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Correspondence |

Management of Recurrent Malignant Pleural EffusionsMalignant Pleural Effusions: An Ever-Recurring Issue? FREE TO VIEW

Fabien Maldonado, MD, FCCP; Philippe Astoul, MD, PhD
Author and Funding Information

From the Department of Thoracic Oncology, Pleural Diseases, and Interventional Pulmonology (Dr Astoul), Hôpital Nord, University of the Mediterranean; and Division of Pulmonary and Critical Care Medicine (Dr Maldonado), Mayo Medical School.

Correspondence to: Philippe Astoul, MD, PhD, Department of Thoracic Oncology, Pleural Diseases, and Interventional Pulmonology, Hôpital Nord, Chemin des Bourrely, 13326 Marseille cedex 20, France; e-mail: pastoul@ap-hm.fr


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2012;142(6):1696. doi:10.1378/chest.12-2038
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To the Editor:

We read with great interest the CHEST Point/Counterpoint Editorials by Lee1 and Light2 (July 2012) on thoracoscopic talc pleurodesis (TTP) vs an indwelling pleural catheter and would like to make several comments. The value of thoracoscopic assessment of the pleural cavity during talc poudrage has not been carefully studied. Thoracoscopy circumvents the limitations of a blind talc application through a chest tube, which as pointed out by Dr Lee, can only be successful with adequate apposition of the visceral and parietal pleura. Thoracoscopy, which is commonly done with local anesthesia or conscious sedation in the outpatient setting, allows for debridement, lysis of adhesions, and optimal talc pleurodesis.

Regarding the study by Dresler et al,3 we agree that the post hoc subset analysis showing a better efficacy of TTP over talc slurry is, at best, hypothesis generating. However, we would like to point out that the complications reported in the TTP arm were staggering, with blood transfusion, atelectasis, pneumonia, respiratory failure, and postoperative death in 4.5%, 1.3%, 9.3%, 8.1%, and 8.4% of patients, respectively. These results do not reflect those described by pulmonologists around the world. It is difficult to argue against the large body of safety data for talc pleurodesis in light of two multicenter prospective European studies.4,5 To answer Dr Light’s concern about the study by Janssen et al,4 one of the authors (P. A.) was involved in both studies and can attest to the extreme caution used in determining the causes of respiratory manifestation observed after talc pleurodesis.

Regional differences in health-care delivery rather than data on efficacy and safety often dictate management. In that context, the data provided by the only cost-effectiveness analysis available, as quoted by both authors,1,2 is of questionable relevance outside of the United States. Furthermore, short drainage times after talc pleurodesis with limited hospitalization have been shown to be effective. It is difficult to imagine that a short initial hospitalization and a literally dirt-cheap pleurodesis agent would offset the cumulative cost and out-of-pocket expenses required for the management of indwelling pleural catheters and their complications. Considering that the calibrated French talc used in the majority of countries (but not in the United States) has a proven record of short- and long-term safety and efficacy, we anticipate that talc pleurodesis will remain the standard of care chosen by most pulmonologists around the world.

References

Lee P. Point: should thoracoscopic talc pleurodesis be the first choice management for malignant effusion? Yes. Chest. 2012;142(1):15-17. [CrossRef] [PubMed]
 
Light RW. Counterpoint: should thoracoscopic talc pleurodesis be the first choice management for malignant pleural effusion? No. Chest. 2012;142(1):17-19. [CrossRef] [PubMed]
 
Dresler CM, Olak J, Herndon JE II, et al; Cooperative Groups Cancer and Leukemia Group B; Eastern Cooperative Oncology Group; North Central Cooperative Oncology Group; Radiation Therapy Oncology Group. Phase III intergroup study of talc poudrage vs talc slurry sclerosis for malignant pleural effusion. Chest. 2005;127(3):909-915. [CrossRef] [PubMed]
 
Janssen JP, Collier G, Astoul P, et al. Safety of pleurodesis with talc poudrage in malignant pleural effusion: a prospective cohort study. Lancet. 2007;369(9572):1535-1539. [CrossRef] [PubMed]
 
Bridevaux PO, Tschopp JM, Cardillo G, et al. Short-term safety of thoracoscopic talc pleurodesis for recurrent primary spontaneous pneumothorax: a prospective European multicentre study. Eur Respir J. 2011;38(4):770-773. [CrossRef] [PubMed]
 

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Tables

References

Lee P. Point: should thoracoscopic talc pleurodesis be the first choice management for malignant effusion? Yes. Chest. 2012;142(1):15-17. [CrossRef] [PubMed]
 
Light RW. Counterpoint: should thoracoscopic talc pleurodesis be the first choice management for malignant pleural effusion? No. Chest. 2012;142(1):17-19. [CrossRef] [PubMed]
 
Dresler CM, Olak J, Herndon JE II, et al; Cooperative Groups Cancer and Leukemia Group B; Eastern Cooperative Oncology Group; North Central Cooperative Oncology Group; Radiation Therapy Oncology Group. Phase III intergroup study of talc poudrage vs talc slurry sclerosis for malignant pleural effusion. Chest. 2005;127(3):909-915. [CrossRef] [PubMed]
 
Janssen JP, Collier G, Astoul P, et al. Safety of pleurodesis with talc poudrage in malignant pleural effusion: a prospective cohort study. Lancet. 2007;369(9572):1535-1539. [CrossRef] [PubMed]
 
Bridevaux PO, Tschopp JM, Cardillo G, et al. Short-term safety of thoracoscopic talc pleurodesis for recurrent primary spontaneous pneumothorax: a prospective European multicentre study. Eur Respir J. 2011;38(4):770-773. [CrossRef] [PubMed]
 
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