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Original Research: Pulmonary Procedures |

Catheter Tract Metastasis Associated With Indwelling Pleural CathetersCatheter Tract Metastasis FREE TO VIEW

Rajesh Thomas, MBBS; Charley A. Budgeon, BSc (Hons); Yi Jin Kuok, MBBS; Catherine Read, BSc (Hons); Edward T. H. Fysh, MBBS; Sean Bydder, MBChB; Y. C. Gary Lee, PhD, FCCP
Author and Funding Information

From the Department of Respiratory Medicine (Drs Thomas and Lee), the Department of Research (Ms Budgeon), the Department of Radiology (Dr Kuok), and the Department of Radiation Oncology (Dr Bydder), Sir Charles Gairdner Hospital; the School of Medicine and Pharmacology (Drs Thomas, Fysh, and Lee), and the Centre for Applied Statistics (Ms Budgeon), University of Western Australia; and the Lung Institute of Western Australia (Drs Thomas, Fysh, and Lee and Ms Read), Perth, WA, Australia.

CORRESPONDENCE TO: Y. C. Gary Lee, PhD, FCCP, UWA School of Medicine & Pharmacology, 533, Harry Perkins Research Bldg, QE II Medical Centre, Perth, WA 6009, Australia; e-mail: gary.lee@uwa.edu.au


FUNDING/SUPPORT: Drs Fysh and Lee have received research grant support from the Sir Charles Gairdner Research Foundation, Cancer Council of Western Australia, Lung Institute of Western Australia (LIWA) Westcare, and the Dust Disease Board of New South Wales, Australia. Dr Lee is a recipient of a National Health and Medical Research Council (NH&MRC) Career Development Fellowship. Dr Thomas has received research scholarship support from NH&MRC, Western Australia Cancer and Palliative Care Network (WACPCN), and LIWA, Australia.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(3):557-562. doi:10.1378/chest.13-3057
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BACKGROUND:  Indwelling pleural catheters (IPCs) are commonly used to manage malignant effusions. Tumor spread along the catheter tract remains a clinical concern for which limited data exist. We report the largest series of IPC-related catheter tract metastases (CTMs) to date, to our knowledge.

METHODS:  This is a single-center, retrospective review of IPCs inserted over a 44-month period. CTM was defined as a new, solid chest wall lesion over the IPC insertion site and/or the tunneled subcutaneous tract that was clinically compatible with a malignant tract metastasis.

RESULTS:  One hundred ten IPCs were placed in 107 patients (76.6% men; 60% with mesothelioma). CTM developed in 11 cases (10%): nine with malignant pleural mesothelioma and two with metastatic adenocarcinoma. CTM often developed late (median, 280 days; range, 56-693) post-IPC insertion. Seven cases had chest wall pain, and six received palliative radiotherapy to the CTM. Radiotherapy was well tolerated, with no major complications and causing no damage to the catheters. Longer interval after IPC insertion was the sole significant risk factor for development of CTM (OR, 2.495; 95% CI, 1.247-4.993; P = .0098) in the multivariate analyses.

CONCLUSIONS:  IPC-related CTM is uncommon but can complicate both mesothelioma and metastatic carcinomas. The duration of interval after IPC insertion is the key risk factor identified for development of CTM. Symptoms are generally mild and respond well to radiotherapy, which can be administered safely without removal of the catheter.

Figures in this Article

Malignant pleural effusion (MPE) is a common cause of morbidity worldwide,1 and its management often requires multiple pleural interventions.2 Needle tract metastasis (NTM) occurs in up to 40% of patients with mesothelioma following pleural interventions (eg, tube thoracostomy and thoracoscopy3) and has been reported, although rarely, with malignancies other than mesothelioma.1

An indwelling pleural catheter (IPC) is increasingly used in the management of MPE worldwide,46 especially when pleurodesis fails or is contraindicated (eg, with trapped lung). The use of IPCs can potentially induce a higher risk of subcutaneous tract metastasis posing an ongoing risk of tumor seeding along the catheter tract.7 Limited literature exists on the incidence and nature of catheter tract metastasis (CTM) related to IPCs, with the largest case series to date consisting of four cases.7 This retrospective review provides the largest study on CTM to our knowledge and describes its clinical presentation and outcome.

