*From the Centre of Respiratory Research (Drs. Janes and Lee), University College London, UK; and Oxford Pleural Unit (Drs. Rahman and Davies), Oxford Centre for Respiratory Medicine and University of Oxford, Oxford, UK.
Correspondence to: Y. C. Gary Lee, MBChB, PhD, FCCP, Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford OX3 7LJ, UK; e-mail: firstname.lastname@example.org
Indwelling pleural catheters are increasingly being used for ambulatory treatment of malignant pleural effusion, particularly for patients unsuitable for pleurodesis. These catheters are often left in situ for the rest of the patient’s life. Tumor metastasis along the tract between pleura and skin surface is a potential complication in patients with chronic indwelling pleural catheters that has seldom been reported. We describe four cases of catheter-tract metastasis that developed between 3 weeks and 9 months after catheter insertion. Catheter-tract metastasis occurred in two patients with mesothelioma despite prophylactic irradiation at time of insertion, and in two patients with metastatic adenocarcinoma. All cases were successfully treated using external-beam radiotherapy without necessitating catheter removal. A retrospective audit in our center showed that catheter-tract metastasis occurred in 6.7% of 45 patients treated with indwelling pleural catheters for malignant pleural effusions. Both clinicians and patients should be aware of this potential complication.
Malignant pleural effusions are common in clinical practice.1 Indwelling pleural catheters have increasingly been advocated for management of recurrent effusions, especially in patients unsuitable for pleurodesis, or in whom pleurodesis has failed.1–5 These catheters are often left in situ for the rest of the patient’s life.
Tumor metastases from the parietal pleura to the skin surface following tracts from pleural procedures (eg, thoracoscopy) are known complications of mesothelioma but are rare with other malignancies.1 Patients with chronic indwelling pleural catheters are at continual risks of tumor spread along catheter tracts. Catheter-tract metastasis has seldom been reported, and its incidence is unclear. We report a series of four patients with catheter-tract metastasis from indwelling pleural catheters: two patients with adenocarcinoma, and two patients with mesothelioma.
A large left pleural effusion developed in a 61-year-old woman (Fig 1, 2
) 4 months after a left pneumonectomy and chest wall resection for lung adenocarcinoma and preoperative chemotherapy. She had significant symptomatic relief after drainage of pleural fluid, which tested positive for malignant cells. Despite second-line chemotherapy with docetaxel, the effusion reaccumulated rapidly and required frequent drainage. Given the prior pneumonectomy, pleurodesis was regarded as inappropriate. Instead, a small-bore indwelling pleural catheter (PleurX; Denver Biomedical; Golden, CO) was inserted for ambulatory fluid drainage, with good symptomatic effect. Three weeks later, a tumor nodule developed (Fig 3
) at the catheter insertion site. This was treated with external-beam radiotherapy (21Gy in three fractions) administered while the catheter remained in situ. Radiotherapy did not affect the function of the catheter. The nodule resolved and was replaced by scar tissue 2 weeks after irradiation. No new nodules developed in the subsequent 3 months of follow-up.
The above case prompted a retrospective audit of the incidence of catheter-tract metastases from indwelling PleurX catheters in the Oxford Pleural Unit. Between June 2002 and February 2006, 45 PleurX catheters were inserted for drainage of malignant pleural effusions. All patients were followed up by the unit, and any catheter-tract metastases were recorded.
Catheter-tract metastasis developed in 3 of 45 patients (6.7%) [Table 1
]. The incidence appeared higher in mesothelioma patients (2 of 15 patients, 13.3%) than in those with metastatic carcinomas (1 of 30 patients, 3.3%). Both of the patients with mesothelioma had such metastases despite prophylactic irradiation within 2 weeks of catheter placement. Tract metastasis developed after 6 months in two patients and 9 months in the third patient. All three patients were successfully treated with radiotherapy with the drain in situ, and the indwelling catheters continued to function well.
We report four cases of catheter-tract metastasis in patients with pleural malignancies managed with indwelling pleural catheters. Our series include two cases of tract metastasis from adenocarcinomas: a complication seldom reported with cancers other than mesothelioma. In addition, we have shown that catheter-tract metastasis can be treated with external-beam irradiation with the catheter in situ. Prophylactic radiotherapy to the insertion site did not prevent metastasis from indwelling catheters in the two patients with mesothelioma.
Ambulatory drainage of recurrent malignant effusions using small-bore indwelling pleural catheters is increasingly used worldwide for the management of malignant pleural effusions, especially in patients who failed pleurodesis, have trapped lungs, or have a limited life expectancy.1 The use of these catheters is generally safe, but the full spectrum of potential side effects has not been established.
The parietal pleura is often affected in malignant pleural diseases.1 Needle tract metastasis along previous pleural puncture sites is well established with mesothelioma, and occurs in up to 40% of patients.5 However, metastasis from adenocarcinomas along pleural puncture sites are uncommon.
Catheter-tract metastasis with indwelling pleural catheters has rarely been reported. In three large series of a combined 374 patients,2–4 only two cases were described. In our population, catheter-tract metastasis occurred in 6.7% of patients who received PleurX catheters.
Prophylactic irradiation of the pleural puncture sites is effective in preventing needle tract metastases from mesothelioma following “one-off” pleural procedures (eg, thoracostomy or thoracoscopy). However, radiotherapy may offer limited protection against ongoing risks of malignant invasion in patients with long-term indwelling pleural catheters. This may explain the development of catheter-tract metastases despite prophylactic radiotherapy in our two mesothelioma patients. External-beam radiotherapy was effective in treating the catheter-tract metastases. Irradiation was performed with the catheter in situ without impairing the catheter drainage.
In summary, catheter-tract metastasis can develop with both metastatic carcinomas and mesothelioma. The incidence is frequent enough that patients should be warned of this potential complication. Larger series are required to establish the incidence and risk factors for catheter-tract metastasis.
Dr. Janes is supported by a Medical Research Council Clinician Scientist Fellowship, Dr. Lee is supported by a Wellcome Advanced Fellowship, and Dr. Rahman is supported by a Medical Research Council Training Fellowship.
Drs. Janes and Rahman do not have any conflict of interests or involvement with organizations with financial interests in the subject matter. Drs. Davies and Lee have been awarded a project grant from the British Lung Foundation to compare conventional pleurodesis with chronic indwelling pleural catheters in patients with malignant pleural effusions. The investigators of the trial have accepted an arrangement to use pleural catheters provided for free by Rocket Med plc (UK), since the acceptance of this manuscript for publication. None of the investigators received any funding from the company.
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