Predictors of clinical use of pleurodesis and/or indwelling pleural catheter therapy for malignant pleural effusion

Our plain-English summary of Predictors of clinical use of pleurodesis and/or indwelling pleural catheter therapy for malignant pleural effusion, by E.T.H. Fysh, S. Bielsa, C.A. Budgeon, et al (Chest, 2015).

The study

• Authors: E.T.H. Fysh, S. Bielsa, C.A. Budgeon, C.A. Read, J.M. Porcel, N.A. Maskell, Y.C.G. Lee
• Journal: Chest
• Published: 2015;147(6):1629-1634
• Cited by: 30 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: The clinical course of patients with malignant pleural effusions (MPEs) varies. The decision to undertake "definitive therapy" (pleurodesis, indwelling pleural catheter [IPC], or both) for MPEs is decided on a case-by-case basis. Identifying factors that predict definitive therapy may help guide early initiation of treatment. The aim of the study was to identify clinical, laboratory, and radiologic predictors associated with clinicians' prescription of definitive therapy for patients with MPE.

Methods: A multicenter, observational study was conducted over 55 months involving tertiary centers in Perth, Western Australia, Australia, and Lleida, Spain. Demographic, clinical, radiologic, biochemical, and histologic data and the treatments received were recorded. Logistic regression was performed to determine the variables useful for predicting definitive therapy.

Results: Data of 540 patients (365 from Perth and 184 from Lleida) were analyzed; 537 fulfilled the criteria of an MPE. Definitive therapy was used in 288 patients (53.6%): 199 received a pleurodesis and 89 an IPC. Univariate analysis of the combined cohort revealed that definitive therapy was more likely if the effusion has low pH, either as a continuous variable (OR, 30.30; P < .01) or with a pH cutoff of < 7.2 (OR, 2.09; P = .03); was large (> 50% of hemithorax) (OR, 2.75; P < .01); or was associated with mesothelioma (OR, 1.83; P < .01). Following multivariate analysis, low pleural pH (OR, 37.04; P < .01), large effusions (OR, 3.31; P < .01), and increasing age (OR 1.02, P = .01) were associated with the use of definitive therapy.

Conclusions: Patients with MPE with an effusion of low pleural fluid pH and large size on radiographs at first presentation are more likely to be treated with pleurodesis and/or IPC.

In plain English

This multicenter observational study examined which patients with malignant pleural effusion (cancer-related fluid around the lung) received "definitive therapy": pleurodesis, an indwelling pleural catheter (IPC), or both. It used prospectively collected data on 540 patients from Western Australia (356) and Lleida, Spain (184); 537 were analyzed. Mesothelioma made up 40.2% and 2.7% of these groups, respectively; asbestos exposure was not studied. In all, 288 patients (53.6%) received definitive therapy: 199 pleurodesis and 89 an IPC. In the combined multivariate model treating pH as continuous, three factors were associated with definitive therapy: decreasing pleural fluid pH (OR 37.0, 95% CI 7.8 to 166.7), effusions over half of one side of the chest (OR 3.31, 95% CI 2.11 to 5.19), and increasing age (marginal OR 1.02, 95% CI 1.00 to 1.04). When pH was split at 7.2, pH lost significance and mesothelioma was associated with definitive therapy (OR 2.05, 95% CI 1.23 to 3.40). The authors concluded that patients with low pleural pH and large effusions at first presentation are more likely to receive pleurodesis or an IPC, while noting missing data.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Multicenter observational study using prospectively collected databases, analyzed with logistic regression
• Who was studied: 540 patients with malignant pleural effusion: 356 from Western Australia (Sir Charles Gairdner, Fremantle and Royal Perth Hospitals; August 2009 to July 2013) and 184 from University Hospital Arnau de Vilanova, Lleida, Spain (December 2007 to April 2012). Three were excluded, leaving 537. Mesothelioma accounted for 40.2% of the Western Australia cohort and 2.7% of the Lleida cohort.
• Exposure: No asbestos or fiber exposure was studied. The factors examined as possible predictors of definitive therapy were clinical, pathologic, radiologic and biochemical: age, sex, home location, cancer type (including mesothelioma), effusion side and size, nonexpandable lung, loculation, comorbidities, medications, and pleural fluid pH, lactate dehydrogenase, protein and glucose.
• Main results:
  • Of the 537 patients, 288 (53.6%) received definitive therapy: 199 (69.1% of these) had pleurodesis and 89 had an IPC. The other 249 (46.4%) received no more than thoracentesis.
  • In the combined cohort's univariate analysis, a large effusion (OR 2.75, 95% CI 1.91 to 3.96) and underlying mesothelioma (OR 1.83, 95% CI 1.23 to 2.72) were associated with definitive therapy, as was decreasing pleural fluid pH (OR 30.30).
  • In the combined cohort's multivariate analysis with pH as a continuous variable, decreasing pleural pH was associated with definitive therapy (OR 37.0, 95% CI 7.8 to 166.7).
  • In the same combined multivariate analysis, effusions larger than 50% of the hemithorax were associated with definitive therapy (OR 3.31, 95% CI 2.11 to 5.19).
  • In the same model, with pH treated as continuous, increasing age was also statistically significant, with a marginal OR of 1.02 (95% CI 1.00 to 1.04). Age was not significant in the model using a pH cutoff of 7.2.
  • When pH was analyzed with a cutoff of 7.2, pH was no longer significant. Instead, mesothelioma was associated with definitive therapy (OR 2.05, 95% CI 1.23 to 3.40).
  • In the separate cohorts' multivariate analyses, low pleural fluid pH was a significant predictor in both: OR 13.70 in Western Australia and OR 41.67 in Lleida. Larger effusions were also significant in both: OR 1.59 in Western Australia and OR 14.95 in Lleida.
  • Definitive therapy was used more often in the Western Australia subgroup than in the Lleida subgroup (57.8% vs 45.7%).
• The authors' conclusion: The authors concluded that patients with malignant pleural effusion whose fluid has a low pH and is large on radiographs at first presentation are more likely to be treated with pleurodesis and/or an IPC.
• Limitations the authors state:
  • As a longitudinal observational study, it had missing data not recorded by referring physicians. This prevented other possible predictors, such as trapped lung, from being included.
  • There was heterogeneity between the two centers.
  • The study described real-life prescribing and could not establish whether the treatment decisions were appropriate.
  • Pleural pH data were only 74% complete but were still included in the combined analysis.

Topics

Medical terms in this study, explained in our Lexicon: Pleurodesis, Indwelling Pleural Catheter, Pleural Effusion, Hemithorax, Mesothelioma, Multivariate Analysis.

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• Protocol of the Australasian Malignant Pleural Effusion-2 (AMPLE-2) trial: a multicentre randomised study of aggressive versus symptom-guided drainage via indwelling pleural catheters — M. Azzopardi, R. Thomas, et al. (2016)
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• Histopathology of removed indwelling pleural catheters from patients with malignant pleural diseases — C.L. Tobin, R. Thomas, et al. (2016)

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