with thoracoscope by biopsy, pleural and cellulose stripping and pleural lesion fulguration. And also hyperthermic perfusion chemotherapy was given by circulation hyperthermic perfusion machine. The perfusion fluid was 2000ml physiological saline containing cisplatin (60~80mg/m2) for 60min at the temperature of 43℃. Results All patients were cured and discharged. And no treatment related death happened. 19 cases had complete response (CR) to treatment, 5 cases with partial response (PR), 1 case with stable disease (SD). The total effective rate was 96%. No hematological toxicity in stageⅡwas found. Patients were found with symptom remission and quality of life improvement. Conclusion Thoracoscopic operation expanded the area of application of the pleural cavity perfusion chemotherapy. Especially, for those patients who cannot tolerate to conventional operation, and patients with pleural adhesion and lung tissue without good expansion can be benefit from this treatment, which had the disadvantages of minimal invasive, reliable diagnostic accuracy, high safety, less adverse reaction and good efficiency for malignant pleural effusion treatment.

        [Key words] thoracoscopy; Lung cancer; malignant pleural effusion; hyperthermic perfusion chemotherapy; Hyperthermic perfusion machine

        [CLC] R 734.2 [Document ID code] B [Article Number] :1671-8194(2011)04-0114-02

        Malignant pleural effusion is one of the most common complications of advanced lung cancer. It will seriously affect the patient's quality of life and survival time. And the median survival of patients with malignant pleural effusion was about 3 months, if it was not well controlled [1]. Therefore, the effective treatment of malignant pleural effusion can relive symptoms, reduce the pain of patients, improve the quality of life as well as prolong the patients’ survival. 25 cases with malignant pleural effusion induced by lung cancer were treated with thoracoscopy combined with hyperthermic perfusion therapy in department of thoracic surgery, the second people's Hospital of Weifang from June 2008 to June 2010. The satisfactory effect was reported as following.

        1 Patient and Methods

        1.1 Patients
            25 cases were enrolled with the median age of 63 year (range from 48 to 75), including 16 males, 9 females, 12 cases of adenocarcinoma of lung, 8 cases of squamous cell carcinoma, 3 cases of pulmonary adeno squamous carcinoma, 2 cases of small cell lung cancer. All patients had pleural effusion at the same side as primary tumor. 17 cases were confirmed by cytological result or histological result from CT guided lung biopsy. 8 cases were diagnosed by histological result from operation or pleural biopsy.

        1.2 Therapeutic plan
        1.2.1 The test and preparation was same as conventional open chest operation
            Double-Lumen endotracheal intubation combined intravenous anesthesia was administered. All patients were in contralateral decubitus position, breathing by normal side. All the operation was under small incision by thoracoscopy. Large amount of pleural effusion was firstly drained in order to avoid mediastinal swing and pulmonary edema caused by re-expansion. Clearance of pleural effusion and jelly like sediment and separation of visceral and parietal pleura was firstly performed. For those patients with adhesion of visceral and parietal pleura which does not affect re-expansion of lung, forced separation was not needed so as to avoid serious bleeding. Then the whole thoracic exploration was performed, including primary lesion, metastatic nodules in visceral pleura, hypertrophy, and enlargement of mediastinal lymph node. The further decision was made according to these situations. For the cases (8 cases in this study) without confirmed diagnose, tumor or pleural biopsy were made. For those peripheral lung cancer lesion satisfied for wedge resection, wedge resection was made. Stripping of cellulose membrane on the surface of visceral pleura as far as possible was needed to make the lung re-expansion sufficiently. Electrical cauterization of the metastatic nodules on visceral pleura was given. After the processing, two silicone chest drainage catheters were placed and connected with a water sealed bottle. One catheter was placed in the top of thoracic cavity, and the other was placed in costophrenic sinus. The two catheters were prepared for hyperthermic perfusion machine connection. Patients were encouraged to cough to make full pulmonary reexpansion.

        1.2.2 The recovery of the patients after operation
        Hyperthermic perfusion chemotherapy was performed at 3~5 days after operation according to the recovery condition of patient. The perfusion fluid was 2000ml physiological saline containing cisplatin (60~80mg/m2), at the temperature of 43℃ for 60min.  Symptomatic treatment such as antiemetic, hydration, electrolyte supplement were given during perfusion. After perfusion, the top catheter was removed, and the lower one was left for drainage. The volume of drainage was less than 100ml/24h.

