Intrapleural streptokinase in the management of malignant multiloculated pleural effusions

Objective: Pleural effusions are a frequent complication of malignancy and cause considerable morbidity from dyspnea. The drainage and control of mali gnant effusions relieve symptoms and maintain quality of life but these are difficult in patients with multiloculated effusions in whom drainage usual ly fails. This observational series reports the use of intrapleural strepto kinase (IPSK) in the management of malignant multiloculated pleural effusio ns resistant to standard chest tube drainage. Methods: Ten consecutive patients with malignant multiloculated pleural eff usions, aged 39 to 89 years, were given 250,000-IU doses of IPSK twice dail y after failure to drain the effusions with a standard chest tube because o f multiloculation and multiseptation, as demonstrated by CT or ultrasound s canning. Outcome was assessed by radiographic improvement and symptom contr ol. Results: All 10 patients responded to between 500,000 and 1,500,000 IU of s treptokinase. There was;an increase in pleural fluid drained (mean volume /- SD; pre-IPSK, 843 +/- 690 mt; post-IPSK, 2,368 +/- 1,051 mL; p < 0.001, paired t test), and radiographic improvement was seen in all 10 patients. A ll subjects tolerated the instillation of streptokinase well. One subject r equired opiate analgesia for transient chest pain, and there were no hemorr hagic or allergic complications, One patient died of unrelated septicemia. Conclusions: This series suggests that IPSK may be useful in the drainage o f malignant multiloculated pleural effusions in patients who fail to drain adequately with a standard chest tube, Malignant pleural effusions should n ot be considered a contraindication to IPSK.