Efficacy and safety of iodopovidone in chemical pleurodesis: A meta-analysis of observational studies

Efficacy and safety of doxycycline versus iodopovidone for pleurodesis through an intercostal tube in malignant pleural effusions: a randomized trial

PURPOSE

The search for an inexpensive agent for chemical pleurodesis in malignant pleural effusion (MPE) continues. We aimed to compare the efficacy and safety of iodopovidone versus doxycycline for pleurodesis in MPE.

METHODS

We randomized consecutive subjects with recurrent symptomatic MPE (1:1) to undergo pleurodesis with either doxycycline or iodopovidone administered through an intercostal tube. The primary outcome was the success rate of pleurodesis at 30 days. The secondary outcomes were the time to pleurodesis, chest pain (assessed using visual analog scale [VAS]) after pleurodesis, and complications (hypotension, acute respiratory failure, empyema).

RESULTS

We randomized 52 and 58 subjects to receive either doxycycline or iodopovidone. The mean (standard deviation [SD]) age of the study population (51% women) was 54.1 (13.6) years. Lung cancer (≥ 60%) was the most common underlying cause of MPE. We observed a similar frequency of success in the doxycycline vs. the iodopovidone group (complete response: 43 (82.7%) vs. 46 (79.3%) subjects; partial response: 7 (13.5%) vs. 10 (17.2%) subjects; p = 0.3). The mean (SD) time to pleurodesis was 1.5 (1.9) days and 1.9 (5.4) days in the doxycycline and iodopovidone groups, respectively. While the VAS for chest pain was significantly higher with iodopovidone (mean [SD] VAS: doxycycline, 31.9 [20.9]; iodopovidone, 41.3 [21.8]; p = 0.017), it did not reach the minimal clinically important difference. The complication rates were similar between the two groups.

CONCLUSION

Iodopovidone was not superior to doxycycline for pleurodesis in MPE. TRIAL REGISTRATION NUMBER/DATE: clinicaltrials.gov (NCT02583282) / October 22, 2015.

Evaluation of the efficacy of several sclerosing agents for pleurodesis in rats

Objective: This study aims to evaluate the efficiencies and effects of different sclerosing agents. Materials and Methods: Thirty-five female Wistar-albino rats were included in this study and divided into five groups randomly. Isotonic saline (group 1), iodopovidone (group 2), rifamycin (group 3), autologous blood (group 4), talc (group 5) were given into intrapleural space. On postoperative 28th day, ipsilateral and contralateral pleural and parenchymal fibrosis and inflammation were evaluated. Results: There were statistically differences between control and other groups on macroscopically pleural fibrosis examination (p=0.004, p=0.001, p=0.001, p=0.000, respectively). Microscopically pleural fibrosis were determined in all groups when compared to control group (p=0.023, p=0.023, p=0.035, p=0.001, respectively). There were no significant differences between sclerosing agent groups (p>0.05). Significant differences were observed according to microscopic pleural inflammation evaluation between talc group and other groups. There was superiority in talc group according to intraparenchymal inflammation grade compared to other groups (p=0.010, p=0.042, p=0.030, respectively). Macroscopically, fibrosis and microscopically, inflammation were significantly observed between talc and other groups in the contralateral pleura (p = 0.037and p=0.009, respectively). Conclusion: Iodopovidone, autologous blood, talc, and rifamycin can be used as effective pleurodesis agents. However, we found that rifamycin and autologous blood are safer as effective pleurodesis agents. We think that these two agents can be used in patients with secondary lung diseases due to their less intraparenchymal inflammation rates. It may be advantageous to prefer other sclerosing agents which has lower costs and less side effects comparing to talc.

Efficacy of hyperthermia pleurodesis: A comparative experimental study on serous membrane of abdominopelvic and thoracic cavities of rats

BACKGROUND

Pleurodesis is a common technique for treating the accumulation of air or liquid in the pleural space caused by pneumothorax or pleural effusion, it is based on the bounding of pleural layers through induced inflammatory lesions. There are several pleurodesis procedures.

OBJECTIVES

To test and describe the inflammatory effect of hyperthermia on the pleural and peritoneal mesothelia of rats, with the aim of testing the effectiveness of this process for inducing pleurodesis.

