Intrapleural talc for the prevention of recurrence in benign or undiagnosed pleural effusions

Effectiveness and safety of povidone iodine for prolonged lung air-leak after lung surgery

BACKGROUND

Pulmonary surgery is often associated with postoperative prolonged parenchymal air-leak. The purpose of this study was to determine efficacy and safety of povidone iodine as treatment of prolonged parenchymal air-leak following all-types of lung surgery.

METHODS

This prospective trial was conducted from June 2019 to December 2020, and designed under PanAfrican Clinical Trials Registry requirements. Patients having prolonged parenchymal air-leak were randomly allocated to povidone iodine protocol (Group A) or surveillance without povidone iodine (Group B). We collected the number of povidone iodine injections required before bubbling stopped, total drainage period, tolerance after injection, complications and side-effects. Comparative study was performed to evaluate povidone iodine efficacy.

RESULTS

Following randomization, Group A included 19 patients, and Group B 21. Both groups were comparable. The mean drainage period was 9.21 days in Group A (6-14 days) and 15.62 days in Group B (7-31 days) (p = 0.001). The mean hospitalization period was 11.05 days in Group A (7-16 days) and 18.9 days in Group B (9-38 days) (p < 0.0001). The mean follow-up period was 6.8 months (3-18 months). No deaths were noted in either groups. Four side-effects were reported in Group A (21%) and four serious complications were noticed in Group B (19%). No recurrences were reported in Group A versus one recurrence of homolateral pneumothorax in Group B (4.76%).

CONCLUSIONS

Povidone iodine is an effective and safe solution for pleurodesis. It is associated with a low complication rate that remains acceptable, and could be proposed as treatment of prolonged parenchymal air-leak after lung resections.

Chylous Cardiac Tamponade with Chylothoraces Secondary to Hodgkin's Lymphoma: Octreotide in Conjuncture with Standard of Care Dietary Fat Restriction

Chylous effusions are a well-known complication from a variety of etiologies including trauma, malignancies, and anatomic defects, with the most common location being in the pleural space. A pericardial chylous effusion (chylopericardium) is uncommon, and a chylopericardium with concomitant bilateral chylous pleural effusions (chylothoraces) has only been reported in less than a handful of case reports. Our patient presented with bilateral chylothoraces and a chylopericardium with tamponade physiology secondary to Hodgkin's Lymphoma. In this article, we discuss our treatment of this patient with the somatostatin analogue octreotide, as well as the standard of care dietary fat restriction, in order to control these effusions until the patient's chemotherapy took effect.

Chylothorax Associated with Substernal Goiter in Graves' Disease Treated with Radioactive Iodine

INTRODUCTION

We present a rare case of chylothorax associated with an intrathoracic goiter in Graves' disease that was treated with radioactive iodine.

CASE REPORT

A 23-year-old woman with Graves' disease was referred to our clinic with a pleural effusion, dyspnea, characteristic bilateral proptosis, and a diffuse goiter. The pleural fluid biochemistry was consistent with chylothorax. However, the chylothorax did not decrease with conservative therapy. Therefore, RAI was administered. Subsequently, the chylothorax and goiter improved more quickly than expected.

CONCLUSIONS

This case illustrates that chylothorax associated with a substernal goiter in Graves' disease can be treated successfully with radioactive iodine instead of surgery.

Effectiveness and Safety of Pleurodesis for Hepatic Hydrothorax: A Systematic Review and Meta-Analysis

BACKGROUND

Hepatic hydrothorax (HH) is a serious complication of end-stage liver diseases, which is associated with poor survival. There is no consensus regarding the treatment of HH.

AIM

To evaluate the effectiveness and safety of pleurodesis for HH in a systematic review with meta-analysis.

METHODS

All relevant papers were searched on the EMBASE and PubMed databases. As for the data from the eligible case reports, the continuous data were expressed as the median (range) and the categorical data were expressed as the frequency (percentage). As for the data from the eligible case series, the rates of complete response and complications were pooled. The proportions with 95 % confidence intervals (CIs) were calculated by using random-effect model.

