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Original Research: INTERVENTIONAL PULMONOLOGY |

Use of an Indwelling Pleural Catheter for the Management of Recurrent Chylothorax in Patients With Cancer* FREE TO VIEW

Carlos A. Jimenez, MD, FCCP; Ashwini D. Mhatre, MD; Carlos H. Martinez, MD; Georgie A. Eapen, MD; Amir Onn, MD; Rodolfo C. Morice, MD, FCCP
Author and Funding Information

*From the Department of Pulmonary Medicine, The University of Texas M.D. Anderson Cancer Center, Houston, TX.

Correspondence to: Carlos A. Jimenez, MD, FCCP, Department of Pulmonary Medicine, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Unit 403, Houston, TX 77030; e-mail: cajimenez@mdanderson.org



Chest. 2007;132(5):1584-1590. doi:10.1378/chest.06-2141
Text Size: A A A
Published online

Background: Recurrent chylothorax is a debilitating condition. We describe the usefulness of an indwelling pleural catheter (IPC) in the palliative management of recurrent symptomatic chylothorax in patients with cancer relapse or progressive disease despite adequate treatment.

Methods: In 10 years, 5,594 patients underwent 8,498 pleural procedures at our institution. Pleural fluid triglycerides were measured in 1,343 patients; of these patients, 130 had a chylothorax. Their medical records were reviewed. In 19 patients, recurrent symptomatic chylothorax appeared in association with cancer relapse. Treating physicians decided to place an IPC in 10 patients, and 9 patients had other palliative interventions. Baseline and postintervention changes in weight, absolute lymphocyte counts, and albumin levels in both groups were statistically compared. Hazard ratio and Kaplan-Meier curves of time to second pleural intervention after index procedure were also evaluated.

Results: The risk of requiring a second pleural intervention after the index procedure during the following 500 days was lower in the IPC group compared to the other pleural interventions (p = 0.030), and Kaplan-Meier curves of time to second intervention were statistically different (p = 0.025). Albumin levels decrease in the IPC group (p = 0.007), but the decline was not worse than the decline observed in the control group (p = 0.329), and recovered rapidly after IPC removal.

Conclusions: Placement of an IPC may be considered as first-line palliative management for patients with symptomatic recurrent chylothorax poorly responsive to the treatment of the underlying malignancy.

Figures in this Article

Approximately one half of all patients with chylothorax have cancer; of these, 70% are lymphoma.13 Management of chylous effusions in the cancer population is generally contingent on the response to treatment of the underlying malignancy. Unfortunately, in patients with poor or no response to cancer therapy, chylothorax may prove extremely difficult to control and often becomes a debilitating condition that significantly affects quality of life. In addition to mechanical interference with lung function caused by intrapleural accumulation of fluid, loss of protein and lipids often leads to metabolic, nutritional, immunologic, and hemodynamic derangements that further complicate performance status and cancer treatment.45

Various conservative approaches have been advocated to palliate recurrent symptomatic chylothoraces associated with cancer. These include repeated thoracentesis and institution of total parenteral nutrition or fat-restricted diet. However, these interventions are bothersome and often have poor results. In search of better outcomes, more aggressive options have been tried. These include thoracic duct ligation, pleuroperitoneal shunting, chemical pleurodesis, and pleurectomy.67 These invasive procedures have unpredictable palliative results, and their associated morbidity and mortality rates makes them suboptimal options for patients with advanced disease. Modalities offering the best chance of effective symptom palliation, the lowest procedure-related morbidity and mortality rates, and the shortest hospital stay represent the most reasonable approach for patients with limited life expectancy. Traditionally, continuous or repetitive drainage has not been recommended for management of recurrent chylothorax because it could lead to volume depletion, malnutrition, and immunosuppresion.3 However, these concerns have not been substantiated by scientific evidence. This study describes our experience using indwelling pleural catheters (IPCs) in patients with symptomatic recurrent chylothorax and cancer relapse or progressive disease despite adequate treatment.

Data Extraction

This is a case-control study in a group of patients with recurrent symptomatic chylothorax associated with cancer relapse or disease progression. The protocol and a waiver of informed consent were approved by The University of Texas M. D. Anderson Cancer Center Institutional Review Board.

