EJCTS Click here to go to Edwards website
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Carol Tan
Artyom Sedrakyan
Tom Treasure
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Tan, C.
Right arrow Articles by Treasure, T.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Tan, C.
Right arrow Articles by Treasure, T.
Related Collections
Right arrow Pleura

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

Carol Tan a , Artyom Sedrakyan b , 1 , John Browne c , d , Simon Swift a , Tom Treasure a , *

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).


   Abstract
Top
 Abstract
1. Introduction
 2. Method
 3. Results
 4. Discussion
 Note Added in Proof
 References
 
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


   1. Introduction
Top
 Abstract
 1. Introduction
2. Method
 3. Results
 4. Discussion
 Note Added in Proof
 References
 
Cancer is one of the most common causes of death and pleural effusion is a frequent feature of disseminated or advanced disease. The sum total of the burden of breathlessness and immobility experienced in the last months of life in cancer sufferers is enormous. Prompt, well-judged and skilled management of the effusion can alleviate breathlessness and improve quality of life.

Pleurodesis, using an intrapleural chemical agent, is widely practiced to obliterate the pleural space, prevent fluid accumulation and improve breathing. Insufflation of a pleural agent can be achieved by video-assisted thoracoscopic surgery (VATS) or at the bedside through a chest tube. Agents used include talc, tetracycline, bleomycin and other anti-neoplastic agents, Corynebacterium parvum, and any number of other irritants and pro-inflammatory drugs. There are some nuances concerning the therapeutic intent: most strategies aim at simply creating inflammation to induce adhesion while others include chemotherapeutic agents to kill intrapleural cancer. There are various practices for duration of drainage, drain size and management of the drain.

The subject was reviewed in 1994 [1]. There has been a recent Cochrane systematic review which is confined to the effectiveness of specified chemical agents and the surgical versus medical approaches [2]. The British Thoracic Society guidelines [3,4] lack a systematic review of the evidence base. Without a clear review of the evidence we are unable to make clear recommendations to colleagues, or even to plan research studies. As the thoracic surgeon members of cancer multidisciplinary teams, we are the last port of call in the management of these patients. It is our perception (and without evidence it can be no more) that opportunities for symptomatic relief are being lost. On the other hand, pleurodesis may fail or result in infection. For the patient under- or over-use may translate into irretrievable loss of quality in the last months of life. It is in that spirit we undertook this systematic review. Compared with the Cochrane review our work has a much wider scope to provide clinical guidance on the use of pleurodesis, choice of the agents, route of delivery and other strategies to improve outcomes.

We addressed the following questions:

1. Is instilling an intrapleural agent necessary to produce pleurodesis?
2. If so, which is the best intrapleural agent?
3. Which is the best way of introducing the intrapleural agent?
4. Are there any ways of improving the technique?
a. Rotation after instillation of agent,
b. Duration of drainage,
c. Size of chest tube.

5. Are other measures such as pleurectomy or decortication and the use of shunts effective in the management of malignant pleural effusion?


   2. Method
Top
 Abstract
 1. Introduction
 2. Method
3. Results
 4. Discussion
 Note Added in Proof
 References
 
2.1 Search and identification of trials
Randomised clinical trials (RCTs) were identified by searching the MEDLINE, EMBASE, Web of Science and Cochrane Controlled Trials Register from 1980 to 2003. The initial search strategy was conservative to retain any likely contributing studies. We used various combinations of MeSH terms and text words that might be related to the treatment of malignant pleural effusion. No language restrictions were applied. The RCT filter designed by the Cochrane Collaboration for identifying RCTs and clinical trials was used for MEDLINE and EMBASE. In addition, we searched the reference lists of trials and reviews to look for additional studies.

Criteria for RCT eligibility were random allocation of patients and non-concurrent use of another experimental medication or device. Discrepancies were resolved with participation of four authors (C.T., A.S., S.S., T.T.).

2.2 Study variables
For each RCT, two authors (C.T., A.S.) abstracted data on (1) the number of patients randomised, (2) publication date, (3) demographics, (4) details of intervention and comparison groups, (5) primary outcome (primary failure/recurrence of the condition) and (6) secondary outcomes (side effects: fever, pain and complications).

2.3 Methodological quality
Methodological quality of RCTs was evaluated based on modified Jadad et al.'s [5] criteria that were as follows:

1. Randomisation and its description.
2. Blinding and its description.
3. Allocation concealment.
4. Intention to treat analysis.

