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.     

Single access videothoracoscopic biopsy and talc pleurodesis in patients with malignant pleural effusion

Aim-Background

Recurrent pleural effusion is frequently observed in clinical experience and malignancy is one of the most frequent causes. Although it is generally necessary to prevent the recurrence of effusion in patients with disseminated neoplastic disease, in others, a diagnosis is required. The aim of this study was to determine the efficacy and safety of biopsy and pleurodesis by a single access videothoracoscopic approach.

Methods

We report a consecutive series of 20 patients (12 men, 8 women, aged 39 to 83 years) who underwent single access videothoracoscopy with pleural biopsy and talc pleurodesis for recurrent pleural effusion. In all cases, indication for the procedure was a recurrent pleural effusion, suspicious for malignancy. Videothoracoscopy was performed under general anaesthesia. For pleurodesis, an average of 8g of sterile talc powder was used. A six-month follow-up was completed for all patients, and efficacy was judged by clinical examination and chest X-ray.

Results

Diagnosis was obtained in all cases. In five cases, the diagnosis was a pleural involvement by breast cancer metastasis, and in four cases, a primary lung cancer was detected. Eight were mesotheliomas and one a parapneumonic collection. In two cases, an unknown-malignancy recurrent pleural effusion was observed. No deaths, talc-induced ARDS or malignant invasion of the scar occurred, but only a postoperative empyema and two subcutaneous emphysemas treated successfully without further operation.

Conclusions

Single access videothoracoscopic pleural biopsy and talc pleurodesis is a safe and effective method for the diagnosis and treatment of malignant pleural effusions.     

Life expectancy of patients with malignant pleural effusion treated with video-assisted thoracoscopic talc pleurodesis

The aim of the current study was to analyse postoperative complications and survival after video-assisted thoracoscopic (VATS) talc pleurodesis for malignant pleural effusion. All patients with morphologically proven malignant pleural effusion who underwent VATS talc pleurodesis from November 1995 to November 2002 were included in retrospective analysis. VATS was performed in general anaesthesia and 5 g of asbestos-free talc was insufflated into the pleural cavity. Postoperative pleural drainage was used until fluid output was less than 100 ml/24 h. Ninety-eight patients (28 male and 70 female) with mean age 59.6 (range 18-82) years were included. Thirteen patients had a bilateral pleural effusion. The most common primary cancer sites were lung (30 cases), breast (25) and ovarium (11). Average duration of the operation was 46 (range 10-120) min. Median duration of postoperative drainage was 3 (range 1-20) days and postoperative hospitalisation 7 (range 3-70) days. Twenty-eight patients had postoperative complications (fever in 17 cases). In seven cases pleurodesis was ineffective. Median survival was 8.4 months. Six-, 12- and 24-month survival was 58% (95% CI [0.47-0.67]), 39% [0.29-0.49] and 20% [0.12-0.29], respectively. Survival data after VATS talc pleurodesis advocate use of this invasive treatment method despite the advanced stage of cancer.     

Rapid pleurodesis in symptomatic malignant pleural effusion.

OBJECTIVE: The objective of the study was to see whether a rapid method of pleurodesis was superior to the standard protocol in patients with symptomatic malignant pleural effusion. METHODS: Between January 2000 and February 2003, a prospective randomised trial was carried out in a sequential sample of 27 patients with malignant pleural effusions documented cytopathologically. Twelve patients were allocated to group 1 (standard protocol) and 15 to group 2 (new protocol). A small-bore catheter (12 Fr) and oxytetracycline (35 mg/kg of body weight) were used in both groups. In group 1, patients had drainage until radiological evidence of lung re-expansion was obtained and the amount of fluid drained was less than 150 ml/day, before oxytetracycline was instilled. The catheter was removed when the amount of fluid drained after instillation was less than 150 ml/day. In group 2, patients had the oxytetracycline instilled in a fractionated-dose manner following frequent aspirations at 6h intervals. The catheter was removed when the total amount of fluid drained after instillation of the oxytetracycline [OT] was less than 150 ml/last three aspirations. Response was evaluated at 1, 3 and 6 months after pleurodesis. RESULTS: There was no statistically significant difference in the demographic features, site of the primary tumour, disease characteristics, and response rates in any evaluation period in both groups (P>0.05). However, the number of days of drainage and hospitalisation, and the cost were significantly lower in the second group (P<0.001). CONCLUSIONS: This new pleurodesis method provided shorter hospital stay resulting in superior cost-effectiveness and palliation without sacrificing the efficacy of pleurodesis.     

