Predictors of talc pleurodesis outcome in patients with malignant pleural effusions

doi:10.1016/j.lungcan.2008.02.017

Lung Cancer

Volume 62, Issue 1, October 2008, Pages 139-144

https://doi.org/10.1016/j.lungcan.2008.02.017 Get rights and content

Summary

Objective

Chemical pleurodesis is an accepted palliative therapy for patients with recurrent, symptomatic, malignant pleural effusions (MPE). The purpose of the study was to determine the factors that have an effect on successful pleurodesis for MPE.

Patients and interventions

Eighty-four consecutive patients with biopsy-proven malignant pleural disease and recurrent, symptomatic MPE were eligible to participate in this study. Five grams of talc mixed in 150 ml of normal saline were administered via tube thoracostomy or small-bore catheters after complete drainage of the pleural effusion.

Results

Seven patients did not return for their 30-day follow-up visit and were excluded from further analysis. Successful pleurodesis was achieved in 63 of 77 eligible patients (81.8%) with MPE. In the univariate analysis, female gender, Karnofsky performance status, pleural fluid pH, cholesterol, and adenosine deaminase level showed a significant association with the probability of success. Multivariate logistic regression analysis showed that pleural fluid pH and ADA levels were independent predictors of talc pleurodesis outcome.

Conclusion

Our results show that pleurodesis using talc as the sclerosing agent is a simple and acceptable procedure with high efficacy for controlling MPE, especially when used in appropriate patients.

Introduction

Malignant pleural effusions (MPE) are a commonly encountered clinical problem in patients with neoplastic disease, contributing to a poor quality of life in this group of patients. In most studies, carcinoma of the lung, metastatic breast carcinoma, and lymphoma are responsible for approximately 75% of all MPE [1]. The treatment of recurrent MPE is known to be difficult, and several methods have been used to control recurrent, symptomatic MPE; however, the treatment is often palliative. Chemical pleurodesis using various sclerosing agents is an accepted palliative therapy for patients with recurrent, symptomatic MPE [1], [2], [3].

Pleurodesis is defined as the symphysis between the visceral and parietal pleural surfaces, the function of which is to prevent accumulation of either air or fluid into the pleural space. Effusions of malignant origin are by far the most common indication for pleurodesis. The principal mechanism of generation of pleurodesis involves an inflammatory process by a sclerosing agent within the pleural space [4], [5]. The utility of various clinical and biochemical parameters in predicting pleurodesis outcome is still controversial.

A better definition of the various characteristics of the patient would help to identify more precisely the population most likely to benefit from pleurodesis. These factors may allow clinicians to make better the treatment decisions in a patient with recurrent MPE. In the present study, we aimed to determine the effects of various clinical and laboratory characteristics on talc pleurodesis outcome for MPE.

Section snippets

Study population

Over the period from May 2004 to July 2007, 84 consecutive patients with biopsy-proven malignancy and recurrent symptomatic MPE were eligible to participate in this study. Informed consent was obtained from all the patients enrolled in the study.

Inclusion in the study required documentation of a MPE, complete lung expansion on chest radiography after drainage, symptoms due to the presence of fluid, improvement of symptoms after drainage, suitability of the patient's general condition for

Results

This series consists of 84 consecutive patients who underwent pleurodesis for recurrent symptomatic malignant pleural effusions. Seven patients were not included in the analysis because of early death or loss to follow-up. The clinical data and patient characteristics are summarized in Table 1. Forty-one patients (53.2%) had malignant mesothelioma, 21 patients (27.3%) had lung cancer, 12 patients (15.6%) had other malignancies, and 3 patients (3.9%) had primaries of unknown origin. Complete and

Discussion

MPE continues to be a leading cause of a poor quality of life in patients with malignancies. Although various methods have been used in the treatment of MPE, chemical pleurodesis has emerged as the most favored method. In the current study, the success rate of talc pleurodesis was 81.8%. This result is consistent with a recent report on the outcome of talc pleurodesis [7]. In the last two decades, efforts have been made to improve pleurodesis outcome. In clinical practice, several sclerosing

Conflict of interest

We have no conflicts of interest that are directly relevant to the content of this study.

Acknowledgement

This study was supported by Research Fund of Osmangazi University, Eskisehir, Turkey.