Between November 1997 and November 2006, 5,594 patients underwent 8,498 pleural procedures at the University of Texas M. D. Anderson Cancer Center. Pleural fluid triglyceride levels were measured in 1,343 patients, and 130 patients had a chylothorax. In 19 patients, recurrent symptomatic chylothorax requiring more than one pleural intervention appeared in association with cancer relapse or disease progression in spite of completion of at least one full course of curative treatment. Based on the clinical judgment of the treating physician, 10 of these patients underwent IPC placement (unilateral, n = 9; bilateral, n = 1), and 9 patients were managed with other palliative interventions (repeated thoracentesis, n = 7; thoracoscopic talc pleurodesis, n = 1; and pleuroperitoneal shunt, n = 1).

Their medical records were reviewed for age; gender; primary malignancy and staging; symptoms; Eastern Cooperative Oncology Group (ECOG) performance status; number of thoracenteses and other pleural interventions; weight changes; radiologic lung reexpansion; patient-reported symptomatic improvement after pleural interventions; complications related to IPC; time to removal of IPC; attainment of pleurodesis; palliative interventions required after the index procedure; administration of chemotherapy, radiotherapy, or bone marrow transplantation (before and after the index procedure); and survival after the index procedure. Serum albumin level, peripheral WBC count, and peripheral absolute lymphocyte count at the time of index procedure (baseline) and at IPC removal or last value before death in patients dying with the IPC in place, and at last pleural intervention in the control group (after intervention) were obtained.

Definitions

Chylothorax was defined as a pleural effusion with a triglyceride level > 110 mg/dL.1,8 Symptomatic pleural effusion was defined as the radiologic presence of pleural fluid regarded as the cause of the dyspnea by the treating physician. An effusion was labeled as recurrent if there was evidence of radiologic reaccumulation of pleural fluid causing the dyspnea after one intervention in the same pleural space during the prior 6 months.

The index procedure was identified as the IPC placement or the second pleural procedure performed in patients of the control group (other interventions). Failure of the palliative approach was defined as needing two pleural interventions after the index procedure.

Time to pleurodesis was calculated as the days between IPC insertion and removal. Time to chylothorax resolution was calculated as days between the index procedure and the first chest radiograph without evidence of pleural effusion in the intervened hemithorax. Adequate lung reexpansion after a pleural procedure was defined as at least 80% pleurae apposition on the affected hemithorax as determined by visual estimation on postprocedure chest radiographs.

Successful pleurodesis was defined as long-term relief of symptoms related to effusion with absence of fluid reaccumulation on chest radiographs until last follow-up or death.9 Partially successful pleurodesis was defined as diminution of dyspnea related to the effusion, with ≤ 50% reaccumulation of fluid when compared to preprocedure chest radiographs but without the need for further therapeutic thoracentesis for the remainder of the patient’s life.9 Complications during or after a pleural procedure were defined as bleeding causing hemodynamic derangement or requiring blood transfusion, presence of pneumothorax, skin infection at the insertion site requiring antibiotics, empyema due to IPC, persistent ipsilateral chest pain after IPC insertion, and catheter obstruction requiring removal with an additional palliative procedure. Symptomatic improvement was defined as improvement in dyspnea documented on the medical record after an intervention in the affected pleural cavity.

Management of IPC and Control Groups

All IPCs (Pleurx Pleural Catheter; Denver Biomedical Inc.; Denver, CO) were inserted under local anesthesia in a procedure room. Ultrasound guidance was used in six patients, and an IV dose of fentanyl citrate (25 to 75 μg) was administered to five patients. Postprocedure posteroanterior and lateral chest radiographs were obtained to confirm catheter position, evaluate lung reexpansion, and search for procedure-related complications.

After IPC insertion, patients and caregivers were educated on the appropriate home care of the catheter and drainage procedures. They were instructed to contact the outpatient pulmonary clinic if the amount of drained fluid decreased significantly in a 24-h period, the shortness of breath had returned or worsened, skin redness, tenderness or secretions were observed around the catheter insertion site, or if they were having pain or discomfort. Sutures left during the insertion procedure were removed after 2 weeks.

