Intrapleural Urokinase for the Treatment of Loculated Malignant Pleural Effusions and Trapped Lungs in Medically Inoperable Cancer Patients  Li-Han Hsu, MD, Thomas C. Soong, MD, An-Chen Feng, MPH, Mei-Ching Liu, MD  Journal of Thoracic Oncology  Volume 1, Issue 5, Pages 460-467 (June 2006) DOI: 10.1016/S1556-0864(15)31612-9 Copyright © 2006 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 1 A 45-year-old woman suffered from a left-sided malignant pleural effusion 3 years after treatment of locally advanced right breast cancer (A). An 8-French self-retaining catheter was inserted. Poor lung reexpansion and loculated pleural effusions became evident on chest radiograph (B) and computed tomography (C) when the drainage ceased. Ultrasonography showed fibrinous septa in the pleural fluid (D). Urokinase was infused daily via an intrapleural catheter for the next 3 days. The fourth dose was given on the day after the repositioning of the catheter into the largest residual locule. A total of 400,000 IU urokinase was infused. Minocycline pleurodesis was undertaken on the fourth day after the administration of the final dose of intrapleural urokinase. Chemotherapy containing docetaxel (Taxotere) was instituted later. At 6-month follow-up, complete success of pleurodesis was noted with residual pleural effusions occupying less than 5% of the left hemithorax, as revealed by chest radiograph (E) and computed tomography (F). Journal of Thoracic Oncology 2006 1, 460-467DOI: (10.1016/S1556-0864(15)31612-9) Copyright © 2006 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 2 A 38-year-old woman became symptomatic for a right-sided malignant pleural effusion 2 years after treatment for bilateral breast cancers (A). An 8-French self-retaining catheter was inserted. A condition of trapped lung was noted on the chest radiograph (B) when the drainage decreased. Bronchoscopy excluded proximal airway obstruction. Following the infusion of 300,000 IU urokinase, the lung reexpanded partially (C). Complete lung reexpansion was achieved after the infusion of urokinase to a total of 600,000 IU (D). The expelled fibrins conglomerated and floated within the fluid collected in the drainage bottle (E). Journal of Thoracic Oncology 2006 1, 460-467DOI: (10.1016/S1556-0864(15)31612-9) Copyright © 2006 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 3 The effect of drainage and intrapleural urokinase (IPUK) therapy on dyspnea for cancer patients with loculated malignant pleural effusions or trapped lungs. The mean levels of dyspnea as determined using a 100-mm visual analogue scale (VAS) before drainage (solid bars), after drainage (hatched bars), and after IPUK (open bars) are shown. The bars represent SDs. The data are shown for all patients (left) and divided according to whether IPUK therapy failed or succeeded (right). Journal of Thoracic Oncology 2006 1, 460-467DOI: (10.1016/S1556-0864(15)31612-9) Copyright © 2006 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 4 A 47-year-old woman with metastatic breast cancer presented with a right-sided symptomatic malignant pleural effusion. When drainage through an 8-French intrapleural catheter ceased, ultrasonography showed fibrinous septa preventing drainage (A). After 300,000 IU of urokinase was instilled intrapleurally, repeated ultrasonograms in the same position showed good lung reexpansion and documented the action of urokinase in breaking down fibrinous septae (B). Journal of Thoracic Oncology 2006 1, 460-467DOI: (10.1016/S1556-0864(15)31612-9) Copyright © 2006 International Association for the Study of Lung Cancer Terms and Conditions