Surgical and non-surgical management of malignant pleural effusions

Our plain-English summary of Surgical and non-surgical management of malignant pleural effusions, by D.B. Fitzgerald, C.F.N. Koegelenberg, K. Yasufuku, et al (Expert Review of Respiratory Medicine, 2018).

The study

• Authors: D.B. Fitzgerald, C.F.N. Koegelenberg, K. Yasufuku, Y.C.G. Lee
• Journal: Expert Review of Respiratory Medicine
• Published: 2018;12(1):15-26
• Type of article: Review
• Cited by: 19 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Optimal management of malignant pleural effusion (MPE) is important in the care of patients with advanced cancer. Surgical (especially video-assisted thoracoscopic surgery (VATS)) and non-surgical strategies are available. Clinicians should be aware of the evidence supporting the use of different modalities to guide treatment choice. Areas covered: This review covers published evidence of the advantages and disadvantages of VATS and non-surgical alternatives for MPE management. Expert commentary: Randomized clinical trials (RCTs) are needed to define the roles and benefits of VATS as existing literature is often flawed by selection bias. Three RCTs have failed to show benefits of VATS talc poudrage over bedside talc pleurodesis. VATS-pleurectomy offered no survival advantage in a RCT of mesothelioma patients. Modification of VATS techniques has reduced the invasiveness and associated risks. Future trials should compare VATS with contemporary, non-surgical approaches (especially combined Indwelling Pleural Catheter (IPC) and chemical pleurodesis therapy). Individualized management for different subgroups of MPE patients should be a long-term research goal. Studies are needed on better patient selection, and adjunct non-invasive, supportive (e.g. nutrition and exercise) therapies.

In plain English

This article was a review, not a new study. The authors summarized published evidence on surgical and non-surgical treatment of malignant pleural effusion, a build-up of fluid around the lung caused by cancer. The article noted that such effusions occur in over 90% of malignant pleural mesotheliomas. It focused on video-assisted thoracoscopic surgery (VATS) used to seal the pleural space with talc. It compared this with bedside talc slurry given through a chest tube and with indwelling pleural catheters. In the largest randomized trial reviewed (482 patients), VATS pleurodesis succeeded in 64% of cases and showed no overall advantage over bedside pleurodesis. In mesothelioma patients, the MesoVATS trial found no survival difference between VATS partial pleurectomy and talc pleurodesis (52% versus 57% at 12 months). Reported VATS complication rates ranged from 3 to 28%. The authors concluded that the high success rates reported for VATS came from studies flawed by selection bias and that randomized trials were needed. They noted that most of the studies reporting VATS success rates were retrospective and almost all came from a single centre, often with a single surgeon.

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: Narrative review of published evidence (no new patient data collected)
• Who was studied: Published studies of patients with malignant pleural effusion from advanced cancer, including lung cancer, breast cancer, ovarian cancer and malignant pleural mesothelioma
• Exposure: Not an asbestos exposure study. The review concerned treatments: VATS (with talc poudrage, pleurectomy or decortication), bedside talc slurry pleurodesis, indwelling pleural catheters and medical thoracoscopy. The talc used for poudrage was described as asbestos-free.
• Main results:
  • The authors reported that three randomized trials had failed to show benefits of VATS talc poudrage over bedside talc pleurodesis.
  • In the largest randomized trial reviewed (Dresler et al., n = 482), VATS pleurodesis was successful in 64% of cases overall and in 67% of cases where full lung expansion was seen during the operation. There was no overall advantage over bedside pleurodesis.
  • In the same trial, talc pleurodesis success was about 75% at 1 month and fell to about 50% at 6 months.
  • The MesoVATS trial in malignant pleural mesothelioma patients found no survival difference between VATS partial pleurectomy and talc pleurodesis at any time-point. The figures were 52% of the VATS partial pleurectomy group versus 57% of the talc pleurodesis group at 12 months, the primary outcome.
  • The MARS trial randomized 50 mesothelioma patients to extrapleural pneumonectomy or no extrapleural pneumonectomy. The radical surgery significantly shortened survival by 5.1 months (19.5 vs. 14.4 months, as printed).
  • A retrospective study of mesothelioma patients in Western Australia (Fysh et al.) found a 32.3% failure rate in both the talc poudrage group (n = 78) and the talc slurry group (n = 86).
  • Across the studies reviewed, reported complication rates for VATS pleurodesis ranged from 3 to 28%.
  • Across the studies reviewed, in-hospital mortality after VATS pleurodesis ranged from 0.81% to 8%.
  • The ASAP trial found that daily drainage through an indwelling pleural catheter, compared with alternate-day drainage, increased the rate of spontaneous pleurodesis (47% vs. 24%).
• The authors' conclusion: The authors concluded that evidence for VATS benefits rests largely on anecdotal series. In their view, the reported high success rates come from studies flawed by selection bias, and randomized trials are required. They called for future trials comparing VATS with non-surgical approaches, especially indwelling pleural catheters combined with chemical pleurodesis.
• Limitations the authors state:
  • The authors stated that most of the studies reporting VATS pleurodesis success rates were retrospective and almost all came from a single centre, often with a single surgeon, which limits interpretation and generalizability.

Topics

Medical terms in this study, explained in our Lexicon: Pleural Effusion, Video-Assisted Thoracoscopic Surgery (VATS), Clinical Trial, Selection Bias, Talc, Talc Pleurodesis, Mesothelioma, Indwelling Pleural Catheter.

Related studies

• Video-assisted management of malignant pleural effusion in breast carcinoma — R. Gasparri, F. Leo, et al. (2006)
• The long-term morbidity of pleuroperitoneal shunts in the management of recurrent malignant effusions — O. Genc, M. Petrou, et al. (2000)
• Malignant Mesothelioma of the Tunica Vaginalis Testis: Outcomes Following Surgical Management Beyond Radical Orchiectomy — P. Recabal, B. Rosenzweig, et al. (2017)
• Thoracoscopic palliative treatment of malignant pleural effusions: results in 273 patients — K. Arapis, R. Caliandro, et al. (2006)
• Palliative treatment of malignant pleural effusions — D. Horn, D. Dequanter, et al. (2010)
• Pharmacokinetic evaluation of intrapleural perfusion with hyperthermic chemotherapy using cisplatin in patients with malignant pleural effusion — H. Sakaguchi, H. Ishida, et al. (2017)

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