To document the safety and efficacy of Alteplase in the management of malignant pleural effusions prior to pleurodesis.
Eighteen patients with malignant pleural effusions continued to have persistent fluid drainage after chest tube placement. Chest radiograph showed persistent pleural fluid and infiltrates, and/or loculated pleural fluid documented on CT scan and/or ultrasound. All eighteen patients were treated with Alteplase instilled intrapleurally in doses ranging from 10mg to 50mg (diluted in 100cc of normal saline) daily or every second or third day. The chest tube was flushed after Alteplase instillation with 30cc to 50cc of normal saline. Alteplase was continued until significant improvement of pleural fluid and loculations/pulmonary infiltrates were noted. Two to four doses of Alteplase was usually required.
Pleural fluid drainage decreased with clearing of loculations and/or pulmonary infiltrates after Alteplase instillation. Pleurodesis was performed only when the pleural fluid drainage was less than 150 cc in 24 hours, using either talc or bleomycin. All patients that were sclerosed after Alteplase instillation had no recurrence of their malignant pleural fluid.
Malignant pleural effusions that are loculated, have pulmonary infiltrates and continue to have persistent fluid drainage may benefit from intrapleural instillation of fibrinolytic agents to help facilitate pleurodesis.
Fibrinolytics may have a role in the management of complicated malignant pleural effusions prior to pleurodesis.
G. Thommi, Genetech