Patients were instructed to drain daily until drainage stopped or they had chest pain/discomfort or persistent cough. Once the amount of daily fluid drainage was < 150 mL for 3 consecutive days, fluid was to be drained every other day. While draining every other day, if the amount of fluid increased > 150 mL, daily drainage was to be restarted. If the amount of fluid drained every other day was < 150 mL on three consecutive occasions (total of 6 days), patients were evaluated clinically and with chest radiographs. The IPC was removed if there was no radiologic evidence of fluid reaccumulation.

In the control group, seven patients had repeated symptom-limited therapeutic thoracenteses as considered necessary based on dyspnea, radiologic findings, and judgment of the treating physician. One patient underwent pleuroscopic pleurodesis using 5 g of sterile talc, with a second dose of talc a week later through a chest tube and a symptom-limited therapeutic thoracentesis 4 weeks after the pleuroscopic pleurodesis. One last patient had a pleuroperitoneal shunt insertion after several symptom-limited therapeutic thoracentesis. The shunt occluded 1 week after its placement, and the patient needed four additional symptom-limited therapeutic thoracentesis.

Dietary modifications were implemented if ordered by the treating physician. Patients underwent chemotherapy or radiation therapy after the index procedure if prescribed by the treating oncologist.

Analysis

Baseline and postintervetion weights, absolute lymphocyte counts, and albumin levels within the IPC group and control group were compared with a Wilcoxon signed-ranked test for paired samples. Changes in weight, absolute lymphocyte counts, and albumin levels at baseline and after intervention between IPC and control groups were compared with a rank-sum test for difference in medians. Hazard ratio and Kaplan-Meier curves of time to second pleural intervention after index procedure were also compared. Other results are presented as percentages, medians, and ranges when appropriate.

Demographics, clinical characteristics, primary malignancies, and treatment modalities are shown in Table 1 . Patients in the IPC group were older, but no statistical differences were found in gender proportions, ECOG performance status, follow-up after index procedure, patients alive at the end of follow-up, days to death after index procedure, or treatment modalities between IPC and control groups.

Table 2 shows patient outcomes. Only one patient required 2 pleural interventions after the index procedure in the IPC group, while six patients (p = 0.011) required 26 procedures after the index intervention in the control group (p = 0.09). There were no statistically significant differences in the number of patients obtaining > 80% lung reexpansion after the index procedure, the number of patients attaining pleurodesis or resolution of the chylothorax, and the number of patients reporting symptomatic improvement or complications among the two groups.

Table 3 presents results of absolute lymphocyte count, weight, and albumin level at baseline and at postintervention points for both groups. In the IPC group, only the albumin level had a statistically significant decline at the postintervention point. Albumin recovered at least to baseline levels within 6 to 103 days (median, 46 days) on those patients who had the IPC removed. On the control group, only weight decreased to a statistically significant level at the postintervention point. None of the other comparisons within or between the groups reached statistical significance.

The risk of requiring a second pleural intervention after the index procedure during the following 500 days was lower in the IPC group as compared to the control group (hazard ratio, 0.13; 95% confidence interval [CI], 0.02 to 0.82; p = 0.030), and Kaplan-Meier curves of time to second intervention (Fig 1 ) were also statistically different (log-rank test, χ2 [1] = 5.034, p = 0.025).

Accumulation of chylous fluid in the pleural space of cancer patients is generally due to disruption of the thoracic duct or obstruction of lymphatic drainage of the pleural space. Obstruction can be caused by underlying malignancy or from mediastinal fibrosis, constrictive pericarditis, or superior vena cava obstruction as a result of prior therapy.911 Treatment of the primary tumor often leads to resolution of the chylothorax,12with mediastinal radiation useful in controlling chylothorax in 68% of patients with lymphoma and in half of patients with metastatic disease.13 Repeated thoracentesis is a reasonable approach for patients with malignancies expected to respond to chemotherapy and/or radiation therapy.