METHODS

35 Sprague-Dawley (male/female) rats were randomized into four treatment groups: Group A (Talc, 10 individuals); group B (control, 5 individuals); group C (hyperthermic isotonic saline, 10 individuals); and group D (filtrate air at 50°, 10 individuals). Inflammatory effect of hyperthermia was the primary outcome parameter.

RESULTS

In the talc group, minimal adhesions between both pleural and peritoneal layers were observed in seven rats. Talc produced peritoneal mesothelium inflammation and fibrosis associated to foreign body giant cells in 80% (8/10) of the sample. Furthermore, clear evidence of a granulomatous foreign-body reaction was detected. No macroscopic and/or microscopic damage was registered in the remaining three groups (control, hyperthermic, and filtrate air).

CONCLUSIONS

Talc is an excellent method for producing pleuro-peritoneal inflammatory lesions. On the contrary, hyperthermia apparently does not induce the macroscopic and microscopic damage that is required for efficient pleurodesis. Therefore, hyperthermia should not be used for pleurodesis procedures.

The comparison of pleurodesis effects of iodopovidone at different concentrations and magnesium silicate: An experimental study

Background

This experimental study aims to investigate the pleurodesis effects of iodopovidone at different concentrations (2% and 4%) and sterile talc in a rat model.

Methods

Forty male Wistar Albino rats were randomly divided into four equal groups including 10 rats in each group. Groups 1, 2, and 3 were designed as the study, and Group 4 as the control group. In Group 1, 4 g sterile talc was given in the slurry form at 20 mL 0.9% saline solution, in Group 2 and Group 3 10% iodopovidone solution were given at 4% and 2% concentrations, respectively, and in Group 4, 0.9% saline was only administrated as 3 mL into the pleural space. All rats were sacrificed on Day 30 and evaluated for macroscopic and microscopic examination. Microscopic evaluation was performed for alveolar collapse, alveolar hemorrhage, alveolar infiltration and fibrosis. Brain, liver, and kidney tissues were also examined.

Results

Iodopovidone macroscopically caused a significant adhesion similar to sterile talc at a concentration of 4%. The pleurodesis effect of iodopovidone at a concentration of 4% was significantly similar to talc, when microscopic parameters were evaluated. Granulomas due to sterile talc were observed in the opposite hemithorax. Brain, liver, and kidney examinations revealed no systemic distribution for both agents.

Conclusion

Iodopovidone is a powerful alternative to sterile talc with its easy accessibility and low cost. In this study, 4% iodopovidone was found to provide effective and safe pleurodesis in rats. We believe that the use of this concentration in clinical studies would provide more effective results.

Efficacy of hyperthermia pleurodesis: A comparative experimental study on serous membrane of abdominopelvic and thoracic cavities of rats

BACKGROUND

Pleurodesis is a common technique for treating the accumulation of air or liquid in the pleural space caused by pneumothorax or pleural effusion, it is based on the bounding of pleural layers through induced inflammatory lesions. There are several pleurodesis procedures.

OBJECTIVES

To test and describe the inflammatory effect of hyperthermia on the pleural and peritoneal mesothelia of rats, with the aim of testing the effectiveness of this process for inducing pleurodesis.

METHODS

35 Sprague-Dawley (male/female) rats were randomized into four treatment groups: Group A (Talc, 10 individuals); group B (control, 5 individuals); group C (hyperthermic isotonic saline, 10 individuals); and group D (filtrate air at 50°, 10 individuals). Inflammatory effect of hyperthermia was the primary outcome parameter.

RESULTS

In the talc group, minimal adhesions between both pleural and peritoneal layers were observed in seven rats. Talc produced peritoneal mesothelium inflammation and fibrosis associated to foreign body giant cells in 80% (8/10) of the sample. Furthermore, clear evidence of a granulomatous foreign-body reaction was detected. No macroscopic and/or microscopic damage was registered in the remaining three groups (control, hyperthermic, and filtrate air).

CONCLUSIONS

Talc is an excellent method for producing pleuro-peritoneal inflammatory lesions. On the contrary, hyperthermia apparently does not induce the macroscopic and microscopic damage that is required for efficient pleurodesis. Therefore, hyperthermia should not be used for pleurodesis procedures.

Iodopovidone pleurodesis for malignant pleural effusions: an updated systematic review and meta-analysis

BACKGROUND

Chemical pleurodesis is an important option for palliation in malignant pleural effusion (MPE).

