Interventional therapies for malignant pleural effusions: The present and the future

Abstract

The approach to management of malignant pleural effusions (MPE) has changed over the past few decades. The key goals of MPE management are to relieve patient symptoms using the least invasive means and in the most cost-effective manner. There is now a realization that patient-reported outcome measures should be the primary goal of MPE treatment, and this now is the focus in most clinical trials. Efforts to minimize patient morbidity are complemented by development of less invasive treatments that have mostly replaced the more aggressive surgical approaches of the past. Therapeutic thoracentesis is simple, effective and generally safe, although its benefits may only be temporary. Pleurodesis is the conventional and for a long time the only definitive therapy available. However, the efficacy and safety of talc pleurodesis has been challenged. Indwelling pleural catheter (IPC) drainage is increasingly accepted worldwide and represents a new concept to improve symptoms without necessarily generating pleural symphysis. Recent studies support the effectiveness of IPC treatment and provide reassurance regarding its safety. An unprecedented number of clinical trials are now underway to improve various aspects of MPE care. However, choosing an optimal intervention for MPE in an individual patient remains a challenge due to our limited understanding of the underlying pathophysiology of breathlessness in MPE and a lack of predictors of survival and pleurodesis outcome. This review provides an overview of common pleural interventional procedures used for MPE management, controversies and limitations of current practice, and areas of research most needed to improve practice in future.

Review of malignant pleural mesothelioma survival after talc pleurodesis or surgery

“…This is consistent with identifying pleurodesis as a palliative therapy in MPM patients (2). Dyspnea, caused by the accumulation of fluids in the pleural space, is an important symptom among MPM patients which negatively impacts quality of life (5). Talc pleurodesis is shown to be effective, safe and successful in the prevention of fluid accumulation achieving a long-term control with a marked improvement of dyspnea (4).…”

“…Talc pleurodesis has been used in the treatment of malignant pleural effusion (MPE), a common complication of advanced malignancies especially breast and lung cancer (4). Talc is distributed over the entire pleural surface by administering it as a dry powder, usually during thoracoscopy, or as slurry via a chest tube (5). Thoracoscopic talc poudrage showed to be an effective and safe procedure in patients with MPE with a high rate of successful pleurodesis and a positive effect on decreasing dyspnea (4).…”

Malignant pleural effusion: from bench to bedside

“…It is conceivable that a multitude of longitudinal measurements will be facilitated by wide-spread use of IPC [92]. It is also conceivable that IPC are expected to provide a powerful valuable tool for local therapies against MPE [74].…”

“…A variety of different chemicals (talc, bleomycin, tetracycline, iodopovide and others) and bacterial products (from Corynobactum parvum, Streptococcus pyogenes, Staphylococcus aureus and others) have been used in clinical studies to achieve pleurodesis [70][71][72][73]. The profound inflammatory response they cause may result in adverse events such as pain and fever but it is believed that the level of inflammation correlates with the likelihood of successful pleurodesis [74].…”

“…IPCs have gained popularity during the last decade as they offer ambulatory management, thereby minimising hospital stay and healthcare costs [2,74]. An IPC is a silicone tube placed in the pleural cavity and tunnelled subcutaneously.…”