Redo medical thoracoscopy is feasible in patients with pleural diseases

ARTICLE IN PRESS doi:10.1510/icvts.2008.188730

Interactive CardioVascular and Thoracic Surgery 8 (2009) 330–333 www.icvts.org

Institutional report - Pulmonary

Redo medical thoracoscopy is feasible in patients with pleural diseases – a series夞 David Breena,b, Anne Fraticellia, Laurent Greilliera, Sugamya Mallawathantria,c, Philippe Astoula,* Division of Thoracic Oncology, Department of Pulmonary Diseases, Faculty of Medicine (Universite ´ de la Me ´ diterrane ´ e), Assistance Publique Ho ˆ pitaux de Marseille, Ho ˆ pital Sainte-Marguerite, 13274 Marseille Cedex 09, France b Department of Respiratory Medicine, CResT Directorate, St. James’s Hospital, Dublin 8, Ireland c Department of Respiratory Medicine, Nottingham University Hospitals NHS Trust, City Hospital Campus, Nottingham, UK a

Received 19 July 2008; received in revised form 21 November 2008; accepted 24 November 2008

Abstract Previous pleural endoscopy is considered to be a relative contraindication to further medical thoracoscopy. We reviewed our experience in patients undergoing more than one thoracoscopy irrespective of the primary indication. From January 2001 to December 2006, patient baseline characteristics, endoscopic appearance and technique, volume of pleural fluid and final histological diagnosis were collated in all patients undergoing more than one thoracoscopy. The endpoints were morbidity and mortality related to the procedures, to compare the length of procedure time between pleural endoscopies in individual patients and the degree of difficulty of the second or subsequent thoracoscopic procedure. During this period, 29 patients underwent ‘redo’ thoracoscopy resulting in a total of 61 procedures (rate of ‘redo’ thoracoscopy; 9.1%). The mean time between thoracoscopies was 5.3"3.8 months. Although pleural adhesions were more common at the time of the subsequent procedure, it did not result in failure to induce a pneumothorax or perform the procedure. There was no difference in the duration of procedure between the primary and subsequent thoracoscopy (Ps0.46), as well as no complications directly attributed to the repeat pleural endoscopy. Repeat medical thoracoscopy is technically feasible in patients with pleural disease without an associated increased morbidity and mortality. 䊚 2009 Published by European Association for Cardio-Thoracic Surgery. All rights reserved. Keywords: Thoracoscopy; Second look; Pleural mesothelioma; Pleural effusion

1. Introduction Thoracoscopy, either performed by physicians (medical thoracoscopy) or surgeons (video-assisted thoracic surgery, VATS), is the gold standard for the management of diagnosed or undiagnosed pleural effusions w1–4x. Occasionally, a repeat procedure is deemed necessary particularly if there was a previous inconclusive procedure, to ascertain endoscopically the response to a treatment, for example chemotherapy in mesothelioma, to monitor non-specific pachypleuritis in patients with a strong suspicion of malignant pleural disease, or to perform talc pleurodesis in the case of recurrent pleural effusions. However, physicians are frequently reluctant to perform a second look thoracoscopy in patients with a previous operation on the ipsilateral side w5, 6x. A previous pleural endoscopy procedure is generally considered to be a relative contraindication to a subsequent medical thoracoscopy in that adhesions could lead to the failure of the procedure, poor visualization and lung or vascular trauma with an associated increased risk of bleeding. 夞 David Patrick Breen is the recipient of a European Respiratory Societyy European Lung Foundation Fellowship (Number 21). *Corresponding author. Tel.: q33 (0) 491 744 736; fax: q33 (0) 491 745 524. E-mail address: [email protected] (P. Astoul). 䊚 2009 Published by European Association for Cardio-Thoracic Surgery

In this paper we retrospectively studied our experience in ‘redo’ thoracoscopy to ascertain the feasibility of a repeat procedure in patients undergoing more than one pleural endoscopy irrespective of the primary indication. 2. Materials and methods 2.1. Patient selection criteria Details of all the thoracoscopies performed in our unit from January 2001 to December 2006 were collected from the department’s computerized database. The study protocol was conducted in accordance with the local research policies. Informed consent was not required by the local ethics committee as the study only entailed a retrospective review of the patients’ medical records. All subjects with more than one thoracoscopy irrespective of the primary indication were identified from this database for further analysis. 2.2. Study population The selected patients presented to a single tertiary referral center in France (Department of Thoracic Oncology; Thoracic Endoscopy Unit, Sainte Marguerite University Hospital, Marseille).

