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Talc Pleurodesis Through Indwelling Pleural Catheters for Malignant Pleural EffusionsTalc Pleurodesis Via Indwelling Pleural Catheters: Retrospective Case Series of a Novel Clinical Pathway FREE TO VIEW

Liju Ahmed, MBBS; Hugh Ip, MBBS; Deepak Rao, MBBS; Nishil Patel, MBBS; Farinaz Noorzad, BSc
Author and Funding Information

From Guy’s and St Thomas’ NHS Trust (Drs Ahmed, Ip, and Rao and Ms Noorzad); and King’s College London (Dr Patel), London, England.

CORRESPONDENCE TO: Hugh Ip, MBBS, Chest Department, 1st Floor, Lambeth Wing, St Thomas’ Hospital, Westminster Bridge Rd, London, SE1 7EH, England; e-mail: Hughip@gmail.com


Drs Ahmed and Ip are joint first authors.

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


Chest. 2014;146(6):e190-e194. doi:10.1378/chest.14-0394
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Malignant pleural effusions cause significant morbidity, but there is no gold standard minimally invasive treatment. A new therapeutic approach combines talc pleurodesis and indwelling pleural catheters (IPCs) to enable outpatient management. This case series summarizes the safety and efficacy data of all patients (24) with a symptomatic malignant pleural effusion who underwent talc pleurodeses via IPCs between December 2010 and July 2013. Successful pleurodesis was achieved in 22 procedures (92%). There was one empyema, one hydropneumothorax, one recurrent effusion, and two minor complications: one drain site wound infection and one complaint of chest pain. Twenty-two procedures (92%) were performed in the outpatient setting. This report confirms the safety and efficacy of administering talc slurry through IPCs in an outpatient setting. Studies in a larger cohort are necessary to define the role of this novel approach in the treatment algorithm of patients with this condition.

Figures in this Article

Malignant pleural effusions affect > 150,000 patients in the United States each year, reflecting advanced disease.1 In the United Kingdom, the estimated incidence is one new case per 1,000 population per year.2 Mean survival ranges from 3 to 12 months after diagnosis3; the primary aim is palliation.

Talc poudrage via video-assisted thoracoscopic surgery (VATS) is generally the preferred treatment.4,5 However, VATS is not widely available, so talc slurry via chest tube is a popular alternative. There is no evidence favoring talc administration via chest tube or VATS; two randomized controlled trials showed comparable outcomes.3,6,7

As an alternative to talc pleurodesis, indwelling pleural catheters (IPCs) have been used.8 IPCs allow long-term drainage of effusions over periods of weeks to months, useful especially in cases of trapped lung, where talc pleurodesis is likely to fail. IPCs can be inserted as day case procedures, unlike chest drains, which usually require hospital admission.

A new therapeutic approach involves delivering talc pleurodesis through an IPC. This exploits the strengths of IPCs and the main benefit of talc pleurodesis, which is preventing recurrence. This novel approach also allows outpatient management.

This case series describes the initial experience of our center. To our knowledge, there are no published data on this approach. There is only one pilot study of doxycycline, now superseded by graded talc, being given through an IPC.9

Study Design

A new treatment protocol was initiated in 2010. To assess outcomes, we performed a retrospective review of procedure documentation, radiology data, and clinic letters. We collected data on the safety, complication rates, and success of talc pleurodesis through an IPC.

Participants

Details of all talc pleurodeses via IPCs between December 2010 and July 2013 were reviewed. We included all procedures on patients with a symptomatic malignant pleural effusion performed by the respiratory department at St. Thomas’ Hospital. Histologic confirmation of the primary tumor was obtained in all cases. Patients were excluded from the study if their primary tumor was small cell lung cancer or lymphoma or if their World Health Organization performance status was > 1.

Interventions

All procedures were performed on an outpatient basis, unless the patient had already been admitted to hospital. Figure 1 outlines the management protocol. Patients were initially assessed for trapped lung with the help of chest radiographs and CT scans (where available), as well as with pleural manometry. An IPC (PleurX) was inserted using a standard technique.10 After the IPC insertion, pleural fluid was drained maximally, guided by pleural manometry and monitoring for chest pain. Patients were then sent home with instructions to drain the IPC daily for 3 days with 1-L vacuum bottles. When patients were unable to perform drainage themselves, district nurse visits were arranged. The volumes of fluid drained were recorded.

