Zentralbl Chir 2008; 133(3): 218-221
DOI: 10.1055/s-2008-1076788
Übersicht

© Georg Thieme Verlag Stuttgart · New York

Chirurgische Therapie des malignen Pleuraergusses

Surgical Therapy for Malignant Pleural EffusionsC. Ludwig1 , E. Stoelben1
  • 1Lungenklinik Merheim, Kliniken der Stadt Köln gGmbH
Weitere Informationen

Publikationsverlauf

Publikationsdatum:
19. Juni 2008 (online)

Zusammenfassung

Der maligne symptomatische Pleuraerguss ist eine häufige Komplikation bösartiger Erkrankungen (ca. 50 %). Das Auftreten ist ein Zeichen der Progredienz der Erkrankung. Die betroffenen Patienten haben eine mittlere Lebenserwartung von 3-12 Monaten. Ziel der Behandlung ist es, den Patienten eine schnelle und effiziente Therapie mit einem kurzen Krankenhausaufenthalt anzubieten. Mittels einer Thoraxdrainage wird der Pleuraerguss entlastet und die Entfaltung der Lunge festgestellt. Sofern dies geschehen ist, wird zur Verklebung der Pleura die thoraskopische Talkumpleurodese empfohlen. Talkum (Erfolgsrate > 80 %) ist das Mittel 1. Wahl, gefolgt von Doxycyclin (70 %). Diese Methode ist komplikationsträchtiger als eine einfache Pleurodese über die bereits liegende Drainage, hat aber die höchste Erfolgsrate. Weitere Möglichkeiten sind Thoraxdauerdrainagen und der pleuroperitoneale Shunt bei Patienten mit sehr reduziertem Allgemeinzustand und / oder gefesselter Lunge.

Abstract

Symptomatic malignant pleural effusions are common in patients with neoplastic disease (50 %). Frequently, they are a sign of advanced disease. These patients have an average life expectancy of 3 to 12 months. The therapeutic aim should be an efficient treatment with a short hospital stay. Chest tube drainage gives rapid relief of symptoms and information on the expansion of the lungs. When complete expansion of the lung is possible, VATS insufflation of talc is recommended. Talc is the most effective sclerosant (80 %) followed by doxycycline (70 %). VATS pleurodesis has a higher complication rate but is more effective than a talc slurry instilled through the chest tube. When the lung is trapped, long-term indwelling pleural drainage and pleuroperitoneal shunts are alternatives.