ARTICLE IN PRESS D. Breen et al. / Interactive CardioVascular and Thoracic Surgery 8 (2009) 330–333

2.3. Methods Thoracoscopy was performed as previously described w7x. Briefly, all patients gave written informed consent for the procedure. The procedure was performed under general anaesthesia with the patient placed in the lateral position with the ‘healthy lung’ down and the arm abducted to open up the intercostal spaces. Subjects were intubated with a single lumen endotracheal tube and maintained on spontaneous ventilation. The site of incision was chosen depending upon the presumed aetiology; the second or third intercostal spaces for a pneumothorax and the fifth or sixth intercostal spaces for a pleural effusion. Old port sites were avoided. After inducing a pneumothorax with a pleural needle, blunt dissection was performed thus creating access to the pleural space via a trocar. In the case of a pleural effusion all pleural fluid was aspirated to create a dry pleural space. A systematic examination of the space was performed and, if indicated, biopsies were performed with an optical biopsy forceps through the same incision site (Wolf Corporation, Knittelgen, Germany). The desired location of the chest drain was chosen under directvision using the optic. The drain was then directed blindly to that site at the end of the procedure and this was connected to negative pressure ranging from –10 to –50 cm H2O. In the case of a diagnostic thoracoscopy, the drain was removed as soon as lung re-expansion occurred; thus allowing drain removal on the table as previously published w8x. When talc pleurodesis was performed, the drain remained in place for a longer period to assist pleural symphysis w9x. In mesothelioma, prophylactic radiotherapy was administered after each thoracoscopy to the incisiony drain site. 2.4. Outcomes Baseline patient characteristics, endoscopic appearance and technique, volume of pleural fluid and final histological diagnosis were collated from the computerized database and the patients’ clinical notes. The endpoints were morbidity and mortality related to the procedures, to compare the length of procedure time between thoracoscopies in individual patients and the degree of difficulty of the second or subsequent thoracoscopic procedure. 2.5. Statistics All data were analyzed using graph pad prism software (Graph Pad Software Inc, San Diego, CA) and a P-0.05 was considered statistically significant. Quantitative values are presented as mean"standard deviation (S.D.) and nominal variables are presented as percentages. A paired t-test was performed to examine if there were significant differences between thoracoscopies in individual patients.

Table 1 Baseline characteristics of patients undergoing thoracoscopy 2001–2006 Total no. of thoracoscopies; n Total no. of patients; n ‘Redo’ thoracoscopies; n No. of patients; n (%) 2 thoracoscopies; n 3 thoracoscopies; n Sex Male; n (%) Female; n (%) Age Mean ("S.D.) Final histological diagnosis: n Mesothelioma*‡ Secondary malignancy Lung Breast Colon Pachypleuritisyinflammation‡ Low grade B-cell lymphoma*

352 320 61 29 (9.1%) 26 3 19 (65.5%) 10 (34.5%) 69.7 ("8.4) 18 7 5 1 1 7 1

*One patient had a diagnosis of mesothelioma and low grade B-cell lymphoma; ‡in three cases the histological diagnosis was different between thoracoscopies (see text).