Chyle is a rich source of lymphocytes, Igs, enzymes, and products of digestion.14Sixty to 70% of ingested fat is transported by the thoracic duct to the bloodstream, and the usual concentration of fat in chyle is 0.4 to 6.0 g/dL, with a protein concentration of 2.2 to 6.0 g/dL.15 Repeated therapeutic thoracentesis may provide temporary relief of respiratory symptoms, but nutritional and immune changes will persist or deteriorate until definitive therapeutic measures become effective. Mortality due to chylothorax can be as high as 50%.3,8 Hashim et al16advocated dietary supplementation with medium-chain triglycerides enterally. Medium-chain triglycerides replenish dietary lipids while minimally increasing chyle flow. Ramos and Faintuch17strongly recommended the use of parenteral nutrition in the primary therapy of thoracic duct fistulas. Unfortunately, dietary prescriptions are poorly tolerated, and when used alone in cancer patients with recurrent chylothorax their success rate is unknown.18 Talc pleurodesis has been proven effective for achieving pleurodesis in patients with chylothorax due to lymphoma,2 but this approach can be complicated by prolonged postprocedure hospitalization due to persistent chest tube drainage or development of ARDS.2,19

Strausser and Flye20 advocated early surgical therapy for palliation of medically untreatable nontraumatic disease. In this study, four patients underwent thoracotomy with ligation of the thoracic duct, and/or pleurectomy or pleurodesis. Three of the four patients had permanent relief of chylous pleural effusions. However, surgical modalities are often accompanied by increased morbidity and prolonged hospitalization, making them a poor choice to relieve symptoms in patients with limited life expectancy.

Pleuroperitoneal shunt has been advocated by some authors2123 to avoid nutritional and immunologic depletion. This may be complicated by neoplastic peritoneal seeding in patients with malignant chylothoraces with positive cytology results and valve malfunction leading to failure of drainage of the chylous effusion. In addition, anatomic defects in the diaphragm may also cause return to the pleural cavity of chylous fluid previously pumped into the peritoneal space.20 These considerations coupled with surgical risks and morbidity make pleuroperitoneal shunt unattractive in the cancer setting. Cope24 proposed a method of thoracic duct ligation by radiologic percutaneous transabdominal technique in patients with postsurgical chylothorax. However, its efficacy in patients with chylothorax secondary to malignancy is not known.

Given the paucity of efficacious palliative treatments for recurrent symptomatic malignancy-related chylothorax, IPC is a low-risk alternative. The insertion procedure is simple and is generally done on an outpatient basis. No complications at the time of catheter insertion or immediately thereafter occurred in any of our patients, and only one patient had a catheter occlusion requiring additional interventions on follow-up. This is similar to the low rate of IPC-related complications reported in our experience and that of others.2527

Chyle contains 400 to 6,800 WBCs per milliliter, the majority of these being lymphocytes.14 Although absolute peripheral lymphocyte count decline has been described during prolonged drainage of chylothorax,3 in our patients this decline was similar to the decline observed in the control group and was statistically not significant.

Our study refutes the traditionally held view that the use of an IPC is contraindicated for the management of chylothorax.28 This recommendation had been based on the theoretical consideration that IPC drainage could lead to nutritional and immunologic impairment. While albumin levels decreased at postintervention point in the IPC group, they recovered rapidly to its baseline value after IPC removal without the need for a specific nutritional intervention. The drop in albumin level noted in the IPC group was not worse than the drop observed on the control group. More importantly, the number of interventions and the risk of requiring further interventions on the affected pleural space were significantly less on the IPC group.

Although cancer patients with recurrent chylothorax are not commonly seen in general hospitals, many practitioners have participated at least once in the care of these patients. The paucity of cases and the advanced underlying disease processes of these patients have made the design and planning of prospective studies almost impossible. Also, there is little in the medical literature that can help physicians decide on the best palliative strategy when they encounter patients with this condition.

Unfortunately, our control group had only one patient treated with pleuroscopic talc pleurodesis, and a proper comparison with this alternative considered by some as first line for recurrent symptomatic chylothorax especially in patients with lymphoma2 is not possible with our data. However, concerns related to the safety of talc pleurodesis for palliation of malignant pleural effusion arise from the results of the largest, recently reported study29 comparing talc poudrage vs talc slurry sclerosis. In this trial,29 unexpectedly high morbidity and mortality rates were reported on patients with ECOG performance status of 2 or better.