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Cited by (24)

A multidirectional two-tube method for chemical pleurodesis could improve distribution of the sclerosing agent within the pleural cavity – A pilot study
2021, Annals of Medicine and Surgery
Citation Excerpt :
Multiple factors may affect the success rate of the talc pleurodesis. A low patient Karnofsky score status (a metric used to assess and quantify the functional performance of patients), age, gender, presence of pleural adhesions, pleural fluid pH, prolonged period between diagnosis of MPE and treatment, and use of systemic corticosteroids are associated with lower rates of successful pleurodesis [16,19]. The type of the tumour associated with malignancy also influences success rates, with mesothelioma and lung cancer showing the lowest success rates [20].
Malignant pleural effusion (MPE) affects approximately 200,000 people in the United States per annum. Chemical pleurodesis is a recommended first line treatment in the management of MPE, however, success rates as low as 43% has been reported. A bedside chemical pleurodesis can cost up to $11,224 and an estimated inpatient annual expenditure of more than $5 billion in the US alone. This study aims to assess the distribution of the talc slurry within the pleural space using human cadaveric models and to determine the force required to push the talc slurry though a 14 Fr chest tube.
The force required to administer the talc slurry through a 14 Fr chest tube was tested using a Zwick/Roelle Z005 mechanical tester, using a porcine thoracic biomodel. Talc slurry distribution within the pleural cavity was assessed by direct visualisation following administration to the human cadaveric models using single and multidirectional two-tube methods.
Maximum force required to push the talc slurry through a 14 Fr chest tube was 11.36 N ± 2.79 N. Distribution of the talc slurry within the pleural cavity was found to be poor with a single tube method. Multidirectional two-tube method of administration showed more even distribution.
The experimental multidirectional two-tube method results in wider distribution of the talc slurry within the pleural cavity and could further improve success rate of the talc pleurodesis.
Echogenic Swirling Seen on Ultrasound and Outcome of Pleurodesis in Malignant Pleural Effusion
2019, Archivos de Bronconeumologia
Pleural effusion adenosine deaminase: A candidate biomarker to discriminate between Gram-negative and Gram-positive bacterial infections of the pleural space
2016, Clinics
Delay in the treatment of pleural infection may contribute to its high mortality. In this retrospective study, we aimed to evaluate the diagnostic accuracy of pleural adenosine deaminase in discrimination between Gram-negative and Gram-positive bacterial infections of the pleural space prior to selecting antibiotics.
A total of 76 patients were enrolled and grouped into subgroups according to Gram staining: 1) patients with Gram-negative bacterial infections, aged 53.2±18.6 years old, of whom 44.7% had empyemas and 2) patients with Gram-positive bacterial infections, aged 53.5±21.5 years old, of whom 63.1% had empyemas. The pleural effusion was sampled by thoracocentesis and then sent for adenosine deaminase testing, biochemical testing and microbiological culture. The Mann-Whitney U test was used to examine the differences in adenosine deaminase levels between the groups. Correlations between adenosine deaminase and specified variables were also quantified using Spearman's correlation coefficient. Moreover, receiver operator characteristic analysis was performed to evaluate the diagnostic accuracy of pleural effusion adenosine deaminase.
Mean pleural adenosine deaminase levels differed significantly between Gram-negative and Gram-positive bacterial infections of the pleural space (191.8±32.1 U/L vs 81.0±16.9 U/L, p<0.01). The area under the receiver operator characteristic curve was 0.689 (95% confidence interval: 0.570, 0.792, p<0.01) at the cutoff value of 86 U/L. Additionally, pleural adenosine deaminase had a sensitivity of 63.2% (46.0-78.2%); a specificity of 73.7% (56.9-86.6%); positive and negative likelihood ratios of 2.18 and 0.50, respectively; and positive and negative predictive values of 70.6% and 66.7%, respectively.
Pleural effusion adenosine deaminase is a helpful alternative biomarker for early and quick discrimination of Gram-negative from Gram-positive bacterial infections of the pleural space, which is useful for the selection of antibiotics.
Thoracoscopic talc versus tunneled pleural catheters for palliation of malignant pleural effusions
2012, Annals of Thoracic Surgery