2.4 Statistical analysis
Where sufficient data were available, meta-analysis was performed (A.S.), and relative risks (RR) with 95% confidence intervals (CI) were calculated. The assumption of homogeneity among the trials was tested using the {chi} 2 statistic formed by summing the weighted difference between each individual estimate and the pooled estimate. In addition I 2 values were evaluated to assess heterogeneity. This describes the percentage of the variability in effect estimates that is due to heterogeneity rather than sampling error. To be conservative, a value greater than 40% was considered as indicative of substantial heterogeneity. Moreover, a random effect method was used to combine the relative risk estimates as a more conservative strategy. Using this method, the variance for each individual study is the sum of within- and between-study components of the variance. The combined RR estimate was based on the weighted average of the individual log RR estimates. The weights correspond to the inverse of the total variance (within plus between) for each study. The 95% CIs were based on the asymptotic normality of the combined estimates. In addition, if substantial heterogeneity was observed, estimates from individual studies were not combined and results were interpreted separately. RevMan 4.2 developed by the Cochrane Collaboration was used in all analyses.


   3. Results
Top
 Abstract
 1. Introduction
 2. Method
 3. Results
4. Discussion
 Note Added in Proof
 References
 
After an initial independent search by two authors (C.T., S.S.), 561 potentially relevant papers were identified (Fig. 1 ). Titles and abstracts were reviewed by three researchers (C.T., S.S., T.T.). All RCTs addressing the above questions were included. In the areas where RCT evidence was lacking, non-randomised studies were considered. This left us with 55 papers of which 46 were RCTs. The data are presented in as logical a sequence as we could devise.


Figure 1
View larger version (28K):
[in this window]
[in a new window]
  		Fig. 1. Search strategy.

 
3.1 Is instilling an intrapleural agent necessary to produce pleurodesis?
We found seven RCTs reporting the effectiveness of seven different intrapleural agents compared with various drainage strategies in preventing recurrence. In two, randomisation was described [6,7] and in five, there was intention to treat analysis [6–10]. Due to significant heterogeneity among the trials a quantitative synthesis was not performed. One study compared two different agents separately (mepacrine and triethylenethiophosphoramide) with saline [11], and talc was the agent under test in two studies [6,12]. The comparison groups were very varied, with three studies in which saline was instilled through the chest tube [8,9,11], one with multivitamin solution [10], two with chest drain alone [6,12] and one with protracted pleural drainage [7]. In this last study, it was the long-term ambulatory drainage that was the method under investigation. The results are given in Fig. 2 .


Figure 2
View larger version (21K):
[in this window]
[in a new window]
  		Fig. 2. Intrapleural agents versus drainage without a sclerosing agent. Studies were not combined due to substantial heterogeneity. Each comparison is presented separately.

 
3.2 Which is the best agent for pleurodesis?
We found 31 RCTs where intrapleural agents were compared with each other for the prevention of recurrence. In 12, the randomisation process was described and in 26 the analysis was on intention to treat. There was a range of doses and techniques. The studies are sufficiently homogeneous to allow meta-analysis and are summarised in a series of forest plots. These show comparisons of various agents with talc (Fig. 3 ) [13–21], tetracycline (Fig. 4 ) [14,22–33], bleomycin (Fig. 5 ) [34–38] and intrapleural chemotherapy and immunotherapy (Fig. 6 ) [39–42]. Talc was compared with other agents in nine studies that included 341 patients. A non-significant reduction in recurrence was found in comparison with bleomycin (RR, 0.64; 95% CI, 0.34–1.20). Similar results were observed when talc was compared to tetracycline (RR, 0.50; 95% CI, 0.06–4.42), but there was larger uncertainty due to wide confidence intervals. There was no significant difference in recurrence when tetracycline (or doxycycline) was compared to bleomycin (RR, 0.92; 95% CI, 0.61–1.38).


Figure 3
View larger version (29K):
[in this window]
[in a new window]
  		Fig. 3. Talc versus other agents. The overall combined estimate of the effect is calculated for the first two comparisons and is presented only numerically (under subtotals 95% CI).

 

Figure 4
View larger version (31K):
[in this window]
[in a new window]
  		Fig. 4. Tetracycline versus other agents. The overall combined estimate of the effect is calculated for the first two comparisons and is presented only numerically (under subtotals 95% CI).