Thoracoscopic talc pleurodesis for recurrent, symptomatic pleural effusion following cardiac operations

Seventeen patients who underwent a cardiac operation developed a recurrent, symptomatic pleural effusion ultimately requiring video-assisted thoracic surgery (VATS) and talc pleurodesis. These patients represented 0.4% of all patients undergoing a cardiac operation over the same time period. Compared with an age- and sex-matched control group of cardiac surgery patients, patients requiring VATS for recurrent pleural effusion were more obese with higher body mass index (31.9 +/- 1.2 versus 28.3 +/- 1.4 kg/M2, P = 0.03), were more likely to have undergone a complex cardiac operation (8/17 versus 1/17, P =.01) and were more frequently on anticoagulation and antiplatelet agents besides aspirin (8/17 versus 2/17, P =.02). Patients underwent 1.86 +/- 0.34 thoracenteses with drainage of 846 +/- 166 mL/thoracentesis prior to referral for VATS. On average, patients underwent VATS 4.83 +/- 1.49 months after their cardiac operation. There were 3 VATS-related complications (17.6%) and no deaths. VATS talc pleurodesis led to symptomatic and radiologic improvement in all patients with a mean follow-up of 8.2 +/- 1.5 months. VATS talc pleurodesis effectively and safely treats the unusual postcardiac surgery patient with refractory pleural effusion.     

Effective treatment of malignant pleural effusion by minimal invasive thoracic surgery: thoracoscopic talc pleurodesis and pleuroperitoneal shunts in 101 patients

Background. For effective palliation of patients with malignant pleural effusion due to advanced neoplastic disease, any proposed treatment should have low procedure-related mortality and morbidity.

Methods. The clinical outcome of 119 thoracoscopies in 101 patients (56 women, 45 men), from 42 to 91 years of age (mean, 68 ± 9 years) with malignant pleural effusions was evaluated in a retrospective study. Video-assisted thoracoscopy (VATS) talc pleurodesis was done in 105 instances, and a pleuroperitoneal shunt was performed 14 times as an alternative when complete expansion of the lung could not be achieved due to tumor implants on the visceral pleura.

Results. The VATS talc pleurodesis resulted in clinically significant improvement of dyspnea in 92.2% of the patients. Thirty-day mortality was 2.8% and morbidity was 2.8%. The mean duration of postoperative survival was 6.7 months. Recurrent pleural effusion occurred in 5.7% of patients after a mean interval of 6 months. Clinical relief of dyspnea was obtained in 73% of the patients treated with pleuroperitoneal shunts. Thirty-day mortality in this group was 21% and morbidity was 14.3%. The mean duration of survival was 4.2 months.

Conclusions. The VATS talc pleurodesis is appropriate for palliation of patients with malignant pleural effusions and should be performed once the diagnosis has been confirmed. Patients with lungs trapped by visceral carcinomatosis may benefit from placement of a pleuroperitoneal shunt as an alternative.     

Long-term follow-up of video-assisted talc pleurodesis in malignant recurrent pleural effusions.

OBJECTIVE: Recurrent pleural effusion is a common condition and often presents a challenge for treatment. The aim of this report is to evaluate the long-term follow-up of thoracoscopic management of malignant recurrent pleural effusions. METHODS: From July 1st, 1992 to February 28th, 2001, out of 2311 VATS procedures performed at our Institution, 690 patients (29.85%) underwent videothoracoscopy (VATS) for recurrent pleural effusion. Of these 611 (88.55%) were treated for a malignant pleural effusion. There were 374 male and 237 female, with a mean age of 61.2 years. In all patients VATS was performed under general anaesthesia. The pleural effusion was carefully aspirated; fibrinous adhesions were taken down while dense fibrous adhesions were selectively divided; some limited decortications were also performed. Multiple pleural biopsies were always performed. Pleurodesis was performed with 5 g of sterile purified talc insufflated through a talc atomizer. One chest tube was left in situ for 3-5 days. RESULTS: Operative mortality was 0.81% (five cases). Postoperative complications occurred in 19 cases (3.1%). Specific histologic diagnosis was obtained in all patients. Follow-up was available for 602 patients (98.5%). After a median follow-up of 64 months (range 5-105 months), talc pleurodesis was successful in controlling recurrence of effusion in 92.7% (558 out of 602) of patients. The success rate did not show any statistically significant difference between patients who underwent postoperative adjuvant therapy and patients who did not. In two patients with failure of talc pleurodesis a redo-VATS was performed. CONCLUSIONS: VATS represents the method of choice for both diagnosis and treatment of malignant recurrent pleural effusions. Talc poudrage is safe and effective in obtaining pleurodesis.     

