Survival in patients with malignant pleural effusion undergoing talc pleurodesis
Introduction
Patients with malignant pleural effusion (MPE) are often symptomatic with breathlessness and their management is typically centred on palliation of their symptoms. [1] Therapeutic aspiration of the pleural fluid brings short-term benefit as the effusion tends to recur quickly and longer term palliative methods are frequently required [2]. The standard management in the UK for patients with MPE who do not have unexpandable lung is performing pleurodesis by applying talc to the pleural space [3].
The life expectancy of patients with MPE is usually expressed in months with median survival times ranging between 3–12 months. [1] It is common practice to reserve pleurodesis for patients with a good level of fitness commensurate with better performance status and to offer therapeutic thoracentesis to frailer patients with a more limited prognosis. A useful tool to predict survival in patients with MPE is the LENT score which is a robust method that provides important prognostic information, but it is yet to be prospectively validated [4]. The score utilises four readily available parameters namely; the pleural fluid LDH level, the Eastern Cooperative Oncology Group (ECOG) performance status, the serum neutrophil to lymphocyte ratio and the histology of the primary tumour to predict the survival of a given patient. More recently, a new tool has been devised to predict the mortality risk at three months in patients with MPE based on clinical and biochemical parameters and is called the PROMISE score [5].
It has been previously noted that in patients with mesothelioma, the survival of patients who undergo pleurodesis (regardless of the method used) is longer in comparison to patients who do not receive this treatment [6] and similar findings were noted in MPE secondary to non-pleural malignancies [7]. It could be argued that this survival difference is inherently related to the selection bias of better performance status patients who are offered pleurodesis; however, this difference was still observed when survival only in patients with higher performance status was studied [7]. Recent data suggest that a survival benefit is seen in MPE patients who have successful pleurodesis in comparison to those who fail pleurodesis and this has been reported in cohorts of patients with mesothelioma [8,9] and other malignancies [10] and where talc [9,11] or other substances such as bleomycin [10] were used to induce pleurodesis.
This study aimed to explore whether there was a difference in survival according to pleurodesis outcome in patients with MPE undergoing pleurodesis using large databases of prospectively collected data on patients with MPE undergoing talc pleurodesis.
Section snippets
Methods
The study utilised two independent and non-overlapping datasets of patients who underwent talc pleurodesis for MPE.
Dataset 1
In this study, 60 patients were included: nine patients were excluded due to uncertainty regarding pleurodesis outcome in two, non-availability of survival data in two, and survival less than a month in five patients. Baseline characteristics are shown in Table 1.
At the end of the follow up period (median 23 months, range 6–34 months), 20 patients (33.3%) were alive. Of these patients, 13 (45.8%) belonged to the group who had successful pleurodesis and seven (23.5%) had pleurodesis failure.
Discussion
This post-hoc analysis from two datasets confirms previously observed survival differences between patients with MPE who achieve successful pleurodesis when compared with those refractory to pleurodesis. After adjusting for important factors that affect survival in patients with MPE; particularly the type of the primary cancer [13] and pleural fluid LDH levels, this survival benefit was still observed.
We attempted to control for other variables that comprise the LENT score [4], and so included
Financial support
Maged Hassan is supported by a European Respiratory Society research fellowship – ERSLTRF 2016 - 7333. Najib Rahman is funded by the Oxford NIHR Biomedical Research Centre.
Contribution
MH conceived the study. MH, RA, RMM, DJM and EOB collected the data in Dataset 1. NAM, RFM, IP and NMR are the main authors of the TIME1 trial and are responsible for Dataset 2. MH performed the statistics and wrote the first draft of the manuscript. NMR critically revised the first draft. All authors reviewed and approved the final manuscript. MH and NMR are responsible for the overall content as guarantors.
Declaration of Competing Interest
None to be declared by the authors.
References (24)
- et al.
Development and validation of response markers to predict survival and pleurodesis success in patients with malignant pleural effusion (PROMISE): a multicohort analysis
Lancet Oncol.
(2018) - et al.
Persistent lung expansion after pleural talc poudrage in non-surgically resected malignant pleural mesothelioma
Ann. Thorac. Surg.
(2015) - et al.
Are intra-pleural bacterial products associated with longer survival in adults with malignant pleural effusions? A systematic review
Lung Cancer Amst. Neth.
(2018) - et al.
Survival in patients with malignant pleural effusions who developed pleural infection: a retrospective case review from six UK centers
Chest
(2015) - et al.
Survival and talc pleurodesis in metastatic pleural carcinoma, revisited
Chest
(1993) - et al.
A randomized controlled trial comparing indwelling pleural catheters with talc pleurodesis (NVALT-14)
Lung Cancer Amst. Neth.
(2017) - et al.
ERS/EACTS statement on the management of malignant pleural effusions
Eur. Respir. J.
(2018) - et al.
Risk factors for pleural effusion recurrence in patients with malignancy: pleural effusion recurrence
Respirology
(2018) - et al.
Management of a malignant pleural effusion: british Thoracic Society pleural disease guideline 2010
Thorax
(2010) - et al.
Predicting survival in malignant pleural effusion: development and validation of the LENT prognostic score
Thorax
(2014)
Pleurodesis outcome in malignant pleural mesothelioma
Thorax
Talc pleurodesis improves survival of patients with malignant pleural effusions: case-control study
Wien. Klin. Wochenschr.
Cited by (25)
The role of an interventional pulmonologist in the management of metastatic pleural effusions (MPE)
2022, Revue des Maladies RespiratoiresPredictors of lung entrapment in malignant pleural effusion
2022, PulmonologyCitation Excerpt :Malignant pleural effusion (MPE) is a common complication in advanced stages of malignancy and affects approximately 15% of oncological patients.1,2 This condition is associated with poor prognosis, with an overall survival (OS) from 3 to 12 months.3,4 Despite the advances in cancer treatments, MPE management remains palliative and focuses on patient's symptoms relief.4-6
The Association Between Pleural Fluid Exposure and Survival in Pleural Mesothelioma
2021, ChestCitation Excerpt :A number of reasons exist why this conclusion may not be safe, even within this large dataset. Pleurodesis success has been associated with improved survival.26,27 Several possible explanations exist for this finding.
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 SurgeryCitation Excerpt :It can cause mild pleuritic chest pain, whereas, a potential serious complication is the adult respiratory distress syndrome [10,11]. Patients who undergo successful talc pleurodesis have a mean survival time of 11 months, opposed to 6.4 months in patients with failed pleurodesis [12]. Talc pleurodesis is carried out via two methods: talc poudrage (insufflation) performed during a thoracoscopy procedure in an operation theatre setting, and talc slurry, which is a bedside administration of talc via a chest tube or a catheter.
Pleurodesis
2021, Encyclopedia of Respiratory Medicine, Second Edition