Point: Should thoracoscopic talc pleurodesis be the first choice management for malignant effusion? Yes

Talc pleurodesis in malignant pleural effusion: a systematic review and meta-analysis

OBJECTIVE

Malignant pleural effusion is a severe and common complication in patients with primary or metastatic malignancies of the pleura. Although talc pleurodesis is widely used for managing malignant pleural effusions, there is still controversy in the literature regarding its superiority compared to other approaches. We conducted this meta-analysis to further investigate its efficacy compared to alternative interventions.

METHODS

We systematically reviewed the PubMed, Cochrane, and Scopus databases to identify studies that fulfilled our inclusion criteria. Study quality was evaluated using validated tools and the pooled Risk Ratio (RR) and confidence interval (CI) were calculated. We performed sensitivity analyses based on the meta-analysis method and type of study.

RESULTS

Twenty-four studies were included in the current systematic review meta-analysis. Talc pleurodesis was associated with statistically significant higher successful pleurodesis rates when compared with all controls [RR (95% CI) 1.15 (1.00, 1.31); P_z = 0.04], only chemical controls [RR (95% CI) 1.26 (1.13, 1.40); P_z < 0.0001], and bleomycin [RR (95% CI) 1.22 (1.05, 1.42); P_z = 0.008]. The comparison between talc pleurodesis and controls at the > 1-month follow-up time point favored talc pleurodesis [RR (95% CI): 1.62 (1.15, 2.27); P_z = 0.005]. Finally, talc poudrage was associated with a statistically significant higher successful pleurodesis rate when compared with all controls. Sensitivity analyses verified the robustness of our results.

CONCLUSION

Talc pleurodesis is an effective MPE management approach presenting borderline statistically significant superiority compared to control methods especially compared to bleomycin as well as when pleurodesis success is evaluated later than 1 month postoperatively.

Analytic comparison of talc in commercially available baby powder and in pelvic tissues resected from ovarian carcinoma patients

OBJECTIVE

Measure the size and shape of talc particles in talcum powder and compare this data to the size and shape of talc particles found in surgically resected tissues from patients with ovarian carcinoma.

METHODS

Using polarized light microscopy (PLM) and scanning electron microscopy (SEM), we measured the size and shape of talc particles in samples of talc-containing baby powder (TCBP) and surgically resected pelvic tissues (hysterectomies) from talc-exposed patients with ovarian carcinoma.

RESULTS

The most frequent class of particles in TCBP can be unequivocally identified as talc, using both polarized light microscopy and scanning electron microscopy with energy dispersive X-ray analysis (SEM/EDX). The talc particles found in resected tissues from ovarian carcinoma patients are similar in size and shape to the most abundant morphological class of particles in TCBP.

CONCLUSIONS

This finding, combined with previous epidemiological literature and tissue-based analytical studies, provides further evidence that the small, isodiametric particles that dominate TCBP can migrate from the perineum and become lodged in distal structures in the female reproductive tract, where they may lead to an increased risk of developing ovarian carcinoma.

Effect of Thoracoscopic Talc Poudrage vs Talc Slurry via Chest Tube on Pleurodesis Failure Rate Among Patients With Malignant Pleural Effusions: A Randomized Clinical Trial

IMPORTANCE

Malignant pleural effusion (MPE) is challenging to manage. Talc pleurodesis is a common and effective treatment. There are no reliable data, however, regarding the optimal method for talc delivery, leading to differences in practice and recommendations.

OBJECTIVE

To test the hypothesis that administration of talc poudrage during thoracoscopy with local anesthesia is more effective than talc slurry delivered via chest tube in successfully inducing pleurodesis.

DESIGN, SETTING, AND PARTICIPANTS

Open-label, randomized clinical trial conducted at 17 UK hospitals. A total of 330 participants were enrolled from August 2012 to April 2018 and followed up until October 2018. Patients were eligible if they were older than 18 years, had a confirmed diagnosis of MPE, and could undergo thoracoscopy with local anesthesia. Patients were excluded if they required a thoracoscopy for diagnostic purposes or had evidence of nonexpandable lung.

