- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT03678090
The Safety and Efficacy of Fibrinolysis in Patients With an Indwelling Pleural Catheter for Multi-loculated Malignant Pleural Effusion.
The Safety and Efficacy of Fibrinolysis in Patients With an Indwelling Pleural Catheter for Multi-loculated Malignant Pleural Effusion: a Prospective Randomized Trial
Study Overview
Status
Conditions
Intervention / Treatment
Detailed Description
Malignant pleural effusion (MPE) is a condition where fluid accumulates in the chest (pleural space) due to the presence of cancer. The malignancy may is usually metastatic from the lung, breast, or elsewhere and the presence of a MPE usually causes significant morbidity, particularly shortness of breath. Once a MPE develops, the patient's disease cannot be cured, but symptoms of dyspnea can be palliated.
Malignant effusions usually recur after thoracentesis, a procedure to remove the fluid. Upon recurrence, patients usually undergo placement of an indwelling pleural catheter (IPC). This is a small tube that drains fluid from inside the chest into a bottle to be discarded. It is very effective at treating shortness of breath and is safe.
On occasion, these catheters stop functioning, leading to an increase in the effusion again. This may be due to small amounts of blood or debris such as fibrin that clog the catheter, or it may be related to the pleural fluid becoming too thick to drain. Medication, namely tissue plasminogen activator (tPA), can be placed inside the catheter to promote drainage. With simple clogging, the tPA acts like "Draino." For fluid that has become too thick and pleural effusions that won't drain due to loculations, the tPA helps dissolve debris in the pleural fluid to promote drainage. Without this drainage, patients remain impaired due to shortness of breath related to the fluid.
tPA is effective at draining the fluid when debris has clogged the catheter or the pleural space. However, the exact dosing is unknown. For "simple" clogging, small doses may be used. When extensive loculations are present, large doses may be required to help the patient. Two retrospective studies have looked at very small doses of tPA placed through the IPC with the goal of breaking up the clogs in the catheter itself. These studies used between 2 and 5 mg of tPA.1,2 At Yale-New Haven Hospital, 25 mg has typically been used due to historical preference. It is unknown whether high doses of tPA improve its therapeutic efficacy.
The investigators hypothesize that higher dose fibrinolysis with 25mg of tPA (compared with 2.5 mg) will provide more effective clearance of fluid loculations, resulting in improved radiographic appearance and less shortness of breath without an increased risk of complications, such as bleeding.
Study Type
Phase
- Phase 2
Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Description
Inclusion Criteria:
- Malignant Pleural Effusion MPE (either cytology proven or recurrent exudative pleural effusion in the context of histologically proven cancer)
- Presence of an indwelling pleural catheter (IPC)
- Nondraining IPC (defined as <50 mL of drainage on the past three drainage attempts) not responding to routine saline flush to assure patency
- Residual pleural fluid remaining on chest x-ray (CXR) or ultrasound
- Dyspnea deemed attributable to the effusion (i.e. symptomatic loculations), as assessed by the treating chest physician and using the modified Borg scale
- Presence of written informed consent from the patient or surrogate
Exclusion Criteria:
- Age <18
- Expected survival less than 14 days
- Known allergy or intolerance to tissue plasminogen activator
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Treatment
- Allocation: Randomized
- Interventional Model: Parallel Assignment
- Masking: Double
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
Active Comparator: tPA standard dosage
Tissue Plasminogen Activator (tPA) dose of 10 to 25 mg.
|
Tissue plasminogen activator 25mg dosage
Other Names:
|
Experimental: tPA low dosage
tPA dose of 2.5mg
|
Tissue plasminogen activator 2.5mg
Other Names:
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Improvement in patient chest X-ray
Time Frame: up to 40 days
|
Defined as change in percentage of hemithorax occupied by the pleural opacity on chest X-ray from the baseline chest X-ray to the X-ray at the end of the study protocol.
|
up to 40 days
|
Improvement on the modified Borg dyspnea scale after tPA
Time Frame: up to 40 days
|
Change in modified Borg dyspnea scale obtained at clinic visit where tPA is administered compared to modified Borg dyspnea scale obtained after post-tPA drainage.
|
up to 40 days
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Time to recurrent loculation
Time Frame: up to 90 days
|
In patients where tPA restores effective drainage, the time to and rate of patients who experience recurrent ineffective drainage due to loculation
|
up to 90 days
|
Rate of pleurodesis
Time Frame: up to 90 days
|
The rate of patients who are able to have the indwelling pleural catheter removed.
|
up to 90 days
|
Improvements in dyspnea using the modified Borg scale
Time Frame: up to 40 days
|
Change in modified Borg dyspnea scale obtained at initial clinic visit compared to scale at the end of the study protocol.
|
up to 40 days
|
Other Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Subgroup analysis of patients with trapped lung
Time Frame: up to 40 days
|
We will also perform subgroup analysis by patients with trapped lung, stratification by primary tumor type, and stratification by the LENT score (a validated prognostic score for predicting mortality in patients with MPE).
|
up to 40 days
|
Collaborators and Investigators
Sponsor
Investigators
- Principal Investigator: Mark Godfrey, MD, Yale University
Study record dates
Study Major Dates
Study Start (Anticipated)
Primary Completion (Actual)
Study Completion (Actual)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Actual)
Study Record Updates
Last Update Posted (Actual)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Additional Relevant MeSH Terms
- Respiratory Tract Diseases
- Neoplasms
- Lung Diseases
- Neoplasms by Site
- Pleural Diseases
- Respiratory Tract Neoplasms
- Thoracic Neoplasms
- Pleural Neoplasms
- Lung Neoplasms
- Pleural Effusion, Malignant
- Pleural Effusion
- Molecular Mechanisms of Pharmacological Action
- Fibrinolytic Agents
- Fibrin Modulating Agents
- Tissue Plasminogen Activator
- Plasminogen
Other Study ID Numbers
- 2000024040
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.
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