Talc Pleurodesis Research Articles

Indwelling pleural catheter versus talc pleurodesis for malignant pleural effusion: a meta-analysis.

Malignant pleural effusion (MPE) results from primary mesothelioma or the spreading of metastatic cancer. Both talc pleurodesis (TP) and indwelling pleural catheter (IPC) improve MPE symptoms. We performed a meta-analysis of randomized controlled trials to compare the efficacy of TP with that of IPC in patients with MPE. PubMed, EMBASE, Cochrane Library, and ClinicalTrials.gov databases were searched for studies published before February 2020. Individual effect sizes were standardized, and a meta-analysis was conducted to calculate a pooled effect size by using random effects models. In total, 4 trials with 500 patients were reviewed. Difference in pleurodesis success rate and change in dyspnea scores at 4 and 6 weeks between MPE patients treated with IPC and those treated with TP for pleurodesis were nonsignificant. The number of hospital inpatient days was significantly lower among patients who were treated with IPC (weight mean difference: 2.19; 95% confidence interval 0.70-3.67) than among those who were treated with TP. No significant difference was shown in adverse event profile between patients treated with IPC and those treated with TP for pleurodesis. In conclusion, both TP and IPC are equally effective in treating patients with MPE. The number of hospitalization days was significantly lower for patients who were treated with IPC, but the magnitude of the difference is of uncertain clinical importance.

OUTCOMES OF TALC PLEURODESIS IN MALIGNANT PLEURAL EFFUSION

TYPE: Abstract Publication TOPIC: Procedures PURPOSE: Malignant pleural effusion (MPE) is a common condition, representing an advanced state of disease with poor survival. Slurry talc pleurodesis (TP) is one of the most effective treatment in patients without trapped lung that significantly improves symptoms. This study aims to determine the success rate of TP in MPE, predictive factors associated and the survival outcome. METHODS: Retrospective study of all patients with MPE submitted to slurry TP, performed between January 2016 and August 2019. Effective pleurodesis was defined by lack of recurrence of pleural effusion in the studied period. RESULTS: 49 patients were identified, 61.2% male, mean age 74±12 years. Most of MPE were originated by lung tumors (63.3%). Other malignancies included were 14.3% gastro-intestinal tumors, 8.2% breast tumors, 8.2% urologic tumors, 4% hematologic tumors and 2% laryngeal tumors. 42.9% had a positive cytology for malignant disease. The procedure was effective in 79.6% of cases. We found 75.5% of 30-day survival post-pleurodesis. In post-pleurodesis relapse group, the average survival estimated was 186 days and for non-relapse group was 405 days. Pleural fluid biochemical, bacteriological and cytological findings and type of tumor had no significant statistical relation with recurrence. Relapse group was significantly older compared to non-relapse group (p=0.025). CONCLUSIONS: In this study, TP had high success rate, prolonging survival. Pleural fluid laboratorial findings and type of tumor may not be enough to predict recurrence post-procedure. CLINICAL IMPLICATIONS: Slurry TP in selected patients is an effective treatment in MPE. The older patients may be at higher risk of post-pleurodesis relapse. DISCLOSURE: No significant relationships. KEYWORDS: pleurodesis, pleural effusion

Thoracoscopy and talc poudrage compared with intercostal drainage and talc slurry infusion to manage malignant pleural effusion: the TAPPS RCT.