INTERVENTIONS

Patients randomized to the talc poudrage group (n = 166) received 4 g of talc poudrage during thoracoscopy while under moderate sedation, while patients randomized to the control group (n = 164) underwent bedside chest tube insertion with local anesthesia followed by administration of 4 g of sterile talc slurry.

MAIN OUTCOMES AND MEASURES

The primary outcome was pleurodesis failure up to 90 days after randomization. Secondary outcomes included pleurodesis failure at 30 and 180 days; time to pleurodesis failure; number of nights spent in the hospital over 90 days; patient-reported thoracic pain and dyspnea at 7, 30, 90, and 180 days; health-related quality of life at 30, 90, and 180 days; all-cause mortality; and percentage of opacification on chest radiograph at drain removal and at 30, 90, and 180 days.

RESULTS

Among 330 patients who were randomized (mean age, 68 years; 181 [55%] women), 320 (97%) were included in the primary outcome analysis. At 90 days, the pleurodesis failure rate was 36 of 161 patients (22%) in the talc poudrage group and 38 of 159 (24%) in the talc slurry group (adjusted odds ratio, 0.91 [95% CI, 0.54-1.55]; P = .74; difference, -1.8% [95% CI, -10.7% to 7.2%]). No statistically significant differences were noted in any of the 24 prespecified secondary outcomes.

CONCLUSIONS AND RELEVANCE

Among patients with malignant pleural effusion, thoracoscopic talc poudrage, compared with talc slurry delivered via chest tube, resulted in no significant difference in the rate of pleurodesis failure at 90 days. However, the study may have been underpowered to detect small but potentially important differences.

TRIAL REGISTRATION

ISRCTN Identifier: ISRCTN47845793.

Talc Pleurodesis: A Medical, Medicolegal, and Socioeconomic Review

BACKGROUND

Talcum has been used in pleurodesis for more than 8 decades. Despite a wealth of research, controversy remains over the optimal sclerosant for pneumothorax and pleural effusions. Talc's historical primacy has been challenged because of its potential for pulmonary toxicity, possible carcinogenicity, and recent concerns surrounding availability and legal liability, thus making this an ideal time for a review.

METHODS

This systematic review of the talc literature, focused on publications after the year 2000, evaluated mechanism of action, efficacy, side effect profile, and alternative sclerosants; included is an overview of current socioeconomic and legal controversies.

RESULTS

The data support talc as the most effective agent for pleurodesis. There is evidence to suggest that mean particle size has a direct relationship with the side effect profile and that significant hypoxemic events after talc administration are exceedingly rare when using available graded talc preparations. Concerns regarding the development of malignant diseases after topical talc application remain incompletely resolved but appear related to cosmetic powder preparations that were contaminated with asbestos. Purified talc in the pleural space has not been implicated. Recent difficulties accessing commercial talc preparations have been solved. Although safe and effective talc alternatives do exist, these agents are not as well studied.

CONCLUSIONS

Talc pleurodesis with modern, purified, graded talc preparations is safe and highly effective. Talc is an inexpensive and accessible option that remains appropriate for pleurodesis despite existing controversies.

Comparison of Efficiency of Pleurodesis Between Video Assisted Thoracoscopic Surgery (VATS) and Standard Thoracostomy

Background

Chemical pleurodesis is generally accepted palliative dyspnea therapy and preventive of re-accumulation of pleural fluid in patients with malignant pleural effusions.

Aim

Comparative analyses of efficiency of chemical pleurodesis between Video Assisted Thoracoscopic Surgery (VATS) and standard thoracostomy.

Methods

From 01.01.2016-01.01.2017 at the Clinic for Thoracic Surgery of University Clinical Center (UCC) Sarajevo retrospective analysis was performed. Studied patients underwent VATS pleurodesis (G1) and standard thoracostomy pleurodesis (G2), with 60 in each group, respecting defined inclusion and exclusion criteria. Pleurodesis success was examined radiologically over the next three months.

