Pleural effusion: pleurodesis: talc insufflation was probably most effective.

Clinical bottom line (level 2a)

  1. Almost two thirds of patients had a good response from pleurodesis.
  2. Around a fifth suffered pain or a fever.
  3. Talc insufflation was probably the most effective method of pleurodesis - it was also the cheapest agent.
  4. Tetracycline, doxycycline, minocycline and Corynebacterium parvum were probably equally effective.
Walker-Renard et al: Annals of Internal Medicine 1994; 120 (1): 56-64
Expires October 2003

The study

Systematic review of controlled and uncontrolled trials of
  • Patients: recurrent, symptomatic, malignant pleural effusions
  • Intervention: chemical pleurodesis (Agents used: doxycycline, minocycline, tetracycline, bleomycin, cisplatin, doxorubicin, etoposide, fluorouracil, interferon-beta, mitomycin-c, corynebacterium parvum, methylprednisolone, and talc)
  • Outcome: success rate and adverse effects


    • Articles found in English and Japanese using MEDLINE, 1966 to 1992 (search terms: malignant pleural effusion and pleurodesis )

    Selection criteria: not detailed
    Appraisal criteria: Selected by three independent blinded reviewers. No assessment of quality of studies.
    Articles excluded if:

    43 studies involving 1168 patients. Only four agents (tetracycline, bleomycin, C. parvum, and Talc) were studied in more than 100 patients.
    No details were given on heterogeneity.

    The evidence

    outcome time to outcome number of patients/total number %
    (95% CI)
    all agents: complete response ? 752/1168 64%
    (62% to 67%)
    pain ? 265/1140 23%
    (21% to 26%)
    fever ? 220/1140 19%
    (17% to 22%)
    complete resolution: talc 2.5 -10 g ? 153/165 93%
    (89% to 97%)
    minocycline 300 mg ? 6/7 86%
    (60% to 111%)
    Corynebacterium parvum 3.5-14 mg ? 129/169 76%
    (69% to 83%)
    doxycycline 500 mg ? 43/60 71%
    (60% to 83%)
    tetracycline 500 mg - 20 mg/kg ? 240/359 67%
    (62% to 72%)
    fluorouracil 2-3 g ? 23/35 66%
    (50% to 81%)
    bleomycin 15-240 units ? 108/199 54%
    (47% to 61%)

    • Other agents used were less successful.

    Comments

    1. The following agents were not included in the systematic review: Calmette-Guerin bacillus cell-wall skeleton, nitrogen mustard, quinacrine, and thiotepa.
    2. Differences between the agents were not addressed.
    3. Talc appears to be the most effective and least expensive agent; however, insufflation has the disadvantages of the need for expensive thoracoscopy and the usual need for general anaesthesia.
    4. Many of the studies had major methodological flaws and there was a wide variation in agents used, patient mix and follow-up and technique. Most agents were only studied on a few patients. Consequently conclusions are difficult to make on current evidence.

    Citation

    1. Walker-Renard PB, Vaughan LM, Sahn SA: chemical pleurodesis for malignant pleural effusions. Annals of Internal Medicine 1994; 120 (1): 56-64
    Search Terms: pleural effusion in Cochrane
    Contributor: Chris Ball and Clare Wotton, October 2000
    Reviewer:

    Clinical Question.
    Patient pleural effusion
    Intervention or Exposure chemical pleurodesis
    Outcome success