Even with a small number of patients, our study provides a strong indication that the IPC is a very good palliative modality for patients with cancer-related recurrent chylothorax, especially for those with ECOG performance status of 2 or better. In this group, pleurodesis is obtained quickly and without considerable nutritional deterioration. Furthermore, regardless of performance status, all of our patients had decreasing pleural fluid accumulation and had significant relief of dyspnea after IPC insertion. We conclude that the IPC should be considered a first-line alternative for palliative management of recurrent symptomatic chylothorax in the setting of cancer relapse or disease progression despite therapy.

Abbreviations: CI = confidence interval; ECOG = Eastern Cooperative Oncology Group; IPC = indwelling intrapleural catheter

The Department of Pulmonary Medicine of the University of Texas M.D. Anderson Cancer Center received an unrestricted educational grant from Denver Biomedical Inc., Denver, CO.

The authors have no conflicts of interest to disclose.

Table Graphic Jump Location
Table 1. Patient Demographics, Clinical Characteristics, Primary Malignancies, and Treatment Modalities
* 

Rank-sum test for difference in medians.

 

χ2 test.

Table Graphic Jump Location
Table 2. Patient Outcomes
* 

Rank-sum test for difference in medians.

 

χ2 test.

 

Indicates significance.

Table Graphic Jump Location
Table 3. Absolute Lymphocyte Count, Weight, and Albumin*
* 

p = 0.038.

 

p = 0.007.

 

p > 0.050.

§ 

Indicates significance.

Figure Jump LinkFigure 1. Time to second pleural intervention (failure) after index procedure (log-rank test, χ2 [1]= 5.034; p = 0.0249).Grahic Jump Location
Valentine, VG, Raffin, TA (1992) The management of chylothorax.Chest102,586-591. [PubMed] [CrossRef]
 
Mares, DC, Mathur, PN Medical thoracoscopic talc pleurodesis for chylothorax due to lymphoma: a case series.Chest1998;114,731-735. [PubMed]
 
Light, RW Chylothorax and pseudochylothorax. Light, RW eds.Pleural diseases2001,327-343 Lippincott, Williams & Wilkins. Philadelphia, PA:
 
Breaux, JR, Marks, C Chylothorax causing reversible T-cell depletion.J Trauma1988;28,705-707. [PubMed]
 
Machleder, HI, Paulus, H Clinical and immunological alterations observed in patients undergoing long-term thoracic duct drainage.Surgery1978;84,157-165. [PubMed]
 
Weissberg, D, Ben-Zeev, I Talc pleurodesis: experience with 360 patients.J Thorac Cardiovasc Surg1993;106,689-695. [PubMed]
 
Browse, NL, Allen, DR, Wilson, NM Management of chylothorax.Br J Surg1997;84,1711-1716. [PubMed]
 
Staats, BA, Ellefson, RD, Budahn, LL, et al The lipoprotein profile of chylous and nonchylous pleural effusions.Mayo Clin Proc1980;55,700-704. [PubMed]
 
Antony, VB, Loddenkemper, R, Astoul, P, et al Management of malignant pleural effusions.Eur Respir J2001;18,402-419. [PubMed]
 
Hirsch, A, Ruffie, P, Nebut, M, et al Pleural effusion: laboratory tests in 300 cases.Thorax1979;34,106-112. [PubMed]
 
Van Renterghem, D, Hamers, J, De Schryver, A, et al Chylothorax after mantle field irradiation for Hodgkin’s disease.Respiration1985;48,188-189. [PubMed]
 
O’Callaghan, AM, Mead, GM Chylothorax in lymphoma: mechanisms and management.Ann Oncol1995;6,603-607. [PubMed]
 
Roy, PH, Carr, DT, Payne, WS The problem of chylothorax.Mayo Clin Proc1967;42,457-467
 
Merrigan, BA, Winter, DC, O’Sullivan, GC Chylothorax.Br J Surg1997;84,15-20. [PubMed]
 
Robinson, CL The management of chylothorax.Ann Thorac Surg1985;39,90-95. [PubMed]
 