There are around 40,000 new cases of malignant pleural effusion in the UK each year. Insertion of talc slurry via a chest tube is the current standard treatment in the UK. However, some centres prefer local anaesthetic thoracoscopy and talc poudrage. There is no consensus as to which approach is most effective. This trial tested the hypothesis that thoracoscopy and talc poudrage increases the proportion of patients with successful pleurodesis at 3 months post procedure, compared with chest drain insertion and talc slurry. This was a multicentre, open-label, randomised controlled trial with embedded economic evaluation. Follow-up took place at 1, 3 and 6 months. This trial was set in 17 NHS hospitals in the UK. A total of 330 adults with a confirmed diagnosis of malignant pleural effusion needing pleurodesis and fit to undergo thoracoscopy under local anaesthetic were included. Those adults needing a tissue diagnosis or with evidence of lung entrapment were excluded. Allocation took place following minimisation with a random component, performed by a web-based, centralised computer system. Participants in the control arm were treated with a bedside chest drain insertion and 4 g of talc slurry. In the intervention arm, participants underwent local anaesthetic thoracoscopy with 4 g of talc poudrage. The primary outcome measure was pleurodesis failure at 90 days post randomisation. Secondary outcome measures included mortality and patient-reported symptoms. A cost-utility analysis was also performed. A total of 166 and 164 patients were allocated to poudrage and slurry, respectively. Participants were well matched at baseline. For the primary outcome, no significant difference in pleurodesis failure was observed between the treatment groups at 90 days, with rates of 36 out of 161 (22%) and 38 out of 159 (24%) noted in the poudrage and slurry groups, respectively (odds ratio 0.91, 95% confidence interval 0.54 to 1.55; p = 0.74). No differences (or trends towards difference) were noted in adverse events or any of the secondary outcomes at any time point, including pleurodesis failure at 180 days [poudrage 46/161 (29%), slurry 44/159 (28%), odds ratio 1.05, 95% confidence interval 0.63 to 1.73; p = 0.86], mean number of nights in hospital over 90 days [poudrage 12 nights (standard deviation 13 nights), slurry 11 nights (standard deviation 10 nights); p = 0.35] and all-cause mortality at 180 days [poudrage 66/166 (40%), slurry 68/164 (42%); p = 0.70]. At £20,000 per quality-adjusted life-year gained, poudrage would have a 0.36 probability of being cost-effective compared with slurry. Entry criteria specified that patients must be sufficiently fit to undergo thoracoscopy, which may make the results less applicable to those patients presenting with a greater degree of frailty. Furthermore, the trial was conducted on an open-label basis, which may have influenced the results of patient-reported measures. The TAPPS (evaluating the efficacy of Thoracoscopy And talc Poudrage versus Pleurodesis using talc Slurry) trial has robustly demonstrated that there is no additional clinical effectiveness or cost-effectiveness benefit in performing talc poudrage at thoracoscopy over bedside chest drain and talc slurry for the management of malignant pleural effusion. Current Controlled Trials ISRCTN47845793. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 26. See the NIHR Journals Library website for further project information.

Influence of the progression of pleural neoplasia on the outcome of pleurodesis in mice.

Purpose: Experimental study aimed at evaluating whether pleural neoplastic disease is associated with the degree of pleural fibrosis over time caused by talc pleurodesis. The study describes changes in levels of inflammatory mediators and determines whether the course of time involved in progression of neoplastic pleural disease is the factor that influences safety of talc pleurodesis usage in mice.Materials and Methods: Animals were randomized into two groups: Cancer group (CG) that received intrapleural injection of Lewis cells or Saline group (SG) that received saline injection. After, the animals were subdivided into Early (pleurodesis 3 days after pleural injection) and Late (pleurodesis 7 days after pleural injection) groups. Half of the animals in each group were euthanized 24 hours after pleurodesis (to obtain the inflammatory data); the remaining animals were killed after 8 days (to obtain the scores of pleural fibrosis).Results: CGs had lower fibrosis scores than SGs comparing early phases to late phases. Inflammation scores were lower in CGs, particularly in Late group. In SGs the inflammation was intense in 100% of the animals.In Late CG group pleural adhesions had the lowest scores; we found intense fibrosis only in SGs. VEGF and LDH levels had increased in animals with cancer, particularly in Late group. Systemic distribution of talc occurred only in Late CG.Conclusions: The time for pleural neoplasia to evolve is inversely proportional to the degree of pleural fibrosis. Earlier pleurodesis yielded the best results related to fibrosis, with less systemic inflammation and is safer in mice.

