Rebuttal From Dr Lee

Abstract

Malignant pleural effusions (MPEs) treated with simple aspiration and intercostal tube drainage without instillation of a sclerosant are associated with high rates of recurrence. According to a survey of >800 physicians who collectively performed >8,000 pleurodesis, thoracoscopic talc poudrage (TTP) was preferred over tube talc slurry (TS).1Lee YC Baumann MH Maskell NA et al.Pleurodesis practice for malignant pleural effusions in five English speaking countries.Chest. 2003; 124: 2229-2238Abstract Full Text Full Text PDF PubMed Scopus (149) Google Scholar Cochrane database and systematic reviews have also shown better outcome with TTP than tube TS.2Shaw P Agarwal R Pleurodesis for malignant pleural effusions.Cochrane Database Syst Rev. 2004; 1: CD002916Google Scholar, 3Tan C Sedrakyan A Browne J et al.The evidence on the effectiveness of management for malignant pleural effusion: a systematic review.Eur J Cardiothorac Surg. 2006; 29: 829-838Crossref PubMed Scopus (174) Google Scholar Although overall success rates in the phase III intergroup study comparing TTP and tube TS were similar, TTP provided more comfort and safety and was more effective than slurry for breast and lung cancers, which account for 50% to 65% of MPEs.4Dresler CM Olak J Herndon II, JE Cooperative Groups Cancer and Leukemia Group B Eastern Cooperative Oncology Group North Central Cooperative Oncology Group Radiation Therapy Oncology Group et al.Phase III Intergroup study of talc poudrage vs talc slurry sclerosis for malignant pleural effusion.Chest. 2005; 127: 909-915Abstract Full Text Full Text PDF PubMed Scopus (428) Google Scholar Moreover, Aelony and Yao5Aelony Y Yao JF Prolonged survival after talc poudrage for malignant pleural mesothelioma: case series.Respirology. 2005; 10: 649-655Crossref PubMed Scopus (35) Google Scholar have demonstrated better survival after talc poudrage for mesothelioma, and 90% of patients with mesothelioma will develop symptomatic MPEs during the course of disease.6Roberts ME Neville E Berrisford RG Antunes G Ali NJ BTS Pleural Disease Guideline Group Management of a malignant pleural effusion: British Thoracic Society Pleural Disease Guideline 2010.Thorax. 2010; 65: ii32-ii40Crossref PubMed Scopus (601) Google Scholar The phase III intergroup study4Dresler CM Olak J Herndon II, JE Cooperative Groups Cancer and Leukemia Group B Eastern Cooperative Oncology Group North Central Cooperative Oncology Group Radiation Therapy Oncology Group et al.Phase III Intergroup study of talc poudrage vs talc slurry sclerosis for malignant pleural effusion.Chest. 2005; 127: 909-915Abstract Full Text Full Text PDF PubMed Scopus (428) Google Scholar excluded patients with trapped lungs because of extensive intrapleural tumor load and pleural loculations, which occur in up to 30% of MPEs and are the main cause for pleurodesis failure. Thoracoscopy facilitates lysis of adhesions, which promotes drainage of pleural loculations to allow the underlying lungs to expand and enhances success of pleurodesis.7Crnjac A Sok M Kamenik M Impact of pleural effusion pH on the efficacy ofthoracoscopic mechanical pleurodesis in patients with breast carcinoma.Eur K Cardiothorac Surg. 2004; 26: 432-436Crossref PubMed Scopus (46) Google ScholarDr Light8Light RW Counterpoint: should thoracoscopic talc pleurodesis be the first choice management for malignant pleural effusion? No.Chest. 2012; 142: 17-19Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar cited concern of talc and acute respiratory failure. I would reiterate that no respiratory failure was observed in 558 patients undergoing thoracoscopy with large-particle talc. The results reaffirm that respiratory failure is attributable to small-particle talc, which is an important consideration for safety.9Janssen JP Collier G Astoul P et al.Safety of pleurodesis with talc poudrage in malignant pleural effusion: a prospective cohort study.Lancet. 