Early and late mortality after pleurodesis for malignant pleural effusion

BACKGROUND: The purpose of this study is to analyze morbidity and mortality and to determine the relative contribution of each of these potential prognosis variables for predicting morbidity and mortality in patients after pleurodesis by thoracotomy or thoracoscopy. METHODS: Between March 1, 1996, and January 31, 2001, a total of 70 patients underwent pleurodesis for recurrent malignant pleural effusion. Thoracoscopy was performed in 54 patients (77%); pleurodesis was achieved by pleural abrasion (n = 15), pleurectomy (n = 5), and talc insufflation (n = 34). Thoracotomy was performed in 16 patients (23%) who also needed pleurectomy and decortication for a trapped lung. RESULTS: Postoperative complications occurred in 24 patients (34%). Factors adversely affecting morbidity with univariate analysis included: three or four metastatic sites (p = 0.003), and thoracotomy (p = 0.009). Factors adversely affecting morbidity with multivariate analysis included: thoracotomy (p = 0.0005) and number of metastatic sites (p = 0.007). Six patient deaths (8.6%) occurred during hospitalization. Factors adversely affecting in-hospital mortality with univariate analysis included: Eastern Cooperative Oncology Group Performance Status 2 to 3 (p = 0.001), lower preoperative serum hemoglobin (p = 0.001), lower preoperative serum albumin (p = 0.0001), and thoracotomy (p = 0.03). Factors adversely affecting in-hospital mortality with multivariate analysis included: preoperative serum albumin less than 60 g/L (p = 0.007) and ECOG Performance Status 2 to 3 (p = 0.008). Twelve patients (17%) died within 90 days after surgery. Factors adversely affecting 3-month mortality with univariate analysis included: ECOG Performance Status 2 to 3 (p = 0.001), lower preoperative serum hemoglobin (p = 0.03), higher preoperative white cells (p = 0.03), lower preoperative serum albumin (p = 0.03), and preoperative thoracentesis more than once per month (p = 0.03). Factors adversely affecting 3-month mortality with multivariate analysis included: ECOG Performance Status 2 to 3 (p = 0.01), preoperative thoracentesis more than once per month (p = 0.03), three or four metastatic sites (p = 0.02), and preoperative white blood cell count > or = 12,000/mm3 (p = 0.03). CONCLUSIONS: Thoracotomy is not indicated in patients with a malignant effusion because of poor survival, a high frequency of complications, and prolonged hospital stay. Pleurodesis thoracoscopy is indicated in patients with good performance status coupled with good nutrition.     

Suitable device for thoracoscopic talc poudrage in malignant pleural effusion

Chemical pleurodesis is widely used in symptomatic patients with malignant pleural effusion to relieve symptoms, prevent fluid recurrence, and improve quality of life. Talc has been repeatedly found to be the most effective sclerosant agent, and thoracoscopic talc poudrage has been found to be the most effective pleurodesis technique. A homogeneous talc distribution on the visceral and parietal pleura helps to achieve complete pleural symphysis. We have recently adopted a new suitable sterile device that delivers talc under low and constant pressure, facilitating uniform coating of the whole pleural surface and avoiding inappropriate deposition of talc clumps.     

Use of an indwelling pleural catheter compared with thorascopic talc pleurodesis in the management of malignant pleural effusions

Therapy for recurrent malignant pleural effusion (MPE) is palliative. Video-assisted thoracic surgery with talc pleurodesis (VATS/TP) is limited to inpatients with completely expandable lung parenchyma. We evaluated the outcomes, safety, and efficacy of an indwelling pleural drainage catheter (PDC) system compared with VATS/TP. Forty-one consecutive patients with symptomatic MPE seen between September 2000 and April 2002 were studied. Patients able to fully re-expand their lungs were treated with VATS/TP; those who could not had PDC placement. Twenty-four (59%) were women. The mean age was 64 +/- 13 years. VATS/TP was performed in only seven patients (17%), and 34 patients had PDC placement. The length of stay (LOS) was 2.8 +/- 5.1 days in the 18 PDC patients who were initially seen as outpatients and 9.4 +/- 9.0 days in the inpatient population (P = 0.013). Short (< 2 days) LOS occurred in 19 (56%) PDC patients but in no VATS/TP patients (P = 0.007). Twenty-eight patients (68%) died during follow-up: three VATS/TP patients (43%) and 25 (74%) PDC patients (P = 0.112). We conclude that the PDC system is an efficacious treatment of patients with MPEs and trapped lungs. The LOS is short in patients initially evaluated as outpatients which contributes to the perception of increased quality of life.     

