4. Malignant pleural effusion in general
Median survival following
diagnosis ranges from 3 to 12
months and is dependent on
the stage and type of the
underlying malignancy
The shortest survival time is
observed in malignant
effusions secondary to lung
cancer
Median survival times in
effusions due to carcinoma of
the breast is up to 15
months
Roberts ME et al. Thorax 2010;65(Suppl 2):32-40
8. The way to successful pleurodesis
Full lung expansion, no endobronchial obstruction,
no trapped lung
Drop in PP of >19 cmH2O after removal of 500 ml of
pleural fluid (0/14) Lan RS et al. Ann Intern Med. 1997;126:768-74
Higher possibility for failure but not contraindication:
pH<7.28 (AUC:0.671, 95% CI, 0.624 to 0.715)
Heffner JE et al. Chest 2000;117:87-95
Primary tumor: lung cancer (63%) or mesothelioma
(61%) vs breast (77%) or other metastatic cancers
(74%) as well as the pleural burden
Bielsa S et al. Lung 2011;189:151-5
9. The way to successful pleurodesis
In case of talc slurry pleurodesis the success rate was
higher if:
the time period between radiological diagnosis of
effusion and administration of talc was less than 30
days
spontaneous expansion was attained after chest
tube drainage
daily drainage of less than 200 ml before talc
administation
Aydogmus U et al. Ann Surg Oncol. 2009;16:745-50.
10. Interactive CardioVascular and Thoracic Surgery 12 (2011) 818–823
European Association for Cardio-Thoracic Surgery
What is the best treatment for malignant
pleural effusions?
Imran Zahida, Tom Routledgeb, Andrea Bille`b, Marco Scarcib,*
Overall 161 papers concluded that chemical
pleurodesis is superior to chronic catheter drainage
and PPS in terms survival length and mortality rates
but in patients with trapped lung syndrome chronic
intrapleural catheter placement is indicated.
11. Indwelling Pleural Catheters Reduce
Inpatient Days Over Pleurodesis for
Malignant Pleural Effusion
Conclusions: Patients treated with IPCs required
significantly fewer days in hospital and fewer
additional pleural procedures than those who
received pleurodesis. Safety profiles and
symptom control were comparable
CHEST 2012; 142(2):394–400
12. Impact of pleural effusion pH on the efficacy of
thoracoscopic mechanical pleurodesis in patients
with breast carcinoma
TMP is a safe palliative
treatment for MPE in breast carcinoma, with a
minimal number of complications and a short
hospital stay; it is more successful than TP in
patients with pH of MPE below 7.3.
European Journal of Cardio-thoracic Surgery 26 (2004)
432–436
14. Usefulness of pigtail catheter in pleurodesis
of malignant pleural effusion
Adel H.A. Ghoneim , Howida A. Elkomy , Ashraf E. Elshora *,
Mohamed Mehrez
Egyptian Journal of Chest Diseases and Tuberculosis (2014)
63, 107–112
Pigtail catheters could be considered a safe, easy,
tolerable and effective alternative method in comparison
to the traditional intercostal tubes in pleurodesis of
malignant pleural effusions.
.
15.
16. Thoracoscopic
pleurodesis
Indwelling pleural
catheters
More inpatient days Could be placed in an
outpatient basis
The procedure of choice if
there is an undiagnosed
pleural effusion
Many patients prefer to limit
hospital days
More expensive The cost gradually increases
due to vacuum bottles
Higher success rate Home care nursing support
is necessary, the patient
usually dies with the catheter
in place
18. Inflammatory injury to the pleura
Light RW et al. Am J Respir Crit Care Med 2000;162:98–104
19. Small particle-size talc is associated with
increased inflammation
Arellano-Orden E et al. Respiration 2013;86:201-9
20. Corticosteroids and pleurodesis
Pleurodesis with talc can be blocked with systemic
administration of corticosteroids
Xie C et al. Am J Crit Care Med 1998; 157: 1441–4
The pleurodesis following intrapleural TGF-β is not
inhibited by corticosteroids
Lee YCG et al. Thorax 2001;56:643
21. Coagulation Cascade - Fibrinolytic
Activity - Proliferation of fibroblasts
Decrease in D-dimers 24h after talc poudrage is
associated with successful pleurodesis
Psathakis K et al. Eur Respir J 2006; 27: 817-21.
