Institutionen f枚r medicin
Enheten f枚r lungmedicin
Karolinska institutet
PLEURODESIS IN CHRONIC EFFUSIONS
Studies on inflammatory mediators, respiratory function, predictability of
treatment outcome, drug efficiency and survival after treatment.
av
Valiant Ukale
AKADEMISK AVHANDLING
som f枚r avl盲ggande av medicine doktorsexamen vid
Karolinska institutet, offentligen f枚rsvaras p氓 svenska spr氓ket i
Thoraxklinikernas f枚rel盲sningssal N2:U1, Karolinska universitetssjukhuset
fredagen den 8 oktober 2004 kl 09.00
Handledare: Fakultetsopponent:
Docent Olle Widstr枚m
Docent Rune Lundgren
Institutionen f枚r medicin
Institutionen f枚r folkh盲lsa och
Enheten f枚r lungmedicin
klinisk medicin
Karolinska institutet
Avdelningen f枚r lungmedicin
Karolinska universitetssjukhuset, Solna
Ume氓 universitet
Bihandledare: Betygsn盲mnd:
Docent Gunnar Hillerdal
Docent Jan-Olof Fernberg, Karolinska institutet
Institutionen f枚r medicin
Docent Bj枚rn Mossberg, Karolinska institutet
Enheten f枚r lungmedicin
Docent Christer Jansson, Uppsala universitet
Karolinska institutet
Karolinska universitetssjukhuset, Solna
Stockholm 2004
ABSTRACT
Metastatic or primary (mesothelioma) malignancy of the pleura often generates major pleural
effusion, giving respiratory distress and low quality of life to the patients. Evacuation of fluid
by thoracocentesis gives only temporary relief, therefore pleurodesis is generally regarded the
best way to give palliation. The principle of pleurodesis is to cause a severe inflammation
with desquamation of the mesothelial cells, resulting in a fibrosis that obliterates the pleural
space. The aims of this thesis were to study various aspects of chemical pleurodesis: the
inflammatory response in the pleura and the systemic inflammatory reaction during such
treatment and also to investigate if the reaction had predictive value on pleurodesis outcome;
the impact of pleurodesis on respiratory function; to compare the efficacy and side effects of
two drugs used for pleurodesis; and the long-term survival after pleurodesis in different
malignancies.
It was found that the cytokine IL-1尾 was present in the pleural fluid before and during chest
tube drainage and increased after quinacrine instillation. However high concentrations of IL-
1尾 values after instillation were related to the need for longer treatment duration.
Successful pleurodesis leads to fibrous adhesions between the lung and costal pleura, which
might restrict lung mobility. Ten patients without radiological signs of tumour infiltration and
without visible signs of tumour growth in the pleural space at thoracoscopy were investigated
after pleurodesis with static and dynamic spirometry, exercise testing with blood gas
determination, and radiospirometry. The study showed that pleurodesis in malignant pleurisy
has very limited influence on respiratory function.
Quinacrine has been used for pleurodesis with good results in our clinic for decades and talc,
which has gradually during recent years become the most commonly used drug for this
purpose world-wide. The comparative study between talc and quinacrine in 110 patients
showed that both drugs were effective for pleurodesis. Fluid accumulation was stopped within
six days in 96% of the talc group and 89% of the quinacrine group.
All 89 prospective patients had verified malignant effusion. The markers investigated for the
systemic inflammatory reaction were erythrocyte sedimentation rate, C-reactive protein, and
leukocyte count from venous blood samples, and fever reaction. Cessation of fluid
accumulation was achieved in 82 patients (92%) and all had a prominent transitional elevation
of the inflammatory parameters. The unsuccessful attempts (8%) caused negligible or very
small elevations, but due to the small number, only the degree of fever after 8 and 48 hours
showed a statistically significant difference. Pleurodesis causes a systemic inflammation and
there is a tendency to a correlation between the success of pleurodesis and the degree of
inflammation caused by the procedure.
Altogether 197 patients with malignant effusion were discharged from our clinic between
January 1, 1991 to September 30, 1994 after a successful pleurodesis. The four most common
primary tumours were lung, breast, lymphoma and ovarian malignancies. The overall median
survival from pleurodesis was 135 days. Patients with breast cancer had the best prognosis
(median survival 216 days). In lung cancer patients, this figure was 28 days and in
lymphomas 168 days. The longer the time from diagnosis of primary tumour to effusion, the
better the prognosis.
ISBN: 91-7140-031-1
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