2007; 369: 1535-1539Abstract Full Text Full Text PDF PubMed Scopus (248) Google Scholar As there are few randomized controlled trials that compare different sclerosing agents, as pointed out by Dr Light,8Light RW Counterpoint: should thoracoscopic talc pleurodesis be the first choice management for malignant pleural effusion? No.Chest. 2012; 142: 17-19Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar I conclude based on systematic reviews by Cochrane and other investigators that talc is the most efficacious agent in inciting not only inflammation necessary to promote pleural fibrosis but also apoptosis of mesothelioma and lung adenocarcinoma cells in vitro.10Nasreen N Mohammed KA Dowling PA Ward MJ Galffy G Antony VB Talc induces apoptosis in human malignant mesothelioma cells in vitro.Am J Respir Crit Care Med. 2000; 161: 595-600Crossref PubMed Scopus (72) Google Scholar, 11Lee P Sun L Lim CK Aw SE Colt HG Selective apoptosis of lung cancer cells with talc.Eur Respir J. 2010; 35: 450-452Crossref PubMed Scopus (19) Google Scholar There is also no randomized controlled trial to date that compares talc pleurodesis (tube TS or thoracoscopy) with indwelling pleural catheters (IPCs), and one can only infer efficacy of the two methods from the reported pleurodesis rates. Pleurodesis occurs spontaneously with IPCs (46%) and TTP (>80%). In addition, IPC use is associated with complications such as catheter malfunction (10%), empyema (3%), and catheter track metastases (1%).12Van Meter ME McKee KY Kohlwes RJ Efficacy and safety of tunneled pleuralcatheters in adults with malignant pleural effusions: a systematic review.J Gen Intern Med. 2011; 26: 70-76Crossref PubMed Scopus (206) Google Scholar IPC is less cost-effective than chest tube pleurodesis if the patient survives >6 weeks.13Olden AM Holloway R Treatment of malignant pleural effusion: PleuRx catheter or talc pleurodesis? A cost-effectiveness analysis.J Palliat Med. 2010; 13: 59-65Crossref PubMed Scopus (93) Google Scholar Thus, we have to wait for randomized controlled trials of IPC with TTP or TS before any recommendation can be made in favor of IPC as the first choice in management of patients with MPE. Malignant pleural effusions (MPEs) treated with simple aspiration and intercostal tube drainage without instillation of a sclerosant are associated with high rates of recurrence. According to a survey of >800 physicians who collectively performed >8,000 pleurodesis, thoracoscopic talc poudrage (TTP) was preferred over tube talc slurry (TS).1Lee YC Baumann MH Maskell NA et al.Pleurodesis practice for malignant pleural effusions in five English speaking countries.Chest. 2003; 124: 2229-2238Abstract Full Text Full Text PDF PubMed Scopus (149) Google Scholar Cochrane database and systematic reviews have also shown better outcome with TTP than tube TS.2Shaw P Agarwal R Pleurodesis for malignant pleural effusions.Cochrane Database Syst Rev. 2004; 1: CD002916Google Scholar, 3Tan C Sedrakyan A Browne J et al.The evidence on the effectiveness of management for malignant pleural effusion: a systematic review.Eur J Cardiothorac Surg. 2006; 29: 829-838Crossref PubMed Scopus (174) Google Scholar Although overall success rates in the phase III intergroup study comparing TTP and tube TS were similar, TTP provided more comfort and safety and was more effective than slurry for breast and lung cancers, which account for 50% to 65% of MPEs.4Dresler CM Olak J Herndon II, JE Cooperative Groups Cancer and Leukemia Group B Eastern Cooperative Oncology Group North Central Cooperative Oncology Group Radiation Therapy Oncology Group et al.Phase III Intergroup study of talc poudrage vs talc slurry sclerosis for malignant pleural effusion.Chest. 2005; 127: 909-915Abstract Full Text Full Text PDF PubMed Scopus (428) Google Scholar Moreover, Aelony and Yao5Aelony Y Yao JF Prolonged survival after talc poudrage for malignant pleural mesothelioma: case series.Respirology. 2005; 10: 649-655Crossref PubMed Scopus (35) Google Scholar have demonstrated better survival after talc poudrage for mesothelioma, and 90% of patients with mesothelioma will develop symptomatic MPEs during the course of disease.6Roberts ME Neville E Berrisford RG Antunes G Ali NJ BTS Pleural Disease Guideline Group Management of a malignant pleural effusion: British Thoracic Society Pleural Disease Guideline 2010.Thorax. 