Thoracoscopic video-assisted talcum pleurodesis (TTP)--effective treatment of malignant pleural effusion

INTRODUCTION: Aim of the palliative therapeutic procedure should be a fast, efficient and pain free treatment of the malignant pleural effusions. PATIENTS AND METHOD: Since 1995 the results of malignant pleural effusions treatment were analyzed retrospectively in 46 patients who underwent 51 video-assisted TTP. The most frequent origin of malignant pleural effusion was breast cancer, followed by bronchial carcinoma. Precondition for video-assisted TTP was the verification of a malignant pleural effusion by cytology. RESULTS: Following TTP one patient suffered from pneumonia, two recurrent diseases occurred. Four patients died due to their severe primary malignancy. Average hospitalization was 8 days (3-55). CONCLUSION: Video-assisted TTP is the standard procedure in palliative treatment of malignant pleural effusion; the recurrence rate is low and the technique minimal invasive.     

Iodized talc pleurodesis for the treatment of pleural effusions.

This prospective study was designed to determine the efficacy of iodized talc pleurodesis in patients with pleural effusions. Thirty-four patients underwent this treatment (three bilaterally) between October 1, 1989, and March 31, 1991. All patients had to have complete or nearly complete lung reexpansion after tube thoracostomy with fluid drainage less than 100 ml in 24 hours. A slurry containing 5 gm of talc and 3 gm of thymol iodide was instilled into the pleural space through the chest tube. Chest tubes were removed after complete reexpansion and clearing of the effusions, usually in 3 to 5 days. The patients' ages ranged from 26 to 88 years (average 50 years). Eighteen patients had lung carcinoma, two had mesothelioma, and one each had carcinoma of the ovary, breast, or anorectum, multiple myeloma, schwannoma, or Hodgkin's lymphoma. Two patients had an unknown adenocarcinoma primary and five other patients had acquired immunodeficiency syndrome. One patient had congestive heart failure. Nineteen patients had left, 12 had right, and three had bilateral pleural effusions. The effusion was serosanguineous in 26 and serofibrinous in eight patients. Serial chest radiography showed complete response in all patients. The period of follow-up ranged from 1 to 21 (average 4.9) months, with no recurrences. Twenty-three patients have died during the follow-up period, and there was no sign that reaccumulated pleural effusion existed in any, despite clinical evidence of systemic tumor progression. These observations indicate that intrapleural instillation of a slurry of iodized talc is a safe, adequate, and effective treatment for control of neoplastic or benign pleural effusions.     

Thoracoscopic pleurodesis in malignant pleural effusions

We performed retrospectively study on 136 thoracoscopies done in our clinic in the period January 2000 and December 2004. We reviewed 136 thoracoscopies, 71 patients were male and 65 were female (mean age 58.4 years). Straw colored effusions were present in 78 cases (57%) and hemorrhagic in 58 cases (43%). The surgical procedure consist in diagnostic of thoracoscopy with drainage of pleural effusion, multiply pleural biopsy, pleurodesis and continuous pleural drainage. In our study, the talc powder (5g) was successfully as sclerosing agent. The primary tumor was: lung-63 (46%), breast-26 (19%), mesothelioma-21 (15.5%), stomach-3, ovarian-3, prostate-3, colon-2, lymphoma-1, leukemia-2, plasmocytoma-1 and unknown primary tumor in 11 cases (8%). Adverse effects included-chest pain-35 cases (25%), fever-20 cases (15%), empyema-6 cases (4.5%), prolonged air leak-5 cases (4%), pulmonary infection-2 cases, acute respiratory failure-1 case, malignant invasion of scar-1 patient. For statistical analysis, the success of talc pleurodesis was defined as the absence of pleural fluid on the follow-up chest radiographs. Pleurodesis was successful in 125 cases (92%) of the patients after 1 month-follow-up. Thoracoscopic talc pleurodesis is a safe, economical and effective treatment for malignant pleural effusion.     

Video-assisted thoracoscopic pleurodesis for malignant pleural effusions

AIM: The objective was to analyse the efficiency, and safety of thoracoscopic pleurodesis (TP). A retrospective study was made of an initial series of 75 patients undergoing lifetime follow-up who received TP in our department for the treatment of malignant pleural effusions (MPE). MATERIAL AND METHODS: From May 1994 to December 1998, 34 men and 41 women with a median age of 63.4 +/- 12.5 years were treated by TP. We performed 36 partial diathermic abrasions on pleura combined with talc insufflation, and in 39 cases only talc poudrage. The mean duration of insention of the chest tube was 4.1 (range 2 to 17) days, with 8.4 (range 5 to 20) days of postoperative hospitalization. There were no severe intraoperative or postoperative complications. The 30-day mortality rate was 1.3% (1 case). The period of follow-up ranged from 2.5 to 40 months (average 6.8). No case of late recurrence has been observed to date. CONCLUSION: Videothoracoscopic pleurodesis (talc poudrage) as a simple and efficient procedure seems to be the best alternative treatment regimen for the management of MPE in a group of selected patients.