Pneumonectomy of Primary Pulmonary Angiosarcoma with Malignant Effusion and Intrapleural Hypotonic Hyperthermic Chemotherapy: Case Report and Review of the Literature

Background: Primary pulmonary angiosarcoma is extremely rare and the prognosis is very poor. We report a combination therapy of pneumonectomy and intrapleural hypotonic hyperthermic chemotherapy (IPHHC). Case report: A 48-year-old male with exertional dyspnea was found to have a left massive pleural effusion. Bronchoscopic examination displayed endobronchial stenosis of the left lower bronchus B8,9,10?and diagnosed with pulmonary angiosarcoma. Chest computed-tomographic scanning revealed a 5-cm mass in the left inferior lobe, which invaded the left upperbronchus. Intrapleural dissemination and malignant pleural effusion were also suspected (cT3N1M1a,?c-stage IV). As a palliative initial therapy, we performed a pneumonectomy. On the 7th?postoperative day, under general anesthesia, we performed video-assisted IPHHC (43°C, 60 min, 200 mg/m2?of CDDP). After the IPHHC, there was no major adverse event (more than Grade 3) during the postoperative course. Histological examination of the resected specimen revealed a highly-cellular growth of atypical spindle cells with a storiform pattern. By immunohistochemical testing, the tumor cells stained positive for markers including CD31 and the factor VIII related antigen, and the diagnosis of pulmonary angiosarcoma was made. No adjuvant chemoradiotherapy was given, and the postoperative clinical course was uneventful. Although there had been a recurrence in the chest wall, the patient eventually died twenty-one months later. Conclusion: As a new therapeutic option, we performed IPHHC after the pneumonectomy for an advanced pulmonary angiosarcoma with malignant pleural effusion. Although the patient had a recurrence in the chest wall, he had a reasonable postoperative outcome, that is, he returned to a work, retained a good quality of life and had a longer survival in spite of the poor prognosis of the pulmonary angiosarcoma.

Observation of the curative effect between Nocardia rubra cell wall skeleton-injection combined with the intrapleural chemotherapy and following the intrapleural chemotherapy

Objective:To observe and compare the curative effect between the intrapleural-chemotherapy combined Nocardia rubra cell wall skeleton-injection and the Nocardia rubra cell wall skeleton-injection after control of the malignant pleural effusion by chemotherapy.Methods:Every time after elimination of pleural effusion,we injected DDP and Nocardia rubra cell wall skeleton at the same time into pleural cavity;or after we emplaced an improved central vena catheter into pleural cavity then took out closed-drainage or eliminated the pleural effusion every day,then injected 5-FU 0.5 qd intrapleural-space.After the malignant pleural effusion had being controlled,800μg Nocardia rubra cell wall skeleton was injected intrapleural-space. (We call it as"improved following-therapy").Results:Using the improved following-therapy,the control rate of malignant pleural effusion increased:CR+PR,79.07%>65.79%(P<0.05),and the incidence rate of the encapsulated pleural effusion that would impact on patient’s respiratory faction decreased.Conclusion:Giving chemotherapy after closed-drainage or immediately after taking out pleural effusion everyday,then giving biotherapy after pleural effusion had been controlled,the curative effect would be enhanced and the side-reaction would be reduced.

Outcomes of Quality of Life Regarding the Next-Generation Thoracoscopic Intrapleural Hyperthermic Chemotherapy of Non-Small Cell Lung Cancer with Dissemination

Background: We have developed a new next-generation intrapleural hyperthermic chemotherapy (IPHC) for non-small cell lung cancer with dissemination, which is a hybrid chemotherapy combined with oral S-1 medication plus conventional cisplatin-based IPHC. We now report the preliminary feasibility and outcome of quality of life (QOL) regarding this hybrid IPHC. Methods: The patient was a 76-year-old male with a 2-cm nodule in the left upper lobe. After partial resection by video-assisted thoracic surgery (VATS), which was diagnosed with advanced pulmonary adenocarcinoma with intrapleural dissemination. We initially performed two regimens of systemic chemotherapy, S-1 (day 1 - 21, 100 mg 2X/day) + CDDP (day 8, 60 mg/m2) and S-1 (day 1 - 14,100 mg 2X/day) + CBDCA (day 1, AUC 5). The regimen of next-generation IPHC is oral S-1 medication (day 1 - 21, 100 mg/day) + intrapleural hyperthermic perfusion of cisplatin (200 mg/m2) with VATS (day 8,43°C, 2 hours). Adverse outcomes, QOL, and pleural effusion were assessed in three regimens. To investigate the outcomes of the QOL, the European Organization for Research and Treatment of Cancer QOL Questionnaire (EORTC QLQ-C30 and QLQ-LC13), the QOL questionnaire for cancer patients treated with anticancer drugs (QOL-ACD), the Cancer Dyspnea Score (CDS), and the St. George’s Respiratory Questionnaire (SGRQ) were used. Results: During the IPHC treatment course, grade 3 neutropenia, anemia, and diarrhea were observed. The physical function after IPHC became worse compared to that before the IPHC. Fatigue during chemotherapy (CBDCA+S-1) was more pronounced than that during the IPHC. Nausea, vomiting, and diarrhea during the IPHC were prevalent than those of chemotherapy. The overall QOL after the IPHC was improved compared to that before the IPHC. Regarding before and after the IPHC, the physical function after the IPHC became worse compared to that before the IPHC, on the other hand, the global QOL before and after the IPHC had not dramatically changed. Pleural effusion was controlled after the IPHC for more than 1 year. Conclusion: The first case of a clinical trial of the next-generation IPHC showed grade 3 adverse events. However, it was an acceptable feasibility compared to the usual platinum doublet chemotherapy. The effectiveness of the IPHC allowed the patient to obtain a good control of the pleural effusion and preserved the patient’s QOL.