 

Figure 5
View larger version (17K):
[in this window]
[in a new window]
  		Fig. 5. Bleomycin versus other agents. Studies were not combined in the comparison of bleomycin versus Corynebacterium parvum due to large heterogeneity. Each comparison is presented separately.

 

Figure 6
View larger version (24K):
[in this window]
[in a new window]
  		Fig. 6. Other comparisons. The overall combined estimate of the effect is calculated for all three comparisons and is presented only numerically (under subtotals 95% CI).

 
In the RCTs where intrapleural chemotherapy or immunotherapy was used, one study used systemic and intraperitoneal treatments in addition to the intrapleural route [40]. Combinations of various agents and doses were included in these studies. Combination therapy (chemotherapy plus immunotherapy) appeared to be superior to either alone (Fig. 6). The final study was a comparison of two different chemotherapy agents (mitoxantrone and mepacrine) and was the only trial we found using these agents [43]. Their figures were therefore not pooled or represented in Fig. 6. There was no significant difference in recurrence of the effusion in the two comparison groups.

3.3 Which is the best way of introducing the intrapleural agent: thoracoscopy or at the bedside?
We found three RCTs covering a total of 141 patients which compared the insufflation of a pleurodesis agent by either VATS or a bedside tube [44–46]. Blinding was not possible in these studies, and an intention to treat approach was used in all analyses. Two employed talc [44,45] and one tetracycline [46]. Talc instillation at thoracoscopy was associated with a reduction in recurrence (RR, 0.21; 95% CI, 0.05–0.93) (Fig. 7 ) but this is only based on 13 events in a total of 112 patients. In the single RCT that compared VATS with bedside instillation of tetracycline, no significant difference was found (RR, 1.05; 95% CI, 0.57–1.94) [46].


Figure 7
View larger version (14K):
[in this window]
[in a new window]
  		Fig. 7. RCTs comparing bedside and VATS techniques. The overall combined estimate of the effect is calculated for the first comparison and is presented only numerically (under subtotals 95% CI).

 
3.4 Are there any ways of improving the technique?
The RCTs addressing technique are summarised in Table 1 .


View this table:
[in this window]
[in a new window]
  		Table 1. RCTs which address strategies to improve the outcome of pleurodesis
 
3.4.1 Following instillation of sclerosant, is rotation of the patient beneficial?
Where a sclerosant is introduced through a chest tube at the bedside it has been the custom to roll and tip the patient from time to time to ensure dispersion. Two RCTs have addressed this, one using macrolides (tetracycline or doxycycline) [47] and the other talc [48]. Neither study showed a difference in recurrence conferred by rotation. Within the study by Mager et al. [48] they observed the distribution of talc using 99mTc-sestamibi-labelled talc suspension and showed that rotation did not influence talc dispersion.

3.4.2 Does shorter chest drain duration affect outcome?
Two RCTs in a total of 52 patients looked at duration of chest drainage following bedside pleurodesis [49,50]. Villanueva et al. [49] compared two drainage strategies, one following the standard protocol of draining to dryness before tube removal, and the other following the shorter protocol of removing the tube after 24 h. The rate of recurrence after tetracycline installation was similar. The second RCT, presented only in abstract form, also showed no difference [50].

3.4.3 Does the size of chest tube affect outcome?
There are no RCTs of large versus small chest tubes using the same method of tube insertion. There is one RCT of 18 patients comparing large chest tube placed during thoracoscopy with small catheters which were percutaneously inserted [51]. Tetracycline was instilled following tube or catheter placement. The recurrence rates were similar (three and two out of nine in each group), but the larger tubes caused more discomfort.

3.5 Are other measures such as pleurectomy or decortication and the use of shunts effective in the management of malignant pleural effusion?
3.5.1 Pleurectomy or decortication
There were no randomised trials reporting on the effectiveness of pleurectomy or decortication for malignant pleural effusion. We found five case series covering 260 patients [52–56], including a series of mesothelioma [56] and other malignant disease patients in which tumour debulking and decortication were part of the procedure. Some patients had parietal pleurectomy for recurrence after attempted pleurodesis. In others, decortication was performed when the lung was seen to be ‘trapped’ by tumour and/or an accumulation of fibrin on the visceral pleura [52,54,56]. Perioperative mortality of up to 12.5% was reported [52], and there appears to be a high incidence of prolonged air leak postoperatively, 10–20%.