Figure Jump LinkFigure 1 –  Flowchart of malignant pleural effusion management at Guy’s and St Thomas’ NHS Trust. BTS = British Thoracic Society; IPC = indwelling pleural catheter.Grahic Jump Location

Patients were reviewed 3 days later by a specialist pleural nurse. They were assessed for lung reexpansion and resolution of effusion with thoracic ultrasound. Six areas of the hemithorax were assessed (Fig 2). When at least five areas had good pleural approximation to the chest wall, this was defined as > 90% of lung reexpansion. In the case of uncertainty, chest radiographs or CT scans were used. If the lung had not reexpanded, continued regular drainage (depending on fluid output) was advised. If the lung was fully reexpanded in five or more areas on ultrasound, and the drainage was < 200 mL/d, talc slurry was delivered through the IPC. Twenty to 25 mL 1% lignocaine was given through the IPC, along with 2.5 to 5 mg oral morphine, followed by 4 g graded talc dissolved in 50 mL normal saline, and flushed with 50 mL normal saline afterward. Patients were observed for at least 1 h following talc instillation.

Figure Jump LinkFigure 2 –  Diagram dividing each hemithorax into six areas for thoracic ultrasound assessment.Grahic Jump Location

They were then sent home with instructions to drain the IPC daily for 3 days with 1-L vacuum drainage bottles. District nurses assisted patients when required. Three days later, pleural symphysis was assessed with thoracic ultrasound. Pleurodesis is demonstrated by the absence of a pleural sliding sign (sliding of the visceral pleura over the parietal pleura during respiration). If there was good pleural approximation and loss of pleural sliding in > 90% of the hemithorax, patients were advised to stop drainage for 2 weeks. If there was no further fluid reaccumulation, the IPC was removed.

Assessments

Complications and hospital admissions were documented on the electronic patient record system. Pleurodesis was assessed 3 days after talc instillation. Pleurodesis success was determined for most patients at 14 days after talc instillation at the point of considering IPC removal.

During the study period, 57 IPCs were inserted for patients with malignant pleural effusions. Thirty-three procedures were excluded from the study because there was no subsequent talc pleurodesis through the IPC (reasons included trapped lung and performance status > 1). The remaining 24 procedures fulfilling the study criteria were analyzed.

The baseline patient characteristics are summarized in Table 1. The median age was 70 y (range, 36-83 y), and there was a predominance of women (58%). The primary tumor was non-small cell lung cancer in 54% and breast cancer in 21%; the remaining 25% was composed of ovarian cancer, rectal cancer, renal cell cancer, tongue cancer, and thymic cancer. Eighteen effusions (75%) were right sided.

Table Graphic Jump Location
TABLE 1 ]  Baseline Patient Characteristics (N = 24)

The postpleurodesis outcomes are summarized in Table 2. Successful pleurodesis was achieved in 22 procedures (92%).

Table Graphic Jump Location
TABLE 2 ]  Outcomes After Pleurodesis

Details of complications are summarized in Table 3. The overall complication rate was 21% (five complications). The major complications (making up 13%) were one hydropneumothorax, one empyema, and one recurrent effusion. The minor complications (making up 8%) were one drain site wound infection and one patient with chest pain.

Table Graphic Jump Location
TABLE 3 ]  Analysis of Complications

One complication was not included in this analysis because it was not attributable to the procedure being investigated: talc slurry through an IPC. The patient developed a pneumothorax after insertion of the IPC, before talc pleurodesis.

This case series of 24 procedures shows that talc pleurodesis via IPC is effective, with successful pleurodesis in 92% of procedures. The procedure is also safe, with a major complication rate of only 12%. Reactions to graded talc were not seen in these patients. There were no IPC blockages following talc slurry instillation. Twenty-two procedures (92%) were performed in the outpatient setting, and no problems resulted from discharging patients home the same day (following talc instillation).