scopies were performed in 26 and 3 patients, respectively. The rate of ‘redo’ thoracoscopy was 9.1%. There were 19 (65.5%) males and 10 (34.5%) females with a mean age of 69.7"8.4 years. In total, 19 repeat procedures were performed on the right side with nine on the left side. In two cases, a second thoracoscopy was performed on the opposite side (one patient with three procedures had a re-do on the right and a single procedure on the left).There was no significant difference in the volume of pleural fluid between procedures, with a mean volume of fluid at the first and second thoracoscopies of 913"665 ml and 1068"985 ml, respectively, (Ps0.07) (Fig. 1). Although pleural adhesions were reported more commonly at the time of subsequent procedures, it did not result in failure to induce a pneumothorax or perform the procedure. Final histological diagnosis was mesothelioma in 18 cases, secondary malignancy in seven cases, non-specific pachypleuritis in seven cases and low grade B-cell lymphoma in one case. There was one patient with dual pathology (mesothelioma and low-grade lymphoma) and three patients where the histological diagnosis differed between thoracoscopies (one patient with an initial diagnosis of pachypleuritis who underwent a second procedure after two months because of a relapse of the pleural effusion

3. Results Baseline patient characteristics are presented in Table 1. During the six-year period of this retrospective study, there were 352 thoracoscopies performed in 320 patients. Therefore, 29 patients underwent a ‘redo’ thoracoscopy resulting in 61 procedures in this cohort; two and three thoraco-

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Fig. 1. Pleural fluid volume.


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and repeat histology confirmed a diagnosis of mesothelioma. The other patients’ histology revealed non-specific changes after chemotherapy for mesothelioma). The mean time to the ‘redo’ procedure for the whole group was 5.3"3.8 months. This did not differ significantly with the mesothelioma cohort (5.5"3.3 months). In the majority of cases of mesothelioma, the ‘redo’ procedure was performed to ascertain endoscopically the response to chemotherapy (ns17), and in most cases, talcage was performed at the time of the subsequent procedure (Table 2). In the cases with secondary malignancy to the pleural space, the second procedure was performed to allow for talc pleurodesis (ns7). Finally, in the setting of a histological diagnosis of pachypleuritis on the first thoracoscopy, the repeat procedure was performed as surveillance for malignancy (ns5). Overall, 24 patients received talc pleurodesis with 21 of these been performed at the time of subsequent thoracoscopy. Drainage time was significantly longer if the patient received talc (Ps0.01). There was no significant difference in the length of procedure between the primary and subsequent thoracoscopies (Ps0.46), with a mean time of 117.5"20.6 min, 116.7"33.7 min and 110.0"17.3 min for the first, second and third thoracoscopies, respectively (Fig. 2). Overall, there were no documented complications directly attributed to the repeat thoracoscopy in this cohort. 4. Discussion Thoracoscopy is a simple and safe procedure and its role in the diagnosis and treatment of malignant pleural effu-

Fig. 2. Overall length of procedure.

sions and pneumothorax is undisputed w1, 7, 9x. However, it is occasionally desirable to be able to perform a second or subsequent thoracoscopy in select situations. However, physicians are frequently uncomfortable with performing a repeat procedure on the ipsilateral side due to concerns about the difficulty of the procedure and the possible increased risk of complications w5, 6x. This paper demonstrates that a subsequent thoracoscopy is feasible and safe. Although the ‘redo’ thoracoscopy was associated with an increased incidence of adhesions, this did not limit the examination or access to the pleural space. There was no prolongation of the procedure time. We have also demonstrated that a repeat procedure is safe with no documented complications directly related to the redo thoracoscopy. In the majority of cases included in this paper, the first thoracoscopy was performed for diagnostic purposes and therefore talc was not administered. Our policy is to remove the chest drain on the table in the setting of

Table 2 Re-do thoracoscopy after prior thoracoscopy in patients with mesothelioma Sex

Age (years)

First procedure (side)

Interval (days)

Second procedure (side)

M M F M M M

69 70 72 74 70 79

L R R R L L

F‡

79

L

84 103 208 222 160 128 322 224

L R R R L L (3rd) L L

M M F M* M噛

61 76 71 67 71

R R R L R

332 93 61 122 65

R R R L R

F* M

74 74

R R

F M M

74 72 83

R L R

236 110 196 84 385 32

R R (3rd) R R L R

M

62

L

224

R

Hospital stay (days)