RESULTS

Twenty case reports including 26 patients and 13 case series including 180 patients were eligible. As for the case reports, the median age was 55 years (range 7-78) and 15 patients were male. The prevalence of ascites was 76 % (19/25). Seventeen (65.38 %) patients responded favorably to pleurodesis. As for the case series, the mean age was 51.5-63.0 years and 83 patients were male. The pooled prevalence of ascites was 90 % (95 % CI 81-97 %) in 7 studies including 71 patients. The complete response rate after pleurodesis was reported in all studies, and the pooled rate was 72 % (95 % CI 65-79 %). Complications related to pleurodesis were reported in 6 studies including 63 patients, and the pooled rate was 82 % (95 % CI 66-94 %).

CONCLUSION

Pleurodesis may be a promising treatment for HH, but carries a high rate of complications.

The efficacy of indwelling pleural catheter placement versus placement plus talc sclerosant in patients with malignant pleural effusions managed exclusively as outpatients (IPC-PLUS): study protocol for a randomised controlled trial

Background

Malignant pleural effusions (MPEs) remain a common problem, with 40,000 new cases in the United Kingdom each year and up to 250,000 in the United States. Traditional management of MPE usually involves an inpatient stay with placement of a chest drain, followed by the instillation of a pleural sclerosing agent such as talc, which aims to minimise further fluid build-up. Despite a good success rate in studies, this approach can be expensive, time-consuming and inconvenient for patients. More recently, an alternative method has become available in the form of indwelling pleural catheters (IPCs), which can be inserted and managed in an outpatient setting. It is currently unknown whether combining talc pleurodesis with IPCs will provide improved pleural symphysis rates over those of IPCs alone.

Methods/Design

IPC-PLUS is a patient-blind, multicentre randomised controlled trial (RCT) comparing the combination of talc with an IPC to the use of an IPC alone for inducing pleurodesis in MPEs. The primary outcome is successful pleurodesis at five weeks post-randomisation. This study will recruit 154 patients, with an interim analysis for efficacy after 100 patients, and aims to help to define the future gold standard for outpatient management of patients with symptomatic MPEs.

Discussion

IPC-PLUS is the first RCT to examine the practicality and utility of talc administered via an IPC. The study remains in active recruitment and has the potential to significantly alter how patients requiring pleurodesis for MPE are approached in the future.

Trial registration

This trial was registered with Current Controlled Trials (identifier: ISRCTN73255764) on 23 August 2012.

A Rare Case of Chylothorax due to Pulmonary Lymphangiectasia in a 7-Year-Old Boy

Pulmonary lymphangiectasia (PL) is a rare condition characterized by dilatation of the lymphatic vessels. Post-neonatal PL is usually associated with pleural effusion and should therefore be suspected in the presence of chylothorax. We describe a post-neonatal manifestation of PL in a 7-year-old boy presenting chylothorax. Radiological examinations included thorax X-ray, ultrasound, and computed tomography scans. After the failure of conservative management (maintenance of the chest tube, total parenteral nutrition, administration of somatostatin synthetic analogues) we performed a thoracoscopic massive ligation of the thoracic duct's collateral along with a lung biopsy. Histology was compatible with type 1 congenital pulmonary lymphangectasia. One month after surgery a thoracoscopic pleurodesis was required for persistent chylothorax. The boy is now doing well 1 year after surgery.

