Rapid Pleurodesis Through an Indwelling Pleural Catheter

Study Overview
=================
Brief Summary
-----------------
The primary objective of the study is to evaluate whether the use of a rapid pleurodesis protocol using 10% iodopovidone immediately after tunneled pleural catheter placement improves time to IPC removal compared to patients who receive an IPC alone.

Detailed Description
-----------------
Patients will be screened throughout the year as part of the clinical referral process to the Interventional Pulmonology service at the Hospital of the University of Pennsylvania for the management of a malignant pleural effusion. Patients eligible for inclusion based on the clinical evaluation will be approached for enrollment. Written consent will be obtained. Patients will subsequently undergo placement of a IPC under MAC as per standard clinical practice followed by complete drainage of the pleural space. Patients randomized to the rapid pleurodesis protocol arm will received 20mL of 10% iodopovidone mixed with 80mL of normal saline instilled intrapleurally through the IPC. Patients randomized to the standard of care arm will have 100mL of normal saline (placebo) instilled intrapleurally through the IPC. The mixture will be allowed to dwell for 2 hours and then completely evacuated through the IPC and the patient will be discharged home. After discharge, all patients will continue to drain their IPC on a daily basis for 7 days. Following this, all patients will continue to drain their IPC on an every-other-day basis until total IPC output is less than 50ml per session over 3 consecutive sessions. At which point they will be asked to undergo a clamp trial of no drainage for 7 days followed by a reattempt at drainage. Patients without return of symptoms over those 7 days and minimal drainage afterwards (<50ml) will be seen in the office for possible IPC removal. Patients with return of symptoms during those 7 days or more than minimal drainage afterwards (>50mL) will be asked to continue drainage until total IPC output is again less than 50mL per session over 3 sessions. After a passed clamp trial, patients will be evaluated in the office with a bedside ultrasound to assess for pleural apposition in 5 of 6 designated points and the absence of pleural effusions. If all criteria are met, the IPC is removed. If there is evidence of residual effusion, continued drainage will be advised. All patients will be evaluated in the office on day 7, day 14, day 30, day 60 and day 90 after IPC placement. On each visit they will be assessed for pleural apposition with ultrasound. At day 30, 60, and 90 all patients will receive a global health related questionnaire (EORTC QLQ30) and a symptom questionnaire. At 90 days, complications rate will be assessed for the entire study period.

Official Title
-----------------
A Randomized, Double Blinded, Controlled Trial of a Rapid Pleurodesis Protocol After Indwelling Pleural Catheter Placement for Malignant Pleural Effusions

Conditions
-----------------
Pleural Effusion, Malignant, Pleurodesis, Pleural Diseases

Intervention / Treatment
-----------------
* Drug: Rapid pleurodesis protocol
* Other: Placebo


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: Diagnosis of MPE as defined by A diagnosis a pleural effusion in the setting of known malignancy. AND Confirmed malignant involvement of the pleural space by fluid cytology or pleural biopsy. OR Evidence of pleural disease on radiographic imaging. OR A recurrent effusion with no other identifiable cause after thorough workup. Symptomatic from the pleural effusions (shortness of breath, cough, or chest pain) Prior thoracentesis with post procedure symptomatic relief Recurrence of symptoms with re-accumulation of pleural effusion Lung re-expansion after thoracentesis on chest imaging within last 30 days Exclusion Criteria: Malignant pleural effusion due to a hematologic malignancy ECOG >4 Any history of trapped lung Prior attempted pleurodesis on the affected site Age <18 Pregnant or lactating Known allergy to iodopovidone (Betadine) Unable or unwilling to provide consent Uncorrectable coagulopathy (INR > 1.5, aPTT > 1.5 x the upper limit of normal) or thrombocytopenia (< 50,000) Anatomic contraindication to IPC (overlying skin abnormalities) Unable or unwilling to care for IPC and adhere to drainage protocol Need for bilateral IPC placement