All patients who had IPC insertion for MPE in our service were entered prospectively into a database, which was interrogated for the period of July 31, 2009, to February 28, 2013. All IPCs were inserted using standard procedures involving a modified Seldinger approach and subcutaneous tunneling. In our center, patients were instructed to perform pleural drainage via the IPC whenever they became symptomatic. CTM cases were captured through review of individual medical records and available imaging up to May 10, 2013. Patient demographics, relevant risk factors, and survival data were recorded. Follow-up period was defined as the interval between the date of IPC insertion and last clinic follow-up or death. The Sir Charles Gairdner Group human research ethics committee, approval number 2009-104, approved the study.

CTM was defined as a new, solid chest wall lesion over the IPC insertion site or tunneled subcutaneous tract that was clinically compatible with a tract metastasis. Biopsies were performed when there was concern over the cause of the lesion(s). A specialist chest radiologist (Y. J. K.) independently reviewed available imaging on all suspected cases. Details of any CTM treatment (usually radiotherapy) were obtained, and the response was judged from independent chart reviews.

Data were analyzed using the R environment for statistical computing.8 Binary logistic regression was used to determine which variables were associated with CTM. Cox proportional hazards regression was used to determine which variables were associated with patient survival. Variables that were significant at 5% significance level were retained in the final multivariate models. Adjusted ORs, hazard ratios (HRs), and 95% CIs were calculated for the final models.

During the study period, 107 patients underwent insertion of 110 IPCs (Rocket Medical plc) for MPE management (Table 1). One patient had IPCs inserted bilaterally, another had two IPCs inserted into separate collections on the same side, and one had IPCs inserted sequentially on the same side. For the purpose of data analysis, individual IPC insertions (n = 110) rather than individual patients were used. Mesothelioma was the commonest underlying malignancy (60%). No patient received prophylactic radiotherapy following IPC insertion, as per our institutional practice.

Table Graphic Jump Location
TABLE 1  ] Demographics Characteristics of Participants

Data are presented as No. (%). CTM = catheter tract metastasis; IPC = indwelling pleural catheter.

a 

A total of 110 IPCs were inserted in 107 patients (one patient had one IPC on both sides, one patient had separate IPCs on the same side simultaneously, and one patient had separate IPCs inserted sequentially on the same side). For the purpose of data modeling and analysis, individual IPC insertions (n = 110) rather than individual patients (n = 107) were used.

b 

Lung cancer (adenocarcinoma): 18 (14); breast carcinoma: 8; ovarian carcinoma: 3; others: 13.

Eleven patients developed a CTM, constituting an incidence rate of 10% (Tables 1, 2). The median age was 63 years (range, 53-83 years). Nine of the patients with CTMs (81.8%) had mesothelioma, one had breast adenocarcinoma, and one had ovarian adenocarcinoma. All patients had undergone pleural interventions (mostly between three and five) prior to IPC insertion. Of all patients with CTM, 63.6% were men and 63.6% had left-sided IPCs.

Table Graphic Jump Location
TABLE 2  ] Details of the 11 Patients With CTM

NA = not applicable. See Table 1 legend for expansion of other abbreviations.

a 

Epithelioid mesothelioma.

b 

Histopathologically proven malignancy: 4 of 11.

c 

Cytology-proven malignancy: 7 of 11.

d 

Modified radiotherapy regimen was used in these patients who lived remotely from the treatment center.

CTM was diagnosed after a median of 280 days (range 56-693 days) post-IPC insertion. In five of the patients who developed CTM, the IPC was removed because of cessation of fluid production; in four of those, CTM was diagnosed after IPC removal. Six patients (four with malignant pleural mesothelioma and two with adenocarcinomas) received chemotherapy prior to CTM diagnosis.

Clinical Presentation

All patients with CTM presented with new chest wall lesions overlying the IPC tract. Seven patients had chest wall pain; most were satisfactorily controlled with oral (usually narcotic) analgesics. One patient had severe CTM-associated pain that necessitated hospitalization for pain control.

Imaging

Radiologic findings were compatible with CTM in all patients (n = 7) in whom CT imaging was performed. CTM occurred around the IPC tract, usually in the lateral or posterolateral chest wall (Figs 1A, 1B). Typically, CT scan appearance was that of linear soft tissue opacity adjacent to the catheter or, in cases where the catheter had been removed, along the old tract. In the early stages, this soft tissue opacity was often interpreted as scarring and in later stages developed nodularity. The enlarging lesions tended to displace or invade the adjacent muscle and subcutaneous tissue and were infrequently associated with cortical erosion of the adjacent rib. CTMs exhibited mild, late contrast enhancement similar to that seen in the pleura in malignant mesothelioma.