OBJECTIVES

To evaluate the status of iodopovidone for pleurodesis in MPE.

METHODS

We performed a systematic review of PubMed and EMBASE databases to identify studies evaluating the role of iodopovidone for pleurodesis in MPE. We calculated the pooled success rate of iodopovidone pleurodesis from observational studies and the risk ratio (RR) of successful pleurodesis (compared to other agents) from randomized controlled trials (RCTs). We pooled the data using the random-effects model. We also assessed the safety of iodopovidone.

RESULTS

We included 26 studies (n = 1132, 15 observational, and 11 RCTs) in our review. The pooled success rate (95% confidence interval [CI]) from 15 observational studies (n = 648) was 90% (86-94). The efficacy rate of iodopovidone was similar with either tube thoracostomy or thoracoscopy. Eleven (n = 484) RCTs compared the efficacy of iodopovidone with other agents (especially bleomycin and talc). We found a similar success rate of iodopovidone compared to other agents with a pooled RR (95% CI) of 0.99 (0.91-1.08). The most frequent adverse event was chest pain. No hypo or hyperthyroidism, or visual disturbance was encountered in any study. There were no deaths attributed to iodopovidone use.

CONCLUSIONS

Iodopovidone is a safe and effective agent for pleurodesis in the management of MPE. Further confirmation is required since the available evidence is limited by the low quality and small sample size of the included studies.

Video-assisted thoracoscopic iodopovidone pleurodesis for malignant pleural effusions in moderate to high-risk Colombian patients

Introduction: In developing countries where talc may not be readily available, video-assisted thoracoscopic (VATS) iodopovidone pleurodesis offers an excellent alternative for the treatment of malignant pleural effusions (MPEs).

Methods: This study analyzes a retrospective experience using VATS iodopovidone pleurodesis for malignant pleural effusions at a single cardiothoracic center in the capital of Colombia evaluating success according to LENT (Lactate, Eastern Cooperative Oncology Group-ECOG, Neutrophil-Lymphocyte ratio, Tumor type) scores. A total of 75 records of patients taken to VATS iodopovidone pleurodesis for MPEs were retrieved from our institutional database during a 5-year period from 2014-2019. Of these, 45 had complete clinical history data necessary to analyze both LENT scores and post-op follow-up imaging.

Results: Of the 45 patients evaluated, 93.3% (42 patients) had either complete resolution of pleural effusions or partial resolution with an asymptomatic recovery within the first month post op. Chest pain was the most common postoperative complaint, which was present in 20% of patients. The mean postoperative ECOG score was 2±1.7. Patients with moderate to high-risk LENT scores had success rates of 96.7% and 92.3% respectively.

Conclusion: Video-assisted thoracoscopic pleurodesis using Iodopovidone-iodine is an effective approach for MPEs. In developing countries where Iodopovidone iodine is readily available and affordable, patients may benefit from this agent with excellent results and minimal complications.

A study of efficacy and safety of tranexamic acid versus iodopovidone in pleurodesis via pigtail catheter in management of recurrent pleural effusion

Background

Researches to detect the ideal agent for pleurodesis are still continuous; iodopovidone is one of the best agents for pleurodesis that are commonly used. Tranexamic acid is also considered by many authors as a safe, cheap, and effective agent for pleurodesis.

Results

Group I (patients subjected to pleurodesis using tranexamic acid) had a higher complete response with a success rate 88% compared with 76% for group II (patients subjected to pleurodesis using iodopovidone) at the end of the study in 12 weeks. Complications were nearly equal in both groups. Chest pain, hypotension, and fever were the most common reported complications.

Conclusions

Tranexamic acid and iodopovidone were found to be effective alternative agents for pleurodesis with low cost and minimal complications.