3.5.2 The use of shunts
There were no randomised trials on the use of shunts in the palliation of malignant pleural effusions. We found four case series covering 250 patients of pleuroperitoneal shunts [57–60]. In all four reports, the main indication for inserting the shunt was the presence of trapped lung, where it was felt that failure of the pleural surfaces to appose would not result in pleurodesis with chemical sclerotherapy. In these groups of patients, effective palliation was reported between 73 and 100%. However, there was a high incidence of shunt complication with shunt occlusion as high as 25% within a median time of 2.5 months [59].


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Method
 3. Results
 4. Discussion
Note Added in Proof
 References
 
The studies reviewed are predominantly small and there are few significant results. This reflects the variable aetiology of the patients studied, their poor prognosis and the difficulty in mounting large comparative studies. This is disappointing for what is a common problem.

On the face of it the evidence in Fig. 2 might suggest that there is no effect of instilling a sclerosing agent. It should be noted however that in the study with the strongest negative effect the drains were left indefinitely which is not a strategy of pleurodesis but a quite different means of coping [7]. Protracted ambulatory drainage alone prevents ‘recurrence’ in that it cannot be evident. In one study, reported in abstract form and available on http://meeting.chestjournal.org/cgi/content/abstract/126/4/726S, 61% of patients had a chest drain until death with an average of 105 days and the longest 315 days. The instillation of an agent is intended to leave the patient with an intact integument, free of impediments. That the fluid is coped with by leaving a tube draining until death is not evidence against the efficacy of the agent. This is a trade-off of strategies which would be better compared on the basis of quality of life. Sclerosing agents are widely used and the practice appears more evidence based.

We found no conclusive evidence supporting the use of a particular sclerosing agent over another, but the trend tends to favour talc (Fig. 3). Talc is widely used at present and this evidence suggests no basis for changing current practice.

Talc can be administered either at video-assisted surgery (VATS) or at the bedside. On the basis of the evidence available here and in the Cochrane review [2], VATS talc insufflation may be associated with fewer recurrences of effusions compared with bedside talc slurry (Fig. 7). This is based on only two randomised trials so a strong recommendation of VATS over the bedside technique cannot be made. However, the high success rate of bedside talc pleurodesis in these studies was associated with a specific protocol within a formal study. If bedside talc slurry is to be employed, the standard of administration would have to be maintained to trial standards and not delegated to less experienced hands if the results are to be reproducible.

When there is a need for tissue (pleural biopsy) to make a diagnosis in addition to palliating the effusion, the clinician may choose VATS over bedside pleurodesis because it allows for full thickness and visually targeted biopsies. The risks of surgery have to be considered but the periprocedural mortality is under 1% (UK Thoracic Surgical Register, http://www.scts.org/). In a patient with only weeks to live, a quicker bedside procedure may be more acceptable, particularly if it is likely to get the patient home sooner.

Reservations about talc usage are related to the reports of pneumonitis following intrapleural talc instillation. This is believed to be due to variability in particle size [61] and it has been postulated that it might be the cause of the variable clinical reporting of pneumonitis. We found 36 reported cases of pneumonitis following talc pleurodesis in the literature, with none recorded in any of the experimental protocols. Where graded talc is used and small particles thus avoided, this complication has not been seen. When the number of patients undergoing this procedure is considered (likely to be tens of thousands in the US and UK alone) this adverse event should be considered very rare. The overwhelming weight of evidence is that talc is safe and that its safety profile is superior to all other agents.

Amongst the received wisdom on performing pleurodesis are the beliefs that the patient should be tipped and rolled, the tube should be left in for a long time and it must be big. Mager et al. [48], investigating the effect of rolling, combined a study of mechanism (dispersal of radio labelled talc) and outcome. They found no difference, refuting the belief and simplifying practice. Shorter drainage duration is as effective as protracted drainage and although the evidence is limited to two studies, a protocol that shortens or obviates the need for hospital admission would be preferred. Increasingly we are managing drains out of hospital and the two considerations, ‘need to be in hospital’ and ‘need to have a drain’, can be separated. Finally, there was no evidence on the benefits of larger chest tube sizes. In one study, results indicate that there may be no difference between large and small tubes [51]. This is supported by evidence found in non-randomised studies [62–70]. These studies included patients in whom the tube was placed under image guidance and/or outpatient drain management protocols were employed. Sclerosant practice varied. The outcomes with the use of smaller drains were found to be similar to larger sizes.

