I commend Drs Maldonado and Astoul for their points in support of thoracoscopic talc poudrage (TTP) as the first choice for malignant pleural effusion.1 Light2 based his rebuttal on the study by Dresler et al,3 where patients with malignant pleural effusions had to demonstrate > 90% lung expansion before they received talc slurry via chest tube or TTP. Thirty-two percent and 27% of patients randomized to talc slurry and TTP groups, respectively, were excluded, and they could have trapped lungs from pleural loculations and extensive tumor load for which thoracoscopic adhesiolysis would be beneficial by promoting fluid drainage and lung expansion. Complications associated with TTP performed by surgeons in these patients with good Eastern Cooperative Oncology Group status (0-2) were higher than those in the published literature,4 particularly blood transfusion (4.5%), respiratory failure (8.1%), and postoperative death (8.4%). The type of talc used was also unclear, because small-particle talc (< 15 μm) could have caused respiratory failure.5 A trial involving 13 centers in Europe and one center in South Africa demonstrated the safety of TTP with large-particle talc (mean size, 24.5 μm). TTP was performed by pulmonologists in 558 patients with Karnofsky scores > 30 or Eastern Cooperative Oncology Group < 4. Thirty-day mortality was markedly lower, at 1.97%. Only one patient (0.17%) developed respiratory failure from contralateral pneumothorax, and no patient required surgical bailout or blood transfusion.6 In his letter to the editor, Medford7 estimated the cost benefits of medical thoracoscopy. Although he referred to patients with unexplained pleural effusions, the arguments of a shorter wait period to perform pleurodesis and a shorter hospital stay with TTP compared with talc slurry would favor TTP as the more cost-effective treatment of malignant pleural effusion against indwelling pleural catheter if patient survival exceeds 6 weeks.