Journal Club November 2022

Subcutaneous octreotide therapy for malignant pleural effusion after pleurodesis with talc powder: a placebo-controlled, triple-blind, randomized trial.

Ershadi R, et al.

Support Care Cancer.

PMID: 36357795

A small but novel RCT from Iran assessing the potential benefit of giving octreotide to patients prior to the administration of talc pleurodesis. The theory being that octreotide might have beneficial effects through improving lymphatic drainage, decreased vascular permeability, and inhibition of inflammatory molecules.

This study was a single-center, placebo-controlled, and triple-blind, randomized trial of patients with proven MPE who were due to undergo talc pleurodesis via thoracoscopy followed by an IPC.

In the intervention arm patients were given S/C octreotide for up to 5 days post procedure. The primary outcome was the amount of discharge from the chest tube before and after pleurodesis and the length of hospital stay.

52 patients were included and randomly allocated to two groups of pleurodesis + octreotide or pleurodesis + placebo in a 1:1 ratio, six were withdrawn leaving 46 patients who completed the 3-month course of the study. There was a typical mix of malignant subtypes but no MPM.

Although small this trial does seem to have shown some benefit from octreotide for MPE post pleurodesis. Chest tube output was lower in the intervention arm which led to a shorter hospital length of stay (2.8 vs 4.6 days). Other secondary analysis looked positive as well with reduced recurrence of the MPE at 3 months. Bigger trial needed to ascertain its efficacy and any potential role in non-pleurodesis MPE management.

Efficacy of Intrapleural or Intrapericardial Injection of Single Bevacizumab in the Treatment of Lung Cancer-Mediated Malignant Effusion.

He D, Guo Z, Xie Z, Zhang Y, Deng Q, Yang H.

Can Respir J. 2022 Oct 31;2022:6763625. doi: 10.1155/2022/6763625. eCollection 2022.

PMID: 36353447 Free PMC article.

Another trial that has attempted to ‘turn off the tap’ in malignant pleural effusions, this time with the anti-VEGF agent bevacizumab. This was an open-label phase 2 trial of patients with MPE related to NSCLC only. A single shot of bevacizumab was given intrapleurally or intrapericardially to 22 patients after full drainage of the effusion.

The primary outcome was a patient reported one- reduction in LCCS- which is unusual for a phase 2 trial. It is also difficult to assess the true impact of the trial agent on the effusion given that it was also drained at randomisation with no comparator group. The authors conclude that “ [bevacizumab] is effective and safe in the treatment of lung cancer-mediated malignant effusions” but I do not think this study demonstrated this. An important area of research but more needed.

No role of antibiotics in patients with chest trauma requiring inter-costal drain: a pilot randomized controlled trial.

Teyi T, et al.

Eur J Trauma Emerg Surg.

PMID: 36370185

A neat RCT from India around the use of prophylactic antibiotics for chest tube insertion. Prophylactic antibiotics are used routinely in many centres for the duration of chest tube placement to reduce the risk of post–traumatic empyema (PTE) which can occur in up to 1.5–25%. However, data on its efficacy is limited.

In this single centre study they randomised 120 patients (1:1) to receive a single dose of co-amoxiclav at the time of chest tube insertion OR ‘prolonged’ coamoxiclav for the duration of chest tube insertion.

The authors concede that they are grossly underpowered to detect non-inferiority, which would need over ten times the recruitment target, especially given there was a low rate of infectious complications in either group (0 in the single shot vs 1 in the prolonged group). Not the definitive trial but adds weight to evidence that prophylactic antibiotics are not required for chest tube insertion.

Possible Role of Chest Ultrasound in the Assessment of Costo-Phrenic Angle Lesions Prior to Medical Thoracoscopy: A Retrospective Pilot Case Series.

Conte EG,  et al.

Diagnostics (Basel).

PMID: 36359431

I have never paid specific attention to the costophrenic angle (CPA) when performing thoracic ultrasound in suspected malignant effusion but this paper by Conte et al suggests I should. They make the argument that the CPA is the most likely area to have visible pleural malignancy on the basis of seeding of malignancy driven by gravity and close apposition between visceral and parietal pleura.

To evaluate further they carried out a retrospective case series comparing the sensitivity of ultrasound of the CPA to finding on a CT thorax with subsequent medical thoracoscopy finding the gold standard.

Twenty-eight cases were recruited. The pre-test probability for malignancy was high and indeed 22/28 (78%) had a final diagnosis of cancer. USS of the CPA detected 23 cases of pleural abnormalities in CPA compared to just 12 on CT. US had a sensitivity of 100% and specificity of 83%. CCT had a sensitivity of 54% and specificity of 100%.

So a small paper and naturally confounded by its retrospective nature but given the ease of the test I will certainly be paying more attention to small lesions in the CPA in the future.

Achieving Molecular profiling in Pleural Biopsies: a multicentre, retrospective cohort study. 

Sundaralingam A, et al.

Chest

PMID: 36410492

The true utility of pleural biopsies in malignant pleural effusion is uncertain in the era of personalised medicine. Sundaralingam et al performed a retrospective assessment of the yield of useful molecular profiling from pleural biopsies with a malignant aetiology. They analysed data from 4 sites with 183 patients included. They then performed a regression analysis to assess the factors associated with a ‘useful’ molecular profile, finding that biopsy type (LAT being most useful) and size were independent positive predictors. US-guided biopsy had the lowest (LAT vs CT-guided vs US-guided (LAT yield 95%, CT-guided 86%, US guided 77%, p = 0.004).

In an era of advancing personalized treatment for malignant pleural disease this is important work. The authors should be commended of collecting information from several sites in different countries to improve generalisability.