Streamlining the interventional pathway in malignant pleural disease

Abstract

Aims
To critically assess whether the interventions for patients with malignant pleural effusions can be streamlined to ensure that patients undergo the smallest number, and most appropriate procedures.

Scope
This thesis will assess the clinical utility of each interventional step from the 2010 British Thoracic Society Pleural Disease guidelines by reviewing the guidelines and literature. Noninterventional steps or data specific to non-malignant pathologies will not be critiqued.

Results
The research topics assessed were the utility of an initial pleural aspiration, whether factors affecting a successful pleurodesis could be identified and whether a new interventional drain could prevent displacement, thus reducing pleurodesis failure.
In a retrospective review of 325 patients with a malignant pleural effusion, 4.3% had transudative biochemistry. In total 48% had positive pleural fluid cytology but this was only sufficient to guide management in 26%. Pleural thickening or nodularity associated with negative pleural fluid cytology (p<0.001 and p=0.006 respectively). In patients who required an aspiration for both diagnostic and therapeutic purposes, 90% of patients required another procedure. Non-expansile lung was associated with pleurodesis failure but the chest radiographs were only 24% sensitive in diagnosing this after a therapeutic aspiration.
Mesothelioma was associated with pleurodesis failure and a rise in C-Reactive protein after talc instillation was associated with pleurodesis success but no baseline factors were predictive. The use of a novel interventional balloon drain did reduce the rate of chest drain displacement from 10.1% (standard care) to 3.9%, but this did not meet statistical significance.

Conclusions
Numerous patients could benefit from be triaged directly to a definitive pleural procedure as the initial intervention often does not provide relevant information. This thesis has not identified methods of improving the patient selection or methods of pleurodesis but there are radiological features which may help guide patient selection for procedures in the future. Further work would be needed to ratify a more streamlined pathway.

Date of Award	May 2021
Original language	English
Awarding Institution	University of Portsmouth
Supervisor	Janis Kay Shute (Supervisor)