Ages Eligible for Study
-----------------
Minimum Age: 18 Years

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
No

Study Plan
=================
How is the study designed?
-----------------

Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Prospective, Randomized, Controlled, Double Blinded, Parallel Design, Trial
Masking: Triple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Placebo Comparator: Standard of care<br>Subjects in this arm will receive placebo only (100mL of normal saline) into the pleural space delivered via the newly placed tunneled intrapleural catheter | Other: Placebo<br>* The pleural space will be evacuated completely through the newly placed IPC Only placebo (normal saline) will be instilled into the pleural space The patient will be transferred to the recovery unit Two hours after instillation the pleural space will be drained After recovery from anesthesia and complete drainage of the pleurodesis mix, the subject will be discharged Subjects will be asked to drain their effusion on a daily basis for the next 7 days and then on an every other day basis.<br>|
| Experimental: Rapid pleurodesis protocol<br>Subjects in this arm will receive the chemical pleurodesing agent of 10% iodopovidone solution delivered to the pleural space via the newly placed tunneled intrapleural catheter | Drug: Rapid pleurodesis protocol<br>* The pleural space will be evacuated completely through the newly placed IPC 20mL of 10% iodopovidone and 80mL of normal saline will be instilled into the pleural space The patient will be transferred to the recovery unit Two hours after instillation the pleural space will be drained After recovery from anesthesia and complete drainage of the pleurodesis mix, the subject will be discharged Subjects will be asked to drain their effusion on a daily basis for the next 7 days and then on an every other day basis.<br>* Other names: iodine pleurodesis;|

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Time to catheter removal | Time to IPC removal will be measured in days from the day of IPC placement to the day of IPC removal after meeting removal criteria as listed above. | 90 days | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in Global Health Related Quality of Life | The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQC30) will be used to assess global health-related quality of life. This is a 30-item questionnaire validated for use in patients with cancer. The QLQ-C30 is composed of both multi-item scales and single-item measures. These include five functional scales, three symptom scales, a global health status / QoL scale, and six single items. Each of the multi-item scales includes a different set of items - no item occurs in more than one scale. All of the scales and single-item measures range in score from 0 to 100. A high scale score represents a higher response level. Thus a high score for a functional scale represents a high / healthy level of functioning, a high score for the global health status / QoL represents a high QoL, but a high score for a symptom scale / item represents a high level of symptomatology / problems. | 30 days, 60 days, and 90 days after catheter placement | 
| Change in symptoms of pain and breathlessness | We will use a 5 point Likert scale (5PLS) that has been created for the trial. Patients will be asked to indicate their degree of shortness of breath or chest pain during sitting, walking and lying down/sleeping on that specific day. Thus, a total of 6 scales will be utilized. Point 1 will be described as no shortness of breath or no chest pain. Point 2 will be described as mild shortness of breath or mild chest pain. Point 3 will be described as moderate shortness of breath or moderate chest pain. Point 4 will be described as severe shortness of breath or severe chest pain. Point 5 will be described as Worst shortness of breath possible or Worst chest pain possible. | 30 days, 60 days, and 90 days after catheter placement | 
| Time to return of clinically significant pleural effusion | This will be measured in days from the day of IPC removal to the day of return of a clinically significant pleural effusion in the same hemithorax that originally required IPC placement. A clinically significant reaccumulation of pleural fluid will be defined as an effusion with a maximum fluid depth greater than 25% of the AP window on chest CT or 1cm thoracic ultrasound along the lateral 1/3 of the thorax that is associated with shortness of breath or chest pain | 90 days | 
| Rate of successful pleurodesis at 90 days | Successful pleurodesis will be defined as removal of the IPC with no clinically significant reaccumulation of pleural fluid as evaluated by chest CT or thoracic ultrasound. A clinically significant reaccumulation of pleural fluid will be defined as an effusion with a maximum fluid depth greater than 25% of the AP window on chest CT or 1cm thoracic ultrasound along the lateral 1/3 of the thorax that is associated with shortness of breath or chest pain. | 90 days | 

 Terms related to the study
=================
Keywords Provided by Centre Hospitalier Valida
-----------------
Indwelling Pleural Catheter, Pleurodesis, Iodopovidone, Pleural Effusion, Malignant