Pleural effusion: diagnosis, treatment, and management

A pleural effusion is an excessive accumulation of fluid in the pleural space. It can pose a diagnostic dilemma to the treating physician because it may be related to disorders of the lung or pleura, or to a systemic disorder. Patients most commonly present with dyspnea, initially on exertion, predominantly dry cough, and pleuritic chest pain. To treat pleural effusion appropriately, it is important to determine its etiology. However, the etiology of pleural effusion remains unclear in nearly 20% of cases. Thoracocentesis should be performed for new and unexplained pleural effusions. Laboratory testing helps to distinguish pleural fluid transudate from an exudate. The diagnostic evaluation of pleural effusion includes chemical and microbiological studies, as well as cytological analysis, which can provide further information about the etiology of the disease process. Immunohistochemistry provides increased diagnostic accuracy. Transudative effusions are usually managed by treating the underlying medical disorder. However, a large, refractory pleural effusion, whether a transudate or exudate, must be drained to provide symptomatic relief. Management of exudative effusion depends on the underlying etiology of the effusion. Malignant effusions are usually drained to palliate symptoms and may require pleurodesis to prevent recurrence. Pleural biopsy is recommended for evaluation and exclusion of various etiologies, such as tuberculosis or malignant disease. Percutaneous closed pleural biopsy is easiest to perform, the least expensive, with minimal complications, and should be used routinely. Empyemas need to be treated with appropriate antibiotics and intercostal drainage. Surgery may be needed in selected cases where drainage procedure fails to produce improvement or to restore lung function and for closure of bronchopleural fistula.

A case series: Egyptian experience in using chemical pleurodesis as an alternative management in refractory hepatic hydrothorax

INTRODUCTION

Chemical pleurodesis is an effective treatment for malignant effusion and pneumothorax. Although this mode of therapy is less widely accepted in treatment of patients with hepatic hydrothorax, the need for palliative treatment in such patients encouraged us to do this work. The aim of study was analysing the outcome of chemical pleurodesis using bovoiodine, Vibramycin and talc slurry in treatment of hepatic hydrothorax.

MATERIAL AND METHODS

A case series randomized study including 23 patients with symptomatic right side hepatic hydrothorax not responding to medical treatment and repeated thoracocentesis was conducted. From March 2007 to March 2008, 19 men and 4 women with a mean age of 54.3 ±8.1 years (range 42-70 years) underwent medical thoracoscopies to achieve pleurodesis by application of 3 sclerosing agents.

RESULTS

Out of the 23 patients pleurodesis was repeated in 20 cases. Three cases did not attend their follow-up so their responses to pleurodesis are not known. The follow-up period of the study was 3 months. The procedure was effective in 15 of 20 patients (75%): 7/8 cases treated with bovoiodine (87.5%), and 4/6 cases with Vibramycin and talc slurry (66.7%) for each. There were 4 recurrences (20%) and a single case of mortality (5%) due to hepatic coma which can be attributed to the course of the disease. We detected minimal morbidity during the follow-up period of 3 months.

CONCLUSIONS

The procedure appears to be indicated for these fragile patients especially when medical therapy fails. Chemical pleurodesis deserves to be considered as an alterative therapy in such patients.

[Bilateral Chylothorax after delivery: an infrequent case treated with videothoracoscopic talc pleurodesis]

Bilateral chylothorax after delivery is a highly infrequent entity. We present the case of a 28-year-old woman who developed progressive dyspnea due to bilateral milky pleural effusion several months after delivery. The effusion was found to contain chylomicrons in the biochemical analysis. Initial conservative treatment failed twice and the chylothorax was successfully treated through sequential bilateral videothoracoscopy with an interval of 6 days between the two interventions and pleurodesis with spray talc.

Pleural effusions of extravascular origin

Most pleural effusions are caused by hydrostatic and oncotic pressure imbalance, inflammation or infection, or abnormalities in lymphatic drainage. A select number of effusions are caused by fluid of extravascular origin. Some of these effusions result from complications of treatment, whereas others are a ramification of the underlying disease. The incidence, pathogenesis, clinical presentation, chest radiographic manifestations, pleural fluid analysis, diagnosis, and management are discussed.

Chylothorax after heart/lung transplantation

Chylothorax is a potentially serious complication of lung and heart-lung transplantation. This article describes the clinical course of chylothorax in 3 heart-lung allograft recipients. We discuss management options, including dietary modifications, octreotide infusion, thoracic duct ligation and embolization, and surgical pleurodesis. In addition, we describe the novel use of aminocaproic acid to reduce lymph flow. We propose a multidisciplinary approach for the management of chylothorax that includes both medical and surgical options.