Additional procedures at 2nd thoracoscopy

Complicationsycomments

8 3 6 5 6 4 7 4

Talcage Talcage Talcage Talcage Talcage Talcage 3g Talcage

4 4 4 3 4 4

5 9 7 6 5

Talcage Talcage Talcage Talcage Talcage

4 5 4 3 4

5 5 9 7 1 39

Talcage Talcage 4g Talcage – Talcage

4g 4g

– – – – – Failure of talc – Apex not visualized due to vascularized adhesions – – – – 2nd procedure performed due to early relapse of effusion – Failure of talc – – – Persistent pneumothorax after 1st procedure R sided mesothelioma diagnosed at VATS

1

–

g g g g g g

4g g g g g g

4g 4g

There were no complications directly related to the second procedure. M, male; F, female; R, right; L, left; g, grams. ‡ Mesothelioma and B cell lymphoma diagnosed. *Biopsies at the second thoracoscopy revealed non-specific changes only. 噛Mesothelial hyperplasia on first biopsies and mesothelioma diagnosed at second thoracoscopy.


diagnostic thoracoscopy only, thus allowing the patient to return to the ward without drainage and facilitate early hospital discharge w8x. This may also reduce the incidence of adhesions along the tube tract, thus making access to the pleural space easier at the time of subsequent procedures. In the setting of mesothelioma, we perform repeat endoscopy to ascertain the response to chemotherapy. Pleural disease, in particular pleural effusions are considered to be non-measurable by computer tomography w10x. Indeed, the two most widely used assessment tools, the World Health Organization (WHO) criteria and the response evaluation criteria in solid tumors (RECIST) unidimensional criteria do not apply to mesothelioma w10–12x. The role of magnetic resonance imaging and positron emission tomography appears more promising but requires further evaluation in large prospective studies w13x. Repeat thoracoscopy with direct visualization of the pleural space and comparison to previous images allows for an objective assessment of response. Talc can then be easily administered at the time of the second procedure if deemed warranted, thus allowing for palliative pleurodesis. Talc is usually not insufflated at the time of the first thoracoscopy as biopsies can be non-diagnostic or reveal non-specific changes in a patient with a high probability of cancer. This is an important point as demonstrated by Janssen et al. where 15% of non-specific pleuritis was false negative after long-term follow-up w14x. In the majority of these cases, the final diagnosis was mesothelioma. Therefore, in patients with a high clinical suspicion of malignancy or mesothelioma, for example, an undiagnosed pleural effusion in a subject with a previous malignancy or a pleural effusion in an asbestos exposed individual, it is essential that repeat thoracoscopy can be performed. In this series, there was one case where initial biopsies suggested pachypleuritis but repeat thoracoscopy and biopsy after recurrence of the pleural effusion revealed mesothelioma. The optimal interval between thoracoscopies is unknown and needs to be assessed in future studies. In six cases repeat thoracoscopy was performed after previous talc pleurodesis. In all these cases access to the pleural space was possible allowing visualization and biopsies. This compares to a paper by Doddoli et al. which demonstrated that VATS was possible in 69% of cases after previous thoracoscopic talc poudrage w15x. The different results in these two papers may be for a number of reasons. In the paper by Doddoli et al. there was a longer time interval between procedures, 23 months vs. 5.3"3.8 months in our paper. Secondly, it could be argued that the initial talcage did not result in an adequate pleurodesis as evidenced by the recurrence of pleural fluid. However, this paper demonstrates that a repeat procedure can be performed safely even after a time interval as long as nine months. Therefore, if a repeat procedure is warranted, the time interval between the first and planned subsequent thoracoscopy should not deter the physician. In all the examples above, it was deemed necessary to repeat the thoracoscopy. This paper demonstrates that a repeat procedure is feasible and safe. There was no difference in procedure length between the primary thoracoscopy and subsequent pleural endoscopies. Although

