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Eur J Cardiothorac Surg 2006;29:829-838
© 2006 Elsevier Science NL

Review

The evidence on the effectiveness of management for malignant pleural effusion: a systematic review

^a Thoracic Unit, Guy's Hospital, St Thomas’ Street, London SE1 9RT, United Kingdom
^b Center for Outcomes and Evidence, Agency for Healthcare Research and Quality, Rockville, MD, USA
^c Clinical Effectiveness Unit, Royal College of Surgeons of England, Keppel Street, London WC1E 7HT, United Kingdom
^d Health Services Research Unit, London School of Hygiene and Tropical Medicine, London WC1E 7HT, United Kingdom

Received 28 October 2005; received in revised form 19 December 2005; accepted 21 December 2005.

^_* Corresponding author. Tel.: +44 20 7188 1034; fax: +44 20 7188 1016. (Email: Tom.Treasure{at}gstt.nhs.uk; tom.treasure{at}ukgateway.net).

The aim of this study was to review systematically the available evidence on pleurodesis for malignant effusion, focusing on the choice of the agents, route of delivery and other strategies to improve outcomes. Four electronic databases (MEDLINE, EMBASE, Web of Science and Cochrane Controlled Trials Register) were searched, reference lists checked and letters requesting details of unpublished trials and data sent to authors of previous trials. Studies of malignant pleural effusion in humans were selected with no language restrictions applied. Criteria for randomised clinical trial (RCT) eligibility were random allocation of patients and non-concurrent use of another experimental medication or device. Methodological quality evaluation of the trials was based on randomisation, blinding, allocation concealment and intention to treat analysis. A random effect model was used to combine the relative risk estimates of the treatment effects whenever pooling for an overall effect was considered appropriate. Forty-six RCTs with a total of 2053 patients with malignant pleural effusions were reviewed for effectiveness of pleurodesis. Talc tended to be associated with fewer recurrences when compared to bleomycin (RR, 0.64; 95% CI, 0.34–1.20) and, with more uncertainty, to tetracycline (RR, 0.50; 95% CI, 0.06–4.42). Tetracycline (or doxycycline) was not superior to bleomycin (RR, 0.92; 95% CI, 0.61–1.38). When compared with bedside talc slurry, thoracoscopic talc insufflation was associated with a reduction in recurrence (RR, 0.21; 95% CI, 0.05–0.93). Strategies such as rolling the patient after instillation of the sclerosing agent, protracted drainage of the effusion and use of larger chest tubes were not found to have any substantial advantages. Talc appears to be effective and should be the agent of choice for pleurodesis. Thoracoscopic talc insufflation is associated with fewer recurrences of effusions compared with bedside talc slurry, but this is based on two small studies. Where thoracoscopy is unavailable bedside talc pleurodesis has a high success rate and is the next best option.

Key Words: Malignant effusion • Pleurodesis • VATS

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