THE ECONOMIC RATIONALE FOR THE USE OF OUTPATIENT PLEURODESIS IN THE TREATMENT OF MALIGNANT PLEURAL EFFUSIONS

Introduction. Exudative tumor pleurisy affects up to 100 000 people a year in Russia, up to 400 000 people a year in Europe. Inpatient treatment of such patients is associated with certain costs, and there are also queues for treatment in oncology hospitals. An outpatient pleurodesis can reduce these problems. The objective was to compare pharmacoeconomic parameters for inpatient pleurodesis and outpatient pleurodesis to determine the most cost-effective treatment option. Methods and materials. 179 patients in the clinic of the Federal State Budgetary Institution Scientific Research Center for Oncology named after N. N. Petrov of the Russian Ministry of Health underwent pleurodesis using various methods (talc, bleocin, combined). The effectiveness of the methods and the direct medical costs of treatment were evaluated. The effectiveness of a stationary thoracoscopic pleurodesis was evaluated according to foreign literature, and the direct medical costs of treatment were calculated. Based on the obtained results, the pharmacoeconomic indicators of CER and ICER were calculated. Results. Direct medical costs for stationary thoracoscopic pleurodesis amounted to 35056.4 rubles with an efficiency of 89 %. Direct medical costs for outpatient pleurodesis were: for talc pleurodesis – 8051.7 rubles, for bleocin and combined pleurodesis – 11799.2 rubles. CER amounted to: for a thoracoscopic pleurodesis in the hospital – 393.9, for talc pleurodesis – 115.35, for bleocin pleurodesis – 188.7, for combined pleurodesis – 155.8. ICER in relation to stationary pleurodesis was 1406.4 for talc pleurodesis, 877.6 for bleocin pleurodesis, 1748.6 for combined pleurodesis. Conclusion . CER was almost 3 times lower with outpatient pleurodesis, which makes it the most cost-effective option for the treatment of tumor exudative pleurisy. ICER was maximal in combined pleurodesis, which makes it preferred among outpatient pleurodesis options. Based on the obtained data, it can be argued that the use of ambulatory pleurodesis as an initial stage of care for patients with tumor exudative pleurisy is economically justified.

Efficacy of talc pleurodesis for malignant and paramalignant pleural effusion: a retrospective analysis of 61 cases

Introduction: Malignant-paramalignant effusions are common after malignancies. Treatment of malign-paramalignant pleural effusion is directed towards palliation of symptoms and improvement in quality of life. Chemical pleurodesis has been widely used to control malignant and para-malignant pleural effusion. The present study aims to reveal the effects of chemical pleurodesis on malignant and paramalignant pleural effusions commonly coexisting with malignant diseases.Methods: 61 patients were retrospectively examined between October 2017 and December 2019. Drainage with 8F intrapleural catheter and chemical pleurodesis (sterile talc powder) were employed in 61 patients with malignant and/or paramalignant effusion. The patient group consisted of patients treated at the thoracic surgery service or consulted from other services. The patients demographics and data on their operated side (left/right), recurrence rate, length of postoperative hospital stay, and complications were extracted from their files.Results: The sample consisted of 48 male (78.6%) and 13 female (21.3%) patients. The patients were between 22 and 82 years and the average age was 60.0 ± 13.2 years. 33 patients (54.0%) were operated on the right side, while 7 (11.4%) and 21 (34.4%) were operated bilaterally or on the left side, respectively. The most common cause of malignant and paramalignant pleural effusion was found to be lung cancer, accounting for 38 (62.2%) of the patients. Postoperative recurrence was observed in 15 (24.5%) patients. The ‎Mann-Whitney U test was used for skewed variables, and the Chi-Square test (or Fisher’s exact test) was used for ‎categorical variables. No significant difference was observed in terms of surgery side (p=0.676), gender (p=0.156) and malignant disease (p=0.979).The average length of hospital stay was 5.3 days.Conclusions: The primary principle is to control the symptoms by removing the intrapleural effusion in the cases of malignant and paramalignant effusions. When recurrence rates were evaluated, intrapleural catheter drainage and chemical pleurodesis are an effective and safe method in selected patients.

The efficacy of hydrogel foams in talc Pleurodesis

BackgroundMalignant pleural effusions are a serious complication of many late stage cancers that adversely affect quality of life. Pleurodesis with talc slurry is a standard treatment option, but clinical failures occur, possible due to poor talc delivery. A novel drug-delivery system was developed that fills the entire thoracic cavity with a liquid foam containing talc. The foam is designed to gel and adhere to the tissue walls at body temperature, to improve talc deposition and efficacy.MethodsRheology, foam stability, and ex-vivo coating and bio-adhesion studies were performed on three concentrations of a novel hydrogel talc foam system that was developed to improve delivery of talc to the pleural surfaces. A New Zealand rabbit model of pleurodesis was used to evaluate effectiveness of the foams at inducing adhesion formation and compared to talc slurry. The rabbits were recovered after they had one of the test agents instilled into their pleura, and then sacrificed after 28 days. Pleurodesis was assessed by a blinded pathologist using a standardized pathological scoring system.ResultsAll talc foam formulations produced foams that gelled at physiological temperatures and were relatively stable for at least two hours. As the concentration of the formulation increased the gelation temperature decreased and the foam adhesiveness increased. Rabbits that received talc foam had significantly greater adhesion formation than talc slurry (mean score of 2.21 vs. 1.18 (p < 0.05)). Rabbits that received the 20% foam developed the most adhesions.ConclusionsThis study demonstrates that our triblock copolymer hydrogel foam delivery system enhances adhesion formation in an experimental model. This novel approach can have important clinical impact, potentially improving efficacy of existing therapies and reducing the need for more invasive treatments.