The effect of iodopovidone versus bleomycin in chemical pleurodesis

Background Malignant pleural effusion continues to be a common problem in patients with metastatic disease. This study was conducted to compare the efficacy and safety of bleomycin pleurodesis with povidone-iodine pleurodesis through a chest drain as palliative treatment for recurrent malignant pleural effusion. Methods Sixty cancer patients (36 males and 24 females) with recurrent malignant pleural effusion were enrolled in a prospective randomized trial. Thirty patients received povidone-iodine pleurodesis and 30 received bleomycin pleurodesis. Age, sex, side of the primary pathology, treatment outcome (recurrence and relapse time), and complications were analyzed. Results The mean age was 59.63 ± 7.68 years in the povidone-iodine group and 57.97 ± 9.27 years in the bleomycin group ( p = 0.452). The complications were identical in both groups: 2 (6.7%) patients had chest pain, 2 (6.7%) had fever, and one (3.3%) had hypotension. There was a good response to therapy in 20 (66.7%) patients in the bleomycin group and 25 (83.3%) in the povidone-iodine group ( p = 0.136). Conclusion The results of this study indicate that povidone-iodine should be considered as a selective chemical agent to perform pleurodesis in patients with recurrent malignant pleural effusion because it has the same effect but costs less than bleomycin.

Transudative chylothorax: an uncommon illness due to a common cause

Chylothorax is defined as presence of chyle in the pleural space. It is commonly associated with cardiothoracic surgery, trauma, malignancy or some benign disorders. Transudative chylothorax is uncommon. A 52-year-old man presented with bilateral chylothorax with preceding history of blunt trauma to the chest. On further evaluation, he was diagnosed to have a transudative chylothorax due to cirrhosis of liver with coexisting chylous ascites and evidence of peritoneopleural communication. The patient was managed with diuretics followed by chemical pleurodesis with iodopovidone.

The management of chemical pleurodesis with viscum album in patients with persistent air leakage

Background

Persistent air leak (PAL) after major pulmonary resection or involved with secondary lung disease is prevalent and associated with significant morbidity. Chemical pleurodesis is a practical therapeutic tool to manage the patients with PAL. Among various sclerosing substances, viscum album (fraxini) is considered effective and safe. The aim of this study was to evaluate the efficacy and safety of viscum album pleurodesis in patients with intractable prolonged air leakage.

Methods

Between February 2013 and February 2015, 73 consecutive patients who underwent pleurodesis due to PAL were enrolled in this study. Pleurodesis was performed using 100 mg of viscum album (fraxini) at 1 time through the indwelling chest tube. Main studied outcomes were focused on success rate of pleurodesis assessed on chest radiography and cessation of the air leak after procedure.

Results

The study population was predominantly male (n=64, 87.7%). The overall success rate was 90.4%. One patient died of pneumonia not related to the viscum album pleurodesis. The mean length of stoppage to air leakage was 28.00±22.19 hours. The mean duration of chest tube drainage after pleurodesis was 2.78±1.35 days. The mean number of pleurodesis was 1.38±0.75. Thirty-six patients (49.3%) complained of chest pain requiring a prescription for pain control. There were no major relevant complications or mortalities.

Conclusions

Air leaks remain an important cause of morbidity. This viscum album pleurodesis could be considered as an option for the treatment of prolonged air leak patients, associated with acceptable side effects.

Lymphangioleiomyomatosis Diagnosis and Management: High-Resolution Chest Computed Tomography, Transbronchial Lung Biopsy, and Pleural Disease Management. An Official American Thoracic Society/Japanese Respiratory Society Clinical Practice Guideline

BACKGROUND

Recommendations regarding key aspects related to the diagnosis and pharmacological treatment of lymphangioleiomyomatosis (LAM) were recently published. We now provide additional recommendations regarding four specific questions related to the diagnosis of LAM and management of pneumothoraces in patients with LAM.

METHODS

Systematic reviews were performed and then discussed by a multidisciplinary panel. For each intervention, the panel considered its confidence in the estimated effects, the balance of desirable (i.e., benefits) and undesirable (i.e., harms and burdens) consequences, patient values and preferences, cost, and feasibility. Evidence-based recommendations were then formulated, written, and graded using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach.

RESULTS

For women who have cystic changes on high-resolution computed tomography of the chest characteristic of LAM, but who have no additional confirmatory features of LAM (i.e., clinical, radiologic, or serologic), the guideline panel made conditional recommendations against making a clinical diagnosis of LAM on the basis of the high-resolution computed tomography findings alone and for considering transbronchial lung biopsy as a diagnostic tool. The guideline panel also made conditional recommendations for offering pleurodesis after an initial pneumothorax rather than postponing the procedure until the first recurrence and against pleurodesis being used as a reason to exclude patients from lung transplantation.

CONCLUSIONS

Evidence-based recommendations for the diagnosis and treatment of patients with LAM are provided. Frequent reassessment and updating will be needed.