        1.3 criterion of therapeutical evaluation
            Therapeutic evaluation was classified according to WHO criteria: Complete remission (CR): ascites disappeared completely, lasting more than 4 weeks; Partial remission (PR): ascites reduced at least 50%, and remission of symptoms continued for more than 4 weeks; Stable disease (SD): the change of ascites with less than 50% decreased or no more than 25% increased; Progressive disease (PD): ascites increased or advanced. Complete remission and partial remission were defined as effective results.

        2 Results
        All patients were cured and discharged with no treatment related death. All the 8 cases who were not been confirmed had clearly diagnosis after operation. Among which 7 cases were underwent wedge resection. All the patients received intrapleural hyperthermic perfusion chemotherapy with no serious adverse reactions. The therapeutic results were 19 cases with CR, 5 cases with PR and 1 case with SD. The total effective rate is 96%. No stage II hematological toxicity happened. Patients with chest tightness, chest pain and other symptoms were relieved or disappeared, and quality of life was improved.

        3 Discussion
            Malignant pleural effusion is a common complication of advanced lung cancer. 8%~15% of lung cancer patients were suffered from pleural effusion [2]. A large amount of pleural effusion leading lung compression, difficulty breathing, is one of the main causes if death of advanced lung cancer, if nor promptly treated. The median survival period was only 3 months. So the effective treatment of malignant pleural effusion can alleviate the symptoms, reduce the pain of patients, improve the quality of life of patients, prolong patients ‘survival. The diagnosis rate or routine cytologic examination of pleural effusion and pleura biopsy methods are low, 60% and 30% respectively [3]. So the treatment for malignant pleural effusion was delayed by the diagnosis difficulty. Lung cancer patients complicated with pleural effusion developed to advanced stage are often too weak to tolerate the conventional open chest operation to confirm the diagnosis. Thoracoscopic operations have the advantages of fewer traumas, quicker recovery, and safety and so on. Especially for pleural disease, it can be used in a large section biopsy under direct vision with multiple incision and high definite diagnosis rate. Most of the studies reported thoracoscopic diagnosis positive rate was 93%~99% [4]. 8 cases in this study were diagnosed by thoracoscopic biopsy. It had remarkable meaning for those patients who cannot tolerate to conventional operation. Furthermore, the effusion separated and encapsulated and insufficient re-expansion of lung tissue are also the reasons that effusion are hardly to be well controlled. Thoracoscopic operation with the ability to separate and strip the hypertrophy of the pleura and fibreboard can make the lung re-expansion. At the same time, the primary tumor can be removed, so as to reduce the load caused by tumor and enhance the antitumor immunity [5]. Therefore, Thoracoscopy had the double roles of both diagnosis and treatment for pleural effusion. Pre-treatment of thoracoscopy provide further chance for malignant pleural effusion therapy. Among many methods of malignant pleural effusion treatment, thoracic cavity perfusion with cisplatin had definite effect with the effective rate of 60% [6]. Hyperthermia as a new therapy for tumor developed in recent years has been used in the treatment of malignant pleural effusion induces by lung cancer. It reported that hyperthermic perfusion chemotherapy with cisplatin controlled the malignant pleural effusion well with the effective rate of 90% above [7]. Hyperthermic perfusion machine which adopt real-time control computer to monitor the pleural cavity temperature is a full closed circulating treatment system. It ensures the pleural cavity temperature effectively, and to further increase the effective rate. Some study reported the effective rate as 100% [8].. Due to the less adverse reaction, high effective rate, good tolerance of patient, hyperthermic perfusion chemotherapy had become the main treatment for malignant pleural effusion. However, the existence of pleural adhesions and poor lung expansion made part of patients cannot be benefited from this therapy. In this study, thoracoscopy combined with hyperthermic perfusion machine can solve the problem well. Based on the advantage of thoracoscopy, the separation of adhesion pleura and stripping the hypertrophy of the pleura and fibreboard were firstly made to re-expanse the lung. Thoracoscopic operation expanded scope of application of hyperthermic perfusion chemotherapy and made the part of patients with pleural adhesions and poor lung expansion be benefited from this therapy. In summary, thoracoscopy combined with hyperthermic perfusion therapy for malignant pleural effusion had remarkable effect with mild adverse reaction, minimally invasive, high safety and high effective rate. It is good choice for clinical application.

        References
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