Background The incidence of malignant pleural effusions (MPE) is increasing and overall prognosis remains poor. In-dwelling pleural catheters (IPCs) relieve symptoms, but increase the risk of pleural infection. We reviewed survival times of cases of pleural infection in patients with IPCs for MPE from 6 UK centres. Methods Baseline data were collected for all IPC insertions from 1/1/05 to 31/1/14. Survival times were analysed by underlying tumour. Results were compared with national data, and with data from a cohort of 789 patients with MPE (the LENT cohort). LENT scores were used to calculate individual predicted life expectancy, which was compared with actual survival. Results Of 672 IPCs inserted across 6 centres during the study period, 25 patients (3.6%) experienced pleural infection. 19/25 were male,median age 69 (range 35-79). 12/25 had mesothelioma, 8/25 lung cancer, 3/25 breast cancer, 1/25 lymphoma and 1/25 thyroid cancer. 18/25 had a performance status of 0-1, and 19/25 received oncological treatment.Survival with MPE and pleural infection compared favourably with the LENT cohort (see figure 1). Median survival with mesothelioma and pleural infection was 753 days (95% confidence interval 446-1089) compared with 339 days in the LENT cohort (95% CI 267-442) and less than 365 days in nationally reported data. Patients with lung cancer and pleural infection also outlived their LENT counterparts; median survival of 138 days (95% CI 62-479) versus 74 days (95% CI 60-90). Patients with breast cancer had similar survival times (167 vs 192 days).
Background Pleural infection remains common with an increasing incidence. It is associated with a high morbidity and mortality. Despite chest tube drainage and antibiotic therapy up to 30% of patients will die or require surgery. Case reports suggest that irrigation of the pleural space with saline may be beneficial but this has never been the tested in the form of a randomised controlled trial. Method Randomised controlled pilot study comparing saline irrigation (250ml normal saline intra-pleurally over one hour, 3 times a day for 3 days) plus best standard care, with best standard care alone, in patients with pleural infection (microbiology positive or pH<7.2 or purulent pleural fluid and clinical infection) requiring chest tube drainage, who had a residual pleural collection on baseline CT thorax. Primary outcome was percentage change in CT pleural volume from day 0 to day 3. Secondary outcomes included referral for surgery, hospital stay and adverse events. Results 47 patients approached, 38 randomised, 3 excluded (drain fell out/no residual fluid on CT/removal of consent). Saline irrigation results in significant reduction in CT pleural collection volume compared to standard care-Irrigation group 29.15% reduction (95% CI 16.2-62) vs Standard care 13.9% (95% CI-4.1-26.3) p<0.04. There was also a significant reduction in the need for thoracic surgery in the irrigation group 9/17 vs 2/18 p=0.01 (OR 9.0, 95% CI 1.56-51.9). No differences were seen in length of hospital stay or fall in inflammatory markers (CPR, WCC and procalcitinin). The safety profile of saline irrigation was good with no serious complications and adverse events did not differ between groups. Conclusion Saline irrigation improves fluid drainage in pleural infection (as measured by volumetric CT), leading to reduction in referral for surgery. No change in hospital stay was noted. This study now needs to be repeated as a large multicentre RCT powered to look at mortality and length of hospital stay.
IntroductionMalignant pleural mesothelioma (MPM) is an aggressive cancer with a poor prognosis. Treatment options are limited, and pemetrexed and cisplatin chemotherapy is the only intervention shown to extend life. Promising new therapies may provide alternate treatment options in the future.Chemotherapy uptake varies in MPM. Some centres report rates as low as 46% in eligible patients. The aim of this study was to explore the characteristics of patients who declined chemotherapy, and to determine which factors were associated with chemotherapy refusal.MethodsProspective data were collected on all patients diagnosed with MPM in one UK tertiary referral centre. Diagnosis of MPM and eligibility for chemotherapy were determined at the regional MPM multidisciplinary meeting. Patients were followed up until death or censored on 13/7/16.Patient characteristics were compared using chi-squared, Fishers Exact and unpaired T-tests. Kaplan Meier curves were drawn to compare survival between patients who accepted and declined chemotherapy. Logistic regression was used to assess associations between patient characteristics and chemotherapy uptake.Results200 patients were diagnosed with MPM between 1/3/08 and 8/6/16. 150 (75%) were eligible for chemotherapy. 93/150 (62%) patients received chemotherapy, 46/150 (31%) declined and 11/150 (7.3%) patients did not receive it for other reasons.Patient characteristics are shown in Table 1. The group who declined chemotherapy were older (mean age 74.4 vs 68.4, p < 0.001), with a higher proportion of females (23.9% vs 10.8%, p = 0.041) and fewer patients with performance status (PS) 0 (17.4% vs 43%, p = 0.005). Patients who received chemotherapy had longer median survival (426 days vs 203 days, p = 0.001, HR 0.519, p = 0.015).The factors associated with chemotherapy refusal were age (regression coefficient 0.144, p < 0.001) and PS ≥ 1 (coefficient 1.052, p = 0.027).ConclusionThis is the first study to report the characteristics of MPM patients who declined chemotherapy. Significant differences were seen compared with patients who received chemotherapy. Further research is needed to determine whether similar patterns are seen in other centres.Reasons for refusal were not collected, but the association with age and worse performance status may reflect concerns about chemotherapy toxicity. Qualitative research could explore patients’ reasons for refusing chemotherapy.Abstract P12 Table 1Characteristics of patients who received chemotherapy and patients who declined chemotherapyReceivedchemoDeclinedchemopTotal (n = 139) 93 (66.9) 46 (33.1) Gender, n (%)MaleFemale 83 (89.2)10 (10.8)35 (76.1)11 (23.9)0.041Laterality, n (%)Right Left 54 (58.1)39 (41.9)27 (58.7)19 (41.3)0.943Age, mean (SD) 68.4 (6.36)74.4 (7.35)<0.001Performance status, n (%)012 40 (43.0)48 (51.6)5 (5.4)8 (17.4)32 (69.6)6 (13.0)0.005Histology, n (%)EpithelioidSarcomatoidBiphasicDesmoplasticNot specified 63 (67.7)15 (16.1)9 (9.7)2 (2.2)4 (4.3)36 (78.3)6 (13.0)1 (2.2)1 (2.2)2 (4.3)0.540IMIG stage, n (%)IIIIIIIVNot documented 28 (...
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