Pleural Effusions in Hematologic Malignancies

Nearly all hematologic malignancies can occasionally present with or develop pleural effusions during the clinical course of disease. Among the most common disorders are Hodgkin and non-Hodgkin lymphomas, with a frequency of 20 to 30%, especially if mediastinal involvement is present. Acute and chronic leukemias, myelodysplastic syndromes, are rarely accompanied by pleural involvement. Furthermore, 10 to 30% of patients receiving bone marrow transplantation develop pleural effusions. In cases of hematologic pleural effusions, drug toxicity, underlying infectious, secondary malignant or rarely autoimmune causes should be carefully sought. In most cases, the pleural fluid responds to treatment of the primary disease, whereas resistant or relapsing cases may necessitate pleurodesis.

Hepatic hydrothorax

A hepatic hydrothorax is a pleural effusion that develops in a patient with cirrhosis and portal hypertension in the absence of cardiopulmonary disease. The pleural effusion is derived from ascitic fluid that enters the chest because of the negative pressure within the pleural space via defects in the diaphragm. The peritoneal-to-pleural flow of fluid can be demonstrated by nuclear scanning, even when the ascites is not clinically apparent. The pleural fluid usually has the characteristics of a transudate. However, an occasional patient with hepatic hydrothorax will develop spontaneous bacterial pleuritis manifest by increased pleural fluid neutrophils or a positive bacterial culture and will require antibiotic therapy. Treatment of the hydrothorax is directed at the underlying liver disease but a dyspneic patient can obtain relief from a thoracentesis or paracentesis. When medical therapy fails, liver transplantation is the treatment of choice. Both transjugular intrahepatic portosystemic shunting and thoracoscopic repair of diaphragmatic defects with pleural sclerosis can provide symptomatic relief, but the morbidity and mortality of these procedures are high because of the fragile nature of the patients.

State of the art in thoracospic surgery: a personal experience of 2000 videothoracoscopic procedures and an overview of the literature

BACKGROUND

Herein we compare our personal experience with a series of > 2000 videothoracoscopic procedures with those reported in the literature to identify the procedures now accepted as the gold standard, those still regarded as investigational, and those considered unacceptable.

METHODS

Between June 1991 and December 2000, we performed 2068 videothoracoscopic procedures, including lung cancer staging (n = 910), wedge resections (n = 261), lobectomies (n = 221), pneumonectomies (n = 6), the diagnosis and treatment of pleural diseases (n = 200), the treatment of pneumothorax (n = 170), giant bullae (n = 57), lung volume reduction surgery (LVRS) for emphysema (n = 41), the diagnosis and treatment of mediastinal diseases (n = 133), the treatment of esophageal diseases (n = 39), and 30 other miscellaneous procedures.

RESULTS

A review of the literature indicates that videothoracoscopy is usually considered the preferred approach for the treatment of spontaneous pneumothorax, the diagnosis of indeterminate pleural effusions, the treatment of malignant pleural effusions, sympathectomy, and the diagnosis and treatment of benign esophageal or mediastinal diseases. The videoendoscopic approach to LVRS for emphysema is still under evaluation. Videothoracoscopic wedge resections for the diagnosis of indeterminate nodules and the treatment of primary lung cancer, metastases, and other malignancies are still controversial due to oncologic concerns. Videoendoscopic major pulmonary resections are usually considered investigational or even unacceptable due to oncologic concerns, technical difficulties, and the risk of complications.

CONCLUSIONS

Although we generally agree with the foregoing recommendations, we consider videoendoscopy the best approach for LVRS and particularly useful for the staging of lung cancer, where we always perform it as the first step of the operation. We widely perform videoendoscopic major pulmonary resections, but we believe that these procedures should only be used in strictly selected cases and at specialized centers.