Results

Average age of all patients was 63.97±8.75 years. Gender related, 45% were men and 55% were women (F/M=1.47:1). Average hospitalization was 7.22±1.37 (G1: 6.68±1.16; G2: 7.44±1.40; Mann-Whitney U-test: p=0.0016) days. Average thoracic drainage duration was 5.45±1.69, (G1: 4.28±1.15,G2: 6.05±1.58; Mann-Whitney U-test p<0.0001) days. Pleurodesis success after first month was 98.30% in G1, 91.60% in G2 (G1 vs. G2; p=0.2089); after second month was 98.30% in G1, 78.30% in G2 (G1 vs. G2; p=0.0011) and after three months was 91.60% in G1, 63.30% in G2(G1 vs. G2; p=0.0006). Average dyspnea degree (0-5) after the pleurodesis was 0.050±0.22 in G1 and 0.62±0.76 in G2 (Mann-Whitney U-test; p=0.0001). Complication were noticed in 9.2% patients, in G1 3.3%, 15.0% in G2.

Conclusion

Difference in pleurodesis efficiency between the G1 and G2 was established after second month and was even more evident after third month in favor of G1. Results show the significant statistical improvement of the degree of dyspnea in G1 as opposite to the G2.

Predictors of talc slurry pleurodesis success in patients with malignant pleural effusions

INTRODUCTION

Malignant pleural effusions are an important burden of malignant disease. Slurry talc pleurodesis remains one of the most common and effective therapeutic options.

AIM

Investigate the predictive factors related with the efficacy of this technique in malignant pleural effusions.

METHODS

Retrospective analysis of all pleurodesis performed during a 10-year period in a Pulmonology Unit. All demographic and clinical data were collected, including the histologic tumoral type and the biochemical, microbiological and cytological fluid features. Efficacy was defined as the lack of recurrence of pleural effusion. It was used Kaplan-Meyer analysis to estimate overall survival.

RESULTS

From a total of 202 patients submitted to pleurodesis (47% men; mean age 66.9±12.02 years). Light's criteria identified 86.6% as exudates. We found 85.1% survival at 30-day post-pleurodesis, which means the therapy used has significant success. A logistic regression model applied explained that variance in post-pleurodesis events was mostly due to age and gender rather than pleural biochemical factors (X²₍₅₎=44.648, p<0.001, R² 28.3%).

CONCLUSION

This study suggests that clinical evaluation of biochemical values, bacteriological results and malignant tumor diagnosis may not be enough to predict post-pleurodesis relapse with high accuracy. Furthermore, we observed, in ten years of pleurodesis performed in our Hospital, that pleurodesis is an effective life prolonging therapy for patients that fit the criteria for this intervention.

The effects of aqueous extract of babassu (Orbignya phalerata) on the pleura and lung parenchyma in rats

PURPOSE

To evaluate macro and microscopically, changes following the use of the aqueous extract of babassu (Orbignya phalerata) in the lung parenchyma and pleura of rats.

METHODS

Sixty adult male rats with average weight of 350 g, were randomized into two groups of 30 animals (experimental and control) further divided into sub-groups of 10 to be sacrificed at 48 h, 72 h and 21 days. The substance was injected into the right pleura of the animals.

RESULTS

There was intense pleuropulmonary macroscopic reaction with statistically significant differences between groups respectively (p<0.05, p<0.02, p<0.03). Microscopically, no statistically significant difference was evident (p>0.05).

CONCLUSION

The aqueous extract of babassu (Orbignya phalerata) was found to be highly irritating to the pleura and lung of rats, evidenced macroscopically by numerous adhesions and inflammation while no major changes were evident microscopically.

Pleural controversies: image guided biopsy vs. thoracoscopy for undiagnosed pleural effusions?