Hashim, SA, Roholt, HB, Babayan, VK, et al Treatment of chyluria and chylothorax with medium-chain triglyceride.N Engl J Med1964;270,756-761. [PubMed]
 
Ramos, W, Faintuch, J Nutritional management of thoracic duct fistulas: a comparative study of parenteral versus enteral nutrition.JPEN J Parenter Enteral Nutr1986;10,519-521. [PubMed]
 
Bonner, G, Warren, J A review of the nutritional management of chyle leakage in adults.J Hum Nutr Diet1998;11,105-114
 
Romero, S Nontraumatic chylothorax.Curr Opin Pulm Med2000;6,287-291. [PubMed]
 
Strausser, JL, Flye, MW Management of nontraumatic chylothorax.Ann Thorac Surg1981;31,520-526. [PubMed]
 
Milsom, JW, Kron, IL, Rheuban, KS, et al Chylothorax: an assessment of current surgical management.J Thorac Cardiovasc Surg1985;89,221-227. [PubMed]
 
Murphy, MC, Newman, BM, Rodgers, BM Pleuroperitoneal shunts in the management of persistent chylothorax.Ann Thorac Surg1989;48,195-200. [PubMed]
 
Cummings, SP, Wyatt, DA, Baker, JW, et al Successful treatment of postoperative chylothorax using an external pleuroperitoneal shunt.Ann Thorac Surg1992;54,276-278. [PubMed]
 
Cope, C Management of chylothorax via percutaneous embolization.Curr Opin Pulm Med2004;10,311-314. [PubMed]
 
Alinsonorin, CY, Jimenez, CA, Ersoy, YM, et al Indwelling pleural catheters for management of recurrent malignant pleural effusions [abstract].Am J Respir Crit Care Med2003;167,A901
 
Tremblay, A, Michaud, G Single-center experience with 250 tunnelled pleural catheter insertions for malignant pleural effusion.Chest2006;129,362-368. [PubMed]
 
Putnam, JB, Jr, Light, RW, Rodriguez, RM, et al A randomized comparison of indwelling pleural catheter and doxycycline pleurodesis in the management of malignant pleural effusions.Cancer1999;86,1992-1999. [PubMed]
 
Denver Biomedical. Pleurx pleural catheter kit: instructions for use. Available at: http://www.denverbiomedical.com/resource_center/PleuralCathKitIFU1130.pdf. Accessed August 27, 2006.
 
Dresler, CM, Olak, J, Herndon, JE, II, et al Phase III intergroup study of talc poudrage vs talc slurry sclerosis for malignant pleural effusion.Chest2005;127,909-915. [PubMed]
 

Figures

Figure Jump LinkFigure 1. Time to second pleural intervention (failure) after index procedure (log-rank test, χ2 [1]= 5.034; p = 0.0249).Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1. Patient Demographics, Clinical Characteristics, Primary Malignancies, and Treatment Modalities
* 

Rank-sum test for difference in medians.

 

χ2 test.

Table Graphic Jump Location
Table 2. Patient Outcomes
* 

Rank-sum test for difference in medians.

 

χ2 test.

 

Indicates significance.

Table Graphic Jump Location
Table 3. Absolute Lymphocyte Count, Weight, and Albumin*
* 

p = 0.038.

 

p = 0.007.

 

p > 0.050.

§ 

Indicates significance.

References

Valentine, VG, Raffin, TA (1992) The management of chylothorax.Chest102,586-591. [PubMed] [CrossRef]
 
Mares, DC, Mathur, PN Medical thoracoscopic talc pleurodesis for chylothorax due to lymphoma: a case series.Chest1998;114,731-735. [PubMed]
 
Light, RW Chylothorax and pseudochylothorax. Light, RW eds.Pleural diseases2001,327-343 Lippincott, Williams & Wilkins. Philadelphia, PA:
 
Breaux, JR, Marks, C Chylothorax causing reversible T-cell depletion.J Trauma1988;28,705-707. [PubMed]
 
Machleder, HI, Paulus, H Clinical and immunological alterations observed in patients undergoing long-term thoracic duct drainage.Surgery1978;84,157-165. [PubMed]
 