Serious complications with talc slurry pleurodesis

OBJECTIVE

Talc is a highly efficacious and commonly employed agent for chemical pleurodesis, which has generally been felt to be well tolerated. However, increasing reports of adult respiratory distress syndrome (ARDS) have heightened safety concerns. A recent case of ARDS prompted us to review our experience with talc pleurodesis.

METHODOLOGY

We conducted a retrospective review of all patients who received talc slurry pleurodesis at Green Lane Hospital, Auckland, New Zealand, between 1 January 1998 and 31 December 1999 and documented all complications occurring within 48 h of the procedure.

RESULTS

Thirty-three talc pleurodesis were performed on 29 patients, most commonly for a malignant pleural effusion. Complications occurred in 15 patients (52% of procedures). Minor complications included tachycardia (n = 11; 33%), pain (n = 9; 27%), fever (n = 8; 24%) and dyspnoea (n = 4; 12%). Major complications occurred in seven patients with hypoxaemia and hypotension. Two of these patients died; one death directly attributable to ARDS, the other hastened by a talc pleurodesis-related tachycardia.

CONCLUSIONS

These results challenge the assumption that talc pleurodesis is a safe procedure. There were a significant number of serious complications, including a death, from ARDS. Physicians and patients should be aware that complications occur frequently after talc pleurodesis which may be life-threatening or fatal.

Thoracoscopy talc poudrage : a 15-year experience

OBJECTIVES

To review our experience with thoracoscopy and talc poudrage during the previous 15 years with regards to efficacy, side effects, morbidity, and mortality.

METHODS

Six hundred fourteen consecutive patients (58.6% female; mean age, 54.5 years) underwent thoracoscopy with talc poudrage from August 1983 to May 1999. Of these, 457 patients had malignant pleural effusions, 108 patients had benign pleural effusions, and 49 patients had spontaneous pneumothorax.

RESULTS

Sixty-four patients were excluded from evaluation for efficacy: 30 patients (4.9%) because the lung did not expand at the time of the procedure and 34 patients (5.5%) because they died within 30 days of the thoracoscopy. All exclusions were in the malignant group. The overall success rate of the 393 patients with malignant pleural effusions was 93.4%, while the overall success for the 108 patients with benign effusions was 97%, although 7 patients (7%) with benign effusions required a second thoracoscopy. The success rate with pneumothorax was 100%. Major morbidity included empyema in 4%, reexpansion pulmonary edema in 2.2%, and respiratory failure 1.3%.

CONCLUSION

Thoracoscopy with talc poudrage is effective in producing a pleurodesis in malignant and benign pleural effusion and in spontaneous pneumothorax. However, it should be noted that the insufflation of talc has a systemic distribution associated with a low rate of morbidity and perhaps does induce ARDS, which is sometimes fatal in a small percentage of patients. Because of these side effects, the search for a better agent should be continued.

Thoracoscopy and talc poudrage in the management of hepatic hydrothorax

STUDY OBJECTIVE

To determine indications, limitations, morbidity and mortality of surgical thoracoscopy for management of hepatic hydrothorax, a rare, but often recurrent, complication in cirrhotic patients.

PATIENTS AND METHODS

From May 1985 through May 1999, 10 men and 8 women, with a mean age of 57.6 years (range, 26 to 76 years), underwent 21 therapeutic thoracoscopies to achieve pleurodesis by application of talc.

RESULTS

The procedure was effective in 10 of 21 procedures. There were four recurrences (19. 1%) that were retreated, with only one being successful. In this specific group, we detected high morbidity (57.1%) and mortality (38.9%) during the follow-up period of 3 months. Diaphragmatic defects were localized and closed five times (23.8%). Hospital stay was approximately 15 days (range, 5 to 41 days).

CONCLUSION

The procedure appears to be indicated for these fragile patients, especially when medical therapy fails. Immediate efficacy was 47.6%, increasing to 60% with videothoracoscopy and suture of the diaphragmatic defect. However, morbidity and mortality were high.

