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Radiation : An Alternative Agent for Pleurodesis
V.K. Arora, Ramesh Varma and K.S. Reddy*
Departments of TB and Chest Diseases and Radiotherapy*, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry Radiotherapy as an alternative agent has been tried for pleurodesis in four proven cases of adenocarcinoma of the lung. This non-invasive technique appears to be beneficial, however, this requires further trials. [Indian J Chest Dis Allied Sci, 35, 2,1993; pp 59-61]
Both chemical and biological agents have been used to produce pleurodesis, but with varying degree of success. Tetracycline, quinicrine, talc and antineoplastic agents are some of the chemicals which have been tried while biological agents like C parvum and streptococcal OK 432 and radioactive isotopes like Au 198, P32, Y20, I131 have been instilled into pleural space l-5, but the prohibitive cost and the safety requirements in handling the isotopes are major drawbacks. In cases of haemorrhagic effusions due to lymphoma, external beam therapy has been found to be effective5,6. It has been observed that close to 90% of malignant effusions caused by lymphoma could be controlled by using mediastinal and hemithorax irradiation. We, therefore, planned to use irradiation as pleurodesis technique in malignant haemorrhagic effusion. Material and Methods
Four patients (3 females and 1 Male) who met the following criteria were included in the 1. Histopathologically proved cases of adenocarcinoma with haemorrhagic pleural 2. Patient who had recurrence of effusion in excess of 500ml within 48 hours after 3. Patients with subjective symptoms of marked orthopnoea with respiratory rate of After aspirating the chest to near dryness, all these cases were taken up for radiation. Radiation dose of 2,000 centi Gray were given to all of them in 10 fractions by two opposing portals covering the entire hemithorax using Cobalt - 60 teletherapy unit over a period of two weeks. Correspondence: Dr V.K, Arora, Director-Professor and Head, Department of TB and Chest Pleurodesis
Table Clinical features and follow up of patients on radiation therapy
follow up for 6 months. No further aspirations required. Response to therapy was classified as complete, partial or failure5. A complete response was defined as complete lack of reaccumulation of fluid 10 days after completion of therapy as evidenced by a dry tap, with subjective and objective improvement of dyspnoea. A partial response was defined as a reaccumulation of pleural fluid without dyspnoea within 10 days after complete course of radiotherapy. Failure was defined as no response either subjectively or in the reaccumulation of fluid. The subjective features of dyspnoea, cough and chest pain and the objective findings of tachypnoea, laboured breathing and restricted chest wall expansion were studied and it was observed that in all the 4 cases, after the completion of radiation therapy, there was a remarkable improvement. The response was complete in 3 cases and partial in one case. Patient with partial response died within 3 months of completion of pleurodesis. The details and follow up of patients is shown in the table. Two patients who were followed up varying from 3 months to one year did not require further re-aspiration. Out of 3 patients who expired, one (case No.4 who expired within 3 months) was re-aspirated after one month and 10 days. The fluid aspirated was loculated but accumulation did not occur. Discussion
Pleurodesis done in patients with malignant effusion is valuable particularly in those patients who are surviving for longer periods and who would otherwise be distressed with breathlessness. There are reports of toxic reaction to the drugs used for pleurodesis which have been mild and appear to be dose related7. Apart from transient fever and local pleuritic pain, convulsions have also been reported following intra-pleural quinacrine8. None of these toxic effects were observed after radiation in our subjects. We conclude that non-invasive technique of radiotherapy used for pleurodesis without any toxic effects appears to be beneficial in patients with bronchogenic adenocarcinoma and haemorrhagic effusions. The control of breathlessness and avoidance of repeated aspirations was of great psychological benefit to the patients. References
Borda I, Krant M. Convulsions following intrapleural administration of quinacrine hydrochloride. JAMA 1967; 201 : 1049-1050. Gellhorn A, Zaidenweber J, Ultman J, Hirschberg E. The use of Atabrine (quinacrine) in the control of recurrent neoplastic effusion : A preliminary report. Dis Chest 1961 ; 39 : 165-175. Hickman JA, Jones MC. Treatment of neoplastic pleural effusions with local instillations of quinacrine (mepacrine). Thorax 1970; 25 : 226-229. Zaloznek AJ, Oswald SG, Langim M. Intrapleural tetracycline in malignant pleural effusions : A randomized study. Cancer 1983; 51 : 752-755. Baily TC, Kisner DL, Sybert A, Macdonald JS, Tsou E, Schein PS. Tetracycline and quinacrine in the control of malignant pleural effusions. Cancer 1978; 41 : 1188-1192. Olopade OI, Uttmann JE. Malignant effusions. Cancer J Clinicians 1991; 41: 166-179. Jones GR. Treatment of recurrent malignant pleural effusion by iodized talc pleurodesis. Thorax 1969; 24 : 69-73. Pass HI. Treatment of malignant pleural and pericardial effusions. In : Devita VT, Hellman S, Cosenberg SA (ed) Cancer : Principles and Practice of Oncology. 3rd ed. Philadelphia : JB Lippincott Company; 1989 : 2317-2327.

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