Undiagnosed pleural effusions present an increasing diagnostic burden upon healthcare providers internationally. The investigation of pleural effusions often requires the acquisition of tissue for histological analysis and diagnosis. Historically there were two options for tissue biopsy: a 'gold standard' surgical biopsy or a "blind" closed pleural biopsy. Over the last decade however, image-guided Tru-cut biopsies and local anaesthetic thoracoscopic (local anaesthetic thoracoscopy) biopsies have become more widespread. Image-guided techniques acquire samples under ultrasound (US) or computed tomography (CT) guidance whereas LAT involves the direct visualisation and biopsy of the pleura with pleuroscopy. Both techniques have been shown to be superior to 'blind' closed pleural biopsy for the diagnosis of pleural or metastatic malignancy. However, closed biopsy remains a viable method of investigation in areas of high incidence of tuberculosis (TB). Beyond this, each investigative technique has its own advantages and disadvantages. Image-guided biopsy is less invasive, usually carried out as an outpatient procedure, and enables tissue biopsy in frail patients and those with pleural thickening but no pleural fluid. Local anaesthetic thoracoscopy (LAT) provides diagnostic and therapeutic capabilities in one procedure. Large volume thoracentesis, multiple pleural biopsies and talc poudrage can be carried out in a single procedure. The overall diagnostic yield is similar for both techniques, although there are no large-scale direct comparisons. Both techniques share low complication rates.

Interventional pulmonologist perspective: treatment of malignant pleural effusion

OPINION STATEMENT

The management of known malignant pleural effusions focuses around the initial thoracentesis and subsequent objective and subjective findings. A completely reexpanded lung after fluid removal and with symptomatic improvement predicts successful pleurodesis. Pleurodesis method depends on center expertise as well as patient preference. Medical thoracoscopy does not require the operating room setting and is performed on the spontaneously breathing patient with similar success rate to surgical thoracoscopy in the appropriately selected patients. However, it is not widely available. Talc insufflation is preferred for even distribution of sprayed particles to pleural surfaces. Most often, patients can be discharged home within 24 to 48 hours after continuous chest tube suction. Indwelling pleural catheter has become popular given the ease of insertion and patient centered home drainage. Coordinated care with good patient and family education and support is paramount to maximizing the beneficial potential of the catheter. Complications are minimal, and catheters are easily removed if patients can no longer benefit from drainage, or if pleurodesis has occurred. In the setting of trapped lung as a result of visceral pleura encasement from tumor, indwelling catheter can still be useful if the patient improves with thoracentesis. However, if no subjective improvement is seen after thoracentesis for trapped lung, then no procedure is recommended and other modes of palliation should be sought.

Pleural Disorders

This chapter provides an overview of both benign and malignant pleural disorders, starting with the relevant anatomy and physiology. The focus is on the management of pneumothoraces and pleural effusions—conditions that are commonly encountered on a general thoracic surgery service. The pleural cavity is lined by parietal and visceral pleura, which are smooth membranes that are continuous with one another at the hilum and pulmonary ligaments. Parietal Pleura: innermost chest wall layer, divided into cervical, costal, mediastinal and diaphragmatic pleura.

Malignant pleural effusions and the role of talc poudrage and talc slurry: a systematic review and meta-analysis

BACKGROUND

Malignant Pleural Effusion (MPE) is common with advanced malignancy. Palliative care with minimal adverse events is the cornerstone of management. Although talc pleurodesis plays an important role in treatment, the best modality of talc application remains controversial.  

OBJECTIVE

To compare rates of successful pleurodesis, rates of respiratory and non-respiratory complications between thoracoscopic talc insufflation/poudrage (TTI) and talc slurry (TS). 

DATA SOURCES AND STUDY SELECTION

MEDLINE (PubMed, OVID),  EBM Reviews (Cochrane database of Systematic Reviews, ACP Journal Club, DARE, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register, Health Technology Assessment and NHS Economic Evaluation Database), EMBASE and Scopus. Randomized controlled trials published between 01/01/1980 - 10/1/2014 and comparing the two strategies were selected. 