Figure Jump LinkFigure 1  A, CT scan (coronal view) of thorax showing catheter tract metastasis (CTM) surrounding the indwelling pleural catheter (IPC) (white round structure) at its entry site (arrow) and exit site (arrowhead). B, PET scan (axial view) showing CTM (arrowhead) overlying the IPC (arrow).Grahic Jump Location
Radiation Therapy

Ten patients were referred for radiotherapy: Six completed therapy, two declined, and two died before treatment started. Five were treated with CT scan-planned 6 MV photons using opposed fields (three with bolus); the most common regimen was 30 Gy in 10 fractions (n = 4) or 20 Gy in five fractions (n = 1). One patient was treated with 12 MeV electrons and received 21 Gy (three fractions) followed 5 months later by 20 Gy (five fractions).

Radiotherapy was tolerated well, with no significant complications. Four of the six patients were judged to have a clinical response. Four patients had IPC in situ during their radiotherapy course; none reported catheter damage or malfunction.

Regression Analyses

Cumulative incidence of CTM reached a plateau at 2 years after IPC insertion (Fig 2). Univariately, CTM developed more commonly with mesothelioma (13.6%) than with metastatic pleural carcinomas (4.6%) but did not reach statistical significance because of small sample sizes. Age, sex, IPC side, and time from cancer diagnosis to IPC insertion were also not significantly associated with CTM development. Multivariate analyses showed that a longer interval post-IPC insertion was the only significant variable predicting higher risk for developing CTM (OR, 2.495; 95% CI, 1.247-4.993; P = .0098). In the survival analyses, cases with CTM (multivariate HR, 2.692; 95% CI, 1.070-6.774; P = .0354) and mesothelioma (multivariate HR, 2.054; 95% CI, 1.288-3.275; P = .0025) had longer survival post-IPC insertion.

Figure Jump LinkFigure 2  Cumulative incidence curve for time from IPC insertion to CTM. See Figure 1 legend for expansion of abbreviations.Grahic Jump Location

This is the largest reported series of IPC-related catheter tract metastases to our knowledge. We showed that CTM could occur particularly, but not exclusively, in patients with mesothelioma, and often causes pain. Radiotherapy is effective and can be delivered safely with the catheter in situ. Our study showed that the duration after IPC placement is the most significant and sole predictor for development of CTM.

IPCs are increasingly used in the management of MPEs worldwide, and their benefits are well established.6,9,10 Adverse events are uncommon, but there is a paucity of studies focusing on IPC complications and their management. NTM is a well-recognized complication of pleural procedures, especially in mesothelioma. Tract metastases associated with IPC are therefore an important clinical concern.

Reports of CTM complicating IPCs are limited in the literature.4,7,11 The largest published series described four cases of CTM in 45 patients with IPC.7 A pooled review of 1,093 patients from 10 studies cited a lower frequency of 0.8%.12 The incidence of 10% in our study is the highest reported and most likely reflects the high incidence of mesothelioma in our cohort and our center’s practice of regular surveillance of patients with IPC for potential complications.

It is noteworthy that CTM can develop in patients with malignancies other than mesothelioma. Our study adds two cases of CTM secondary to metastatic adenocarcinoma to the literature, which consists of only three previous reported cases.7,13,14

The mechanism of CTM remains unclear. The conventional belief is that cancer cells directly spread from puncture points at the parietal pleura to adjacent subcutaneous tissue. Fluid leak from the pleural cavity to the subcutaneous tissue along the subcutaneous tunnel is another potential source of malignant seeding. The risk of IPC-related CTM may be higher, as IPCs are often placed for the remaining duration of the patients’ lives and may, therefore, pose ongoing risk of tumor seeding, which is different from needle tract spread from one-off procedures.

