Diagnostic and Therapeutic Intuitive surgical Approaches for - - PowerPoint PPT Presentation

6/22/2018 1

Diagnostic and Therapeutic Approaches for Pleural Disease

Yaron B. Gesthalter, MD Interventional Pulmonary Medicine Department of Pulmonary, Allergy and Critical Care Thoracic Oncology Program University of California San Francisco

Disclosures

• Intuitive surgical

Learning Objectives

• Review fundamental pleural pathophysiology
• Review pleural diagnostics and their limitations
• Therapeutic approaches emphasizing malignant pleural

effusions

Talk outline

• Intro
• Burden of disease
• Anatomy/physiology
• Diagnostics – modalities and their limitations
• Radiographic characterization
• Characterizing the chemical and physical properties of the

pleural space

• Treatment strategies
• Malignant pleural effusion

6/22/2018 2

Pleural Effusion Burden?

Effusion etiology = 62/100 Consecutive MICU patients CHF 35% Atelectasis 22% Simple parapneumonic 11% Hepatic hydrothorax 8% Hypoalbuminemia 8% Malignancy 3% Pancreatitis 1% EVCM 1% Euremic pleurisy 1% Empyema 1% Unkown 4% Introduction

Mattison et al Chest 1997 Light R Pleural Disease 6th ed 2013 Panadero-Rodriguez et al ERJ1989

CHF 35% Atelectasis 22% Simple parapneumonic 11% Hepatic hydrothorax 8% Hypoalbuminemia 8% Malignancy 3% Pancreatitis 1% Vascular catheter migration 1% Euremic pleurisy 1% Empyema 1% Unkown 4%

Pleural Effusion Burden – Morbidity

Introduction

Rajesh et al Curr Op Pul Med 2015 Sabur et al Respiration 2013

• >50% of patients with malignant

pleural effusions report dyspnea making it the most common symptom related to malignancy

Cartaxo et al Chest 2011 Puri et al Ann Thorac Surg 2012

Pleural Effusion Burden – Morbidity

Introduction

Pleural Effusion Marker of Disease Severity

Introduction

DeBiasi et al ERJ 2014

6/22/2018 3

Florida State University

Anatomy and Physiology

The Pleural Organ

Mechanical Coupling

Feller-Kopman D; NEJM 2018

The Pleural Organ

Anatomy and Physiology

𝑄𝑚𝑓𝑣𝑠𝑏𝑚 𝑔𝑚𝑣𝑗𝑒 𝑞𝑠𝑝𝑒𝑣𝑑𝑢𝑗𝑝𝑜 = 𝑄𝑚𝑓𝑣𝑠𝑏𝑚 𝑔𝑚𝑣𝑗𝑒 𝑏𝑐𝑡𝑝𝑠𝑞𝑢𝑗𝑝𝑜

Rajesh et al Curr Op Pul Med 2015

Before After 1 liter thoracentesis

Symptoms

Pathology

6/22/2018 4

Diagnostics

• Imaging
• Biochemical analysis
• Path/cytological analysis

Diagnostics

The Ideal Pleural Imaging Study

• Easy to perform
• Safe
• Cheap
• Objective measurements
• Good spatial resolution
• Ability to document for future reference

Diagnostics - Imaging

Chest X-rays

Diagnostics - Imaging

6/22/2018 5

Pleural CT

Diagnostics - Imaging

Point of Care Thoracic Ultrasound

5 cm 10 cm Lung Diagnostics - Imaging Diagnostics - Imaging

Quantifying an effusion – Is CT good enough?

Pre-thoracentesis Post-thoracentesis

Diagnostics - Imaging

6/22/2018 6

Thoracic Ultrasound

• Cheap and readily

available

• Improves procedural

safety (PTX from 9% to 1%)

• Dynamic - guides

procedures, increase procedural success

• Operator dependent -

training

Cavanna et al World J Surg Oncol 2014 Gordon et al Arch Intern Med 2010

Diagnostics - Imaging Diagnostics - Imaging Diagnostics - Imaging Diagnostics - Imaging

6/22/2018 7

Diagnostics

• Pleural biochemical analysis – light’s criteria
• Microbiology
• Cytology/pathology

Diagnostics - Laboratory

Pleural effusion

Transudate Exudate

Yes No Cell predominance Other Lymphocytic >50%

pH <7.2 Glucose < 60 Serum-pleural protein >3.1 Serum-pleural albumin >1.2

Consider TB vs malignancy Consider infection Consider drainage +/- fibrinolytics

Pleural:serum protein >0.6 Pleural protein >2/3 ULN Pleural:serum LDH >0.5 * Pleural protein >2.9 * Pleural cholesterol >45

Diagnostics - Laboratory

Pleural Cytology Diagnostic Yields

• Pleural fluid cytology –
• 1st thora = 60-65%
• 2nd thora = additional 27%
• 3nd thora = additional 5%

Hooper et al Thorax 2010

Diagnostics – Cyto/Path

Pleural Fluid Cytology

Diagnostics – Cyto/Path

6/22/2018 8

Closed Pleural Biopsy

• Diagnostic sensitivity

43-59%

• Improved when done

with ultrasound or CT guidance

Ferreiro et al Ann of Thor Med 2017

Diagnostics – Cyto/Path

Medical Thoracoscopy

• Diagnostic sensitivity

97%

• Outpatient procedure
• Single port
• Patient under

moderate sedation

• Provides diagnostic

modality and therapeutic modality

Diagnostics – Cyto/Path

Pleural Biopsy

Diagnostics – Cyto/Path

Malignant Pleural Effusion Treatment

• Aim
• Symptom relief
• Minimize health care interaction
• Strategies
• Observation
• Serial Thoracentesis
• Indwelling pleural catheter
• Pleurodesis
• Approach depends on
• Patient prognosis
• Patient preference

Therapeutics

6/22/2018 9

Malignant Pleural Effusion

Prognostication

Clive OA Thorax 2014

Low risk Mean survival = 319 days Moderate risk Mean survival = 130 days High risk Mean survival = 44 days 50 100 150 200 Days Cumulative Survival 0.00 0.25 0.50 0.75 1.00 Therapeutics

Serial Thoracentesis

• Easy
• No need for

“hardware” or routine changes

• Effects short lived
• Cumulative procedural

risk

Therapeutics

Tunneled Pleural Catheter (TPCs)

Therapeutics

www.researchgate.net

Therapeutics

TPC Placement

6/22/2018 10

TPC Placement

Therapeutics

www.thoracickey.com

TPCs are Safe and Effective

Van Meter MAM JGIM 2010

Therapeutics Complications Benefits

TPC in Non-Malignant Effusions

Bhatnagar et al Chest Clinic 2013 Chamber et al Am J Med Sci 2017 Patil et al Chest 2017

Therapeutics Therapeutics

The Non-Expandable Trapped Lung

Albores et al NEJM 2015

6/22/2018 11

The Patient Experience

Bhatnagar et al BMJ 2015

Therapeutics

Chemical Pleurodesis

Therapeutics

TPC vs Pleurodesis

Primary endpoints at 42 days

Therapeutics

Davies JAMA 2012

Summary

• Pleural effusions are a marker of disease severity and

warrant attention with initial presentation

• A wide variety of diagnostics tools remain limited,

though clinical judgment coupled with minimally invasive pleural biopsies can bridge this gap

• There is a wide range of therapeutic options that can be

tailored to clinical circumstances and patient preferences

Therapeutics

6/22/2018 12

Thank you all for listening…