Clinical Outcomes, Safety and Efficacy of Intrapleural Hyperthermic Chemotherapy for Thoracic Malignant Diseases with Pleural Effusion

Background: We have performed the cisplatin-based intrapleural hyperthermic chemotherapy (IPHC) for advanced lung cancer with pleural effusion and for malignant pleural mesothelioma (MPM). Retrospectively, the outcomes of the IPHC were evaluated. Methods: For 14 years from February, 2000 to February, 2014, we performed 14 cases of IPHC including 8 lung cancers (staged-IV) and 6 MPMs (staged-III: 5;IV: 1). We divided these cases in two groups;the lung cancer group (LC group) and MPM group, and assessed the perioperative factors, toxicities, and effectiveness. Results: The patient age averaged 66.5 ± 11.1 years old (11 males and 3 females). The pathology was 7 pulmonary adenocarcinomas, 1 pulmonary angiosarcoma, and 6 epithelial type MPMs. The regimens of the IPHC were CDDP (300 mg) plus saline (n = 12), CDDP (100 mg) plus saline (n = 1), and CDDP (300 mg) plus distilled water (n = 1). The operation and IPHC time was 204 ± 70 and 59 ± 19 minutes, respectively. Intraoperative complication was observed in 2 lung injuries due to exfoliation of the pleural adhesion in the LC group. Blood loss was 292 ± 365 ml. The postoperative complication, i.e., subcutaneous emphysema, was observed as grade 2 pulmonary fistula (7.1%, 1/14), which was significantly observed in the LC group (1/8, 12.5%) compared to the MPM group (0/8, 0%) (p = 0.040). The hematological toxicity of more than grade 3 was observed in only one case of anemia (7.1%, 1/14) and in the LC group (25%, 1/8). The grade 3 anemia (25%, 1/8) and grade 2 neutropenia (25%, 1/8) in the LC group were significantly observed compared to those in the MPM group (0%, 0/6), respectively (p = 0.040). The postoperative cytology of the malignant cells in the pleural effusion resulted in the negative (n = 6), positive (n = 7), and not evaluated (n = 1), and the control rate was calculated to be 46.2% (6/13). There was no significant difference between the two groups (p = 0.083), that is, 42.9% (3/7) in the LC group and 50.0% (3/6) in the MPM group. For the postoperative amounts of the pleural effusion, reduction (n = 10), unchanged (n = 3), and not evaluated (n = 1), the control rate was calculated to be 76.9% (10/13). There was a significant difference between the two groups (p = 0.042), that is, 71.4% (5/7) in the LC group and 83.3% (5/6) in the MPM group. Conclusion: The IPHC treatment resulted in no major complications, and fewer adverse events of more than grade 3. The outcome of the IPHC was safety, and a very effective control of the malignant cells and pleural effusion.

Description of Prescribing Practices of Intrapleural Tissue Plasminogen Activator and Intrapleural DNase Administration at a Tertiary Academic Medical Center

Objectives: To describe the prescribing practices, preparation and administration techniques of intrapleural (IP) tissue plasminogen activator (t-PA) and IP DNase in patients at a tertiary academic medical center. Methods: Adult patients receiving IP t-PA and IP DNase between January 1-December 31, 2012 were retrospectively evaluated. Patients were included if they received IP t-PA and/or IP DNase for a pleural infection and were excluded if they received IP t-PA or IP DNase for chest tube clearance. Results: A total of 197 doses of IP t-PA and IP DNase received amongst 30 patients were included. The mean age of the patients included was 62 years old with 50% of the patients being female. Of the 30 patients included, 18 patients (60%) received both IP t-PA and IP DNase and 12 patients (40%) received only IP t-PA. The median dose of IP t-PA received was 4 mg (IQR 2-10) and the median dose of IP DNase received was 5 mg (IQR 5-5). Systemic antibiotics were administered to 77% of patients prior to IP t-PA or IP DNase administration. Improved pleural effusion drainage was reported in 70% of patients. Increased pain in the chest cavity during administration of IP t-PA or IP DNase was reported in 7% of patients. Conclusion: The majority of patients at our institution received concomitant IP t-PA and IP DNase after systemic therapy for treatment of pleural infections had been attempted. Administration of IP t-PA and IP DNase demonstrated improved drainage of pleural infections with minimal harm to patients.