2010; 65: ii32-ii40Crossref PubMed Scopus (601) Google Scholar The phase III intergroup study4Dresler CM Olak J Herndon II, JE Cooperative Groups Cancer and Leukemia Group B Eastern Cooperative Oncology Group North Central Cooperative Oncology Group Radiation Therapy Oncology Group et al.Phase III Intergroup study of talc poudrage vs talc slurry sclerosis for malignant pleural effusion.Chest. 2005; 127: 909-915Abstract Full Text Full Text PDF PubMed Scopus (428) Google Scholar excluded patients with trapped lungs because of extensive intrapleural tumor load and pleural loculations, which occur in up to 30% of MPEs and are the main cause for pleurodesis failure. Thoracoscopy facilitates lysis of adhesions, which promotes drainage of pleural loculations to allow the underlying lungs to expand and enhances success of pleurodesis.7Crnjac A Sok M Kamenik M Impact of pleural effusion pH on the efficacy ofthoracoscopic mechanical pleurodesis in patients with breast carcinoma.Eur K Cardiothorac Surg. 2004; 26: 432-436Crossref PubMed Scopus (46) Google Scholar Dr Light8Light RW Counterpoint: should thoracoscopic talc pleurodesis be the first choice management for malignant pleural effusion? No.Chest. 2012; 142: 17-19Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar cited concern of talc and acute respiratory failure. I would reiterate that no respiratory failure was observed in 558 patients undergoing thoracoscopy with large-particle talc. The results reaffirm that respiratory failure is attributable to small-particle talc, which is an important consideration for safety.9Janssen JP Collier G Astoul P et al.Safety of pleurodesis with talc poudrage in malignant pleural effusion: a prospective cohort study.Lancet. 2007; 369: 1535-1539Abstract Full Text Full Text PDF PubMed Scopus (248) Google Scholar As there are few randomized controlled trials that compare different sclerosing agents, as pointed out by Dr Light,8Light RW Counterpoint: should thoracoscopic talc pleurodesis be the first choice management for malignant pleural effusion? No.Chest. 2012; 142: 17-19Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar I conclude based on systematic reviews by Cochrane and other investigators that talc is the most efficacious agent in inciting not only inflammation necessary to promote pleural fibrosis but also apoptosis of mesothelioma and lung adenocarcinoma cells in vitro.10Nasreen N Mohammed KA Dowling PA Ward MJ Galffy G Antony VB Talc induces apoptosis in human malignant mesothelioma cells in vitro.Am J Respir Crit Care Med. 2000; 161: 595-600Crossref PubMed Scopus (72) Google Scholar, 11Lee P Sun L Lim CK Aw SE Colt HG Selective apoptosis of lung cancer cells with talc.Eur Respir J. 2010; 35: 450-452Crossref PubMed Scopus (19) Google Scholar There is also no randomized controlled trial to date that compares talc pleurodesis (tube TS or thoracoscopy) with indwelling pleural catheters (IPCs), and one can only infer efficacy of the two methods from the reported pleurodesis rates. Pleurodesis occurs spontaneously with IPCs (46%) and TTP (>80%). In addition, IPC use is associated with complications such as catheter malfunction (10%), empyema (3%), and catheter track metastases (1%).12Van Meter ME McKee KY Kohlwes RJ Efficacy and safety of tunneled pleuralcatheters in adults with malignant pleural effusions: a systematic review.J Gen Intern Med. 2011; 26: 70-76Crossref PubMed Scopus (206) Google Scholar IPC is less cost-effective than chest tube pleurodesis if the patient survives >6 weeks.13Olden AM Holloway R Treatment of malignant pleural effusion: PleuRx catheter or talc pleurodesis? A cost-effectiveness analysis.J Palliat Med. 2010; 13: 59-65Crossref PubMed Scopus (93) Google Scholar Thus, we have to wait for randomized controlled trials of IPC with TTP or TS before any recommendation can be made in favor of IPC as the first choice in management of patients with MPE.