Successful talc slurry pleurodesis in patients with nonmalignant pleural effusion

BACKGROUND

Chemical pleurodesis is an effective treatment for malignant pleural effusion and pneumothorax. This mode of therapy is, however, less widely accepted in the treatment of patients with refractory benign or undiagnosed pleural effusion.

STUDY OBJECTIVES

To analyze the outcome of talc slurry pleurodesis in patients with nonmalignant pleural effusions.

DESIGN

Retrospective and partly prospective analysis of clinical outcome.

SETTING

Hadassah University Hospital, Jerusalem, Israel.

PATIENTS AND PARTICIPANTS

Between 1992 and 1997, we treated 16 patients with nonmalignant pleural effusion using talc slurry pleurodesis. The cause of effusion was congestive heart failure in 6 patients, liver cirrhosis in 4 patients, yellow nail syndrome in 1 patient, systemic lupus erythematosus in 1 patient, chylothorax in 1 patient, and undiagnosed in 3 patients.

INTERVENTIONS

Nine patients were hospitalized, and seven patients received treatment in a day-care setting. Follow-up ranged from 2 months to 3 years.

RESULTS

Complete success was observed in 12 cases (75%), partial success in 3 cases (19%), and pleurodesis was ineffectual in 1 case (6%). There were no significant complications after the procedure in any of our patients. A review of the English-language medical literature revealed an additional 110 reported cases of nonmalignant pleural effusion that were treated with chemical pleurodesis. Of these cases, talc was used in 65% with a success rate of nearly 100%.

CONCLUSIONS

Chemical pleurodesis, and specifically talc slurry, is an effective treatment for recurrent benign or undiagnosed pleural effusion. This procedure is safe and easily performed and, in selected cases, can be performed in an outpatient day-care setting.

Thoracoscopy and video-assisted thoracic surgery

Thoracoscopy is an old technique that has been recently revived with the development of video-endoscopic technology. Video-assisted thoracic surgery (VATS) is now an established surgical approach with proven benefits in the management of pleural diseases. It has been found to be particularly useful in establishing the diagnosis of pleural metastasis with an option for treatment. It also has an established therapeutic role in the management of the fibrinopurulent phase of empyema and the treatment of hemothorax. The technique is still continually evolving, and refinement of instrumentation promises to further reduce surgical trauma in selected procedures.

Respiratory failure following talc pleurodesis

BACKGROUND

Sterile talc is currently the agent of choice for pleurodesis. Its success rate is excellent, and talc is generally well tolerated. However, a recent experience with fulminant pneumonitis following talc pleurodesis prompted a review of our experience.

METHODS

A retrospective review of patients undergoing talc pleurodesis at our institution between December 1993 and December 1997 was performed, documenting respiratory and other complications. Statistical analysis was performed using Student's t test and Pearson correlations.

RESULTS

Seventy-eight patients received 89 talc pleurodesis procedures. Respiratory complications or death occurred in 33%; 9% of patients developed adult respiratory distress syndrome. There was no statistical difference in outcomes between patient groups, methods of application, or talc dosages utilized.

CONCLUSIONS

This series revealed a significantly higher rate of serious complications than that reported in the current literature, without implicating a clear reason for these outcomes. Our data raise questions about the safety of talc pleurodesis.

Systemic distribution of talc after intrapleural administration in rats

STUDY OBJECTIVES

Many reports have shown the efficacy of talc to induce an effective pleurodesis. However, there is little information about the side effects related to this sclerosing agent. The objective of this experimental study is to recognize the systemic distribution of talc after its instillation into the pleural space of rats.

DESIGN

Forty animals were assigned to receive talc through a catheter placed in a left minimal thoracotomy. They were randomly divided in two groups: group 1 received 20 mg of talc and group 2 received 10 mg in the same total volume of 1 mL of saline solution. Half of the animals in each group were killed 24 h and the other half 48 h after the procedure. BAL was collected and histologic sections of both lungs, chest wall, liver, kidneys, spleen, heart, and brain were examined. Crystals were tracked using polarized light and we have used a "birefringent particles index of deposition" in an attempt to quantify the amount or talc encountered in different organs.