Patients with successful pleurodesis after talc insufflation
have significantly higher levels of bFGF in their pleural
fluid and there is a significant negative correlation
between bFGF levels and tumor size.
Antony VB et al. Chest 2004;126:1522-8
Pleural adhesions are reduced after tetracycline if either
heparine or urokinase are given intrapleurally
Strange C et al. Am J Respir Crit Care Med 1995;151:508-15
22. VEGF – angiogenesis and pleurodesis
Intrapleuraladministration ofTGF-β
and anti-VEGF IV
r =0.84, p<0.01
Guo YB et al. Chest 2005; 128:1790-7
26. Agent Comments
Talc (4 gr) Inexpensive, widely available, high success
rate, much more studies, graded type (French
talc), ―gold‖ standard
Tetracycline (1.5 gr)
doxycycline (500 mgr)
minocycline (400 mgr)
The second most usually used, complete
success rate: 60-65%, severe chest pain
(lorazepam, midazolam)
Bleomycin (0.75 mgr/kg) Success rate: 50-54%, expensive
Mitoxantrone (40 mgr) A few studies, cardiotoxicity, very expensive
Silver nitrate (20 ml, 0.5%) The first agent that was used, a few clinical
studies with small number of patients
Iodopovidone (100 ml, 2%) Promising agent with high success rate (>80%),
inexpensive, widely available, a few clinical
studies
27. Other agents
Corynebacterium parvum Walker-Renard PB et al. Ann Intern Med
1994;120:56-64
Nitrogen mustard Kinsey DL et al. Arch Surg 1964;89:389-91
OK-432 Kishi K et al. Eur Respir J 2004;24:263-6
Quinacrine Ukale V et al. Lung Cancer 2004;43:323-8
28. Talc is the most effective sclerosant available for
pleurodesis. (A)
Graded talc should always be used in preference to
ungraded talc as it reduces the risk of arterial
hypoxaemia complicating talc pleurodesis. (B)
Talc pleurodesis is equally effective when
administered as a slurry or by insufflation. (B)
Roberts ME et al. Thorax 2010;65(Suppl 2):32-40
29. Talc Pleurodesis for the Management of Malignant Pleural
Effusions in Japan
Intern Med 52: 1173-1176, 2013
Talc pleurodesis is an effective and safe treatment for the
management of malignant pleural effusion
in Japanese patients.
30. TP was significantly more effective than TS;
both methods were safe but TS had a higher
incidence of thoracic pain during the procedure
Talc poudrage versus talc slurry in the treatment of
malignant pleural effusion.
A prospective comparative study
Alessandro Stefani, Pamela Natali, Christian Casali,
Uliano Morandi
European Journal of Cardio-thoracic Surgery 30 (2006)
827—832
31. •18 RCTs and
2 non-RCTs
• 1,525 patients
with MPE who
underwent
pleurodesis
Xia H et al. PLoS ONE 2014;9(1):e87060.
32. Efficacy and Safety of Talc Pleurodesis for
Malignant Pleural Effusion: A Meta-Analysis
PLoS ONE 9(1):January 27, 2014
The success rate of talc pleurodesis was significantly
higher than that of control therapies (relative risk,
1.21; 95% confidence interval, 1.01–1.45;p = 0.035)
with similar adverse events. In addition,
thoracoscopic talc poudrage was more effective than
bedside talc slurry (relative risk, 1.12; 95%
confidence interval, 1.01–1.23; p = 0.026).
33. Both methods of talc delivery are similar in efficacy; TTI may be better for
patients with either a lung or breast primary
Dresler CM et al. Chest 2005; 127:909-15.
35. 3 hrs.Post-”poudrage” 3 hrs. Post-”slurry”
TALC “SLURRY”: Is the patientreceiving
the RIGHT DOSE OF TALC?
