Table 1 Characteristics of the patients Table 2 Grading of the extent of pleural effusion and thickness on CT findings

Lung cancer, Carcinomatous pleuritis, CT examination, Loculation, Intrapleural instillation therapy

Table 1 Characteristics of the patients Table 2 Grading of the extent of pleural effusion and thickness on CT findings

654 表2の 日胸 疾 会 誌24(6), ご と く, 胸 水 量 をCT所 見 上V0か らV5ま で, 胸膜 の肥 厚 の状態 をTOか らT4ま で の各段 階 に分 1986. け, そ の模 式 図 を図1に 示 した. VlとV2と は半 月上 に 貯 留 した 胸 水 の頂 点 が胸 隔 の 厚 さの1/2を 越 え るか 否 かで 分け た. 大 量 の胸 水 を認 め る もので, 肺 に含気 を 残 す もの はV3, 肺 に含 気 を残 さない ものはV4, の対側 へ の 変位 を認 め る もの をV5と 縦隔 した. 胸 膜 の 肥 厚 に つい てはT1, T2は 各 々胸膜 の 肥厚 が一 部(Tl)ま た は全 周 に及ぶ もの(T2)と した. 被 包化 は, 図1の ご と く, 臓 側胸 膜 と壁 側胸 膜 との接 点 が鈍(round)な もの とし, 臓側 胸膜 が 肺 に対 して 凹 とな って い る もの をT3, 凸 とな って い る もの をT4と して 区別 した(但 し両者 の差 は肥 厚 の程 度の 差 とい うよ りも, 被 包 化 さ れ る胸 水 量 の少 ない ものがT4へ わ れ た). さらにCT上, loculation と進 行 す る よ うに思 胸 水中 に明 らか な隔壁 形 成 を 認め るか, また は治療 時 に混 入 した空 気 が複 数 の鏡面 を形 成 した り胸 水 中 にtrapさ れ た 状 態 が 見 られ た も Fig. 1 Schematic example of grading the extent of pleural effusion (Vl-V5), the thickness of the pleura (T3-T4) and loculation. のを 多房 化 とした(図1, 結 治 療開 始 か らCT撮 厚 との関 係 は図3A, 図2). 果 影 までの期 間 と胸 水量, 胸 膜 肥 Bの ご と くであ った. 胸水 量 は, v0 v1 v2 v3 v4 v5 (A) prior n=34 after n=29 1-2 2-3 n=6 3-6 n. 8 6-12 12 m T0 T1 T2 T3 T4 (B) Fig. 2 The loculated pleural space. A) Without contrast medium. Multiple free air spaces were observed in pleural effusion. B) With i.p. instillation of contrast medium, The loculated pleural space was demonstrated more clearly. prior after 1-2 2-3 3-6 6-12 12- n=34 n=29 n=6 m Fig. 3 Analysis of the CT findings concerning the period after the initial instillation. A) Volume of the pleural effusion. B) Thickness of the pleura. Both were liable to increase in proportion to the period of observation.

0 1 2 3-5 6-10 11- n=35 n=18 n=14 n=15 n=13 n=6 (A) Fig. 4 Analysis of the CT findings concerning the number of i. p. instillation therapy procedures. A) Volume of the pleural effusion. B) Thickness of the pleura. Concerning the number of therapy, both had the same tendency in Fig. 2. 0 1 2 3-5 6-10 11- n=35 n=18 n=14 n=15 n=13 n=6 Fig. 5 Analysis of the cases of loculated pleural space from the standpoint of the period of the observation. A) Incidence of the loculation. Loculation observed in approximately half (46. 4%) of the cases in which the observation period was less than 1 month and then the incidence gradually decreased with time. B) The observation period of 21 cases with loculated pleural effusion. In 13 cases, loculation developed within 1 month after the initiation of the local therapy. (B) n=21(%)

Table 3 Characteristics of the Patients with Loculated Pleural Space Hist: histology, Prim: primary site, Surv: survival time, Inst: i. p. instillation Adc: adenocarcinoma, Sqc: squamous cell carcinoma, Lcc: large cell carcinoma, RUL: right upper lobe, RML: right middle lobe, RLL: right lower lobe, LMBr: left main bronchus, LUL: left upper lobe, LLL: left lower lobe,?: (primary site)unknown.

n=21 (%) Fig. 6 Analysis of the cases of loculated pleural effusion from the standpoint of the number of i. p. instillations. A) Incidence of the loculation. There was no clear relationship between the incidence and the number of i. p. instillations, but at least i. p. instillation seems to be a trigger for the biginning of loculation. B) The number of i. p, instillations in 21 cases of loculated pleural effusion. In 13 cases (61. 5%) only less than 3 instillations were performed.

1) Anderson, C. B., Philpott, G. W. & Ferguson, T. B.: The treatment of malignant pleural effusions. Cancer, 33: 916, 1974. Abstract CT Findings of 53 Cases of Carcinomatous Pleuritis -Loculation of the Pleural Space- Yasuki Fukuda, Takeshi Homma, Masayuki Nakata, Shuuichi Yoneda, Yukio Noguchi and Seiichi Yoshida Saitama Cancer Center, Saitama, 362 Japan To investigate the clinical course and the prognosis of carcinomatous pleuritis following local therapy, we studied 101 CT films of 53 cases of carcinomatous pleuritis complicated with primary lung cancer. The histological types of the 53 cases included 43 adenocarcinomas, 4 squamous cell carcinomas, 4 small cell carcinomas and 2 large cell carcinomas. The median survival time was 6 months after the initial i. p. instillation. The mean number of i. p. instillations was 6. 1 times, median was 3. Instillated drugs were adriamycin, OK-432, ACNU, Mitomycin, aclacinorubicin or others. In the cases failed in pleurodesis, thickening of the pleura, reaccumulation of the pleural effusion and the loculated pleural space were observed at CT examination.

The loculated pleural space was observed in 21 cases (39. 6%), and the loculation of 13 cases developed within 1 month after the initiation of the local therapy or with less than 3 times i. p. instillation. In 12 out of 13 cases, malignant cells remained or reappeared in pleural effusion in spite of local treatment after the loculation. There was no statistical significance between the mean survival time of cases with loculated pleural space (4 months) and that of cases without loculation (8 months). The i. p. instillation of sclerosing agents are accepted to be rational and useful in the treatment of malignant pleural effusion. On the other hand, the drug instillation seems to have the disadvantage of the development of the loculated pleural space in the early stage of the local therapy. The loculation of the pleural space not only made it difficult to remove the pleural effusion and to reexpand the lung, but also was one of the causes of refractry pleuritis. So, to minimize the development of loculation, it is suggested that local therapy should be begun as soon as possible after the detection of the pleural effusion with the aim of complete reinflation of the atelectatic lung and complete closure of the pleural space (pleurodesis).