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Table of Contents 
ORIGINAL ARTICLE
Year : 2017  |  Volume : 23  |  Issue : 3  |  Page : 321-324

Prognostic factors of 30-day survival of patients with malignant pleural effusion


Department of Respirology and Critical Illness, Faculty of Medicine University of Indonesia, Jakarta, Indonesia

Date of Web Publication17-Jul-2017

Correspondence Address:
Zulkifli Amin
Department of Respirology and Critical Illness, Faculty of Medicine University of Indonesia, Salemba Raya No. 6, Jakarta
Indonesia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPC.IJPC_2_17

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 » Abstract 


Background: Treatment of malignant pleural effusion (MPE) depends on the 1 month prognosis of patients. Until now, there is no study evaluate factors affecting 1 month survival. Aims: This study aims to determine the predictors of survival within 1 month. Methods: Prospective study of 102 patients with MPE. Biochemistry data of pleural fluid, characteristics of tumor, and massiveness of the effusion were analyzed to determine their effect on 30-day survival of the patients. Univariate analysis was performed using Chi-square. All prognostic factors that had P < 0.25 were included in multivariate analysis using Cox regression. Results: Median age of patients was 51 years, most of them were female (56%). Common primary sites of tumor were lung (31%), breast (19%), and lymphatic tissue (11%). In univariate analysis, factors that have P < 0.25 were low glucose concentration in pleural fluid (P = 0.01), high lactate dehydrogenase concentration in pleural fluid (P = 0.25), and high risk tumor (P = 0.24). In multivariate analysis, only low glucose concentration was significantly related to poor survival within 1 month (hazard ratio 2.85 [1.10–7.61], P = 0.03). Conclusions: Low level of glucose in pleural fluid is an important factor related to 30-day survival in patients with MPE. It can be used to determine prognosis-based treatment objectively.


Keywords: Malignant pleural effusion, prognostic factor, survival


How to cite this article:
Amin Z, Iskandar SD, Sibli. Prognostic factors of 30-day survival of patients with malignant pleural effusion. Indian J Palliat Care 2017;23:321-4

How to cite this URL:
Amin Z, Iskandar SD, Sibli. Prognostic factors of 30-day survival of patients with malignant pleural effusion. Indian J Palliat Care [serial online] 2017 [cited 2020 Apr 1];23:321-4. Available from: http://www.jpalliativecare.com/text.asp?2017/23/3/321/210796





 » Introduction Top


Malignant pleural effusion (MPE) may decrease survival and quality of life.[1] The main goal of MPE treatment is drainage the excessive volume in the pleural space to relieve symptoms and increase the quality of life of the patients. In general, selection of most appropriate treatment must be individualized.[2] MPE can be treated with conventional or modern technique, depends on the short-term (1 month) prognosis of the patients and the progressivity of the disease.[3] According to British Thoracic Society guideline, patients with life expectancy below 1 month, should be treated by transient pleural aspiration. If the life expectancy is longer, then the patients should be treated by tube thoracostomy or more advanced technique such as pleurodesis and long-term indwelling catheter.[4] Other guideline states that pleurodesis should be planned only if the patient has life expectancy more than 3 months.[5]

Unfortunately, there is no study evaluates factors affecting 1 month survival in patients with MPE until now. This study aims to determine whether 1 month survival is affected by the biochemistry of the pleural fluid, characteristics of tumor, and massiveness of the effusion. Hopefully, following this study, the determination of treatment technique can be more objective.


 » Methods Top


This study was a prospective study, approved by Ethical Committee of Faculty of Medicine University of Indonesia – Cipto Mangunkusumo Hospital (No. of Approval: 99/PT02.FK/ETIK/2012).

Target population of this study was patients with MPE who were hospitalized in Cipto Mangunkusumo Hospital within 2012–2016. The diagnosis of MPE based on physical examination, thorax imaging, and pleural fluid analysis. These findings were confirmed by cytology of pleural fluid. Negative or inconclusive results were confirmed by second cytology examination. Any patients with negative cancer cells or inconclusive results from the second examination were excluded from this study. The demographical, clinical, characteristics of tumor, and pleural fluid analysis data were collected. There were 102 patients included in this study. Patients were followed up for a period of 30 days.