Efficacy and Safety of Povidone-iodine Pleurodesis in Malignant Pleural Effusions

INTRODUCTION

Malignant pleural effusion (MPE) is determined by the detection of malignant cells in pleural fluid or pleural tissue. Neoplasm of lung, breast, ovary and lymphoma are the causes of more than 75% of MPE. Pleurodesis is a usual technique in the management of MPE to achieve a symphysis between two layers of the pleura, and various chemical agents have been used in an attempt to produce pleurodesis. With regard to complications and limitations of these sclerosing agents, efficacy and safety of povidone-iodine have been investigated in this study.

MATERIALS AND METHODS

Between June 2014 and June 2016, 63 consecutive patients were admitted to the Department of Thoracic Surgery because of symptomatic MPE. After insertion of a chest tube, pleurodesis with instillation of povidone-iodine was performed. Thyroid and renal function tests were checked, and success rate as well as recurrence of MPE was monitored in the next follow-up visits.

RESULTS

The complete response to this procedure was about 53.57%, and failure of treatment was 10.71% with efficacy of 82.2%. The most common complication was pain during instillation (26.9%). Changes in thyroid and renal function tests were not significant.

CONCLUSION

Povidone-iodine is a safe and effective agent with minor side effects in pleurodesis of patients with MPEs and can be used as an accessible and low-cost alternative than other sclerosing agents.

Effectiveness of chemical pleurodesis in spontaneous pneumothorax recurrence prevention: a systematic review

Objectives

Spontaneous pneumothorax is a common pathology. International guidelines suggest pleurodesis for non-resolving air leak or recurrence prevention at second occurrence. This study comprehensively reviews the existing literature regarding chemical pleurodesis efficacy.

Design

We systematically reviewed the literature to identify relevant randomised controlled trials (RCTs), case–control studies and case series. We described the findings of these studies and tabulated relative recurrence rates or ORs (in studies with control groups). Meta-analysis was not performed due to substantial clinical heterogeneity.

Results

Of 560 abstracts identified by our search strategy, 50 were included in our systematic review following screening. Recurrence rates in patients with chest tube drainage only were between 26.1% and 50.1%. Thoracoscopic talc poudrage (four studies (n=249)) provided recurrence rates of between 2.5% and 10.2% with the only RCT suggesting an OR of 0.10 compared with drainage alone. In comparison, talc administration during video-assisted thoracic surgery (VATS) from eight studies (n=2324) recurrence was between 0.0% and 3.2%, but the RCT did not demonstrate a significant difference compared with bleb/bullectomy alone. Minocycline appears similarly effective post-VATS (recurrence rates 0.0–2.9%). Prolonged air leak and recurrence prevention using tetracycline via chest drain (n=726) is likely to provide recurrence rates between 13.0% and 33.3% and autologous blood patch pleurodesis (n=270) between 15.6% and 18.2%.

Conclusions

Chemical pleurodesis postsurgical treatment or via thoracoscopy appears to be most effective. Evidence for definitive success rates of each agent is limited by the small number of randomised trials or other comparative studies.

Outcome of pleurodesis using different agents in management prolonged air leakage following lung resection

BACKGROUND AND AIMS

Prolonged air leaks (PAL) are a common problem after pulmonary resection. PAL can be a source of significant complications. One of the treatment options is chemical pleurodesis.

MATERIAL AND METHODS

The efficiency of three methods of treatment of PAL after lung resection was evaluated. In Iodine_ group aqueous iodine solution (lat.Tinctura Jodi) was applied intrapleurally (30 patients); in Doxycycline_group (34 patients) 200 mg of Doxycyclin was given and in Drainage_group 35 patients were applied Lidocaine solution only.

RESULTS

The group investigated was similar with regard to age [F = 0.04, P = 0.96] and the amount of air leakage (approx. 462 mL/min). The shortest drainage time and hospital stay was observed in the Iodine_group [10.57, P < 0.001]. However, this therapy was connected with strongly perceptible chest pain (P < 0.0001]). The number of case of pneumothorax recurrence was low and it was the same was seen in other methods of treatment [F = 0.87, P = 0.42]. Allergic reactions were not observed. The number of episodes of tachycardia, hypotension, dyspnea, pneumonia, subcutaneus empyema, fluid collection, emphysema, pneumothorax recurrence and number of re-thoracotomies were statistically similar in all three methods of treatment.

