RU2159621C1 - Method for carrying out pleurodesis in the cases of malignant tumor pleuritis - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves introducing collagen powder into the pleural cavity in the amount of 1.0-1.5 g as suspension in physiological sodium chloride solution. 10- 15 ml of 2% Lidocaine solution is additionally added to the suspension for making pleural cavity anesthesia and preventing pain syndrome when contacting to collagen particles. EFFECT: enhanced effectiveness of pleurodesis; avoided pain syndrome and temperature response; prevented recidivation. 3 cl

Description

 The invention relates to medicine, in particular to oncology, and can be used in the treatment of primary and secondary malignant tumor pleurisy.

 The following methods are known for the treatment of tumor pleurisy caused by damage to the pleural sheets by a primary malignant tumor process (mesothelioma) or dissemination of tumors of other organs through the pleura: conservative therapy with diuretics, puncture or drainage of the pleural cavity with evacuation of contents, systemic and intrapleural chemotherapy, surgery, pleural (pleurectomy, pleuropneumonectomy) (RA Matthay, Lung Cancer 1993, 14, 189-200). However, the effect of conservative measures, if it is expressed, is temporary. For example, a few days after pleural puncture or drainage, the fluid accumulates again, which requires repeated elimination interventions, while the quality of life of patients cannot be considered satisfactory. In addition, the periodic evacuation of a significant amount (1-3 liters of pleural fluid) further weakens the patient due to the removal of proteins, immunoglobulins, and electrolytes together with the fluid. Surgical procedures are quite traumatic and can be performed in a very small part of this heavy contingent of patients, accompanied by a significant number of complications and high mortality. The pleuroperitoneal shunt is inconvenient for patients, it can become clogged. Systemic chemotherapy in many cases, characterized by a cytostatic effect in relation to the primary tumor, does not provide a pronounced therapeutic effect in relation to pleurisy. At the same time, the absence or significant decrease in the rate of accumulation of pleural exudate, even without a radical cure from the tumor process, allows us to achieve a significant improvement in the quality of life of patients. One way to solve this problem is to create methods of chemical pleurodesis.

A known method of pleurodesis in spontaneous pneumothorax by spraying in the pleural cavity of collagen in an amount of 0.7-1.0 g under a pressure of 0.25 atm in an air volume of 20-30 cm ² with visual inspection of the uniformity of atomization (AS USSR N 1517950 Bull N 40 1989). The doses of collagen indicated in the copyright certificate and the route of its administration do not ensure the achievement of pleurodesis in malignant tumor pleurisy. This is due to the fact that with spontaneous pneumothorax, the pleura is intact, and with tumor pleurisy, the pleural sheets are thickened, covered with plaque of fibrin. Thickening of the visceral pleura prevents the spread of lung tissue after thoracoscopy, which contributes to the development of complications (chronic pleural empyema, pyopneumothorax). According to the severity of the condition, the majority of patients with malignant tumor pleurisy cannot undergo the surgical intervention (thoracoscopy) necessary to drain the pleural cavity, atomize collagen powder and visually control the uniformity of atomization.

 There is a method of pleurodesis in malignant tumor pleurisy by introducing powdered tetracycline into the pleural cavity, in which the patient is drained of the pleural cavity, drained and intrapleurally injected with tetracycline powder, after which drainage is left in the pleural cavity (Martinez-Moragon E., Aparicio J. M., Sanchis J., Sanchis F., Gil-Suay V., Eur Respir J 1997, 10, 2380-2383). The described procedure allows pleurodesis to be achieved in 60-70% of patients with a subsequent improvement in the quality of life due to a significant decrease in exudation. This method is a prototype of the invention.

 The disadvantages of this method are the low effectiveness of treatment, severe pain, significant temperature reaction of the body, the threat of renal failure associated with nephrotoxicity of tetracycline.

 The basis of the invention is the task of creating a method of pleurodesis in malignant tumor pleurisy, providing high treatment efficiency, reducing pain, eliminating the temperature reaction.