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procedure length as a surrogate marker may have inherent flaws, we do not believe that this is a factor in the majority of our cases. Indeed, it is obvious that the indications and diagnostic evaluation may differ between thoracoscopies, however, in 79% of our cases – mesothelioma and pachypleuritis – a thorough diagnostic evaluation including repeat biopsies was undertaken to assess for response to chemotherapy or an alternative diagnosis. There was no increased morbidity or mortality associated with the ‘redo’ thoracoscopy. The increased length of hospital stay recorded in Table 2 is due to the administration of talc and the necessity for longer drainage time to obtain a good pleurodesis and not related to increased complications. In conclusion, if repeat thoracoscopy is deemed necessary, this paper demonstrates that physicians can safely and successfully perform this procedure. References w1x Antony VB, Loddenkemper R, Astoul P, Boutin C, Goldstraw P, Hott J, Rodriquez Panadero F, Sahn SA. Management of malignant pleural effusions. Eur Respir J 2001 Aug;18:402–419. w2x Antunes G, Neville E, Duffy J, Ali N. Pleural diseases group, Standards of Care Committee, British Thoracic Society. BTS guidelines for the management of malignant pleural effusions. Thorax 2003;58 (Suppl 2):ii29–ii38. w3x Rodriguez-Panadero F, Janssen JP, Astoul P. Thoracoscopy: general overview and place in the diagnosis and management of pleural effusion. Eur Respir J 2006 Aug;28:409–422. w4x Lang-Lazdunski L, Pilling JE. Video assisted thoracoscopic surgery is still the standard. Br Med J 2007 Feb;334:273. w5x Yim AP, Liu HP, Hazelrigg SR, Izzat MB, Fung AL, Boley TM, Magee MJ. Thoracoscopic operations on reoperated chests. Ann Thorac Surg 1998 Feb;65:328–330. w6x Cardillo G, Facciolo F, Regal M, Carbone L, Corzani F, Ricci A, Martelli M. Recurrences following videothoracoscopic treatment of primary spontaneous pneumothorax: the role of redo-videothoracoscopy. Eur J Cardiothorac Surg 2001 Apr;19:396–399. w7x Boutin C, Astoul P. Diagnostic thoracoscopy. Clin Chest Med 1998 Jun;19:295–309. w8x Astoul P, Seitz B, Boutin C. Diagnostic thoracoscopy in short-term hospitalisation. Acta Endosc 1990;20:79–83. w9x Viallat JR, Rey F, Astoul P, Boutin C. Thoracoscopic talc poudrage pleurodesis for malignant effusions. A review of 360 cases. Chest 1996 Dec;110:1387–1393. w10x Therasse P, Arbuck SG, Eisenhauer EA, Wanders J, Kaplan RS, Rubinstein L, Verweij J, Van Glabbeke M, van Oosterom AT, Christian MC, Gwyther SG. New guidelines to evaluate the response to treatment in solid tumors. European Organization for Research and Treatment of Cancer, National Cancer Institute of the United States, National Cancer Institute of Canada. J Natl Cancer Inst 2000 Feb;92:205–216. w11x Miller AB, Hoogstraten B, Staquet M, Winkler A. Reporting results of cancer treatment. Cancer 1991 Jan;47:207–214. w12x van Klaveren RJ, Aerts JG, de Bruin H, Giaccone G, Manegold C, van Meerbeeck JP. Inadequacy of the RECIST criteria for response evaluation in patients with malignant pleural mesothelioma. Lung Cancer 2004 Jan;43:63–69. w13x Ceresoli GL, Chiti A, Zucali PA, Rodari M, Lutman RF, Salamina S, Incarbone M, Alloisio M, Santoro A. Early response evaluation in malignant pleural mesothelioma by positron emission tomography with w18Fx fluorodeoxyglucose. J Clin Oncol 2006 Oct;24:4587–4593. w14x Janssen JP, Ramlal S, Mravunac M. The long-term follow-up of exudative pleural effusion after non-diagnostic thoracoscopy. J Bronchol 2004 Jul;11:169–174. w15x Doddoli C, Barle ´si F, Fraticelli A, Thomas P, Astoul P, Giudicelli R, Fuentes P. Video-assisted thoracoscopic management of recurrent primary spontaneous pneumothorax after prior talc pleurodesis: a feasible, safe and efficient treatment option. Eur J Cardiothorac Surg 2004 Nov;26:889–892.