Prophylactic radiation for NTM remains controversial, with conflicting results from three small randomized trials.3,15,16 Although prophylactic radiotherapy has not been tested in patients with IPCs, concerns exist about whether it would provide any benefits. First, IPC presents a continual threat of CTM and is less likely to be controlled using prophylactic radiotherapy immediately after insertion. The median time of CTM development in our series was 280 days after IPC insertion, which favored that malignant spread occurred after, rather than at the time of, catheter placement. Second, the incidence of CTM was only 10%, even in an endemic area of mesothelioma (eg, our practice). Third, our study suggests that most patients with CTM had only mild to moderate symptoms responsive to analgesics and radiotherapy. It would be difficult to justify subjecting all patients with IPC to routine prophylactic radiotherapy.

Most of the CTMs reported to date7 and in this study were in patients with mesothelioma. Mesothelioma is known for its higher propensity to metastasize along pleural puncture tracts. The higher incidence of CTM in these patients should not deter the use of IPC in mesothelioma. The best practice to prevent tract metastases is to minimize the number of pleural procedures performed. IPC has been shown to significantly reduce the number of pleural interventions in patients with MPE. For every CTM that developed, there would be several tract metastases saved, if the alternatives of repeated thoracentesis or surgical pleurodesis were performed.

We found that CTM often developed late after IPC insertion (median, 280 days). In our multivariate analyses, the longer the patient survival after IPC insertion, the higher the risk of CTM. Patients with mesothelioma have a significantly longer median survival (12 months) than those with metastatic carcinomas (3-4 months). Mesothelioma per se was not an independent risk factor after adjusting for survival.

The best treatment of CTM is unclear. There is little information on the palliative benefit of radiotherapy, although it is widely practiced.17 In our cohort, palliative radiotherapy was safe and effective, with no reported damage to the IPC.

Our study has limitations. Although this series is the largest for CTM, the total number remained small, given its low incidence, and data were retrospectively collected. Large cohorts from multicenter collaboration will be required to confirm our findings. Similar to all prior studies, diagnoses of tumor tract metastases were made on clinical and radiologic grounds, and histologic confirmation was only pursued if mimics of CTM were suspected.18 Finally, Western Australia has one of the highest incidences of mesothelioma; hence, our incidence of CTM is skewed.

In summary, clinicians using IPC should be aware of CTM, especially as a late complication, in patients with mesothelioma and metastatic malignancies. Patients should be educated to report early lesions. Radiotherapy appears effective, and removal of IPC is unnecessary.

Author contributions: Y. C. G. L. is guarantor of the study. R. T. and Y. C. G. L. contributed to conception and design of the study, pleural data collection, and drafting, revision, and final approval of the manuscript; C. A. B. contributed to statistical analyses and drafting, revision, and final approval of the manuscript; Y. J. K. contributed to imaging analyses and drafting, revision, and final approval of the manuscript; C. R. and E. T. H. F. contributed to pleural data collection and drafting, revision, and fInal approval of the manuscript; and S. B. contributed to radiotherapy data collection and drafting, revision, and final approval of the manuscript.

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Lee was a coinvestigator of the TIME-2 trial, for which Rocket Medical plc provided the indwelling catheters and supplies without charge. He has served on the advisory board of CareFusion Corporation and Sequana Medical. Drs Thomas, Kuok, Fysh, and Bydder, and Mss Budgeon and Read have reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Role of sponsors: The sponsors had no role in the design of the study, the collection and analysis of the data, or in the preparation of the manuscript.

CTM

catheter tract metastasis

IPC

indwelling pleural catheter

MPE

malignant pleural effusion

NTM

needle tract metastasis

Lee YC, Light RW. Management of malignant pleural effusions. Respirology. 2004;9(2):148-156. [CrossRef] [PubMed]
 
West SD, Lee YC. Management of malignant pleural mesothelioma. Clin Chest Med. 2006;27(2):335-354. [CrossRef] [PubMed]
 
Boutin C, Rey F, Viallat JR. Prevention of malignant seeding after invasive diagnostic procedures in patients with pleural mesothelioma: a randomized trial of local radiotherapy. Chest. 1995;108(3):754-758. [CrossRef] [PubMed]
 
Tremblay A, Michaud G. Single-center experience with 250 tunnelled pleural catheter insertions for malignant pleural effusion. Chest. 2006;129(2):362-368. [CrossRef] [PubMed]
 
Putnam JB Jr, Walsh GL, Swisher SG, et al. Outpatient management of malignant pleural effusion by a chronic indwelling pleural catheter. Ann Thorac Surg. 2000;69(2):369-375. [CrossRef] [PubMed]
 