(Adapted from Rodriguez-Panadero et al, Eur Respir J 2006;28:200-218)
36. Thoracoscopic talc poudrage:
observational studies
Viallat JR et al. Chest 1996;110:1387-93
360 patients with MPE, 90.2% success rate at 1 month and 82.1% life-
long pleural symphysis
Ribas Milanez de Campos et al. Chest 2001;119:801-6
393 patients with MPE, success rate: 96.4% for breast cancer and 93.4%
for other malignancies
Kolschmann S et al. Chest 2005; 128:1431–5
102 consecutive patients with MPE, success rate was 89.4% at 1 month
and 82.6% at 6 months
Rodriguez-Panadero F et al. Respiration 2012;83:91-8
460 patients with MPE, success rate: 87.4%
37.
38. TTI (=“Talc poudrage” was performed in general
anesthesia and double-lumentracheal intubation!!
TYPE OF TALC NO SPECIFIED,
NOR SIZE OF PARTICLES!!
45. Multicentre (13 European
hospitals, and one in South
Africa), open-label, prospective
cohort study of 558 patients with
malignant pleural effusion who
underwent thoracoscopy and talc
poudrage with 4 g of calibrated
French large-particletalc
Janssen JP et al. Lancet 2007; 369: 1535-9
46. Betadine for pleurodesis
Study Comments
Olivares-Torres CA et al.
Chest 2002;122:581-3
Prospective study, CRR: 50/52
(96.1%), mean follow-up: 13±1.46
months, 3 patients intense pleuritic
pain
Agarwal R et al.
Respirology 2006;11:105-8
Prospective study, CRR: 32/37
(86.5%), mean follow-up: 5 months
Neto JD et al.
Respirology 2010;15:115-8
Retrospective study, 61 procedures
in 54 patients, success rate: 98.4%,
mean follow-up: 5.6 months
Mohsen TA et al.
Eur J Cardiothorac Surg 2011;40:282-6
RCT, MPE due to breast cancer,
success rate: 20/22 (91%) with talc
poudrage and 17/20 (85%) with
betadine
47. IN SUMMARY: (Up to date)talc is the sclerosantof choice
for controlof malignant pleural effusions
• Achieves control of effusions in about 90% of the cases
• It can be used as poudrage (preferred)or slurry.
• Low cost
• Low rate of complications in large series
• BE CAREFUL ABOUT:
• - USING TRUE TALC
• - SIZE OF TALC PARTICLE
• - AVOID USE OF PRESSURIZED SPRAYS (can be very cold and with
additives as propellents)
• - GIVE PROPHYLACTIC HEPARIN
48. Careful selection of patient and the appropriate
procedure is the first step to successful management
Graded talc is the sclerosing agent of first choice
As medical thoracoscopy is the gold standard for every
undiagnosed pleural effusion, in case of MPE talc
poudrage at the same time is absolutely indicated
The opportunity of TPCs should always be discussed
with the patient
49. Pleurodesis: practical issues (1)
Small-bore chest tubes are equally effective with large-bore
Negative pressure should be applied after 24 hours if there is
no full lung expansion
Corticosteroids and NSAIDs reduce the success rate
Do not administer sclerosing agent in case of trapped lung
It is not necessary to wait for fluid production <150 ml/24h if
there is full lung reexpansion
Caglayan B et al. Ann Surg Oncol 2008;15:2594-9, Teixeira LR et al. Chest 2002;121:216-9, Lardinois D et al.
Eur J Cardiothorac Surg 2004;25:865-71, Villanueva AG et al. Thorax 1994;49:23-5
50. Pleurodesis: practical issues (2)
In case of loculated MPE, administration of fiblinolytics
intrapleurally have been used before pleurodesis
Even though it is a common practice, there are no RCTs
that evaluated the efficacy of intrapleural lidocaine
Rotation of the patient after administration of the agent
does not increase success rate but may reduce pain
There are no RCTs about how many days the chest
tube should remain after the administration of talc (fluid
production <150 ml/24h)
Hsu LH et al. J Thorac Oncol 2006;1:460-7, Lorch DG et al. Chest 1988;93:527-9, Dryser SR et al. Chest
1993;104:1763-6,