CONCLUSION

Iodine pleurodesis can be considered as one of possible treatment methods of PAL after lung resection as it showed favorable results compared with Doxycycline pleurodesis or drainage alone regarding duration of air leakage, hospitalization and pneumothorax recurrence with only slightly increased pleural pain.

Povidone-iodine pleurodesis versus talc pleurodesis in preventing recurrence of malignant pleural effusion

Background

Malignant pleural effusions continue to be a common problem in patients with metastatic disease, leading to a significant reduction in quality of life with progressive dyspnea, dry cough, chest pain and reduced physical activity. This study was conducted to compare the efficacy, safety, and outcome of Talc Powder Pleurodesis (TPP) with Povidone-iodine Pleurodesis (PIP) through a chest drain as a palliative preventive treatment of recurrent malignant pleural effusion.

Methods

A total of 39 neoplastic patients with recurrent malignant pleural effusion were enrolled in a prospective randomized trial. Twenty-one patients received Talc pleurodesis (group A), and eighteen patients (group B) received Povidone-iodine pleurodesis. The continuous variables were expressed as mean values ± standard deviation (SD) and compared using the unpaired t-test. The discrete variables were expressed as percentage and compared using the chi-square test (χ²) test. p-values of less than 0.05 were considered significant.

Results

Our study included 11 males and 28 females, the mean age was (71.0 ± 5.0) years for group A and (70.9 ± 5.1) years for group B (non-significant). Post-procedure analgesic requirements were recorded in both groups. Four patients in each group had fever (>38°C) within 48 hours of the procedure. Both groups achieved good symptomatic relief. There were no in-hospital deaths. The mean post-procedure hospital stay was (4.7 ± 1.2) days for group A and (4.2 ± 1.0) for group B (non-significant). At follow-up recurrence of significant pleural effusion requiring intervention was noted in four and five patients in group A and group B, respectively (non-significant difference).

Conclusion

Povidone-iodine pleurodesis can be considered as a good alternative to Talc pleurodesis for recurrent malignant pleural effusion. The drug is available, cost effective, safe and can be administered through an intercostal drain and repeated if necessary.

Iodopovidone pleurodesis for isolated pulmonary Langerhan's cell histiocytosis in a two year old child

Isolated pulmonary involvement in Langerhans Cell Histiocytosis (LCH) is rare in childhood. The authors report a 2-y-old boy who presented with acute history of fever, cough and respiratory distress; later developed pneumothorax; whose CT thorax showed diffuse pulmonary cystic lucencies bilaterally. Lung biopsy confirmed pulmonary LCH with CD1a positivity. Recurrent spontaneous pneumothoraces are common in patients of pulmonary LCH; which necessitates rapid intervention. The authors share their experience of successfully using iodopovidone in pleurodesis for repeated pneumothorax episodes in this child with rare diagnosis of isolated pulmonary LCH.

Povidone-iodine for persistent air leak in an extremely low birth weight infant

Chemical pleurodesis with povidone-iodine has been used to treat congenital idiopathic chylothorax in neonates. We report successful use of povidone-iodine in an extremely premature infant to treat a pneumothorax that had persisted for more than one week despite high-frequency ventilation.

Pleurodesis with povidone-iodine, as an effective procedure in management of patients with malignant pleural effusion

OBJECTIVE

Overtime, malignant pleural effusion (MPE) arises in advanced-stages of malignancies and frequently heralds a poor prognosis. If the underlying malignancy is chemo sensitive, systemic chemotherapy may control pleural effusion. A common method for the management of the patients with refractory MPE is pleurodesis through the introduction of sclerosing agents such as talc, bleomycin administered/instilled into the pleural cavity. However, the present prospective study aimed to investigate the efficacy and safety of pleurodesis with povidone-iodine (Betadine) in patients with MPE admitted in Sari General Hospital during 2008-2011.

METHODS

Thirty-six patients who underwent pleurodesis by instilling povidone-iodine through a thoracostomy tube, as a bedside procedure were enrolled in the study. For evaluating the effect of povidone-iodine on thyroid gland, the authors measured the thyroid function tests before and after the pleurodesis at 1 week.

RESULTS

The response to this procedure was complete in 26 patients (72.2%) and partial in 7 patients (19.4%). Treatment failure was displayed in 3 patients (8.3%). The overall success rate was 91.6%. In post-procedure, the most common complaints of the patients were pain (35.9%) followed by dyspnea, burning and fever. Povidone-iodine does not affect on thyroid function tests.