Literatur

  • 1 Adler R H, Sayek I. Treatment of malignant pleural effusion: a method using tube thoracostomy and talc.  Ann Thorac Surg. 1976;  22 8-15
  • 2 Aelony Y. Talc pleurodesis and acute respiratory distress syndrome.  Lancet. 2007;  369 1494-1496
  • 3 Aelony Y, King R R, Boutin C. Thoracoscopic talc poudrage in malignant pleural effusions: effective pleurodesis despite low pleural pH.  Chest. 1998;  113 1007-1012
  • 4 Antunes G, Neville E, Duffy J et al. BTS guidelines for the management of malignant pleural effusions.  Thorax. 2003;  58 Suppl 2 ii29-ii38
  • 5 Brega-Massone P P, Conti B, Magnani B et al. Minimally invasive thoracic surgery for diagnostic assessment and palliative treatment in recurrent neoplastic pleural effusion.  Thorac Cardiovasc Surg. 2004;  52 191-195
  • 6 Bresticker M A, Oba J, LoCicero 3rd  J et al. Optimal pleurodesis: a comparison study.  Ann Thorac Surg. 1993;  55 364-366 ,  discussion 367
  • 7 Burrows C M, Mathews W C, Colt H G. Predicting survival in patients with recurrent symptomatic malignant pleural effusions: an assessment of the prognostic values of physiologic, morphologic, and quality of life measures of extent of disease.  Chest. 2000;  117 73-78
  • 8 Cardillo G, Facciolo F, Carbone L et al. Long-term follow-up of video-assisted talc pleurodesis in malignant recurrent pleural effusions.  Eur J Cardiothorac Surg. 2002;  21 302-305 ,  discussion 305-306
  • 9 Diacon A H, Wyser C, Bolliger C T et al. Prospective randomized comparison of thoracoscopic talc poudrage under local anesthesia versus bleomycin instillation for pleurodesis in malignant pleural effusions.  Am J Respir Crit Care Med. 2000;  162 1445-1449
  • 10 Dresler C M, Olak J, Herndon 2nd  J E et al. Phase III intergroup study of talc poudrage vs talc slurry sclerosis for malignant pleural effusion.  Chest. 2005;  127 909-915
  • 11 Genc O, Petrou M, Ladas G et al. The long-term morbidity of pleuroperitoneal shunts in the management of recurrent malignant effusions.  Eur J Cardiothorac Surg. 2000;  18 143-146
  • 12 Hartman D L, Gaither J M, Kesler K A et al. Comparison of insufflated talc under thoracoscopic guidance with standard tetracycline and bleomycin pleurodesis for control of malignant pleural effusions.  J Thorac Cardiovasc Surg. 1993;  105 743-747 , discussion 747-748
  • 13 Heffner J E, Brown L K, Barbieri C A. Diagnostic value of tests that discriminate between exudative and transudative pleural effusions. Primary Study Investigators.  Chest. 1997;  111 970-980
  • 14 Hsu C. Cytologic detection of malignancy in pleural effusion: a review of 5255 samples from 3811 patients.  Diagn Cytopathol. 1987;  3 8-12
  • 15 Janssen J P. Is thoracoscopic talc pleurodesis really safe?.  Monaldi Arch Chest Dis. 2004;  61 35-38
  • 16 Kolschmann S, Ballin A, Gillissen A. Clinical efficacy and safety of thoracoscopic talc pleurodesis in malignant pleural effusions.  Chest. 2005;  128 1431-1435
  • 17 Kolschmann S, Ballin A, Juergens U R et al. Talc pleurodesis in malignant pleural effusions.  Pneumologie. 2006;  60 89-95
  • 18 Lee K A, Harvey J C, Reich H et al. Management of malignant pleural effusions with pleuroperitoneal shunting.  J Am Coll Surg. 1994;  178 586-588
  • 19 Loddenkemper R. Thoracoscopy: results in non cancerous and idiopathic pleural effusions.  Poumon Coeur. 1981;  37 261-264
  • 20 Mager H J, Maesen B, Verzijlbergen F et al. Distribution of talc suspension during treatment of malignant pleural effusion with talc pleurodesis.  Lung Cancer. 2002;  36 77-81
  • 21 Maskell N A, Lee Y C, Gleeson F V et al. Randomized trials describing lung inflammation after pleurodesis with talc of varying particle size.  Am J Respir Crit Care Med. 2004;  170 377-382
  • 22 Musani A I, Haas A R, Seijo L et al. Outpatient management of malignant pleural effusions with small-bore, tunneled pleural catheters.  Respiration. 2004;  71 559-566
  • 23 Ohm C, Park D, Vogen M et al. Use of an indwelling pleural catheter compared with thorascopic talc pleurodesis in the management of malignant pleural effusions.  Am Surg. 2003;  69 198-202 ,  discussion 202
  • 24 Petrou M, Kaplan D, Goldstraw P. Management of recurrent malignant pleural effusions. The complementary role talc pleurodesis and pleuroperitoneal shunting.  Cancer. 1995;  75 801-805
  • 25 Sanchez-Armengol A, Rodriguez-Panadero F. Survival and talc pleurodesis in metastatic pleural carcinoma, revisited. Report of 125 cases.  Chest. 1993;  104 1482-1485
  • 26 Shaw P, Agarwal R. Pleurodesis for malignant pleural effusions. Cochrane Database Syst Rev 2004: CD002916
  • 27 Shoji T, Tanaka F, Yanagihara K et al. Phase II study of repeated intrapleural chemotherapy using implantable access system for management of malignant pleural effusion.  Chest. 2002;  121 821-824
  • 28 Sorensen P G, Svendsen T L, Enk B. Treatment of malignant pleural exudates with talcum instillation and pleural drainage.  Ugeskr Laeger. 1984;  146 1485-1487
  • 29 Steger V, Mika U, Toomes H et al. Who gains most? A 10-year experience with 611 thoracoscopic talc pleurodeses.  Ann Thorac Surg. 2007;  83 1940-1945
  • 30 Tan C, Sedrakyan A, Browne J et al. The evidence on the effectiveness of management for malignant pleural effusion: a systematic review.  Eur J Cardiothorac Surg. 2006;  29 829-838
  • 31 Ukale V, Agrenius V, Hillerdal G et al. Pleurodesis in recurrent pleural effusions: a randomized comparison of a classical and a currently popular drug.  Lung Cancer. 2004;  43 323-328
  • 32 Viallat J R, Rey F, Astoul P et al. Thoracoscopic talc poudrage pleurodesis for malignant effusions. A review of 360 cases.  Chest. 1996;  110 1387-1393
  • 33 Walker-Renard P B, Vaughan L M, Sahn S A. Chemical pleurodesis for malignant pleural effusions.  Ann Intern Med. 1994;  120 56-64
  • 34 Yim A P, Chan A T, Lee T W et al. Thoracoscopic talc insufflation versus talc slurry for symptomatic malignant pleural effusion.  Ann Thorac Surg. 1996;  62 1655-1658

Dr. C. Ludwig

Lungenklinik Merheim · Kliniken der Stadt Köln gGmbH

Ostmerheimerstr. 200

51109 Köln

Telefon: 00 49 / 2 21 / 89 07 86 40

Fax: 00 49 / 2 21 / 89 07 35 33

eMail: ludwigc@kliniken-koeln.de