Statistical analysis

Data were analyzed using SPSS program (IBM). In the univariate analysis, pleural fluid value (protein, glucose, lactate dehydrogenase [LDH]), characteristic of tumor (high-risk tumor, metastasis to other organ), and the massiveness of effusion were analyzed using Chi-square. All prognostic factors that had P < 0.25 were included in multivariate analysis using Cox regression. The results will be presented in hazard ratio (HR) and hazard function curve.

Prognostic factors cut-off and definition

High-risk tumor (lung, gastrointestinal, ovary, renal, soft tissue, oral, and prostate) was defined as tumor that had a median survival less than the entire median survival, as stated by Heffner et al.[6] Cutoff the value of protein effusion was 3.85 g/dl, as stated by Bielsa et al.[7] Cutoff value of glucose and LDH effusion was 60 mg/dl and 600 U/L, respectively, as stated by Martínez-Moragón et al.[8] Massive effusion was defined as complete or almost complete opacification on thorax X-ray.


 » Results Top


The current study consisted of 102 eligible patients. The characteristics of the study population were outlined in [Table 1]. The median age of the patients was 51-year-old, and most of them were female (56%). Dyspnea and cough were the main symptoms of the patients. The most common sites for primary tumor were lung (31%), breast (19%), and lymphatic tissue (11%). Other sites for primary tumor (18%) that also found in this study were prostate, thyroid, oropharynx, bladder, and musculoskeletal.
Table 1: Characteristic of study population (n=102)

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Results of univariate analysis were described in [Table 2]. Biochemical parameter of pleural fluid showed that only glucose and LDH that had P < 0.25. Patients with higher glucose levels and lower LDH levels had better survival. Interestingly, the patients with high-risk tumor had longer survival, with P value below 0.25. The massiveness of effusion did not influence 30-day survival of the patients significantly.
Table 2: Univariate analysis of prognostic factors

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Among the prognostic factors, only glucose concentration, LDH concentration, and the presence of high-risk tumor were evaluated into multivariate stepwise logistic regression analysis. Based on the analysis [Table 3], only low concentration of glucose in pleural fluid was found as the predictor of 30-day survival (HR = 2.85, P = 0.03). The cumulative hazard of low glucose concentration to 30-day-survival was presented in [Figure 1].
Table 3: Multivariate analysis of prognostic factors with P<0.25

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Figure 1: Cumulative hazard of low concentration of glucose to 30 day-survival

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 » Discussion Top


The finding of tumor cells in pleural fluid indicates advanced stage of the disease. It causes poor survival and quality of life. Heffner et al. reported that 1 month survival of patients with MPE was 80.3%.[6] However, 1 month survival in our study only 55.9%. The median age of patients in our study was 51 years. It was different from other studies that show median age of patients with MPE usually older than 60 years.[9],[10] The distribution of sex in our study did not different from other study.[10] The survival in patients with MPE was not associated with age and gender.[11] Lung and breast cancer predominated as the primary site of tumor, as found in other study.[6],[7],[12]

Low glucose concentration in pleural fluid was known to be associated with poor survival, although different cutoff values had been reported. Martínez-Moragón et al. found that concentration of pleural fluid glucose <60 mg/dl was a good predictor of lower survival (5 months vs. 11 months, P < 0.01).[8] This relationship could be explained because an abnormal pleural membrane (tumor or fibrosis) impaired glucose transfer from blood to pleural fluid across pleural membrane.[13] In our multivariate analysis, low glucose concentration was the only significant predictor of poor survival within 1 month (HR 2.85 [1.10–7.61], P = 0.03).

The concentration of LDH in pleural fluid was known to be associated with prognosis of the patients. High LDH level worsened the survival of patients. Martínez-Moragón et al. reported that LDH concentration >600 U/L was a significant predictor of poor survival (6 months vs. 10 months, P < 0.01).[8] Other multivariate study also found a mean survival of 2.9 months if LDH concentration >560 U/L.[7] However, in our multivariate study, high LDH concentration insignificantly related to 30-day survival of the patients.

Bielsa et al. reported a mean survival of 2.2 months if protein concentration in pleural fluid <3.85 g/dl.[7] Low concentration of protein was associated with a lower survival due to plasmatic hypoproteinemia accompanying an advanced emaciation stage. Contrarily, low protein concentration was not significantly related to 30-day survival in our study.

