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Rajesh Thomas, MBBS; Y. C. Gary Lee, PhD, FCCP
Author and Funding Information

From the Department of Respiratory Medicine, Sir Charles Gairdner Hospital; the School of Medicine and Pharmacology, University of Western Australia; and the Lung Institute of Western 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


FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST the following conflicts of interest: Dr Lee was a coinvestigator of the TIME-2 (Second Therapeutic Intervention in Malignant Effusion 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. Dr Thomas has reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

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):e111-e112. doi:10.1378/chest.14-0872
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To the Editor:

The global incidence of mesothelioma is rising, and > 90% of patients will suffer from a malignant pleural effusion (MPE). Indwelling pleural catheters (IPCs) are increasingly used to manage MPEs. In our series of 110 IPC insertions for malignant effusion drainage, the overall incidence of catheter tract metastases (CTMs) was 10%.1 Specifically, CTM complicated nine of the 66 IPCs (13.6%) placed in mesothelioma patients. We thank Dr Bertolaccini and colleagues for pointing out that this is the largest series of CTMs in patients with IPCs.

Dr Bertolaccini and colleagues also raised the role of prophylactic radiotherapy for patients with IPCs. We have reservations about recommending this practice.2 First, an IPC presents a constant risk of subcutaneous deposit of tumor cells. The data from our study show that CTM often develops late (median, 281 days; range, 58-694 days) after IPC insertion; therefore, CTM is less likely to be related to the initial insertion or to be protected by prophylactic radiotherapy postinsertion.

Second, the usefulness of prophylactic radiotherapy has yet to be confirmed. Of the three randomized trials published,3-5 two have shown no benefits from routine administration of prophylactic radiotherapy postpleural procedures. A multicenter randomized study, the Surgical and Large Bore Pleural Procedures in Malignant Pleural Mesothelioma and Radiotherapy Trial, is recruiting patients who have pleural interventions (including IPC insertion) to further examine the benefits of prophylactic radiotherapy.

Third, even if prophylactic radiotherapy is effective for patients with IPCs, the low incidence of CTM argues against subjecting all patients to treatment and its associated cost and morbidity. No predictors exist to identify patients at high risk of developing CTM. In our series, the survival interval after IPC insertion was the sole significant independent risk factor for development of CTM (multivariate OR, 2.495; 95% CI, 1.247-4.993; P = .0098). However, predicting survival in individual patients with mesothelioma is notoriously challenging.

Fourth, radiotherapy to the CTM after its development remains a reasonably effective treatment. None of the six patients in our study had any adverse events. Importantly, IPC does not need to be removed during the radiotherapy course.

Finally, as more effective chemotherapy becomes available, the rate of CTM is likely to decrease. Routine prophylactic radiotherapy after IPC insertion should not be recommended based on the available evidence and the points raised here.

References

Thomas R, Budgeon CA, Kuok YJ, et al. Catheter tract metastasis associated with indwelling pleural catheters. Chest. 2014;146(3):557-562.
 
Davies HE, Musk AW, Lee YCG. Prophylactic radiotherapy for pleural puncture sites in mesothelioma: the controversy continues. Curr Opin Pulm Med. 2008;14(4):326-330. [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]
 
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]
 

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References

Thomas R, Budgeon CA, Kuok YJ, et al. Catheter tract metastasis associated with indwelling pleural catheters. Chest. 2014;146(3):557-562.
 
Davies HE, Musk AW, Lee YCG. Prophylactic radiotherapy for pleural puncture sites in mesothelioma: the controversy continues. Curr Opin Pulm Med. 2008;14(4):326-330. [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]
 
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]
 
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