RESULTS

Talc crystals were found in every organ of all animals studied (100%). There was no statistical difference either on the dose of talc used or in the time of death. The amount of talc was statistically different in the organs, which made us divagate about a route of absorption.

CONCLUSIONS

We conclude that there is a progressive deposition of talc particles in the organs examined after its administration into the pleural space of normal rats. This report suggests that there is a rapid absorption of talc through the pleural surface and that the systemic distribution thereafter is not dose related. Further studies are necessary to assess the amount of crystals and the clinical correlation to these findings.

Medical thoracoscopic talc pleurodesis for chylothorax due to lymphoma: a case series

STUDY OBJECTIVES

Recurrent chylothorax as a complication of lymphoma has had unsatisfactory outcomes. Serial thoracentesis, tube thoracostomy, and pleurodesis via chest tube have been ineffective and compromise the nutritional and immune status of the patient. Medical thoracoscopic talc pleurodesis has been safe and effective in the treatment of some other varieties of recurrent pleural effusions. Our objective was to investigate the safety and efficacy of medical thoracoscopic talc pleurodesis in the palliation of chylothorax related to lymphoma.

DESIGN

This is a report of 24 hemithoraces treated in 19 consecutive patients with lymphoma-related chylothorax, failing chemotherapy or radiation therapy. The average patient age was 55 years.

INTERVENTIONS

Medical thoracoscopy was performed under local anesthesia and conscious sedation in a bronchoscopy suite. Sedation included midazolam (mean dose, 6 mg; range, 2-14 mg) with either meperidine (mean dose, 94 mg; range 25-140 mg), or morphine (mean dose, 18 mg; range 4-40 mg). Pleurodesis was performed with insufflation of sterile asbestos-free talc, (4-8 g). After pleurodesis, chest tubes were placed, with the mean duration of chest tube placement being 4 days, range 3 to 10 days.

RESULTS

One patient died a few days after the procedure due to causes related to the primary disease process. Follow-up was for at least 90 days following the procedure. Patients were assessed at 30, 60, and 90 days following the procedure. At each of these endpoints, all patients remaining alive were without recurrence of pleural effusions, which was confirmed by chest radiography. Eight patients in the series died of the effects of their malignancy during the 90-day evaluation interval. Complications included medication reactions in two patients (8.3%) and ARDS in one patient (4.1%).

CONCLUSION

Many patients with lymphoma-related chylothorax are refractory to chemotherapy and/or radiation therapy. In this group, medical thoracoscopic talc pleurodesis has an acceptable complication rate and a 100% success rate in the prevention of recurrence of pleural effusions at 30, 60, and 90 days following the procedure.

Prospective randomized trial of talc slurry vs bleomycin in pleurodesis for symptomatic malignant pleural effusions

OBJECTIVE

Symptomatic malignant pleural effusions are common sequelae in patients with certain malignancies. Pleurodesis via bedside thoracostomy is the current treatment option most commonly used. To our knowledge, this is the first prospective randomized trial to examine which agent, bleomycin or talc slurry, is superior in terms of effectiveness, safety, and cost.

PATIENTS AND METHODS

Between July 1992 and March 1995, 35 patients presenting to our medical center with symptomatic malignant pleural effusions were prospectively randomized to undergo chemical pleurodesis with either bleomycin or talc slurry via bedside thoracostomy. The conditions of patients were assessed and graded before and after treatment concerning pain, dyspnea, and chest radiographs.

RESULTS

Twenty-nine patients who underwent 33 treatments (14 with bleomycin and 19 with talc) were available for follow-up. Follow-up ranged from 2 weeks to 8 months (mean, 1.7 months). Both groups demonstrated notable improvement in both pain and dyspnea following treatment, but there were no statistically significant differences between groups in the amount of improvement (two-tailed Student's t test). Permanent control of effusions, defined objectively on chest radiograph, was achieved with 11 bleomycin treatments (79%) and 17 talc treatments (90%) (p=0.388). The procedures were well tolerated and no significant adverse effects were observed. Talc is a much less costly agent than bleomycin ($12.36 cost to our medical center per treatment for talc vs $955.83 for bleomycin).

