The palliative treatment with intrapleural streptokinase in patients with multiloculated malignant pleural effusion: a double-blind, placebo-controlled, randomized study

Abstract

Expansion of the lung is necessary for successful pleurodesis therapy in patients with malignant pleural effusion (MPE). However, this is often impossible in multiloculated MPEs. The aim of this study was to investigate the effect of the fibrinolytic agent, streptokinase, on pleurodesis therapy used in the management of multiloculated MPE. Forty patients with multiloculated MPEs were randomly assigned to two groups: fibrinolytic and control. In the fibrinolytic group, 250,000 IU of streptokinase in 50 ml saline was applied into the pleural space at 24-36-48-60 h after opening a tube thoracostomy. In the control group, the same procedure was carried out using only 50 ml saline solution. Both groups were compared based on the following: (1) volume of pleural drainage at 24-48, 48-72, and 24-72 h, (2) chest computer tomography images before and after therapy, (3) dyspnea symptoms after therapy, and (4) recurrence rate. The mean drainage volumes for the fibrinolytic and control groups were 493 and 248 cc at 24-48 h, 446 and 198 cc at 48-72 h, and 939 and 446 cc at 24-72 h (P < 0.001). Comparison of the two groups by computer tomography revealed that 17 patients (85 %) in the fibrinolytic group had greater than 40 % improvement, whereas only 7 patients (35 %) in the control group had the same degree of improvement (P = 0.001). The dyspnea symptoms disappeared in 90 % of the patients in the fibrinolytic group and in 55 % of the patients in the control group (P = 0.03). Recurrence rate was 11 % in fibrinolytic group and 45 % in control group (P = 0.07). Streptokinase is a reliable treatment option in obtaining effective pleural drainage and increasing lung expansion in patients with multiloculated MPE.

Translational Research in Pleural Infection and Beyond

“…However, PAI-1 can be targeted with mitigation of pleural injury in animals and adjunctive PAI-1targeting monoclonal antibodies allow reduction in the dose of IPFT. 28 This strategy was designed to mitigate bleeding risk, and can be extended to treat other loculated (eg malignant) pleural effusions 29 . In a related vein, single chain urokinase (scuPA) has been manufactured through the NIH/NHLBI SMARTT program and is moving towards phase I dose escalation clinical trial testing in patients with loculated empyema.…”

“…Over 1500 people per million population develop an exudative pleural effusion a year; pleural infection and malignant pleural effusion (MPE) being the leading causes. Active plasma extravasation from juxtapleural hyperpermeable blood vessels is a cardinal mechanism of effusion development 29,[37][38][39][40][41][42][43] and has been shown in animal models of various pleural effusions [44][45][46][47][48][49][50] .…”

ERS/EACTS statement on the management of malignant pleural effusions

“…Four controlled studies, three of which were randomised, investigated the role of intra-pleural fibrinolysis for the treatment of loculated MPE [89,[111][112][113]. The first, which used a historical control group, prospectively evaluated 36 patients with symptomatic loculated MPE after drainage with an 8F catheter who were unsuitable for surgery [89].…”

“…The third study randomly allocated 40 patients with loculated MPE on CT to receive intra-pleural streptokinase (four separate doses of 250 000 U) or placebo (saline) administered through a 20F tube, after which talc slurry pleurodesis was performed [112]. The fibrinolytic group had higher daily drainage volumes at all time points ( p<0.001), with a greater proportion of patients showing CT improvements of >40% (85% versus 35%, p=0.001).…”

Effect of medical thoracoscopy‐guided intrapleural docetaxel therapy to manage malignant pleural effusion in patients with non‐small cell lung cancer: A pilot study

“…The chemical agent can be injected using a thoracoscope or intrapleural catheter, and the efficiency varies depending on the agent. To date, the safety and efficacy of chemical agents used in pleurodesis have been studied; however, comparable data were not available, and choosing the ideal agent remains controversial . Talc, doxycycline and antineoplastic agents, such as docetaxel, paclitaxel and bleomycin, are used as chemical agents.…”