CONCLUSIONS

Povidone-iodine is an effective, inexpensive, safe and feasible agent for chemical pleurodesis in management of MPE.

Effectiveness and safety of iodopovidone in an experimental pleurodesis model

OBJECTIVES

Chemical pleurodesis is an important therapeutic tool to control recurrent malignant pleural effusion. Among the various sclerosing agents, iodopovidone is considered effective and safe. However, in a recent study, ocular changes were described after iodopovidone was used in recurrent pneumothorax. The aim of the study was to evaluate the efficacy and morbidity of iodopovidone pleurodesis in an experimental model.

METHODS

New Zealand rabbits were submitted to intrapleural injection of iodopovidone at concentrations of 2%, 4% and 10%. Biochemical (lactic dehydrogenase, proteins, triiodothyronine, free thyroxine, urea and creatinine) and immunological (Interleukin-8 [IL-8], VEGF and TGFβ) parameters were measured in the pleural fluid and blood. After 1, 3, 7, 14 and 28 days, groups of animals were euthanized, and macro- (pleura) and microscopic (pleura and retina) analyses were performed.

RESULTS

An early pleural inflammatory response with low systemic repercussion was observed without corresponding changes in thyroid or renal function. The higher concentrations (4% and 10%) correlated with greater initial exudation, and maximum pleural thickening was observed after 28 days. No changes were observed in the retinal pigment epithelium of the rabbits.

CONCLUSION

Iodopovidone is considered to be an effective and safe sclerosing agent in this animal model. However, its efficacy, tolerance and safety in humans should be further evaluated.

A randomized controlled trial of the efficacy of cosmetic talc compared with iodopovidone for chemical pleurodesis

BACKGROUND AND OBJECTIVE

Talc is an effective and widely used agent for chemical pleurodesis. However, limited availability and high cost hamper the routine use of talc in resource poor countries. In this study, we compared the efficacy and safety of iodopovidone with that of cosmetic talc, for chemical pleurodesis.

METHODS

Patients with recurrent pleural effusions and/or spontaneous pneumothorax were prospectively randomized to undergo pleurodesis with cosmetic talc (5g) or iodopovidone (20mL of a 10% solution) by tube thoracostomy. The cosmetic talc was pretested for impurities (asbestos-free) and particle size (20-60µm), using energy dispersive analysis by X-ray and scanning electron microscopy. The success rate (complete or partial), time to pleurodesis and safety of these two agents was compared.

RESULTS

Pleurodesis was performed in 73 patients (39 with iodopovidone, 34 with cosmetic talc; 56 men, 17 women; mean age 51.7 years; 38 pleural effusions, 35 pneumothoraces). A complete response was obtained in all patients with pneumothorax in both the iodopovidone and talc groups. Among patients with pleural effusions, a complete response was observed in 16/19 and 15/19 patients in the iodopovidone and talc groups, respectively. A partial response was observed in two additional patients from each group. The time to pleurodesis was similar in the two groups. Minor side-effects (fever, chest pain) were observed with similar frequencies in the two groups. None of the patients experienced hypotension or ARDS.

CONCLUSIONS

Iodopovidone and cosmetic talc are equally efficacious and safe agents for chemical pleurodesis.

Intrapleural therapy

Numerous intrapleural therapies have been adopted to treat a vast array of pleural diseases. The first intrapleural therapies proposed focused on the use of fibrinolytics and DNase to promote fluid drainage in empyema. Numerous case series and five randomized controlled trials have been published to determine the outcomes of fibrinolytics in empyema treatment. In the largest randomized trial, the use of streptokinase had no reduction in mortality, decortication rates or hospital days compared with placebo in the treatment of empyema. Criticism over study design and patient selection may have potentially affected the outcomes in this study. The development of dyspnoea is common in the setting of malignant pleural effusions. Pleural fluid evacuation followed by pleurodesis is often attempted. Numerous sclerosing agents have been studied, with talc emerging as the most effective agent. Small particle size of talc should be avoided because of increased systemic absorption potentiating toxicity, such as acute lung injury. Over the past several years, the use of chronic indwelling pleural catheters have emerged as the preferred modality in the treating a symptomatic malignant pleural effusion. For patients with malignant-related lung entrapment, pleurodesis often fails due to the presence of visceral pleural restriction; however, chronic indwelling pleural catheters are effective in palliation of dyspnoea. Finally, the use of staphylococcal superantigens has been proposed as a therapeutic model for the treatment of non-small lung cancer. Intrapleural instillation of staphylococcal superantigens increased median survival by 5 months in patients with non-small cell lung cancer with a malignant pleural effusion.