CONCLUSION

Given the similar efficacy and significant cost advantage, we conclude that talc is the agent of choice when utilizing pleurodesis for control of symptomatic malignant pleural effusions.

Intrapleurally instilled mitoxantrone in metastatic pleural effusions: a phase II study

Thirty cases (breast cancer-20 cases, malignant lymphoma-4 cases, different malignancies-6 cases) of histologically/cytologically verified malignant pleural effusion (MPE) in 29 patients were treated with intrapleurally instilled mitoxantrone (30 mg). The therapy was well tolerated. At evaluation, 25 patients had died of progressive disease. The median survival was 3 months (range 0.3-21.3 months). There were 26 responders (12 complete responses (CR), 14 partial responses (PR)), whereas 4 patients relapsed and 3 of these had an early relapse (within 3 months). Patients achieving PR or CR had a low risk (15%) of treatment failure. Five patients were subjected to a pharmacokinetic evaluation. This demonstrated rapidly declining plasma and pleural exudate levels of mitoxantrone within the first 6 hours. At 24 hours after instillation, mitoxantrone was only detected in circulating mononuclear cells. This study shows that mitoxantrone is efficacious in the treatment of MPE, and may represent a cost-effective alternative.

Thoracoscopic management of malignant pleural effusions

Malignant pleural effusion is a common condition and often presents a challenge for treatment. We report our experience from a single institution with the use of video-assisted thoracoscopic surgery (VATS) in the management of malignant effusions. From September 1992 to April 1995, 69 patients (31 men, 38 women; age range, 38 to 76 years) underwent diagnosis and/or treatment of malignant effusions; these included 46 pleural biopsies, 34 talc insufflations, and 16 limited decortications. There was no mortality and there were no intraoperative complications. Postoperative complications occurred in seven patients (10%). Specific histologic diagnoses were obtained in all but 6 patients (87%). Malignant effusion was confirmed in 25 of 46 cases (54%). Thoracoscopic talc insufflation with or without additional decortication was successful in 32 of 34 cases (94%) in controlling recurrence of effusion after a mean follow-up of 6 months among the survivors (22 patients died during the follow-up period without effusion reaccumulation). We conclude that VATS not only provides an accurate diagnosis but also allows effective therapeutic procedures to be performed for malignant effusions that are associated with an acceptable morbidity.

Talc slurry is an effective pleural sclerosant in rabbits

Insufflated talc is probably the most effective agent for creating a pleurodesis both in the clinical situation and in animals. However, the insufflation of talc requires an invasive procedure such as thoracoscopy or thoracotomy. Recently, there have been reports that talc in a slurry was effective in the clinical situation. The objective of this project was to determine whether talc in a slurry at varying doses is an effective sclerosant in an experimental model in rabbits. Talc, 50, 100, 200, and 400 mg/kg, in a 2-mL slurry was injected intrapleurally through a small catheter in male rabbits. Eleven rabbits received each dose. Twenty-eight days after the instillation, the animals were killed. The pleural spaces were assessed grossly for evidence of pleurodesis and microscopically for evidence of fibrosis and inflammation. The degree of pleurodesis (on a scale of 0 to 4) after the injection of 50, 100, 200, and 400 mg/kg of talc was 1.1 +/- 0.9, 1.5 +/- 1.1, 2.7 +/- 0.6, and 3.4 +/- 0.5, respectively. The degree of microscopic fibrosis similarly increased with increasing doses of talc. These scores were similar to those we have reported with the tetracycline derivatives. In contrast to the results with tetracycline derivatives, none of the rabbits developed fibrothorax or hemothorax. From this study, we conclude that talc in a slurry is a very effective pleural sclerosant in rabbits and does not produce hemothoraces as do the tetracycline derivatives.