Viscum pleurodesis is as effective as talc pleurodesis and tends to have less adverse effect

PurposeMany patients diagnosed with advanced cancer have malignant pleural effusion that does not respond to chemotherapy or radiation therapy. These patients often have respiratory symptoms, especially dyspnea. In order to relieve these symptoms, various procedures including chemical pleurodesis have been performed. Although talc is the most widely used and effective sclerosing agent, there it has various adverse effects. The objective of this study was to determine whether Viscum (ABNOVA Viscum® Fraxini Injection, manufactured by ABNOVA GmbH, Germany) could be used as an agent to replace talc in clinical practice.MethodsData of 56 patients with malignant pleural effusion who received chemical pleurodesis after tube thoracostomy from January 2003 to December 2017 were retrospectively reviewed to analyze clinical course and response after pleurodesis with each agent.ResultsAfter pleurodesis, changes in numeric rating scale (NRS) was 1.4 ± 1.6 in the talc group and 0.5 ± 1.5 in the Viscum group (p = 0.108). Changes in white blood cell counts after pleurodesis were 4154.8 ± 6710.7 in the talc group and 3487.3 ± 6067.7 in the Viscum group (p = 0.702). Changes in C-reactive protein (CRP) were 9.03 ± 6.86 in the talc group and 6.3 ± 7.5 in the Viscum group (p = 0.366). The success rate of pleurodesis was 93.3% in the talc group and 96% in the Viscum group (p = 0.225).ConclusionViscum pleurodesis showed comparable treatment results with talc pleurodesis while its adverse effects such as chest pain and fever tended to be relatively weak.

A low-cost alternative to atomizer in talc pleurodesis.

A low-cost alternative to atomizer in talc pleurodesis.

Effect of Thoracoscopic Talc Poudrage vs Talc Slurry via Chest Tube on Pleurodesis Failure Rate Among Patients With Malignant Pleural Effusions

Malignant pleural effusion (MPE) is challenging to manage. Talc pleurodesis is a common and effective treatment. There are no reliable data, however, regarding the optimal method for talc delivery, leading to differences in practice and recommendations. To test the hypothesis that administration of talc poudrage during thoracoscopy with local anesthesia is more effective than talc slurry delivered via chest tube in successfully inducing pleurodesis. Open-label, randomized clinical trial conducted at 17 UK hospitals. A total of 330 participants were enrolled from August 2012 to April 2018 and followed up until October 2018. Patients were eligible if they were older than 18 years, had a confirmed diagnosis of MPE, and could undergo thoracoscopy with local anesthesia. Patients were excluded if they required a thoracoscopy for diagnostic purposes or had evidence of nonexpandable lung. Patients randomized to the talc poudrage group (n = 166) received 4 g of talc poudrage during thoracoscopy while under moderate sedation, while patients randomized to the control group (n = 164) underwent bedside chest tube insertion with local anesthesia followed by administration of 4 g of sterile talc slurry. The primary outcome was pleurodesis failure up to 90 days after randomization. Secondary outcomes included pleurodesis failure at 30 and 180 days; time to pleurodesis failure; number of nights spent in the hospital over 90 days; patient-reported thoracic pain and dyspnea at 7, 30, 90, and 180 days; health-related quality of life at 30, 90, and 180 days; all-cause mortality; and percentage of opacification on chest radiograph at drain removal and at 30, 90, and 180 days. Among 330 patients who were randomized (mean age, 68 years; 181 [55%] women), 320 (97%) were included in the primary outcome analysis. At 90 days, the pleurodesis failure rate was 36 of 161 patients (22%) in the talc poudrage group and 38 of 159 (24%) in the talc slurry group (adjusted odds ratio, 0.91 [95% CI, 0.54-1.55]; P = .74; difference, -1.8% [95% CI, -10.7% to 7.2%]). No statistically significant differences were noted in any of the 24 prespecified secondary outcomes. Among patients with malignant pleural effusion, thoracoscopic talc poudrage, compared with talc slurry delivered via chest tube, resulted in no significant difference in the rate of pleurodesis failure at 90 days. However, the study may have been underpowered to detect small but potentially important differences. ISRCTN Identifier: ISRCTN47845793.

