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Journal Club November 2021

Non-Traumatic Chylothorax and Chylopericardium: Diagnosis and Treatment Using an Algorithmic Approach Based on Novel Lymphatic Imaging. 

Gurevich A, et al.

Ann Am Thorac Soc.

PMID: 34797746

Recurrent chylothoraces can be tricky to manage with significant variation in strategies between centres. This interesting study used magnetic resonance imaging of lymphatics to assess the different physiological patterns in 52 patients with nontraumatic chylous pleural effusions.

The authors identified 3 distinct patterns of lymphatic abnormalities. Namely:

(1) abnormal pulmonary lymphatic flow from the thoracic duct only;

(2) abnormal pulmonary lymphatic flow from retroperitoneal lymphatic networks with or without involvement of the thoracic duct;

(3) chylous ascites presenting as chylous pleural effusion.

This had significant implications for management as abnormality 1 and 2 and could be successfully treated with thoracic duct embolization or interstitial embolization of retroperitoneal lymphatics respectively. This resulted in resolution in 93% of cases.

Ambulatory Thoracoscopic Pleurodesis Combined With Indwelling Pleural Catheter in Malignant Pleural Effusion

Foo C et al.

Front Surg

PMID: 34760917

With the TACTIC trial opening soon across the UK this study from the Cambridge group will provide some reassurance to recruiting centres. They present a case series of combining thoracoscopic talc poudrage and IPC insertion into a single day case procedure. Over a 3-year period they performed this in 45 patients with malignant effusions. Over ¾ of patients were pleurodesed at 3 months with a median length of stay in hospital of 0 days. Welcome news when planning pleural services during the pandemic.

Improving mesothelioma follow-up care in the UK: a qualitative study to build a multidisciplinary pyramid of care approach

Davey et al.

BMJ Open

PMID: 34758990  

Pleural disease research has advanced hugely in the last 2 decades, but the focus has been on quantitative research. Which is why it is refreshing to see this robustly performed qualitative study by Davey et al funded by Mesothelioma UK. Their aim was to co-produce follow-up care guidelines for mesothelioma with key stake holders; patients with mesothelioma and their carers (n=11), mesothelioma specialist nurses (n=9) and local clinical commissioning group members (n=15).

Using a framework method for analysis of the issues raised at each consultation group discussion, a set of infographics were produced to maximise the potential impact of the recommendations on mesothelioma follow-up care pathways both regionally and nationally. The core recommendation was for all patients to have access to a mesothelioma specialist nurse within a respiratory led mesothelioma care pathway. Five other recommendations were also endorsed including timely information provision, streamlined care, and personalised links between secondary and community support services.

Treatment patterns and outcomes for patients with malignant pleural mesothelioma in England in 2013-2017: A nationwide CAS registry analysis from the I-O Optimise initiative

Baas et al.

Lung Cancer

PMID: 34823894

This is a retrospective assessment of mesothelioma incidence and management in England between 2013 and 2017. They used the national CAS registry in England so should be comprehensive. 9458 patients were diagnosed across the period with a median age of 75.

The findings are informative with the points of interest being:

1. Over half of patients received best supportive care alone after diagnosis

2. 5% underwent some form of surgery

3. Overall median survival was just 8.3 months

It highlights the importance of trials that focus on palliative interventions in mesothelioma which might aid the majority of patients. It also re-enforces that non-chemotherapeutic options are needed to improve patient outcomes which remained fairly static across the study period.

Durvalumab with platinum-pemetrexed for unresectable pleural mesothelioma: survival, genomic and immunologic analyses from the phase 2 PrE0505 trial

Forde et al.

Nature Medicine

PMID: 34750557

Durvalumab is an anti-PD-L1 antibody which was combined with cisplatin and pemetrexed chemotherapy in this phase 2 trial (PrE0506) of untreated mesothelioma. Nature Medicine is an unusual journal for a phase 2 trial but it was published here as it has some excellent embedded genomic and immune cell analysis alongside the standard reporting of progression free survival.

Durvalumab itself seems to work well with patients surviving a median of 20 months which when allied to similar encouraging results from the DREAM trial and launched the ongoing phase 3 PrE0506/DREAM3R trial (NCT04334759), which compares durvalumab with chemotherapy to chemotherapy alone.

Mesothelioma has always been associated with a low tumour mutation burden. Although tumours with TMB in the lower end of the spectrum are historically thought to have TMB-independent mechanisms of response to immunotherapy, this study showed that a higher immunogenic mutation load distinguished responding tumours, particularly in the epithelioid MPM group. These findings might lead to more personalised immunotherapy of mesothelioma in the future and is being tested within DREAM 3.

Optimal anatomical location for needle chest decompression for tension pneumothorax: A multicenter prospective cohort study

Azizi et al.

Injury

PMID: 34756305

A simple study for an important question. In the case of a tension pneumothorax- what is the best anatomical location for a needle decompression? Especially if the patient has a high BMI.

The ATLS recommends the 4th/5th intercostal space mid axillary line, the ETC trauma and RCS guidelines suggest the more classical 2nd intercostal space in the midclavicular line.

In a random sample of 392 patients who attended an ED department their chest wall thickness was measured using ultrasound in both locations.

For most patients the chest wall thickness was the same in both locations, however, in patients with a BMI over 25 the chest wall was significantly thicker at the mid-axillary line site. They calculated hypothetical failure rates with a 45mm venflon was more than doubled in the mid-axillary site (6.2%).

Bilateral re-expansion pulmonary edema: an uncommon complication of the pneumothorax drainage

Benhamed et al.

Arch Clin Cases

PMID: 34754921

To finish with an image case as ever. This one is a case report of a young male patient who developed re-expansion pulmonary oedema after insertion of a one-way valve device for primary spontaneous pneumothorax.

An unpleasant experience for patient and operator. We have actually had a very similar case at our centre and it remains unclear how a small drain with valve could have generated the negative pressure required for RPO development.

Perhaps some with a better knowledge of the physiology could theorise?

2nd December 2021

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