TREATMENT OF MALIGNANT PLEURAL EFFUSIONS BY TALC POUDRAGE

Management of Indwelling Tunneled Pleural Catheters: A Modified Delphi Consensus Statement

BACKGROUND

The management of recurrent pleural effusions remains a challenging issue for clinicians. Advances in management have led to increased use of indwelling tunneled pleural catheters (IPC) because of their effectiveness and ease of outpatient placement. However, with the increase in IPC placement there have also been increasing reports of complications, including infections. Currently there is minimal guidance in IPC-related management issues after placement.

RESEARCH QUESTION

Our objective was to formulate clinical consensus statements related to perioperative and long-term IPC catheter management based on a modified Delphi process from experts in pleural disease management.

STUDY DESIGN AND METHODS

Expert panel members used a modified Delphi process to reach consensus on common perioperative and long-term management options related to IPC use. Members were identified from multiple countries, specialties, and practice settings. A series of meetings and anonymous online surveys were completed. Responses were used to formulate consensus statements among panel experts, using a modified Delphi process. Consensus was defined a priori as greater than 80% agreement among panel constituents.

RESULTS

A total of 25 physicians participated in this project. The following topics were addressed during the process: definition of an IPC infection, management of IPC-related infectious complications, interventions to prevent IPC infections, IPC-related obstruction/malfunction management, assessment of IPC removal, and instructions regarding IPC management by patients and caregivers. Strong consensus was obtained on 36 statements. No consensus was obtained on 29 statements.

INTERPRETATION

The management of recurrent pleural disease with IPC remains complex and challenging. This statement offers statements for care in numerous areas related to IPC management based on expert consensus and identifies areas that lack consensus. Further studies related to long-term management of IPC are warranted.

Particle size, distribution, and behavior of talc preparations: within the United States and beyond

PURPOSE OF REVIEW

Talc remains a common sclerosant utilized for pleurodesis. However, the use of talc has documented complications and debate has persisted regarding the safety of talc as well as the differences in talc preparations available throughout the world. We sought to describe an up-to-date review of talc preparations available and the impact these preparations may have on the safety profile of talc.

RECENT FINDINGS

Within laboratory-based examinations, talc particle size available within the United States appears to be more consistent with prior reported 'safe' particle sizes. The presence of talc within protein-based solutions appears to modify the overall milieu of the solution and likely results in particle aggregation.

SUMMARY

The use of talc remains well accepted for pleurodesis as evidenced by inclusion by multiple guidelines. The medical fields' current understanding of talc and its basic interactions within the pleural space remain limited. Multiple questions related to the pleural space and pleurodesis remain unanswered.

Talc and Silver Nitrate Induce Systemic Inflammatory Effects During the Acute Phase of Experimental Pleurodesis in Rabbits

STUDY OBJECTIVE

s: To determine whether talc (TL) and silver nitrate (SN), two effective pleurodesis agents, induce a systemic inflammatory response in the acute phase of experimental pleurodesis in rabbits.

DESIGN

Samples of blood and pleural fluid were collected after 6, 24, and 48 h from rabbits injected intrapleurally with 3 mL saline solution, TL (400 mg/kg), or 0.5% SN, and were assayed for WBC count, percentage of neutrophils, and levels of lactate dehydrogenase (LDH), interleukin (IL)-8, and vascular endothelial growth factor (VEGF). The pleural liquid production was compared in the three different groups. A sample of blood collected from animals preinjection was used as the control.

RESULTS

At 6 h after pleural injection, the mean blood WBC count and percentage of neutrophils were significantly elevated in the TL group, whereas the mean LDH and IL-8 levels were significantly increased in the SN group. VEGF was undetectable in the preinjection serum and saline solution-injected animals, but was increased in the serum after the pleural injection of both TL and SN to a comparable degree. SN elicited a more intense acute pleural inflammation reaction than did TL, with higher WBC count and IL-8 levels found in the pleural fluid, mainly within the first 6 h. LDH and VEGF levels, and pleural liquid production were also higher for SN, and they increased with time.

CONCLUSIONS

In the acute phase of pleural injection, TL induced a transient increase in blood WBC count and percentage of neutrophils, while SN induced increases in blood LDH and IL-8 levels. Both TL and SN induced significant increases in blood VEGF levels. SN induced an earlier and more intense acute pleural inflammation than TL. Pleural liquid VEGF levels were higher after SN injection and increased, as did pleural liquid production. These findings suggest that the intrapleural injection of TL and SN produce a systemic inflammatory response that may have a role in the pathogenesis of fever and ARDS, which occur with pleurodesis.