Weissberg, D, Ben-Zeev, I Talc pleurodesis: experience with 360 patients.J Thorac Cardiovasc Surg1993;106,689-695. [PubMed]
 
Browse, NL, Allen, DR, Wilson, NM Management of chylothorax.Br J Surg1997;84,1711-1716. [PubMed]
 
Staats, BA, Ellefson, RD, Budahn, LL, et al The lipoprotein profile of chylous and nonchylous pleural effusions.Mayo Clin Proc1980;55,700-704. [PubMed]
 
Antony, VB, Loddenkemper, R, Astoul, P, et al Management of malignant pleural effusions.Eur Respir J2001;18,402-419. [PubMed]
 
Hirsch, A, Ruffie, P, Nebut, M, et al Pleural effusion: laboratory tests in 300 cases.Thorax1979;34,106-112. [PubMed]
 
Van Renterghem, D, Hamers, J, De Schryver, A, et al Chylothorax after mantle field irradiation for Hodgkin’s disease.Respiration1985;48,188-189. [PubMed]
 
O’Callaghan, AM, Mead, GM Chylothorax in lymphoma: mechanisms and management.Ann Oncol1995;6,603-607. [PubMed]
 
Roy, PH, Carr, DT, Payne, WS The problem of chylothorax.Mayo Clin Proc1967;42,457-467
 
Merrigan, BA, Winter, DC, O’Sullivan, GC Chylothorax.Br J Surg1997;84,15-20. [PubMed]
 
Robinson, CL The management of chylothorax.Ann Thorac Surg1985;39,90-95. [PubMed]
 
Hashim, SA, Roholt, HB, Babayan, VK, et al Treatment of chyluria and chylothorax with medium-chain triglyceride.N Engl J Med1964;270,756-761. [PubMed]
 
Ramos, W, Faintuch, J Nutritional management of thoracic duct fistulas: a comparative study of parenteral versus enteral nutrition.JPEN J Parenter Enteral Nutr1986;10,519-521. [PubMed]
 
Bonner, G, Warren, J A review of the nutritional management of chyle leakage in adults.J Hum Nutr Diet1998;11,105-114
 
Romero, S Nontraumatic chylothorax.Curr Opin Pulm Med2000;6,287-291. [PubMed]
 
Strausser, JL, Flye, MW Management of nontraumatic chylothorax.Ann Thorac Surg1981;31,520-526. [PubMed]
 
Milsom, JW, Kron, IL, Rheuban, KS, et al Chylothorax: an assessment of current surgical management.J Thorac Cardiovasc Surg1985;89,221-227. [PubMed]
 
Murphy, MC, Newman, BM, Rodgers, BM Pleuroperitoneal shunts in the management of persistent chylothorax.Ann Thorac Surg1989;48,195-200. [PubMed]
 
Cummings, SP, Wyatt, DA, Baker, JW, et al Successful treatment of postoperative chylothorax using an external pleuroperitoneal shunt.Ann Thorac Surg1992;54,276-278. [PubMed]
 
Cope, C Management of chylothorax via percutaneous embolization.Curr Opin Pulm Med2004;10,311-314. [PubMed]
 
Alinsonorin, CY, Jimenez, CA, Ersoy, YM, et al Indwelling pleural catheters for management of recurrent malignant pleural effusions [abstract].Am J Respir Crit Care Med2003;167,A901
 
Tremblay, A, Michaud, G Single-center experience with 250 tunnelled pleural catheter insertions for malignant pleural effusion.Chest2006;129,362-368. [PubMed]
 
Putnam, JB, Jr, Light, RW, Rodriguez, RM, et al A randomized comparison of indwelling pleural catheter and doxycycline pleurodesis in the management of malignant pleural effusions.Cancer1999;86,1992-1999. [PubMed]
 
Denver Biomedical. Pleurx pleural catheter kit: instructions for use. Available at: http://www.denverbiomedical.com/resource_center/PleuralCathKitIFU1130.pdf. Accessed August 27, 2006.
 
Dresler, CM, Olak, J, Herndon, JE, II, et al Phase III intergroup study of talc poudrage vs talc slurry sclerosis for malignant pleural effusion.Chest2005;127,909-915. [PubMed]
 
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