To our knowledge, these are the first published safety and efficacy data on talc pleurodesis via an IPC. The strength of the data is its real-world relevance. Reasonably experienced pleural units should be able to safely replicate this novel approach of talc pleurodesis through an IPC for appropriate patients. Because of the study design, we lacked a control group and objective records of symptom improvement. There was also variability in the timing of pleurodesis assessment because of the limitations of the study design, and clinical priorities. The review of our tertiary hospital records did not capture data on patients when they were admitted to other (eg, secondary) hospitals.

Patients with a performance status > 1 were excluded, although they may have benefitted. We chose conservative exclusion criteria to ensure safety (in the outpatient setting) during this study.

This study adds to the evidence that malignant pleural effusions can be managed safely in an outpatient setting. This allows patients to spend quality time at home rather than in hospital and is likely to be cost effective. Previous studies involved outpatient pleurodesis through a chest drain rather than an IPC.11-14 Furthermore, these studies did not describe the use of graded talc, generally accepted as the most effective sclerosant.4

The next step is a multicenter randomized controlled trial. This would enable physicians to offer the best treatment to alleviate suffering in this important patient group.15

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Ahmed is a researcher on a study site for the IPC-PLUS trial (ISRCTN73255764). Drs Ip, Rao, and Patel and Ms Noorzad have reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions:CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.

IPC

indwelling pleural catheter

VATS

video-assisted thoracoscopic surgery

Haas AR, Sterman DH, Musani AI. Malignant pleural effusions: management options with consideration of coding, billing, and a decision approach. Chest. 2007;132(3):1036-1041. [CrossRef] [PubMed]
 
Rahman NM, Ali NJ, Brown G, et al; British Thoracic Society Pleural Disease Guideline Group. Local anaesthetic thoracoscopy: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010;65(suppl 2):ii54-ii60. [PubMed]
 
Roberts 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(suppl 2):ii32-ii40. [CrossRef] [PubMed]
 
Shaw P, Agarwal R. Pleurodesis for malignant pleural effusions. Cochrane Database Syst Rev. 2004;;(1):CD002916.
 
Tan C, Sedrakyan A, Browne J, Swift S, Treasure T. The evidence on the effectiveness of management for malignant pleural effusion: a systematic review. Eur J Cardiothorac Surg. 2006;29(5):829-838. [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]
 
Yim AP, Chan AT, Lee TW, Wan IY, Ho JK. Thoracoscopic talc insufflation versus talc slurry for symptomatic malignant pleural effusion. Ann Thorac Surg. 1996;62(6):1655-1658. [CrossRef] [PubMed]
 
Davies HE, Mishra EK, Kahan BC, et al. Effect of an indwelling pleural catheter vs chest tube and talc pleurodesis for relieving dyspnea in patients with malignant pleural effusion: the TIME2 randomized controlled trial. JAMA. 2012;307(22):2383-2389. [CrossRef] [PubMed]
 
Wyckoff CC, Anderson ED, Read CA, Lee RE. The use of intrapleural doxycycline via PleurX catheter in the treatment of malignant pleural effusions: preliminary report. Chest. 2007;132(4_MeetingAbstracts):432a.
 
Musani AI, Haas AR, Seijo L, Wilby M, Sterman DH. Outpatient management of malignant pleural effusions with small-bore, tunneled pleural catheters. Respiration. 2004;71(6):559-566. [CrossRef] [PubMed]
 
Patz EF Jr, McAdams HP, Goodman PC, Blackwell S, Crawford J. Ambulatory sclerotherapy for malignant pleural effusions. Radiology. 1996;199(1):133-135. [CrossRef] [PubMed]
 
Spiegler PA, Hurewitz AN, Groth ML. Rapid pleurodesis for malignant pleural effusions. Chest. 2003;123(6):1895-1898. [CrossRef] [PubMed]
 
Saffran L, Ost DE, Fein AM, Schiff MJ. Outpatient pleurodesis of malignant pleural effusions using a small-bore pigtail catheter. Chest. 2000;118(2):417-421. [CrossRef] [PubMed]
 
