Dear Editor,
I have read the manuscript entitled “Soft Tissue Sarcoma Metastatic to Pleura” by Yildirim et al. (1) published between the pages 197-200 in Journal of Tuberculosis and Thorax, issue number 56(2) of 2008. I should, firstly, congratulate the authors.
Indeed, I want to point out some remarks about this manuscript.
1. There is a history of pleurodesis that did not yield a successful result during the course of the patient’s treatment. However, I believe pleurodesis should not have been carried out in this patient.
Malignant pleural effusion (MPE) is a common com- plication of advanced cancer. The presence of MPE eliminates the possibility of radical cancer treatment, but palliative care plays an important role for these patients. Chemical pleurodesis is one of the options to avoid development of recurrent pleural effusions and thus palliate symptoms (2). In order pleurodesis to be successful, MPE should be drained by serial thoracen- tesis or chest tube insertion to achieve complete lung re-expansion. Regardless of the volume of pleural space drainage, pleurodesis should be carried out as soon as the condition is diagnosed by chest roentgenogram because inflammation induced by pleurodesis would cause the parietal and visceral lay- ers of the pleura to adhere, and the space would dis- appear, only when they come into close contact with each other. Sahn argued that patients are suitable candidates for pleurodesis if and when expected sur- vival is at least several months, the patient is not
debilitated, and the pleural fluid pH is ≥ 7.30. The author has also argued that pleural fluid pH < 7.30 not only suggests a short survival-time but also predicts a poor response to chemical pleurodesis (3). Moreover, fibrosis involving the pleural surfaces in the low-pH effusions diminishes the effectiveness of pleurodesis in producing pleural symphysis (4). In this case, the pleural fluid pH was 7.05 and complete apposition of the pleural surfaces had not been achieved despite fibrinolytic treatment. Therefore, the chance that this patient will benefit from pleurodesis is very little, if any.
2. The agent used during pleurodesis was not speci- fied and there is a risk of deterioration in the clinical progress of the patient due to the complications of pleurodesis. A number of antineoplastic and non-anti- neoplastic chemical agents have been used for pleu- rodesis. Currently, the most successful and widely- used agents include talc, the tetracyclines, and bleomycin (3,5). In addition to these, erythromycin, minocycline, methylprednisolone acetate, cisplatin, cytarabine, doxorubicin, etoposide, fluorouracil, inter- feron-β, and mitomycin-C have been used rarely dur- ing pleurodesis (6). Pleurodesis is not an entirely benign procedure due to various side effects and seri- ous complications caused by these agents. These range from mild and generally temporary complica- tions and side effects such as pain, fever, nausea, vomiting, diarrhea, vertigo, dizziness, and uncomfort- able feeling to more serious complications requiring complicated treatments such as atrial arrhythmia, res- piratory failure, pulmonary oedema, adult respiratory
Soft tissue sarcoma metastatic to pleura
Sami KARAPOLAT
Department of Chest Surgery, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey.
Yazışma Adresi (Address for Correspondence):
Dr. Sami KARAPOLAT, Dokuz Eylül Üniversitesi Tıp Fakültesi, Göğüs Cerrahisi Anabilim Dalı, İnciraltı, Balçova İZMİR - TURKEY
e-mail: samikarapolat@yahoo.com
487 Tüberküloz ve Toraks Dergisi 2008; 56(4): 485-488
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distress syndrome, pneumonitis, empyema, pulmonary fibrosis, bone marrow suppression, renal toxicity (6).
The negative effects of these complications on the qual- ity of life is a serious issue, considering that survival may be as short as several months in these patients and, therefore, pleurodesis needs to be performed when it is definitely indicated.
Best regards.
REFERENCES
1. Yildirim H, Metintas M, Ak G, et al. Soft tissue sarcoma metastatic to pleura. Tuberk Toraks 2008; 56: 197-200.
2. Laisaar T, Palmiste V, Vooder T, et al. Life expectancy of patients with malignant pleural effusion treated with
video-assisted thoracoscopic talc pleurodesis. Interact Cardiovasc Thorac Surg 2006; 5: 307-10.
3. Sahn SA. Pleural diseases related to metastatic malignan- cies. Eur Respir J 1997; 10: 1907-13.
4. Sahn SA. Malignant pleural effusions. In: Shields TW, Locicero III J, Ponn RB, Rusch VW (eds). General Thoracic Surgery. 6th ed. Philadelphia: Lippincott Williams &
Wilkins, 2005: 935-43.
5. Lee YC, Baumann MH, Maskell NA, et al. Pleurodesis prac- tice for malignant pleural effusions in five English-speaking countries: Survey of pulmonologists. Chest 2003; 124:
2229-38.
6. Walker-Renard PB, Vaughan LM, Sahn SA. Chemical pleu- rodesis for malignant pleural effusions. Ann Intern Med 1994; 120: 56-64.
Tüberküloz ve Toraks Dergisi 2008; 56(4): 485-488 488
Yanıt
Hüseyin YILDIRIM1, Muzaffer METİNTAŞ1, Güntülü AK1, Emine DÜNDAR2, Sinan ERGİNEL1
1 Department of Chest Diseases, Faculty of Medicine, Osmangazi University, Eskişehir, Turkey, 2 Department of Pathology, Faculty of Medicine, Osmangazi University, Eskişehir, Turkey.
From the authors
We greatly appreciate the comments on our paper.
Previous studies have shown that a low pleural fluid pH correlates with the extent of intrapleural tumour burden and that various physiological variables, such as pleural fluid pH, may be indicative of the outcome of pleurode- sis (1). Firstly, we do not believe that pleural fluid pH <
7.30 is a contraindication for pleurodesis, but only pre- dictor of success. Aelony demonstrated a very high ra- te of successful pleurodesis in patients suffering from re- current malignant pleural effusions with low pleural pH (2). Heffner et al. reported, in a recent meta-analysis, that pleural fluid pH has only modest value for predic- ting symptomatic failure, and should be used with cauti- on when selecting patient for pleurodesis (3). We agree that there was a little chance for successful pleurodesis because complete apposition of pleural surfaces can not be achieved. Nevertheless, it is difficult to accurately determine the predictors of successful pleurodesis.
Secondly, we used 4 g steril talc for pleurodesis. In clinical practice, pleurodesis with various sclerosing agents is a simple and acceptable procedure with high
efficacy for controlling malignant pleural effusions. Se- veral studies have shown that talc, whether by poudra- ge or slurry, is the most effective pleurodesis agent ava- ilable. However, there are serious concerns about its sa- fety. For this patient, there were no side effects or comp- lications attributable to the procedure. The cause of death is related to the advanced nature of the patient’s underlying disease, but not side effects of pleurodesis.
We thank reader for their remarks and suggestions.
REFERENCES
1. Sahn SA. Pleural disease related to metastatic malignan- cies. Eur Respir J 1997; 10: 1907-13.
2. Aelony Y, King RR, Boutin C. Thoracoscopic talk poudrage in malignant pleural effusions: effective pleurodesis despite low pleural pH. Chest 1998; 113: 1007-12.
3. Heffner JE, Nietert PJ, Barbieri C. Pleural fluid pH as a pre- dictor of pleurodesis failure--analysis of primary data.
Chest 2000; 117: 87-95.
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