Patients with a malignant effusion have a mean life expectancy of only several months. It is, therefore, incumbent upon physicians caring for these patients to manage their effusions in a manner that will provide them the most high-quality days during the remainder of their lives.
Dr Lee’s1 conclusion that the optimal treatment of pleural effusion is thoracoscopic talc pleurodesis appears to be based on two reviews, which were both published in 2006 and concluded that talc was the sclerosant of choice and that thoracoscopy was the preferred technique. Neither of these reviews included the article by Dresler et al,2 which showed that overall there was no difference in the percentage of successful pleurodesis whether the patient received talc via tube thoracostomy or via thoracoscopy. Lee goes on to note that in the study reported by Dresler et al,2 the pleurodesis was more successful in patients with breast and lung carcinoma subjected to thoracostomy. This means that the patients with other malignancies who received thoracoscopy did worse. This study was not originally designed for subset analysis, so one must be careful of making conclusions from subset analysis. As Davies et al3 point out, all randomized trials to date have failed to show a benefit of thoracoscopic talc poudrage over bedside chemical pleurodesis in the treatment of malignant pleural effusion.