A malignant pleural effusion (MPE) is a late complication of malignancy that affects respiratory function and quality of life. A strategy for palliation of the symptoms caused by MPE should permanently control fluid accumulation, preclude any need for reintervention, and limit hospital length of stay (LOS). We compared video-assisted thorascopic (VATS) talc insufflation with placement of a tunneled pleural catheter (TPC) to assess which intervention better met these palliative goals.
We conducted a retrospective chart review of consecutive MPE at a single institution from 2005 through June 2011. Primary a priori outcomes were reintervention in the ipsilateral hemithorax, postprocedure LOS, and overall LOS.
One hundred nine patients with MPE were identified. Fifty-nine patients (54%) had TPC placed, and 50 (46%) were treated with VATS talc. Patients who underwent TPC placement had significantly fewer reinterventions for recurrent ipsilateral effusions than patients treated with VATS talc (TPC 2% [1 of 59], talc 16% [8 of 50], p = 0.01). Patients treated with TPC had significantly shorter overall LOS (TPC LOS mean 7 days, mode 1 day; talc mean 8 day, mode 4 days, p = 0.006) and postprocedure LOS (TPC post-procedure LOS mean 3 days, mode 0 days; talc mean 6 days, mode 3 days, p < 0.001). Type of procedure was not associated with differences in complication rate (TPC 5% [3 of 59], talc 14% [7 of 50], p = 0.18), or in-hospital mortality (TPC 3% [2 of 59], talc 8% [4 of 50], p = 0.41).
TPC placement was associated with a significantly reduced postprocedure and overall LOS compared with VATS talc. Also, TPC placement was associated with significantly fewer ipsilateral reinterventions. Placement of TPC should be considered for palliation of MPE-associated symptoms.
Predictors of mortality within three months in the patients with malignant pleural effusion
2010, European Journal of Internal Medicine
Citation Excerpt :
The response rate of the drainage-only method and the pleurodesis in the first 30 days after the procedure was also investigated, after excluding those who died within a month following the drainage or the pleurodesis. The responses were classified as, (1) a complete response (no reaccumulation of the fluid), (2) a partial response (reaccumulation of the fluid below the pre-drainage level), and (3) a non-response (reaccumulation of the fluid above the pre-drainage level) [9]. A conventional large-bore chest tube (28–32 F) with an underwater seal was placed in the 6th–7th intercostal space in the posterior axillary line.
Malignant pleural effusion (MPE) has a limited life expectancy (3–12 months). We investigated the predictors of the early mortality (EM) within three months.
The patients were retrospectively grouped according to the death within three months (Group I) and survival more than three months (Group II). Demographical, clinical, and biochemical parameters in the fluid were analysed to determine their effects on the EM. The 30-day response rate of talc pleurodesis was investigated.
The study included 85 patients (Group I/Group II = 40/45). The patients in Group I died within a median of 28 days. Twenty-six patients in Group II died in a median of 205, but 19 were still alive (median 200 days). The median survival was longer in renal cell, colorectal, breast, liver, ovarian and oropharynx carcinoma, and mesothelioma. Sixty-two patients (63%) underwent talc pleurodesis, which prevented the fluid reaccumulation (p = 0.04). The significant factors of the EM in the univariate analysis were the presence of high-risk tumors (lung, stomach, soft tissue, bladder, esophagus, prostate, cervix, and lymphoma), the low Karnofsky performance score (KPS) (p < 0.0001), the low pH value of the fluid (p = 0.05), and the low concentration of glucose (p = 0.01), total protein (p < 0.0001), and albumin (p < 0.0001) in the fluid. According to the multivariate analysis high-risk tumors (p = 0.03), a lower KPS (p < 0.001), and glucose value (p = 0.04) were the predictors of the EM.
Talc pleurodesis prevents the fluid reaccumulation. High-risk tumors, a poor performance status, and lower pleural fluid glucose concentration are predictors of the EM within three months in the patients with a MPE.
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2022, Journal of Thoracic Disease

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^☆: This study has been presented as a thematic poster at the 14th Annual Congress of European Respiratory Society.

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Predictors of talc pleurodesis outcome in patients with malignant pleural effusions☆

Summary

Objective

Patients and interventions

Results

Conclusion

Introduction

Section snippets

Study population

Results

Discussion

Conflict of interest

Acknowledgement

Chest

Chest

Chest

Chest

Lung Cancer

Lung Cancer

Management of malignant pleural effusions

Eur Respir J