Update on Management of Pleural Disease

The goal of this paper is to review and summarize the most recent updates in the management of both benign and malignant pleural diseases. Multiple trials evaluating the use of non-surgical techniques for the management of pleural infection have been published in the last 5 years. Additionally, the use of tunneled pleural catheter (TPC) placement in the management of non-infectious recurrent pleural effusions is being increasingly studied. Finally, the separate use of TPC placement or talc pleurodesis as well as a combined rapid pleurodesis protocol involving both talc poudrage and TPC placement has been published in the area of symptomatic recurrent malignant pleural effusion. Exciting advances have been made in the field of pleural disease management. In this paper, we summarize the most relevant trials, provide a list of pertinent references for review, and discuss future research directions.

Efficacy, Safety and Re-occurrence of Pneumothorax and Hydro-pneumothorax With Talc and Pyodine Pleurodesis

Efficacy, Safety and Re-occurrence of Pneumothorax and Hydro-pneumothorax With Talc and Pyodine Pleurodesis

AMBULATORY PLEURODESIS: SUCCESSFUL USE OF TALC WITH INDWELLING PLEURAL CATHETER FOR MANAGEMENT OF BILATERAL MALIGNANT PLEURAL EFFUSIONS

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Malignant pleural effusions affect more than 750,000 patients each year in Europe and the United States and account for greater than 125,000 hospitalizations and have an estimated cost of $5 billion per year1,2. Treatment for malignant pleural effusions with expandable lung would favor treatment with talc pleurodesis and often requires days of inpatient hospitalization for management and observation3. Placement of indwelling pleural catheters (IPCs) can be used as successful alternative for management of symptoms in an ambulatory setting3,4. Additionally, administration of talc through an IPC shows increased probability of pleurodesis4. We present a patient with bilateral malignant pleural effusions with successful bilateral pleurodesis using talc instilled through bilateral IPCs. CASE PRESENTATION: A 72-year-old man with a past medical history significant for metastatic melanoma presented to the ED with complaints of progressive dyspnea at rest. Imaging revealed large bilateral pleural effusions with symptomatic improvement with therapeutic thoracentesis. Initial studies were consistent with exudative effusion with negative cytology and patient was discharged with follow-up in Pulmonary Clinic. He underwent repeat large-volume thoracentesis with repeat cytology showing metastatic melanoma. Given rapidly re-accumulating fluid and symptoms, a left IPC was placed with significant improvement and a right IPC was placed 2 weeks later with continued improvement and decreased effusions on repeat U/S. At this time, further management with talc pleurodesis was discussed to ideally eliminate the need of IPCs and enhance the patient’s quality of life. Talc was instilled per IPC plus protocol4 with subsequent ultrasound monitoring with <25 cc of output daily. Given good apposition, the left IPC was removed and 2 weeks later, talc was administered to the right IPC with similar results on ultrasound with upcoming removal of right IPC given continued good apposition and decreased drainage. DISCUSSION: We demonstrate a validated alternative treatment strategy in a patient with bilateral malignant pleural effusions. This presents a plausible alternative to patients to decrease hospital days and expenses, while improving quality of life and allowing for pleurodesis in an outpatient setting. We show success using bilateral IPCs with sequential talc pleurodesis and removal of IPCs. No hospitalizations were made during this time period and the patient tolerated all procedures well. CONCLUSIONS: Given continued advancement in techniques, we continue to show patient-centered care in a challenging population with an outpatient centered treatment approach and use of U/S imaging for clinical management. Reference #1: 1. Marel M, Zrustova M, et al. The incidence of pleural effusion in a well-defined region: epidemiology study in Central Bohemia. Chest 1993; 104:1486-9. Reference #2: 2. Taghizadeh N, Fortin M, Tremblay A. US hospitalizations for malignant pleural effusions: data from the 2012 National Inpatient Sample. Chest 2017;151:845–854. Reference #3: 3. Feller-Kopman D, Reddy C, et al. Management of Malignant Pleural Effusions. An Official ATS/STS/STR Clinical Practice Guidelines. Am J Respir Crit Care Med. 2018 Oct 1; 198(7):839-849. 4. Bhatnagar R, Keenan E, et al. Outpatient Talc Administration by Indwelling Pleural Catheter for Malignant Effusion. N Engl J Med. 2018 Apr 5;378(14):1313-1322. DISCLOSURES: No relevant relationships by Michael Gonzales, source=Web Response No relevant relationships by Tyson Sjulin, source=Web Response No relevant relationships by John Untisz, source=Web Response