 The problem is solved in that in the method of pleurodesis in malignant tumor pleurisy, including drainage of the pleural cavity, draining it by active aspiration of the fluid and the administration of the drug, according to the invention, as a medicine, powdered collagen is introduced, which is introduced into the pleural cavity in an amount of 1-1 , 5 g in the form of a suspension in physiological solution of sodium chloride.

 It is advisable to take a physiological solution of sodium chloride in an amount of 30-50 ml.

 It is also advisable for anesthesia of the pleural cavity and the prevention of pain during contact with collagen particles in an additional 10-15 ml of a 2% lidocaine solution.

 The introduction of 1-1.5 g of powdered collagen in the form of a suspension in physiological solution of sodium chloride is optimal to achieve complete adequate contact of collagen with pleural sheets and achieve reliable pleurodesis in tumor pleurisy in 90% of patients.

 An amount of physiological saline of 30-50 ml is optimal for the distribution of powdered collagen throughout the pleural cavity, a larger amount will not ensure contact of collagen with pleural leaves, and a smaller one will not allow collagen to be adequately distributed in the pleural cavity.

 10-15 ml of a 2% solution of lidocaine is injected into the pleural cavity for the purpose of anesthesia of the pleural sheets and prevention of pain. A larger amount can be toxic to the body, as it has a systemic effect when it enters the bloodstream through the pleura. A smaller amount of lidocaine is not enough for reliable anesthesia of the pleural cavity.

 The method is as follows. Under local anesthesia with a solution of novocaine (lidocaine) 0.5%, the pleural cavity is punctured in the 10 intercostal space along the scapular line. Upon receipt of exudate in the syringe, the pleural cavity is drained with a tube with an inner diameter of 5-8 mm. The depth of the introduction of drainage into the pleural cavity is 5-8 cm. The exudate is evacuated through the drainage. It is necessary to strictly avoid getting into the pleural cavity of air during inspiration, for which the peripheral end of the drainage should always be in an underwater position. After the evacuation of the bulk of the exudate, the drainage is connected to active aspiration under pressure of minus 20 cm of water column for 3-5 hours to achieve complete drainage of the pleural cavity. Then, through a drainage tube, a suspension of 1-1.5 g of powdered collagen in 30-50 ml of physiological solution of sodium chloride and 10-15 ml of a 2% solution of lidocaine is introduced into the pleural cavity. The drainage is squeezed for 6 hours, during which the patient periodically changes the position of the body (on the back, on one and the other side, on the abdomen) to maximize contact of the injected collagen with the pleura sheets, and then reconnect to active aspiration. Drainage is removed when the rate of pleural exudate intake reaches 100 ml per day. If after 3 days the amount of liquid separated through the drainage exceeds 100 ml per day, then the procedure is repeated.

 The method is illustrated by the following examples.

 Example 1. Patient G., 51 years old (medical history N28,). The diagnosis is squamous cell carcinoma of the right lung of the fourth stage, carcinomatosis of the pleura on the right, right-sided pleurisy, metastases in the pelvic bones and kidneys. The diagnosis was made in the summer of 1988. During the fall of 1988, 3 courses of polychemotherapy were carried out according to the MASS scheme. A stabilization of the process was achieved with respect to the primary tumor, however pleurisy continued to recur. Pleural punctures were repeatedly performed with the evacuation of a large amount of exudate (a total of about 4 liters). Condition upon admission to a moderate hospital. Complaints of shortness of breath with minimal physical exertion, pain in the right half of the chest. Clinically and radiologically - a large amount of fluid in the right pleural cavity. The right pleural cavity was drained in the 10 intercostal space along the posterior axillary line, about 2.5 liters of saturated hemorrhagic pleural exudate were evacuated. The patient's well-being has improved significantly. The drainage is connected to an active aspiration system under pressure of minus 20 cm water column. A day after drainage under the control of ultrasound, the absence of free fluid in the right pleural cavity was confirmed. A suspension of 1 g of powdered collagen in 50 ml of physiological solution of sodium chloride and 10 ml of a 2% solution of lidocaine was introduced through the drainage into the pleural cavity. No pain syndrome at the time of administration was noted. The drainage is pinched for 6 hours, during which the patient was rotated in a lying position, and then again connected to active aspiration. Over the next 24 hours, the amount of exudate recovered through drainage was 230 ml, over the next day - 70 ml, then - 50 ml. After three days, the drainage is removed. No temperature reaction or pain was observed during the observation period. The patient was discharged from the hospital on the 4th day after drainage of the pleural cavity without complaints of shortness of breath. Dynamic observation in the oncology clinic revealed a complete remission of right-sided pleurisy within 2 months.