Management of malignancy-associated pleural effusion: current and future treatment strategies

Management of recurrent malignant pleural effusion, a common complication of malignancy, poses a challenge to clinicians. Although almost one century has elapsed since the introduction of the pleurodesis procedure, the ideal approach and best agent are still to be defined. Optimally, pleurodesis should be done at the bedside with a minimally invasive procedure, and suitable agents to achieve pleural symphysis should be inexpensive, available worldwide and free of adverse effects. To date, no substance completely fulfills these requirements. Silver nitrate should be considered for pleurodesis because of its low cost and ease of handling. Although talc has been used most frequently to induce pleurodesis, reports of death due to acute respiratory failure have raised concerns about the safety of this agent. Tetracycline, an effective alternative used in the past, is no longer commercially available. This agent has been substituted with derivatives of tetracycline, such as minocycline and doxycycline with success rates similar to those with tetracycline. Several antineoplastic agents have been injected into the pleural space with the aim of producing pleural symphysis, the most representative of this group being bleomycin. Recent knowledge of the molecular mechanisms involved in pleural inflammation has brought into focus new substances, such as transforming growth factor beta and vascular endothelial growth factor, which may be used as pleurodesis agents in the future. Nevertheless, more studies are necessary to better define the potential of these substances in the induction of pleural symphysis.Ideally, a sclerosing agent should be cost-effective, available worldwide and easily administered. Talc will probably stand as the preferred agent to be used for pleurodesis in malignant pleural effusion because of its efficacy, easy manipulation and handling. However, further investigation is necessary to minimize adverse effects related to talc.

Development of a disposable spray canister for talc pleurodesis. A preliminary report

Talc pleurodesis has been used for more than 50 years in both the United States and in Europe, and it has proven to be safe and effective in patients with malignant pleural effusions as well as recurrent pneumothorax. In this preliminary report, we describe a disposable, single-use spray canister that allows intrapleural administration of sterile, asbestos-free Luzenac talc, thus facilitating thoracoscopic talc insufflation for pleurodesis, particularly in patients with recurrent malignant effusions. The talc is delivered ready to use, administered via a hollow plastic delivery catheter that can be inserted through the pleural trocars used during thoracoscopy. Use of this spray canister allows practitioners to avoid complex handling and sterilization procedures required for bulk talc powder.

Pleural effusions: pathophysiology and management

OBJECTIVE

To review the pathophysiology and management of pleural effusions, including available agents for pleural sclerosis.

DATA SOURCES

A MEDLINE search (1966 to present) was performed that included clinical studies in the English language involving the pathophysiology and management of pleural effusions; references used in those articles were screened for additional published information.

STUDY SELECTION

All clinical trials were considered for potential inclusion in the review.

DATA SYNTHESIS

Pleural effusion is an accumulation of fluid in the pleural space that results when homeostatic forces that control the flow into and out of the area are disrupted. The management of transudative pleural effusions is primarily directed at treatment of the underlying disease. There are several treatment options for pleural effusions, including chemical pleurodesis. Many of the trials that examine the use of talc, bleomycin, and doxycycline have poorly described study designs and end points, with inconsistent evaluation of patients. Each agent is considered to be generally effective and safe, with fever and pain as the most frequently reported adverse effects. The use of talc requires sterilization, and many clinicians use general anesthesia with instillation, which increases the risk associated with the procedure. Bleomycin is generally safe; however, it should not be used in doses exceeding 40 mg/m2. Only uncontrolled trials support the use of doxycycline; however, it provides an effective, safe, and relatively inexpensive alternative.

CONCLUSIONS

Pleural effusions are defined as an accumulation of fluid in the pleural space. Treatment is generally palliative. Intrapleural administration of talc, bleomycin, and doxycycline are effective sclerosing agents for treatment of recurrent, symptomatic pleural effusions. Although the most cost-effective agent has not been determined, doxycycline is an inexpensive alternative to bleomycin, and may have fewer adverse effects than talc.

Efficacy of short term versus long term tube thoracostomy drainage before tetracycline pleurodesis in the treatment of malignant pleural effusions

BACKGROUND

A study was undertaken to compare the efficacy of short term tube thoracostomy drainage with standard tube thoracostomy drainage before instillation of tetracycline for sclerotherapy of malignant pleural effusions.

METHODS

The study consisted of a randomised clinical trial in a sequential sample of 25 patients with malignant pleural effusions documented cytopathologically. Fifteen patients were randomly assigned to group 1 (standard protocol) and 10 to group 2 (short term protocol). Patients in group 1 had tube thoracostomy suction drainage until radiological evidence of lung re-expansion was obtained and the amount of fluid drained was < 150 ml/day, before tetracycline (1.5 g) was instilled. The chest tube was removed when the amount of fluid drained after instillation was < 150 ml/day. Patients in group 2 also had suction drainage, but the tetracycline (1.5 g) was instilled when the chest radiograph showed the lung to be re-expanded and the effusion drained, which was usually within 24 hours. The chest tube was removed the next day.

RESULTS

The response to tetracycline sclerotherapy in the two groups was the same (80%) but the duration of chest tube drainage was significantly shorter for patients in group 2 (median two days) than for those in group 1 (median seven days).

CONCLUSIONS

The duration of chest tube drainage before sclerotherapy for malignant pleural effusions need not be influenced by the amount of fluid drained daily but by radiographic evidence of fluid evacuation and lung re-expansion. Shorter duration of drainage will reduce the length of hospital stay without sacrificing the efficacy of pleurodesis.