Prise en charge diagnostique et thérapeutique du mésothéliome pleural malin en 2019

Malignant pleural mesothelioma (MPM) is a rare tumor, usually due to previous asbestos exposure. Its glob prognosis is poor, without validated curative treatment to date. Diagnosis relies ideally on thoracoscopy with pleural biopsies, ± combined with talc pleurodesis. Surgery with curative intent, included with multimodal treatment, is restrained to highly selected patients. Radiotherapy is also of limited indication in MPM. Standard first line chemotherapy does quite poorly, improved by addition of bevacizumab. No treatment is validated as second line or further even if anti-PD-1/PD-L1 ± anti-CTLA-4 antibodies exhibited promising results in phase II trials (MAPS-2…). Thus the search of new treatments, strategies and biomarkers is a crucial goal, and recruitment of patients in clinical trials is strongly encouraged. Other immunotherapies alone or combined with standard treatments and/or targeted therapies, multimodal strategies including intrapleural therapy are currently assessed.In France, the national network of clinical expert centers for MPM, “MESOCLIN”, aims at proposing an optimal treatment to all patients systematically discussed in regional (±national) MTB dedicated to MPM, and at stimulating clinical and translational research in close collaboration with its partners: Mesopath, Mesobank, IFCT… and patients associations.

ES19.03 RCT's on Malignant Pleural Effusion Talc Pleurodesis Managment

This talk will focus on 2 recently completed multicentre RCT's in talc pleurodesis for malignant pleural effusions; IPC plus trial (NEJM 2018) and the TAPPS trial (in submission). A summary of these 2 trials is below: IPC Plus - Methods: Over a period of 4 years, we recruited patients with malignant pleural effusion at 18 centers in the United Kingdom. After the insertion of an indwelling pleural catheter, patients underwent drainage regularly on an outpatient basis. If there was no evi- dence of substantial lung entrapment (nonexpandable lung, in which lung expansion and pleural apposition are not possible because of visceral fibrosis or bronchial ob- struction) at 10 days, patients were randomly assigned to receive either 4 g of talc slurry or placebo through the indwelling pleural catheter on an outpatient basis. Talc or placebo was administered on a single-blind basis. Follow-up lasted for 70 days. The primary outcome was successful pleurodesis at day 35 after randomization. Results: The target of 154 patients undergoing randomization was reached after 584 patients were approached. At day 35, a total of 30 of 69 patients (43%) in the talc group had successful pleurodesis, as compared with 16 of 70 (23%) in the placebo group (hazard ratio, 2.20; 95% confidence interval, 1.23 to 3.92; P=0.008). No significant be- tween-group differences in effusion size and complexity, number of inpatient days, mortality, or number of adverse events were identified. No significant excess of blockages of the indwelling pleural catheter was noted in the talc group. Conclusions: Among patients without substantial lung entrapment, the outpatient administration of talc through an indwelling pleural catheter for the treatment of malignant pleural effusion resulted in a significantly higher chance of pleurodesis at 35 days than an indwelling catheter alone, with no deleterious effects. (Funded by Becton Dickinson; EudraCT number, 2012-000599-40.) TAPPS - Methods We recruited patients with malignant pleural effusion from 17 United Kingdom hospitals over 5 years. On an open-label basis, patients were randomly assigned to receive either 4g talc poudrage at thoracoscopy under conscious sedation, or chest tube insertion under local anesthetic followed by 4g talc slurry. Follow-up lasted for six months. The primary outcome was pleurodesis failure rate three months after randomization, defined as the need for further pleural intervention during follow-up. Secondary outcomes including mortality and cost-effectiveness were also assessed. Results The target of 330 patients was reached after 583 were approached. At three months, pleurodesis failure rate was 36/161 (22%) with poudrage and 38/159 (24%) with slurry (adjusted odds ratio (OR) 0.91, 95% confidence interval (CI) 0.54-1.55, p=0.74). No statistically significant differences were noted in any secondary outcome. Numbers of adverse events were similar between groups. Using a standard threshold, poudrage had a 36% probability of being cost-effective. Conclusions In patients with malignant pleural effusion, there appears to be no additional clinical or cost-effectiveness benefit to choosing talc poudrage at physician-led thoracoscopy over talc slurry through chest tube. (Funded by the United Kingdom National Institute for Health Research). Pleural effusion, Talc pleurodesis, Malignant pleural effusion