 Example 2. Patient O., 48 years old (medical history N64). The diagnosis is left-sided pleurisy of unknown etiology. Received with complaints of shortness of breath with minimal physical exertion, coughing, sweating. The described complaints are from the summer of 1998, the deterioration is from February 1999. Puncture of the left pleural cavity was performed three times with the evacuation of a large amount of exudate, which brought temporary relief. Clinical and laboratory examination failed to establish the cause of pleurisy. 03/17/99 an operation was performed - video-thoracoscopic revision of the left pleural cavity, pleural biopsy. Revealed thickened parietal and visceral pleura, many isolated and merging formations from 2 mm to 1.5 cm in diameter, as well as free fluid in an amount of about 500 ml. The fluid has been evacuated. With a histological examination of pleural biopsy samples - metastases of glandular cancer. The pleural cavity is drained by two drains, one of which is installed above the diaphragm in the 10 intercostal space along the posterior axillary line. In the postoperative period, a thorough laboratory examination was performed to search for the primary tumor (x-ray, bronchological, ultrasound, fibroesophagogastroscopy, irrigoscopy, thyroid scintigraphy, mammography), the source of metastasis has not been established. A day after the operation, drainage was removed from the second intercostal space, and the remaining drainage located above the diaphragm was connected to the active aspiration system. A day later, after ultrasound confirmation of drainage of the left pleural cavity, a suspension of 1.5 g of powdered collagen in 30 ml of physiological solution of sodium chloride and 15 ml of 2% lidocaine solution was introduced into the latter through drainage. The drainage is clamped for 6 hours, the patient is rotated. Then the drainage tube is again connected to the active aspiration system. Over the next day, exudation - 170 ml, then - 40 ml. Drainage removed. The patient's condition improved significantly, shortness of breath was almost stopped, she walks up the stairs to the 3-4 floor without stopping. After 4 days, systemic polychemotherapy was started. Further observation for 1 month revealed a complete remission of malignant pleurisy.

 According to the proposed method, 16 patients with tumor pleurisy were treated. In 15 patients, reliable pleurodesis was achieved without the development of relapses, a temperature reaction and pain were not observed. The observation time ranged from 1 to 8 months.

 Thus, the proposed method ensures the achievement of pleurodesis in 90% of patients, eliminates pain, does not require the use of narcotic analgesics, is not accompanied by a temperature reaction, prevents the development of relapses, is simple, reliable, performed in the treatment room or in the dressing room under local anesthesia, does not require involvement a large number of medical personnel, safe for the patient.

Claims (3)

 1. The method of pleurosis in malignant tumor pleurisy, including drainage of the pleural cavity, draining it by active aspiration of the fluid and the introduction of the drug, characterized in that as a medicine, use powdered collagen, which is introduced into the pleural cavity in an amount of 1-1.5 g in the form of a suspension in physiological solution of sodium chloride.  2. The method according to claim 1, characterized in that the physiological solution of sodium chloride is taken in an amount of 30-50 ml.  3. The method according to claim 1 or 2, characterized in that the suspension is additionally injected with 10-15 ml of a 2% lidocaine solution.