Fysh ET, Waterer GW, Kendall PA, et al. Indwelling pleural catheters reduce inpatient days over pleurodesis for malignant pleural effusion. Chest. 2012;142(2):394-400. [PubMed]
 
Janes SM, Rahman NM, Davies RJ, Lee YC. Catheter-tract metastases associated with chronic indwelling pleural catheters. Chest. 2007;131(4):1232-1234. [CrossRef] [PubMed]
 
R Development Core Team. A Language and Environment for Statistical Computing. Vienna, Austria: R Foundation for Statistical Computing; 2013.
 
Davies HE, Mishra EK, Kahan BC, et al. Effect of an indwelling pleural catheter vs chest tube and talc pleurodesis for relieving dyspnea in patients with malignant pleural effusion: the TIME2 randomized controlled trial. JAMA. 2012;307(22):2383-2389. [CrossRef] [PubMed]
 
Boshuizen RC, Thomas R, Lee YC. Advantages of indwelling pleural catheters for management of malignant pleural effusions. Current Respiratory Care Reports. 2013;2(2):93-99. [CrossRef]
 
Musani AI, Haas AR, Seijo L, Wilby M, Sterman DH. Outpatient management of malignant pleural effusions with small-bore, tunneled pleural catheters. Respiration. 2004;71(6):559-566. [CrossRef] [PubMed]
 
Van Meter ME, McKee KY, Kohlwes RJ. Efficacy and safety of tunneled pleural catheters in adults with malignant pleural effusions: a systematic review. J Gen Intern Med. 2011;26(1):70-76. [CrossRef] [PubMed]
 
Reichner CA, Read CA. Subcutaneous metastatic seeding after removal of a Pleurx catheter. J Bronchology Interv Pulmonol; 2006:13(2):97.
 
Riker D, Sell R. Ultrasound-guided percutaneous biopsy to diagnose indwelling pleural catheter metastasis. J Bronchology Interv Pulmonol. 2012;19(2):165-167. [CrossRef] [PubMed]
 
Bydder S, Phillips M, Joseph DJ, et al. A randomised trial of single-dose radiotherapy to prevent procedure tract metastasis by malignant mesothelioma. Br J Cancer. 2004;91(1):9-10. [CrossRef] [PubMed]
 
O’Rourke N, Garcia JC, Paul J, Lawless C, McMenemin R, Hill J. A randomised controlled trial of intervention site radiotherapy in malignant pleural mesothelioma. Radiother Oncol. 2007;84(1):18-22. [CrossRef] [PubMed]
 
Davis SR, Tan L, Ball DL. Radiotherapy in the treatment of malignant mesothelioma of the pleura, with special reference to its use in palliation. Australas Radiol. 1994;38(3):212-214. [CrossRef] [PubMed]
 
Shrestha RL, Wood BA, Lee YC. Pseudo-tumor mimicking indwelling pleural catheter tract metastasis in mesothelioma. J Bronchology Interv Pulmonol. In press.
 

Figures

Figure Jump LinkFigure 1  A, CT scan (coronal view) of thorax showing catheter tract metastasis (CTM) surrounding the indwelling pleural catheter (IPC) (white round structure) at its entry site (arrow) and exit site (arrowhead). B, PET scan (axial view) showing CTM (arrowhead) overlying the IPC (arrow).Grahic Jump Location
Figure Jump LinkFigure 2  Cumulative incidence curve for time from IPC insertion to CTM. See Figure 1 legend for expansion of abbreviations.Grahic Jump Location

Tables

Table Graphic Jump Location
TABLE 1  ] Demographics Characteristics of Participants

Data are presented as No. (%). CTM = catheter tract metastasis; IPC = indwelling pleural catheter.

a 

A total of 110 IPCs were inserted in 107 patients (one patient had one IPC on both sides, one patient had separate IPCs on the same side simultaneously, and one patient had separate IPCs inserted sequentially on the same side). For the purpose of data modeling and analysis, individual IPC insertions (n = 110) rather than individual patients (n = 107) were used.

b 

Lung cancer (adenocarcinoma): 18 (14); breast carcinoma: 8; ovarian carcinoma: 3; others: 13.