SIMULTANEOUS BILATERAL SPONTANEOUS PNEUMOTHORAX (SBSP) AS THE FIRST PRESENTATION OF COPD

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: A secondary spontaneous pneumothorax is defined as pneumothorax secondary to underlying lung disease that occurs without a trauma or iatrogenic cause [1,2]. Simultaneous bilateral spontaneous pneumothorax (SBSP) forms a total of 1.3% of all spontaneous pneumothorax cases [3]. CASE PRESENTATION: A 66-year-old male with significant smoking history who presented to the Emergency Department (ED) for exertional shortness of breath of 3 weeks duration associated with mild chest pain and persistent dry cough. The patient initially went to a secondary hospital where he was diagnosed with bilateral pneumothoraces and was treated with bilateral pigtail chest tubes and oxygen therapy. However, he was in moderate respiratory distress; hence he was referred to a tertiary hospital. In ED, his vital signs were normal except for low oxygen saturation. Physical examination was remarkable for moderate distress, decreased breath sounds bilaterally and bilateral pigtail chest tubes attached. Laboratory studies including metabolic panel and complete blood counts were normal except for leukocytosis of 19.7 K/CMM. Computed tomography scan showed 60-70% bilateral pneumothoraxes, 2 chest tubes, and bilateral patchy consolidation (Figure 1). Patient was followed by repeated physical examinations and CXRs. His right pneumothorax improved and the chest tube was removed. However, the left chest tube showed persistent air leak necessitating pleurodesis with Doxycycline initially and Talc later as the patient wanted to be treated conservatively. Later, he became hemodynamically unstable, CXR showed right tension pneumothorax and an urgent right chest tube was inserted which normalized his vital signs. However, shortly after, he became unstable again, repeated CXR showed recurrent right tension pneumothorax, another chest tube was inserted complicated by right hemothorax; hence he was taken emergently for Video-Assisted Thoracoscopic Surgery (VATS) for hemothorax evacuation. Biopsy from VATS showed dense fibrosis and honeycombing emphysematous changes. Right-sided talc pleurodesis was done, and both chest tubes were removed. Repeated CXR demonstrated small left pneumothorax. Patient was discharged home, pulmonary rehabilitation and smoking cessation were strongly recommended. DISCUSSION: SBSP is a rare life-threatening emergency that requires immediate recognition and treatment. The presentation may vary from mild respiratory distress to cardiopulmonary failure. Diagnosis is confirmed on radiological findings and bilateral chest tubes are the initial appropriate treatment which in 82% of cases can stop air leak in 48 hours. However, the persistent air leak is an indication for surgery with VATS being most common. CONCLUSIONS: Presentation of SBSP can vary from mild respiratory symptoms to respiratory failure, diagnosis can be confirmed on chest radiography and the treatment is emergent chest tube placement. Reference #1: [1]Sahn SA, Heffner JE. Spontaneous pneumothorax. N Engl J Med. 2000 Mar 23;342(12):868-74. Review. PubMed PMID: 10727592. [2] Noppen M, De Keukeleire T. Pneumothorax. Respiration. 2008;76(2):121-7. https://doi.org/10.1159/000135932. Epub 2008 Jun 26. Review. PubMed PMID: 18708734 [3] Esther Graf-Deuel, Andreas Knoblauch: Simultaneous bilateral spontaneous pneumothorax. Chest. 1994;105:1142–6. DISCLOSURES: No relevant relationships by Noor Hajjaj, source=Web Response no disclosure on file for Chandler Patton; no disclosure on file for Julio Pernia; No relevant relationships by Ahmad Sharayah, source=Web Response

Talc Pleurodesis for the Treatment of Secondary Spontaneous Pneumothorax and Pleural Effusion

