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Point and Counterpoint |

Rebuttal From Drs Gillespie and DeCampRebuttal From Drs Gillespie and DeCamp FREE TO VIEW

Colin T. Gillespie, MD, FCCP; Malcolm M. DeCamp, MD, FCCP
Author and Funding Information

From the Division of Pulmonary and Critical Care Medicine (Dr Gillespie), Division of Thoracic Surgery (Dr DeCamp), and Robert H. Lurie Comprehensive Cancer Center (Dr DeCamp), Northwestern University Feinberg School of Medicine.

CORRESPONDENCE TO: Malcolm M. DeCamp, MD, FCCP, Division of Thoracic Surgery, Northwestern Memorial Hospital, 676 N St Clair St, Ste 650, Chicago, IL 60611; e-mail: mdecamp@nmh.org


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. 2015;148(1):14-15. doi:10.1378/chest.15-0427
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We appreciate the comments and arguments put forth by our colleagues Drs Lee and Feller-Kopman1 from Johns Hopkins University and agree whole heartedly with their emphasis on the palliative goals in treating malignant pleural effusion (MPE). Where we continue to disagree is how best to achieve this. Much of the data they present actually supports our contention that MPEs represent a heterogeneous problem with multiple viable management options and, in the absence of lung entrapment, no gold standard for treatment.

As stated in our initial discussion, the tunneled pleural catheter (TPC) (a not-so-small 16F catheter, by the way) is really a different animal from the small-bore chest tube with regard to size and its fundamental nature as a tunneled indwelling ambulatory chest tube intended for long-term use. Although we concur in the setting of trapped lung that the TPC is the treatment of choice, we refute the concept that clinical equipoise supports TPC and small-bore tubes as better than alternatives for all MPEs. The recommendation cited by the British Thoracic Society (BTS) in support of TPCs, to be clear, is a recommendation with qualification. The BTS authors specifically recognize that TPCs “are effective in controlling recurrent and symptomatic malignant effusions in selected patients [italics added],”2 trapped lung being the consensus “selected” indication.

The results of the Second Therapeutic Intervention in Malignant Pleural Effusion Trial (TIME2) demonstrated that TPCs are not superior to pleurodesis in relieving dyspnea or improving quality of life.3 TPCs were associated with reduced length of stay but more-frequent adverse events. Drs Lee and Feller-Kopman1 acknowledge this in their analysis and somehow extrapolate that result as similar to the effectiveness of published large-bore chest tube pleurodesis series. The frequency of serious and nonserious complications in the two arms of the trial is surprising. Although not statistically significant, a 40% complication rate was seen in the TPC group and 13% in the talc group. It is possible that the prospective nature of TIME2 revealed a more accurate incidence of complications missed in the prior retrospectively collected data.3

Recently, the authors of TIME2 published a follow-up cost-effectiveness analysis of the two arms of the trial.4 The results presented in this investigation are interesting. They reported no significant difference in the mean cost of treating MPEs with TPCs compared with talc pleurodesis, despite the decreased length of stay associated with the indwelling catheter. For patients with a truncated life expectancy of < 14 weeks, the TPC demonstrated a significant cost savings. Compartmentalization of value to specific populations supports our assessment of MPE as a heterogeneous disorder with multiple potential treatment options.

The problem of MPEs is complex. The BTS recommends multiple treatment strategies, including talc pleurodesis through chest tube (size not specified), as first-line therapy for MPE, with indwelling TPC used in a select subgroup of patients. The best data we have at present suggest no more than equivalence compared with classic large-bore chest tube drainage and pleurodesis. There are no good head-to-head comparisons that state otherwise. Although the recent attention focused on the problem of MPE is encouraging, the answer to our debate lies in future well-designed prospective investigation.

References

Lee HJ, Feller-Kopman DJ. Point: should small-bore pleural catheter placement be the preferred initial management for malignant pleural effusions? Yes. Chest. 2015;148(1):9-10.
 
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]
 
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]
 
Penz ED, Mishra EK, Davies HE, Manns BJ, Miller RF, Rahman NM. Comparing cost of indwelling pleural catheter vs talc pleurodesis for malignant pleural effusion. Chest. 2014;146(4):991-1000. [CrossRef] [PubMed]
 

Figures

Tables

References

Lee HJ, Feller-Kopman DJ. Point: should small-bore pleural catheter placement be the preferred initial management for malignant pleural effusions? Yes. Chest. 2015;148(1):9-10.
 
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]
 
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]
 
Penz ED, Mishra EK, Davies HE, Manns BJ, Miller RF, Rahman NM. Comparing cost of indwelling pleural catheter vs talc pleurodesis for malignant pleural effusion. Chest. 2014;146(4):991-1000. [CrossRef] [PubMed]
 
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