Unusual thoracic manifestation of metastatic malignant melanoma

Massive pleural effusion due to metastatic malignant melanoma is rare. We report a case of bilateral (massive on left side) pleural effusion as a metastatic manifestation of cutaneous malignant melanoma. In our case, successful outcome of pleurodesis with vincristine is significant as this agent is rarely used.

Diagnosis and management of malignant pleural effusions

Malignant pleural effusions (MPEs) complicate the clinical course of patients with a broad array of malignancies, which are most often due to lymphomas or carcinomas of the breast, lung, gastrointestinal tract or ovaries. Patients may present with a MPE as the initial manifestation of a cancer or develop an effusion during the advanced phases of a known malignancy. In either circumstance, the median survival after presentation with a MPE is 4 months. Effusions may result from direct pleural invasion (MPE) or indirect effects (paraneoplastic effusions), such as impairment of fluid efflux from the pleural space by lymphatic obstruction or pleural effects of cancer radiation or drug therapy. Because only 50% of patients with cancer who develop a pleural effusion during their clinical course have a MPE, careful evaluation of the effusion to establish its aetiology is required to direct therapy. Management is palliative with interventions directed towards decreasing the volume of intrapleural fluid and the severity of associated symptoms.

Recent advances in the diagnosis and management of malignant pleural effusions

Malignant pleural effusions (MPEs) are an important complication for patients with intrathoracic and extrathoracic malignancies. Median survival after diagnosis of an MPE is 4 months. Patients can present with an MPE as a complication of far-advanced cancer or as the initial manifestation of an underlying malignancy. Common cancer types causing MPEs include lymphomas, mesotheliomas, and carcinomas of the breast, lung, gastrointestinal tract, and ovaries. However, almost all tumor types have been reported to cause MPEs. New imaging modalities assist the evaluation of patients with a suspected MPE; however, positive cytologic or tissue confirmation of malignant cells is necessary to establish a diagnosis. Even in the presence of known malignancy, up to 50% of pleural effusions are benign, underscoring the importance of a firm diagnosis to guide therapy. Rapidly evolving interventional and histopathologic techniques have improved the diagnostic yield of standard cytology and biopsy. Management of an MPE remains palliative; it is critical that the appropriate management approach is chosen on the basis of available expertise and the patient's clinical status. This review summarizes the pathogenesis, diagnosis, and management of MPE. Studies in the English language were identified by searching the MEDLINE database (1980-2007) using the search terms pleura, pleural, malignant, pleurodesis, and thoracoscopy.

Who Gains Most? A 10-Year Experience With 611 Thoracoscopic Talc Pleurodeses

BACKGROUND

Thoracoscopic talc pleurodesis is a therapeutic option for recurrent pleural effusion.

METHODS

This retrospective study included 611 patients who underwent thoracoscopic talc pleurodesis between 1994 and 2003. We analyzed the risk factors, efficiency, outcome, follow-up, and survival, while taking into consideration primary disease and general condition.

RESULTS

The mean follow-up was 319 days (range, 31 to 1994). A total of 105 (17.2%) of 611 patients died within 30 days after treatment. Risk factors for death within 30 days included a Karnofsky index of less than 50%, a body mass index of less than 25 kg/m2, malignant disease, and male gender. Treatment was successful in 347 (68.6%) of 506 patients, and 451 (89.1%) reported an improvement in symptoms. Previous thoracic irradiation and a chest tube drainage time exceeding 10 days negatively influenced the outcome of pleurodesis. The survival rate was negatively influenced by a preoperative Karnofsky index of less than 60% and by malignant disease.

CONCLUSIONS

Patients with pleural effusion due to malignant disease gain from early pleurodesis. The most favorable outcome after talc pleurodesis was seen in women whose lungs were fully expandable, in patients whose Karnofsky index exceeded 60%, in patients whose body mass index was greater than 25 kg/m2, and in patients with benign disease.