The evidence on the effectiveness of management for malignant pleural effusion: a systematic review

Abstract

The aim of this study was to review systematically the available evidence on pleurodesis for malignant effusion, focusing on the choice of the agents, route of delivery and other strategies to improve outcomes. Four electronic databases (MEDLINE, EMBASE, Web of Science and Cochrane Controlled Trials Register) were searched, reference lists checked and letters requesting details of unpublished trials and data sent to authors of previous trials. Studies of malignant pleural effusion in humans were selected with no language restrictions applied. Criteria for randomised clinical trial (RCT) eligibility were random allocation of patients and non-concurrent use of another experimental medication or device. Methodological quality evaluation of the trials was based on randomisation, blinding, allocation concealment and intention to treat analysis. A random effect model was used to combine the relative risk estimates of the treatment effects whenever pooling for an overall effect was considered appropriate. Forty-six RCTs with a total of 2053 patients with malignant pleural effusions were reviewed for effectiveness of pleurodesis. Talc tended to be associated with fewer recurrences when compared to bleomycin (RR, 0.64; 95% CI, 0.34-1.20) and, with more uncertainty, to tetracycline (RR, 0.50; 95% CI, 0.06-4.42). Tetracycline (or doxycycline) was not superior to bleomycin (RR, 0.92; 95% CI, 0.61-1.38). When compared with bedside talc slurry, thoracoscopic talc insufflation was associated with a reduction in recurrence (RR, 0.21; 95% CI, 0.05-0.93). Strategies such as rolling the patient after instillation of the sclerosing agent, protracted drainage of the effusion and use of larger chest tubes were not found to have any substantial advantages. Talc appears to be effective and should be the agent of choice for pleurodesis. Thoracoscopic talc insufflation is associated with fewer recurrences of effusions compared with bedside talc slurry, but this is based on two small studies. Where thoracoscopy is unavailable bedside talc pleurodesis has a high success rate and is the next best option.

Efficacy of pleurodesis for malignant pleural effusions in breast cancer patients

“…Talc has been reported as safe and efficacious for pleurodesis [15][16][17][18][19][20][21][22][23]. A Cochrane review reported that pleurodesis with talc provided the highest relative chance of MPE nonrecurrence when compared with bleomycin, tetracycline, mustine or chest-tube drainage alone [24].…”

Suitable device for thoracoscopic talc poudrage in malignant pleural effusion

“…1,4 Talc is widely recognized as the sclerosant agent of choice in view of its clinical effi cacy, safety profi le, and low cost, whereas thoracoscopic talc pleurodesis has been suggested as the most effective pleurodesis technique. 2,3,5 In fact, during video-assisted thoracoscopy, pleural fl uid can be removed completely, loculations and adhesions can be divided when present, and talc can be insuffl ated equally in the pleural space under visual control.…”

“…Two recent systematic reviews 2,3 found that the relative risk for successful pleurodesis favored talc over other sclerosants and suggested that thoracoscopic talc poudrage was the technique of choice for pleurodesis in patients with MPE.…”

Malignant Pleurisy Associated with Primary Lung Cancer Well Controlled by Pleurodesis Using Distilled Water

“…1A) T a b l e 1 . L a b o r a t o r y Da t a b e f o r e a n d a f t e r P l e u r o d e s i s wi t (5,6,8), talc (7,8), and so on. Although the success rates of pleurodesis using OK-432 and talc are 88% (5) and over 90% (8) …”