RESULTS

Twenty-eight potential studies were identified of which 24 studies were further excluded, leaving four studies. No statistically significant difference in the probability of successful pleurodesis was observed between TS and TTI groups (RR 1.06; 95 % CI 0.99-1.14; Q statistic, 4.84). There was a higher risk of post procedural respiratory complications in the TTI group compared to the TS group (RR 1.91, 95% CI= 1.24-2.93, Q statistic 3.15). No statistically significant difference in the incidence of non-respiratory complications between the TTI group and the TS group was observed (RR 0.88, 95% CI= 0.72-1.07, Q statistic 4.61).

CONCLUSIONS

There is no difference in success rates of pleurodesis based on patient centered outcomes between talc poudrage and talc slurry treatments.  Respiratory complications are more common with talc poudrage via thoracoscopy.

Efficacy and safety of talc pleurodesis for malignant pleural effusion: a meta-analysis

Background

Talc pleurodesis has been widely used to control malignant pleural effusion; however, it is still not clear whether talc pleurodesis is more effective than other local therapies. We performed a meta-analysis to evaluate the efficacy and safety of talc pleurodesis in the management of malignant pleural effusion.

Methods

PubMed, Embase, and Web of Science were searched for English-language studies of clinical controlled trials comparing talc pleurodesis with control therapies until August 8, 2013. Success rate and incidence of adverse events were evaluated. Relative risks were estimated using random- or fixed- effects model and statistical heterogeneity was assessed using I² test.

Results

Twenty trials involving 1,525 patients with malignant pleural effusion were included. 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).

Conclusions

The current evidences suggested the benefit for talc pleurodesis in the treatment of malignant pleural effusion. Talc pleurodesis, especially thoracoscopic talc poudrage pleurodesis, should be performed in patients with malignant pleural effusion, especially those with life-expectancy longer than one month.

The treatment of pleural carcinosis with malignant pleural effusion

BACKGROUND

Pleural carcinosis is caused by tumors of the chest (e.g., lung and breast cancer) or elsewhere in the body (e.g., ovarian carcinoma) that metastasize to the visceral and/or parietal pleura. Recurrent malignant pleural effusion due to pleural carcinosis is one of the most common findings in oncology. It affects about 56 000 patients per year in Germany alone.

METHODS

This review is based on pertinent literature retrieved by a selective search of the Medline database (key words: malignant pleural effusion, pleural carcinosis) and on the authors' clinical experience.

RESULTS

Although many retrospective studies have been published, there has been only one randomized controlled trial of treatment, in which permanent pleural catheters were compared with talcum pleurodesis. Patients with pleural carcinosis have a median survival of less than 12 months. Many are suffering from progression of their underlying disease, with generalized tumor involvement; thus, the symptomatic treatment of pain and dyspnea is often the main therapeutic issue. The underlying tumor, usually an adenocarcinoma, can be diagnosed either by histology or by cytology. The main complication is progressive respiratory failure. The treatment is palliative, rather than curative. The main approaches are drainage of the effusion (by thoracocentesis or with permanent pleural catheters) and pleurodesis (obliteration of the pleural space by causing the visceral and parietal pleura to adhere to each other).

CONCLUSION

Pleural carcinosis with symptomatic malignant pleural effusion is treated palliatively. The appropriate treatment in each case should be determined through discussion with the patient, with the goal of improving the patient's quality of life.

Medical pleuroscopy

There has been an exciting expansion in the practice of medical pleuroscopy in recent years. As technology has become more available and confidence in the use of equipment has grown, medical thoracoscopy has become a core diagnostic and therapeutic tool in pleural disease care. Despite this, many areas of medical pleuroscopy practice remain conspicuously devoid of well-established evidence. More knowledge is needed in those areas where there is currently a degree of equipoise. Many areas where pleuroscopy currently has a marginal role require high-quality randomized trials be undertaken with a view to informing future practice and guidelines.