Terra RM, Kim SY, Pego-Fernandes PM, Teixeira LR, Vargas FS, Jatene FB. Is silver nitrate pleurodesis for patients with malignant pleural effusion feasible and safe when performed in an outpatient setting? Ann Surg Oncol. 2011;18(4):1145-1150. [CrossRef] [PubMed]
 
Maskell NA. Treatment options for malignant pleural effusions: patient preference does matter. JAMA. 2012;307(22):2432-2433. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1 –  Flowchart of malignant pleural effusion management at Guy’s and St Thomas’ NHS Trust. BTS = British Thoracic Society; IPC = indwelling pleural catheter.Grahic Jump Location
Figure Jump LinkFigure 2 –  Diagram dividing each hemithorax into six areas for thoracic ultrasound assessment.Grahic Jump Location

Tables

Table Graphic Jump Location
TABLE 1 ]  Baseline Patient Characteristics (N = 24)
Table Graphic Jump Location
TABLE 2 ]  Outcomes After Pleurodesis
Table Graphic Jump Location
TABLE 3 ]  Analysis of Complications

References

Haas AR, Sterman DH, Musani AI. Malignant pleural effusions: management options with consideration of coding, billing, and a decision approach. Chest. 2007;132(3):1036-1041. [CrossRef] [PubMed]
 
Rahman NM, Ali NJ, Brown G, et al; British Thoracic Society Pleural Disease Guideline Group. Local anaesthetic thoracoscopy: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010;65(suppl 2):ii54-ii60. [PubMed]
 
Roberts 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(suppl 2):ii32-ii40. [CrossRef] [PubMed]
 
Shaw P, Agarwal R. Pleurodesis for malignant pleural effusions. Cochrane Database Syst Rev. 2004;;(1):CD002916.
 
Tan C, Sedrakyan A, Browne J, Swift S, Treasure T. The evidence on the effectiveness of management for malignant pleural effusion: a systematic review. Eur J Cardiothorac Surg. 2006;29(5):829-838. [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]
 
Yim AP, Chan AT, Lee TW, Wan IY, Ho JK. Thoracoscopic talc insufflation versus talc slurry for symptomatic malignant pleural effusion. Ann Thorac Surg. 1996;62(6):1655-1658. [CrossRef] [PubMed]
 
Davies HE, Mishra EK, Kahan BC, et al. Effect of an indwelling pleural catheter vs chest tube and talc pleurodesis for relieving dyspnea in patients with malignant pleural effusion: the TIME2 randomized controlled trial. JAMA. 2012;307(22):2383-2389. [CrossRef] [PubMed]
 
Wyckoff CC, Anderson ED, Read CA, Lee RE. The use of intrapleural doxycycline via PleurX catheter in the treatment of malignant pleural effusions: preliminary report. Chest. 2007;132(4_MeetingAbstracts):432a.
 
Musani AI, Haas AR, Seijo L, Wilby M, Sterman DH. Outpatient management of malignant pleural effusions with small-bore, tunneled pleural catheters. Respiration. 2004;71(6):559-566. [CrossRef] [PubMed]
 
Patz EF Jr, McAdams HP, Goodman PC, Blackwell S, Crawford J. Ambulatory sclerotherapy for malignant pleural effusions. Radiology. 1996;199(1):133-135. [CrossRef] [PubMed]
 
Spiegler PA, Hurewitz AN, Groth ML. Rapid pleurodesis for malignant pleural effusions. Chest. 2003;123(6):1895-1898. [CrossRef] [PubMed]
 
Saffran L, Ost DE, Fein AM, Schiff MJ. Outpatient pleurodesis of malignant pleural effusions using a small-bore pigtail catheter. Chest. 2000;118(2):417-421. [CrossRef] [PubMed]
 
Terra RM, Kim SY, Pego-Fernandes PM, Teixeira LR, Vargas FS, Jatene FB. Is silver nitrate pleurodesis for patients with malignant pleural effusion feasible and safe when performed in an outpatient setting? Ann Surg Oncol. 2011;18(4):1145-1150. [CrossRef] [PubMed]
 
Maskell NA. Treatment options for malignant pleural effusions: patient preference does matter. JAMA. 2012;307(22):2432-2433. [CrossRef] [PubMed]
 
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