Pleural effusion: malignant: thoracoscopic talc poudrage led to fewer recurrences than bleomycin pleurodesis

Clinical bottom line (level 1b)

  1. Patients with a malignant pleural effusion who undergo thoracoscopic talc poudrage compared with bleomycin pleurodesis were less likely to have a recurrence (NN T = 2 at 6 months) .
  2. There was no clear difference in mortality rates, length of stay in hospital or use of analgesia post-procedure.
Diacon et al: American Journal of Respiratory and Critical Care Medicine 2000; 162 : 1445-1449
Expires October 2003

The study

Unblinded ?concealed randomised trial without intention-to-treat
Setting: university hospital, Switzerland

36 patients (aged mean 67, 58% male) with symptomatic pleural effusions and documented underlying malignancy (42% breast cancer; 42% non-small-cell lung cancer)

Excluded if
  • severe coagulation disorder
  • known adverse reaction to study medication
  • previous drainage or previous attempts at pleurodesis
  • expected survival < 1 month
  • incomplete lung expansion after 12 to 24 hours on intercostal drainage
  • no improvement in symptoms after drainage
  • loculated effusions

Control Group: (n = 19, 16 analysed): bleomycin pleurodesis: 15 min after instillation of 20 ml 1% lidocaine, 60 IU bleomycin in 100 ml or nomral saline was instilled and the tube clamped. After 2 hours, the tube was opened and kept under suction (-25 cm H20) until removal at least 48 hours later.
Experimental Group: (n = 17, 15 analysed): thoracoscopic talc poudrage under local anaesthesia: following drainage and blunt adhesiolysis, 5 g of asbestos-free talc was sprayed into the pleural cavity. A thorocostomy tube was inserted and kept under suction (-25 cm H20) for at least 48 hours
Pleural effusions were drained using a small bore thoracoscopy tube. The tube was removed as least 48 hours after the procedure and when < 200 ml of fluid drained per day.
86% followed for 6 months

The evidence

Outcome Time to outcome CER EER RRR
(95% CI)		 ARR
(95% CI)		 NNT
(95% CI)
recurrent effusion 6 months 11
(68.8%)		 2
(13.3%)		 81%
(27% to 95%)		 55.4%
(26.9% to 83.9%)		 2
(1 to 4)
death 6 months 7
(43.8%)		 11
(73.3%)		 -68%
(-220% to 11%)		 -29.6%
(-62.6% to 3.46%)		 -3
(NNT = 29 to infinity;
NNH = 2 to infinity)

Comments

  1. Patients were stratified according to tumour type and chemotherapy planned.
  2. No major complications or deaths were noted due to the procedures.
  3. Patients in both groups spent similar lengths of time in hospital (roughly 7 days). Use of analgesia post-procedure was also similar.

Citation

  1. Diacon AH, Wyser C, Bolliger CT, et al: prospective randomized comparison of thoracoscopic talc poudrage under local anesthesia versus bleomycin instillation for pleurodesis in malignant pleural effusions. American Journal of Respiratory and Critical Care Medicine 2000; 162 : 1445-1449
Search Terms: in ACP Journal Club other articles noted
Contributor: Chris Ball, October 2001
Reviewer: Clare Wotton

Clinical Question.
Patient malignant pleural effusion
Intervention or Exposure talc poudrage using thorascopy
Comparison bleomycin pleurodesis
Outcome pain, recurrent effusion, death