Should Thoracoscopic Talc Pleurodesis Be the First Choice Management for Malignant Effusion? Yes
CHEST / 142 / 1 / JULY 2012
Abbreviations : IPC 5 indwelling pleural catheter ; MPE 5malignant pleural effusion ; TS 5 talc slurry ; TTP 5 thoracoscopic talc poudrage
Malignant pleural effusion (MPE) accounts for 22% of all pleural effusions, and in the United States .150,000 new cases are diagnosed annually. 1 Carcinoma of any organ can metastasize to the pleura, and when malignant cells are detected in the pleural ﬂuid or in pleural tissue they denote dissemination and poor prognosis. Median survival after the diagnosis of MPE is 4 to 6 months and is dependent on type of neoplasm.2
During the course of disease, 50% of patients with breast cancer, 25% with lung cancer, and . 90% with mesothelioma develop symptomatic MPE ( Fig 1 ). 2 , 3 Although therapeutic thoracentesis provides effective symptom relief, most MPEs recur within a month, and it should not be the treatment of choice if patients have good Karnofsky Performance Scale scores (. 30) or Eastern Cooperative Oncology Group Performance Status 1.4 , 5 In fact, repeated thoracentesis carries a risk of pneumothorax and empyema and impedes success with subsequent drainage procedures and thoracoscopy because of pleural adhesions.2
MPE is effectively managed by complete drainage of ﬂuid and administration of intrapleural sclerosant. For successful pleurodesis, the underlying lung must reexpand for apposition of the pleura to occur, and pleurodesis can be performed by instilling sclerosant into the pleural space via intercostal tube or small-bore catheter or by thoracoscopic talc poudrage (TTP).6 – 8 Commonly used sclerosants are talc, tetracycline derivatives, and bleomycin.1 , 2 , 8 Talc gives a success rate of 81% to 100%, which is in contrast to 65% to 76% achieved with tetracycline and its derivatives and 61% with bleomycin.1 , 2 , 8 , 9 Fever and pleuritic chest pain are more often observed with talc, and ARDS following talc slurry (TS) has been reported from the United Kingdom and United States, where nongraded talc (50% particle size , 15 mm) is used.10 , 11 Maskell and colleagues12 demonstrated that patients who underwent pleurodesis with nongraded talc had greater alveolar-arterial oxygen gradient at 48 h compared with those who received graded talc (particle size . 15 mm). In a multicenter trial of 558 patients with MPE who underwent TTP using graded talc, there was no occurrence of deaths, ARDS, or pneumonitis.13
Cochrane database systematic review of 36 randomized controlled trials of 1,499 patients who underwent pleurodesis supports the use of intrapleural sclerosants to prevent recurrence, with talc as the sclerosant of choice and TTP as the preferred technique, which should be considered if patients have good performance status.14 A systematic review also reported signiﬁcant reduction in MPE recurrence following TTP rather than TS.15 Although a phase III intergroup study showed comparable outcome between two groups randomized to receive TTP and TS, patients who under went thoracoscopy reported greater comfort and safety. MPEs due to lung and breast cancers were also more effectively palliated with TTP. 16 Stefani and colleagues,17 who randomized 109 patients to TTP and TS, also demonstrated better immediate (87.5% vs 73%) and lifelong pleurodesis successes (82% vs 62%) in favor of TTP. When MPEs with low pH ,7.3 were evaluated, superior outcome was observed with TTP compared with TS (81% vs 55%), since intrapleural loculations associated with low pH can be lysed during thoracoscopy to promote drainage.18 When 859 physicians who collectively performed .8,300 pleurodesis annually for patients with pleural effusions were surveyed, the majority preferred talc over other agents because of its perceived efﬁcacy, and TTP over TS. 19 Physicians have also observed prolonged survival in patients who experienced successful pleurodesis, including those with malignant mesothelioma.20 , 21 This could be attributed to other actions of talc, such as causing apoptosis of lung cancer and mesothelioma cells in vitro as well as altering the biologically active and angiogenic micro-environment of the pleural space to an angiostatic milieu due to endostatin induction.22 – 24
Figure 1. Breast cancer with right massive pleural effusion and contralateral mediastinal shift.
Figure 2. Trapped right lung after fluid drainage.
It is arguable that since palliation is the primary objective, long-term indwelling pleural catheters (IPCs), originally designed for patients with trapped lungs ( Fig 2 ), symptomatic loculated effusions from failed pleurodesis, and advanced cancers with short life expectancies, would represent a viable alternative to pleurodesis.9 , 25 An IPC is inserted in an ambulatory setting via tunneled technique and provides access to the pleural space for ﬂuid drainage when symptoms recur. The majority of patients with MPEs derived immediate symptomatic relief regardless of primary neoplasm, which was sustained up to 30 days, and most did not require subsequent procedures. About 40% experienced spontaneous pleurodesis after 2 to 6 weeks of IPC, thereby allowing its removal.25 Malfunction of the catheter (9.1%), pneumothorax requiring chest tube (5.9%), pain (5.6%), and blocked catheter (3.7%) are complications commonly encountered, whereas empyema (2.8%), cellulitis (3.4%), and tumor metastases along the catheter tract (1%) were less common.26 IPCs can fracture during removal, which can lead to iatrogenic severing of IPC; patients must learn to care for IPCs, and IPCs can be costly. In a cost analysis study, chest tube pleurodesis was found to be more cost-effective than IPC if patient survival was . 6 weeks. 27 Cost will be an important consideration as effective chemotherapeutic agents targeting cancers at the molecular level are developed, which will translate to longer survival.28 The evidence presented lends impetus to TTP as the ﬁ rst choice in the management of patients with MPEs.
Pyng Lee, MD, FCCP Singapore
Afﬁ liations: From the Division of Respiratory and Critical Care Medicine , National University Hospital, Yong Loo Lin School of Medicine, National University of Singapore . Financial/nonﬁ nancial disclosures: The author has reported to CHESTthat no potential conﬂicts of interest exist with any companies/organizations whose products or services may be discussed in this article . Correspondence to: Pyng Lee, MD, FCCP, Division of Respiratory and Critical Care Medicine, National University Hospital, Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, Level 10, 1E Kent Ridge Rd, Singapore 119228; e-mail: firstname.lastname@example.org © 2012 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.
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