Interventional therapies for malignant pleural effusions: the present and the future

Our plain-English summary of Interventional therapies for malignant pleural effusions: the present and the future, by R. Thomas, R. Francis, H.E. Davies, et al (Respirology, 2014).

The study

• Authors: R. Thomas, R. Francis, H.E. Davies, Y.C. Lee
• Journal: Respirology
• Published: 2014;19(6):809-22
• Type of article: Review
• Cited by: 49 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

The approach to management of malignant pleural effusions (MPE) has changed over the past few decades. The key goals of MPE management are to relieve patient symptoms using the least invasive means and in the most cost-effective manner. There is now a realization that patient-reported outcome measures should be the primary goal of MPE treatment, and this now is the focus in most clinical trials. Efforts to minimize patient morbidity are complemented by development of less invasive treatments that have mostly replaced the more aggressive surgical approaches of the past. Therapeutic thoracentesis is simple, effective and generally safe, although its benefits may only be temporary. Pleurodesis is the conventional and for a long time the only definitive therapy available. However, the efficacy and safety of talc pleurodesis has been challenged. Indwelling pleural catheter (IPC) drainage is increasingly accepted worldwide and represents a new concept to improve symptoms without necessarily generating pleural symphysis. Recent studies support the effectiveness of IPC treatment and provide reassurance regarding its safety. An unprecedented number of clinical trials are now underway to improve various aspects of MPE care. However, choosing an optimal intervention for MPE in an individual patient remains a challenge due to our limited understanding of the underlying pathophysiology of breathlessness in MPE and a lack of predictors of survival and pleurodesis outcome. This review provides an overview of common pleural interventional procedures used for MPE management, controversies and limitations of current practice, and areas of research most needed to improve practice in future.

© 2014 Asian Pacific Society of Respirology.

In plain English

This article was an invited review, not a new study: it reported no original patient data and did not examine asbestos exposure. The authors summarized treatments for malignant pleural effusion (fluid around the lung caused by cancer, including pleural mesothelioma): fluid drainage, pleurodesis (sealing the pleural space, usually with talc), indwelling pleural catheters and pleuroperitoneal shunts. Citing other studies, they reported that the largest randomized trial found no significant difference in 30-day fluid control between talc poudrage and talc slurry (78% vs 71%), that talc pleurodesis fails in about 30% of patients, and that a systematic review found catheters improved symptoms in about 95% of cases of recurrent malignant pleural effusion. They cited a Western Australian mesothelioma registry review in which 42% of 320 patients needed pleurodesis. They also cited a study in which tumour grew along the catheter tract in about 10% of 110 patients in a region with a high incidence of mesothelioma. The authors concluded that malignant pleural effusion covers a diverse patient population. They said research must find ways to guide treatment for individual patients.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Invited narrative review of the published literature (no original data)
• Who was studied: No study population; the review covered published research on patients with malignant pleural effusion, including effusions from pleural mesothelioma and from metastatic cancers
• Exposure: No asbestos exposure was studied. The review covered treatments for malignant pleural effusion: therapeutic thoracentesis, pleurodesis (talc and other agents), indwelling pleural catheters and pleuroperitoneal shunts
• Main results:
  • Citing the largest randomized trial (another study), the authors reported no significant difference in fluid control at 30 days between thoracoscopic talc poudrage and chest-tube talc slurry pleurodesis (78% vs 71%)
  • In that cited trial (Dresler et al.), 2.3% of patients died of respiratory failure attributed to talc, whether talc was given as poudrage or slurry
  • The authors stated that, according to recent data, talc pleurodesis fails in about 30% of patients
  • The authors noted that more than 30 randomized trials of chemical pleurodesis had been done, but they often had few patients and few reached statistical significance
  • A cited systematic review (19 studies, 1370 patients) found that indwelling pleural catheters improved symptoms in about 95% of cases of recurrent malignant pleural effusion
  • In the cited TIME-2 trial, catheter and talc pleurodesis gave similar benefits in breathlessness and quality of life over the first 42 days, and the catheter was superior for breathlessness by 6 months
  • A cited review of the Western Australian mesothelioma registry over 5 years found that 42% of 320 patients needed pleurodesis to control the effusion
  • A cited study found catheter tract metastases in about 10% of 110 patients with indwelling catheters in a region with a high incidence of mesothelioma
• The authors' conclusion: The authors concluded that malignant pleural effusion is an umbrella term covering a diverse patient population. They said patients are likely to respond differently to treatments, so research must look for factors that can guide treatment choice for individual patients

Topics

Medical terms in this study, explained in our Lexicon: Pleural Effusion, Clinical Trial, Thoracentesis, Pleurodesis, Talc Pleurodesis, Indwelling Pleural Catheter.

Related studies

• Protocol of the Australasian Malignant Pleural Effusion-2 (AMPLE-2) trial: a multicentre randomised study of aggressive versus symptom-guided drainage via indwelling pleural catheters — M. Azzopardi, R. Thomas, et al. (2016)
• Aggressive versus symptom-guided drainage of malignant pleural effusion via indwelling pleural catheters (AMPLE-2): an open-label randomised trial — S. Muruganandan, M. Azzopardi, et al. (2018)
• Indwelling pleural catheter versus talc pleurodesis for malignant pleural effusion: a meta-analysis — M. Yeung, E.W. Loh, et al. (2020)
• Thoracoscopic palliative treatment of malignant pleural effusions: results in 273 patients — K. Arapis, R. Caliandro, et al. (2006)
• Current controversies in the management of malignant pleural effusions — M. Azzopardi, J.M. Porcel, et al. (2014)
• Catheter Tract Metastasis in Mesothelioma Patients with Indwelling Pleural Catheters: A Retrospective Cohort Study — M.A. Mitchell, P. Li, et al. (2019)

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