Biological pleurodesis with powder collagen at malignant pleural effusion

1
Biological pleurodesis with powder collagen at
malignant pleural effusion

• A.Akopov, V.Egorov, V.Varlamov
• Research Institute of Pulmonology,
  Saint-Petersburg, Russian Federation

2
Objective

• Malignant pleural effusions are a common medical
  problem.
• Rapid recurrence of pleural effusions requires
  repeated thoracocentesis, therefore increasing
  the risk of complications.
• For these reasons the increasing distribution
  therapy by introduction in a pleural cavity of
  various sclerosing agents (talc, tetraciclin,
  bleomicin etc.) with the purpose of obliteration
  of a pleural cavity and exudation discontinuance.

3
Objective

• Research Institute of Pulmonology has wide
  experience in application of the biological agent
  - powder collagen - for achievement of pleural
  obliteration in patients with spontaneous
  pneumothorax.
• Collagen is a natural biopolymer functioning as a
  temporarily directing skeleton for regeneration
  which is gradually replaced with organism's own
  fabrics.
• Tests of collagenic pleurodesis induction
  performed on dogs resulted in the full and
  uniform obliteration of dogs' pleural cavities.
  Results of histological examination showed that
  collagen sprayed in a pleural cavity caused sharp
  fibrinotic pleurisy without stimulating
  exudation.

Varlamov V.V. et al, ERJ, 1990
4
Objective

• Experiments on 47 mongrel dogs
• (irritative effects on the pleura)

Preparations Changes in pleural cavity
Talc Solid adhesions
Tetracyclin No adhesions
Fibrine glue No adhesions
Calcium chloride No adhesions
Acethylcholine No adhesions
Papain Hyperemia of pleura, death of animals
Pyrogenal No adhesions
Polimerized hemoglobin No adhesions
Procollagen No adhesions
Modified collagen Solid adhesions along with whole extension
5
Objective

• Comparison of recurrences in 297 patients with
  primary spontaneous pneumothorax

Methods of therapy Number of patients Frequency of pneumothorax recurrences
Drainage 82 28,0
Thoracotomy, pleurectomy 112 0,9
Thoracoscopic biological pleurodesis with powder collagen 103 1,0
6
Patients

• 45 patients with malignant pleural effusions and
  expected survival of gt 1 month (January 1997 to
  December 2002)
• 19 men and 26 women at the average age of 64,3
  years
• Malignant pleural effusions were proved by
  cytological examination (20 patients) or pleural
  biopsy (25 patients)
• Primary tumors were
• lung cancer - 22 patients (0,49)
• breast cancer - 17 patients (0,38)
• ovarian cancer - 4 patients (0,09)
• prostate cancer - 2 patients (0,04)

7
Patients

• Side of effusions
• right-side effusions - in 22 patients (0,49)
• left-side effusions - in 20 patients (0,44)
• bilateral effusions in 3 patients (0,07)
• Complaints
• dyspnea 45 patients
• tachycardia - 39 patients
• pain - 35 patients
• All patients previously received systemic
  chemotherapy which did not affect the effusions

8
Method

• Powder collagen was derived from the cattle skin.
  The size of particles did not exceed 0,1 mm. The
  powder collagen was sterilized by placing it into
  1 nitrofurilacrolein solution for 12-hours with
  consequent gamma-wave irradiation for 3-hours.
• The collagen was verified sterile using the
  biological indicators.

9
Method

• In all patients videothoracoscopy were carried
  out under general endotracheal narcosis and
  one-lung ventilation.
• After visualisation of a pleural cavity, complete
  evacuation of all remaining fluid and estimation
  of the potential for lung reexpansion, 1 g of
  powder collagen was insufflated under pressure of
  0,2 atm.
• At the end of the operation two drainage tubes
  were installed.
• The tubes were kept under suction (25 cm H2O) and
  drainage was resumed until the fluid effused was
  less than 100 mL per day.

10
Method

• Responses were classified as
• complete response (CR) at absence of clinical and
  radiological recurrence
• partial response (PR) at the absence of clinical
  while at the presence of radiological fluid
  reaccumulation which did not require additional
  intervention
• failure (F) reaccumulation of fluid causing
  symptoms or requiring thoracocentesis.
• All patients were called in for an examination
  every 3-months. They all had a thorough
  clinicoroentgenological examination in order to
  administer (if necessary) any additional
  thoracocenteses within the first year.

11
Results

• The mean volume of pleural fluid drained before
  videothoracoscopy was 2,20,7 L (ranged from 1,3
  to 3,4 L).
• The average duration of the operations was 24 min
  (ranged from 17 to 47 min). Endotracheal tubes
  were removed in the operating room from all
  patients.
• The early postoperative period proceeded without
  serious complications and deaths.
• The average duration of drainage after operation
  was 2,7 days (ranged from 1,5 to 7 days)
• The average postoperative hospital stay was
  7,00,5 days (ranged from 4 to 14 days).

12
Results

• Temporary temperature rise occurred in 4 patients
  (0,09) within first three days did not
  exceed 38C.
• No major chest pain symptom developed after the
  operation.
• The toxic effects connected with collagen
  dispersion were not marked.
• Dyspnea and cough were significantly reduced by
  the procedure.
• All patients were discharged from hospital in
  good condition.

13
Results

• Median survival after pleurodesis induction was
• 5,5 months for the patients with lung cancer and
• 9,1 months for the patients with breast cancer.
• To sum up, at the follow-up in 12 months there
  were 5 patients with recurrences of effusion
  (0,11).
• In 40 of 45 patients (0,89) who underwent
  thoracoscopic collagen insufflation
  reaccumulation of pleural fluid was not
  registered and additional thoracocentesis was not
  required.

14
Results

• In 1 month (45 patients alive)
• CR - 43 (0,96), PR - in 2 (0,04), F - 0
• In 3 months (41 patients alive)
• CR - 29 (0,71), PR - in 10 (0,24), F - 2
  (0,05)
• In 6 months (27 patients alive)
• CR - 16 (0,59), PR - in 7 (0,26), F - 4
  (0,15)
• In 12 months (11 patients alive)
• CR - 10 (0,91), PR - in 1 (0,09), F - 0

15
Conclusion

• Videothoracoscopic powder collagen insufflation
  is simple, safe and effective method of
  biological pleurodesis induction in malignant
  pleural effusions, which allows achieving
  response and preventing relapses of fluid
  accumulation in a pleural cavity in the majority
  of patients.