Streptokinase for malignant pleural effusions: a randomized controlled study

Abstract

Effective palliative treatment in malignant pleural effusion can only be carried out when the lung is fully expanded after drainage of effusion. We investigated the efficacy of intrapleural fibrinolytics for lysing fibrin deposits and improving lung reexpansion in patients with malignant pleural effusion. We randomly allocated 47 patients with malignant pleural effusion into 2 groups: a fibrinolytic group of 24 were given 3 cycles of 250,000 U intrapleural streptokinase; the control group of 23 received pleural drainage only. Pleurodesis with 5 mg of talc slurry was performed in all patients who had lung reexpansion after drainage. Patient characteristics, pleural drainage, lung expansion assessed by chest radiography, and pleurodesis outcomes were compared between the 2 groups. Patient characteristics were similar in both groups. Lung reexpansion was adequate for performing talc pleurodesis in 96% of patients in the fibrinolytic group and 74% in the control group. In the fibrinolytic group, the mean volume of daily pleural drainage before streptokinase administration was 425 mL, and it increased significantly to 737 mL after streptokinase infusion. Intrapleural administration of streptokinase is advisable for patients with malignant pleural effusion.

Management of Malignant Pleural Effusions—What Is New

“…Two small trials of intrapleural instillation of streptokinase in patients with MPE previously found no significant difference in fluid recurrence rates after pleurodesis even though pleural fluid drainage and lung re-expansion improved. 91,92 Similar findings have been reported in the TIME-3 randomized trial (n ¼ 71) that used intrapleural urokinase (100,000 IU, three doses 12 hourly) followed by talc pleurodesis in patients with a septated, nondraining malignant effusion. 93 Urokinase instillation reduced the effusion size on chest radiograph but did not improve dyspnea or pleurodesis failure rates.…”

ERS/EACTS statement on the management of malignant pleural effusions

“…Four controlled studies, three of which were randomised, investigated the role of intra-pleural fibrinolysis for the treatment of loculated MPE [89,[111][112][113]. The first, which used a historical control group, prospectively evaluated 36 patients with symptomatic loculated MPE after drainage with an 8F catheter who were unsuitable for surgery [89].…”

“…The second study randomised 47 patients with symptomatic MPE to receive intra-pleural streptokinase (250 000 IU twice daily for three doses) or pleural drainage only [111]. No information was provided regarding the existence of pleural adhesions.…”

Management options for the complicated pleural space

“…Randomized, controlled evaluation of intrapleural streptokinase for MPE revealed lung re-expansion for a greater number of patients (96 % versus 75 %) and increased subsequent success with doxycycline pleurodesis (75 % versus 56 %) [9]. An indwelling pleural catheter can also be inserted with ultrasound guidance into the dominant loculated space for symptom relief.…”