Delivery of Talc for Pleurodesis of Malignant Pleural Effusions

Abstract

To the Editor Dr Bhatnagar and colleagues 1 examined the effect of thoracoscopic talc poudrage vs talc slurry on pleurodesis in individuals with malignant pleural effusions and found no significant differences between the procedures. We have a number of concerns about the study.The term thoracoscopic talc poudrage usually refers to video-assisted thoracoscopic surgery and not to medical thoracoscopy, as described in the study, which may be confusing for readers. Furthermore, the type of procedure performed by the authors was not clearly described in the Methods section, suggesting that a range of techniques was used (including rigid, semi-rigid, and flexible medical thoracoscopy) with variation in efficiency. 2 This hypothesis is reinforced by the multi-institutional design of the study and could lead to possible bias.Although there are no published data comparing the efficiency of video-assisted thoracoscopic surgery vs medical thoracoscopy talc pleurodesis, it is largely accepted by most surgical teams that video-assisted thoracoscopic surgery leads to better results regarding recurrence of pleural effusion. Videoassisted thoracoscopic surgery allows for more efficient drainage of loculated effusions trapped in dense fibrous bands and distribution of talc throughout the pleural cavity, whereas medical thoracoscopy, as well as the slurry technique, do not allow adhesiolysis and only permit application of talc in a few parts of the pleural cavity. Hence, it would have been interesting to know the proportion of loculated effusions managed in both groups.In addition, the flowchart (Figure 1 in the article 1 ) indicated that 5 patients were excluded from the analysis in both groups after 90 days, although the primary outcome at 90 days was achieved. Was this a mistake? Most studies focus on 30 days after talc pleurodesis as the first date of assessment. 3 The authors should clarify why they used 90 days as the end point for the primary outcome.Additional studies should be conducted to compare medical vs surgical thoracoscopy to define the treatment algorithm for malignant pleural effusions.