Table Graphic Jump Location
TABLE 2  ] Details of the 11 Patients With CTM

NA = not applicable. See Table 1 legend for expansion of other abbreviations.

a 

Epithelioid mesothelioma.

b 

Histopathologically proven malignancy: 4 of 11.

c 

Cytology-proven malignancy: 7 of 11.

d 

Modified radiotherapy regimen was used in these patients who lived remotely from the treatment center.

References

Lee YC, Light RW. Management of malignant pleural effusions. Respirology. 2004;9(2):148-156. [CrossRef] [PubMed]
 
West SD, Lee YC. Management of malignant pleural mesothelioma. Clin Chest Med. 2006;27(2):335-354. [CrossRef] [PubMed]
 
Boutin C, Rey F, Viallat JR. Prevention of malignant seeding after invasive diagnostic procedures in patients with pleural mesothelioma: a randomized trial of local radiotherapy. Chest. 1995;108(3):754-758. [CrossRef] [PubMed]
 
Tremblay A, Michaud G. Single-center experience with 250 tunnelled pleural catheter insertions for malignant pleural effusion. Chest. 2006;129(2):362-368. [CrossRef] [PubMed]
 
Putnam JB Jr, Walsh GL, Swisher SG, et al. Outpatient management of malignant pleural effusion by a chronic indwelling pleural catheter. Ann Thorac Surg. 2000;69(2):369-375. [CrossRef] [PubMed]
 
Fysh ET, Waterer GW, Kendall PA, et al. Indwelling pleural catheters reduce inpatient days over pleurodesis for malignant pleural effusion. Chest. 2012;142(2):394-400. [PubMed]
 
Janes SM, Rahman NM, Davies RJ, Lee YC. Catheter-tract metastases associated with chronic indwelling pleural catheters. Chest. 2007;131(4):1232-1234. [CrossRef] [PubMed]
 
R Development Core Team. A Language and Environment for Statistical Computing. Vienna, Austria: R Foundation for Statistical Computing; 2013.
 
Davies HE, Mishra EK, Kahan BC, et al. Effect of an indwelling pleural catheter vs chest tube and talc pleurodesis for relieving dyspnea in patients with malignant pleural effusion: the TIME2 randomized controlled trial. JAMA. 2012;307(22):2383-2389. [CrossRef] [PubMed]
 
Boshuizen RC, Thomas R, Lee YC. Advantages of indwelling pleural catheters for management of malignant pleural effusions. Current Respiratory Care Reports. 2013;2(2):93-99. [CrossRef]
 
Musani AI, Haas AR, Seijo L, Wilby M, Sterman DH. Outpatient management of malignant pleural effusions with small-bore, tunneled pleural catheters. Respiration. 2004;71(6):559-566. [CrossRef] [PubMed]
 
Van Meter ME, McKee KY, Kohlwes RJ. Efficacy and safety of tunneled pleural catheters in adults with malignant pleural effusions: a systematic review. J Gen Intern Med. 2011;26(1):70-76. [CrossRef] [PubMed]
 
Reichner CA, Read CA. Subcutaneous metastatic seeding after removal of a Pleurx catheter. J Bronchology Interv Pulmonol; 2006:13(2):97.
 
Riker D, Sell R. Ultrasound-guided percutaneous biopsy to diagnose indwelling pleural catheter metastasis. J Bronchology Interv Pulmonol. 2012;19(2):165-167. [CrossRef] [PubMed]
 
Bydder S, Phillips M, Joseph DJ, et al. A randomised trial of single-dose radiotherapy to prevent procedure tract metastasis by malignant mesothelioma. Br J Cancer. 2004;91(1):9-10. [CrossRef] [PubMed]
 
O’Rourke N, Garcia JC, Paul J, Lawless C, McMenemin R, Hill J. A randomised controlled trial of intervention site radiotherapy in malignant pleural mesothelioma. Radiother Oncol. 2007;84(1):18-22. [CrossRef] [PubMed]
 
Davis SR, Tan L, Ball DL. Radiotherapy in the treatment of malignant mesothelioma of the pleura, with special reference to its use in palliation. Australas Radiol. 1994;38(3):212-214. [CrossRef] [PubMed]
 
Shrestha RL, Wood BA, Lee YC. Pseudo-tumor mimicking indwelling pleural catheter tract metastasis in mesothelioma. J Bronchology Interv Pulmonol. In press.
 
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