Current and future therapy for malignant pleural effusion

Several options are available for treatment of malignant pleural effusions in patients with non-small-cell lung cancer. Repeat thoracentesis may be appropriate for the patient with limited survival and a slowly recurrent effusion. Pleurodesis with a sclerosing agent administered via a chest tube is the most widely used therapy, though controversy exists as to which drug produces the best results. Pleuroperitoneal shunting remains an option for those patients whose lung is trapped by tumor. Video-assisted thoracoscopy is likely to change the treatment patterns of malignant pleural effusion. Thoracoscopic pleurectomy can be performed with minimal morbidity. Alternatively, sclerosing agents such as talc can be easily and uniformly introduced into the thoracic cavity under thoracoscopic control. Future therapy is likely to entail a diagnostic thoracentesis followed by a definitive thoracoscopic procedure.

Diagnosis and treatment of malignant pleural effusion

Pleural effusion is a common and important complication of malignancy which may at times be difficult to diagnose or treat. Its well recognized association with numerous diseases plus the limitations of our usual diagnostic tests may occasionally cause difficulty. In the oncology patient there are a number of common medical problems associated with the development of pleural effusion which frequently coexist with the malignancy. Pleural effusion may be a presenting or late sign of cancer, and when recurrent can be a vexing symptomatic problem. Fortunately, an increasing number of effective diagnostic and therapeutic modalities are available which, when judiciously applied, facilitate our approach.

Pleuroscopy in patients with pleural effusion and pleural masses

We performed diagnostic pleuroscopy in 66 patients with pleural effusion and in 14 with pleural masses. The findings were diagnostic in 76 patients (95%). Pleural metastases were found in 63 patients, primary pleural or lung tumor in 5, and less common findings in the remainder. Only 1 minor complication occurred, and there were no deaths. Malignant pleural effusion causing dyspnea was managed successfully by talc insufflation under direct vision in 31 of 35 patients. Talc also was used with equal success and without complications in management of recurrent pneumothorax. We conclude that pleuroscopy is a useful diagnostic and therapeutic procedure. It is simple and well tolerated, has a diagnostic yield of 95%, and is virtually free from complications. It provides the best way of insufflating talc for pleurodesis.

The treatment of recurrent malignant pleural effusion

Effective control of a recurrent malignant pleural effusion can greatly improve the quality of life of the cancer patient. At least a dozen different techniques have been advocated for controlling this common complication of malignant disease. The present review collects and examines the clinical results of all techniques designed to treat this problem. The pathophysiology and diagnostic evaluation of the effusion are also discussed. On the basis of comparisons involving effectiveness, morbidity, and convenience, we recommend intrapleurally administered tetracycline with thoracostomy drainage as the technique of choice. Instillation of a talc suspension with thoracostomy drainage is also a safe and effective technique and should be employed when tetracycline fails or is contraindicated.

Cytostatic Therapy of Pleural Effusion Caused by Metastatic Carcinoma of the Breast

Effusions are a frequent complication in the course of disseminated breast cancer. Intracavitary instillation of radioactive gold, particulate irritants such as talc, alkylating agents, quinacrine, fluorouracil, bleomycin have been used for symptomatic control. The usefulness of intracavitary administration of antineoplastic agents in the management of recurrent, intractable neoplastic effusions has been evaluated in 43 patients in which 67 instillations were made and 58 were evaluable (table 1). Many drugs were used, particularly alkylating agents an HN2 and as Thio-TEPA and antimetabolite as fluorouracil (table 2). In the present series 19 of the 58 patients (32.7 %) with metastatic carcinoma of the breast had objective control of the neoplastic effusion for periods ranging from 45 to 485 days (table 2). In comparison with other methods of treatment, cytostatic therapy of pleural effusion caused by metastatic carcinoma of the breast does not produce a higher percentage of therapeutic response. Particularly talc poudrage has been employed with better results.

Talc Pleural Poudrage in the Treatment of Recurrent Neoplastic Effusions

Between 1966 and 1970, 23 talc pleural poudrages for neoplastic effusions were performed in 22 patients at the National Cancer Institute in Milan. No recurrence was observed in 16 cases and in another 2 the effusion recurred to a minor degree. Talc poudrage was ineffective in 2 patients and 3 died postoperatively. The median survival of the patients who had a complete remission of their pleural effusions was 8 months, with minimum of 2 months and maximum of 2 years. The best results were obtained in patients with pleural mesotheliomas or pleural metastatic carcinomas other than lung cancer. Talc pleural poudrage seemed to be more effective when performed early in patients not yet in the preterminal phase.

Treatment of recurrent malignant pleural effusion by iodized talc pleurodesis

Chemical pleurodesis using iodized talc is an effective method of treating symptomatic recurrent malignant pleural effusions. Twenty-three effusions occurring in 21 patients treated by this method are described with two illustrative case reports. The procedure eliminated the need for further chest aspiration in all but one instance. The histological appearances of the pleura at intervals after pleurodesis are also described.