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Journal Club April 2022

Silver Nitrate-Coated Versus Standard Indwelling Pleural Catheter for Malignant Effusions: The SWIFT Randomized Trial. 

Shrager JB, et al.

Ann Am Thorac Soc.

Devised as a method to increase the rates of pleurodesis following surgery the silver nitrate coated catheter (SNCIPC) was trialled in 20 hospitals in the US and UK. Any studies in malignant pleural effusions are challenging given the aggressive nature of the underlying disease so the authors should be applauded.

Unfortunately, after recruiting 119 patients with MPE (various primaries) there was no difference in the primary outcome of pleurodesis success.

It should be noted that the primary outcome was quite rigorous, demanding pleural fluid output via the catheter to be less than 50 mL on 3 consecutive drainages over a minimum of 5 days, and a chest radiographic assessment demonstrated opacification. Previous studies have used a more liberal definition of pleurodesis.

Secondly the study recruited more hospitalised patients than would normally be expected for a device designed to liberate patients from healthcare interventions with 39% of participants in the SNCIPC group inpatients at randomisation. This resulted in exactly the same proportion (39%) dying before 90 day follow up, significantly reducing the power of the trial.

Perhaps most importantly patients in the usual care arm (IPC) had an improved quality of life at day 14 and day 30. The authors rightly conclude “This study does not support the wider use of the SNCIPC device”.

Anetumab ravtansine versus vinorelbine in patients with relapsed, mesothelin-positive malignant pleural mesothelioma (ARCS-M): a randomised, open-label phase 2 trial. 

Kindler HL, et al.

Lancet Oncol.

For patients with pleural mesothelioma who have progressed on 1st line chemotherapy few treatment options exist. This open-label randomised trial compared the antibody-drug conjugate anetumab ravtansin to vinorelbine. Anetumab ravtansine (also known as BAY 94–9343) is an antibody–drug conjugate including a fully human IgG1 anti-mesothelin antibody. Mesothelin is a tumour differentiation antigen that is highly expressed in several cancers, including mesothelioma.

589 patients were enrolled and 248 mesothelin-overexpressing patients were randomly allocated to the two treatment groups (166 patients to receive anetumab ravtansine and 82 patients to receive vinorelbine). 

In this study, anetumab ravtansine was not superior to vinorelbine in terms of progression-free survival (3.9 vs 4.0 months) or overall survival (4.3 vs 4.5 months). A post-hoc analysis showed that BAP1 mutations were observed in patients who did not respond to anetumab ravtansine, potentially supporting the notion that BAP1 mutations confer resistance to spindle poisons.

Cost-effectiveness of ambulatory care management of primary spontaneous pneumothorax: an open-label, randomised controlled trial. 

Luengo-Fernandez R, et al

Thorax.

The RAMPP trial was a multicentre, open-label, randomised controlled trial comparing ambulatory management of primary pneumothorax. Using the RAMPP trial data, a prospective, within-trial economic analysis was done to determine whether ambulatory management of patients with PSP was cost-effective. When compared with standard care. patients in the ambulatory care group had significantly lower healthcare costs (−£788, 95% CI difference: −1527 to −50; p=0.037) than those in the standard care group.

Challenging the Paradigm of Persistent Air Leak: Are We Prolonging the Problem? 

Walker SP, et al.

Am J Respir Crit Care Med. 2022 Mar 30. doi: 10.1164/rccm.202109-2149PP. Online ahead of print.

PMID: 35353640

An interesting opinion piece regarding whether our longstanding approach to intervening in a pneumothorax is the correct one.

Alteplase Dose Assessment for Pleural infection Therapy (ADAPT) Study-2: Use of 2.5 mg alteplase as a starting intrapleural dose. 

Popowicz N, et al

Respirology.

Since the MIST2 trial was published there has been a drive towards reducing the dose of alteplase given intrapleurally for pleural infection. In this single centre case series a dose of 2.5mg of alteplase (MIST2 used 10mg) was used in all patients (n=69) presenting with pleural infection. It seemed to work effectively in most with just 17 patients required dose escalation of tPA; most (n = 12) for attempted drainage of distant non-communicating locule(s).

13th June 2022

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