Many studies reported that patients with breast cancer, mesothelioma, and lymphoma had longer survival than patients with lung, ovary, and gastrointestinal cancer.[6],[7],[8] Heffner et al. grouped tumors with median survival <4 months (median survival of entire MPE patients) as high-risk tumors. It consists of cancers of the lung, gastrointestinal, ovary, renal, soft tissue, oral, and prostate.[6] Interestingly, we found that patients with high-risk tumor had better 30-day survival. It can be possibly explained because patients with high-risk tumor usually get more comprehensive treatment, such as hemodialysis for renal impairment or more potent antibiotic for lung cancer with infections. Obviously, it needs further exploration or subgroup analysis to answer this problem.

Most common cause of massive pleural effusion was malignancy (53.6%). Massive MPE was related with the extent of the metastasis in pleura. Patients with nonmassive MPE had a significantly better survival than those with massive MPE (8 months vs. 5 months, P < 0.01).[14] However, our study found that this massiveness was not related with prognosis within 1 month.


 » Conclusions Top


Low level of glucose in pleural fluid is an important prognostic factor related to 30-day survival in patients with MPE (HR = 2.85). It can be used to determine prognosis-based treatment objectively.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

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Psallidas I, Kalomenidis I, Porcel JM, Robinson BW, Stathopoulos GT. Malignant pleural effusion: From bench to bedside. Eur Respir Rev 2016;25:189-98.  Back to cited text no. 1
    
2.
Stathopoulos GT, Kalomenidis I. Malignant pleural effusion: Tumor-host interactions unleashed. Am J Respir Crit Care Med 2012;186:487-92.  Back to cited text no. 2
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Leung L, Hsin M, Lam KC. Management of malignant pleural effusion: Options and recommended approaches. Thorac Cancer 2013;4:9-13.  Back to cited text no. 3
    
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Roberts ME, Neville E, Berrisford RG, Antunes G, Ali NJ; BTS Pleural Disease Guideline Group. Management of a malignant pleural effusion: British thoracic society pleural disease guideline 2010. Thorax 2010;65 Suppl 2:ii32-40.  Back to cited text no. 4
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Muduly D, Deo S, Subi TS, Kallianpur A, Shukla N. An update in the management of malignant pleural effusion. Indian J Palliat Care 2011;17:98-103.  Back to cited text no. 5
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6.
Heffner JE, Nietert PJ, Barbieri C. Pleural fluid pH as a predictor of survival for patients with malignant pleural effusions. Chest 2000;117:79-86.  Back to cited text no. 6
    
7.
Bielsa S, Salud A, Martínez M, Esquerda A, Martín A, Rodríguez-Panadero F, et al. Prognostic significance of pleural fluid data in patients with malignant effusion. Eur J Intern Med 2008;19:334-9.  Back to cited text no. 7
    
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Martínez-Moragón E, Aparicio J, Sanchis J, Menéndez R, Cruz Rogado M, Sanchis F. Malignant pleural effusion: Prognostic factors for survival and response to chemical pleurodesis in a series of 120 cases. Respiration 1998;65:108-13.  Back to cited text no. 8
    
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Anevlavis S, Kouliatsis G, Sotiriou I, Koukourakis MI, Archontogeorgis K, Karpathiou G, et al. Prognostic factors in patients presenting with pleural effusion revealing malignancy. Respiration 2014;87:311-6.  Back to cited text no. 9
    
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Zamboni MM, da Silva CT Jr., Baretta R, Cunha ET, Cardoso GP. Important prognostic factors for survival in patients with malignant pleural effusion. BMC Pulm Med 2015;15:29.  Back to cited text no. 10
    
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Burrows CM, Mathews WC, Colt HG. Predicting survival in patients with recurrent symptomatic malignant pleural effusions: An assessment of the prognostic values of physiologic, morphologic, and quality of life measures of extent of disease. Chest 2000;117:73-8.  Back to cited text no. 11
    
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Abrao FC, Peixoto RD, de Abreu IR, Janini MC, Viana GG, de Oliveira MC, et al. Prognostic factors in patiehnts with malignant pleural effusion: Is it possible to predict mortality in patients with good performance status? J Surg Oncol 2016;113:570-4.  Back to cited text no. 12
    
13.
Good JT Jr., Taryle DA, Sahn SA. The pathogenesis of low glucose, low pH malignant effusions. Am Rev Respir Dis 1985;131:737-41.  Back to cited text no. 13
    
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Jiménez D, Díaz G, Gil D, Cicero A, Pérez-Rodríguez E, Sueiro A, et al. Etiology and prognostic significance of massive pleural effusions. Respir Med 2005;99:1183-7.  Back to cited text no. 14
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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