Talc Pleurodesis for the Treatment of Secondary Spontaneous Pneumothorax and Pleural Effusion

Survival in patients with malignant pleural effusion undergoing talc pleurodesis

ObjectivesRecent observations indicate a potential survival benefit in patients with malignant pleural effusion (MPE) who achieve successful pleurodesis in comparison to patients who experience effusion recurrence post pleurodesis. This study aimed to explore this observation using two datasets of patients with MPE undergoing talc pleurodesis. Materials and MethodsDataset 1 comprised patients who underwent talc pleurodesis at Oxford Pleural Unit for MPE. Dataset 2 comprised patients enrolled in the TIME1 clinical trial. Pleurodesis success was defined as absence of need for further therapeutic procedures for MPE in the three months following pleurodesis. Data on various clinical, laboratory and radiological parameters were collected and survival was compared according to pleurodesis outcome (success vs. failure) after adjusting for the aforementioned parameters. ResultsDataset 1 comprised 60 patients with mean age 74.1±10.3 years. The most common primary malignancies were mesothelioma, breast and lung cancer. 29 patients (48.3%) achieved pleurodesis. The adjusted odds ratio (aOR) for poor survival with pleurodesis failure was 2.85 (95% CI 1.08–7.50, =p 0.034).Dataset 2 comprised 259 patients from the TIME1 trial. The mean age was 70.8±10.3 and the most common primary malignancies were mesothelioma, lung and breast cancer. Pleurodesis was successful in 205 patients (79%). aOR for poor survival was 1.62 (95% CI 1.09–2.39, p = 0.015). ConclusionAchieving pleurodesis seems to impart a survival benefit in patients with MPE. Further studies are required to explore factors that may contribute to this phenomenon and to address the difference in survival between pleurodesis and indwelling pleural catheter interventions.

Primary Typical Carcinoid of The Pleura, A Rare Incidental Finding

Roughly 30% of carcinoids are found in the thoracic cavity, with the overwhelming majority of these being found in the lung parenchyma. We present a case of a rarely found primary pleural carcinoid incidentally diagnosed in a 73 year old male who presented with recalcitrant spontaneous pneumothorax requiring surgical intervention. The patient was taken to the operating room for a right video assisted thoracic surgery, partial pleurectomy, and talc pleurodesis. At the time of the operation, there were no abnormalities noted in the pleura or chest wall, and the patient did well post operatively. Pathologic examination of the pleura revealed a 3mm well differentiated neuroendocrine carcinoid tumor. Laboratory and imaging studies did not indicate another site of tumor. The importance of a multidisciplinary approach to the diagnosis, treatment, and surveillance is emphasized.

Non-intubated video-assisted thoracoscopic surgery vs. intubated video-assisted thoracoscopic surgery for thoracic disease: a systematic review and meta-analysis of 1,684 cases.

Non-intubated video-assisted thoracoscopic surgery (NIVATS) has been increasingly used in lobectomy, bullectomy, wedge resection, lung volume reduction, sympathectomy and talc pleurodesis, which may reduce postoperative complications. However, the benefits of non-intubated and intubated methods of VATS remain controversial. We comprehensively searched PubMed, Web of Science, Embase and the Cochrane Library, and performed a systematic review to assess the two techniques. Random and fixed-effects meta-analytical models were used based on the low between-study heterogeneity. Study quality, publication bias, and heterogeneity were assessed. Compared to intubated methods, NIVATS had a lower postoperative complications rate [odds ratio (OR): 0.63; 95% confidence interval (CI), 0.46-0.86; P<0.01], shorter global in-operating time [weighted mean difference (WMD): -35.96 min; 95% CI, -48.00 to -23.91; P<0.01], shorter hospital stay (WMD: -1.35 days; 95% CI, -1.72 to -0.98; P<0.01), shorter anesthesia time (WMD: -7.29 min; 95% CI, -13.30 to -1.29; P<0.01), shorter chest-tube placement time (WMD: -1.04 days; 95% CI, -1.75 to -0.33; P<0.01), less chest pain (WMD: -1.31; 95% CI, -2.45 to -0.17; P<0.05) and lower perioperative mortality rate (OR: 0.13; 95% CI, 0.02-0.99; P=0.05). NIVATS is a safe, efficient and feasible technique for thoracic surgery and may be a better alternative procedure owing to its advantage in reducing postoperative complications rate, hospital stay, and chest pain.