Trapped lung is recognised by an air/fluid level after drainage and a lung that will not re-expand. It can defeat pleurodesis simply due to the mechanical difficulty of getting the pleural surfaces to appose. Options for management under these circumstances include pleurectomy/decortication, a pleuroperitoneal shunt and long-term drainage which we have already addressed. Two retrospective studies have looked at the consequences and outcome of trapped lung and suggest that in itself, it may be well tolerated by some patients [71,72], so we found no strong evidence for an intervention. The focus in these patients should be on the extent to which breathlessness is a limiting symptom, and if it can be reliably relieved. In the case of trapped lung there may be arguments for accepting the situation. Unavailing surgical interventions impose a further burden on the patient with the additional substantial risk of introducing infection.


   Note Added in Proof
Top
 Abstract
 1. Introduction
 2. Method
 3. Results
 4. Discussion
 Note Added in Proof
References
 
Since completing the search an RCT in 482 patients has been published, comparing chest tube talc slurry versus thoracoscopic poudrage [73]. It showed similar effectiveness and does not substantially alter our conclusions.


   Footnotes
 
1 Disclosure Statement: Dr Artyom Sedrakyan is currently employed by the Agency for Healthcare Research and Quality, a government research agency which produces reports on quality of care in USA. The views expressed are solely those of the authors and do not reflect the official position or policy of the Agency for Healthcare Research and Quality or the US Department of Health and Human Services. Back


   References
Top
 Abstract
 1. Introduction
 2. Method
 3. Results
 4. Discussion
 Note Added in Proof
 References
 

  1. Walker-Renard PB, Vaughan LM, Sahn SA. Chemical pleurodesis for malignant pleural effusions. Ann Intern Med 1994;120:56-64.[Abstract/Free Full Text]
  2. Shaw P, Agarwal R. Pleurodesis for malignant pleural effusions. Cochrane Database Syst Rev 2004, CD002916..
  3. Maskell NA, Butland RJ. BTS guidelines for the investigation of a unilateral pleural effusion in adults. Thorax 2003;58(Suppl. 2):ii8-ii17.[Free Full Text]
  4. Antunes G, Neville E, Duffy J, Ali N. BTS guidelines for the management of malignant pleural effusions. Thorax 2003;58(Suppl. 2):ii29-ii38.[Free Full Text]
  5. Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, McQuay HJ. Assessing the quality of reports of randomized clinical trials: is blinding necessary?. Control Clin Trials 1996;17:1-12.[CrossRef][Medline]
  6. Sorensen PG, Svendsen TL, Enk B. Treatment of malignant pleural effusion with drainage, with and without instillation of talc. Eur J Respir Dis 1984;65:131-135.[Medline]
  7. Putnam Jr. JB, Light RW, Rodriguez RM, Ponn R, Olak J, Pollak JS, Lee RB, Payne DK, Graeber G, Kovitz KL. A randomized comparison of indwelling pleural catheter and doxycycline pleurodesis in the management of malignant pleural effusions. Cancer 1999;86:1992-1999.[CrossRef][Medline]
  8. Groth G, Gatzemeier U, Haussingen K, Heckmayr M, Magnussen H, Neuhauss R, Pavel JV. Intrapleural palliative treatment of malignant pleural effusions with mitoxantrone versus placebo (pleural tube alone). Ann Oncol 1991;2:213-215.[Abstract/Free Full Text]
  9. North SA, Au HJ, Halls SB, Tkachuk L, Mackey JR. A randomized, phase III, double-blind, placebo-controlled trial of intrapleural instillation of methylprednisolone acetate in the management of malignant pleural effusion. Chest 2003;123:822-827.[Abstract/Free Full Text]
  10. Zaloznik AJ, Oswald SG, Langin M. Intrapleural tetracycline in malignant pleural effusions. A randomized study. Cancer 1983;51:752-755.[CrossRef][Medline]
  11. Mejer J, Mortensen KM, Hansen HH. Mepacrine hydrochloride in the treatment of malignant pleural effusion. A controlled randomized trial. Scand J Respir Dis 1977;58:319-323.[Medline]
  12. Leverenz A, Heckmayr M, Tischer-Neuhauss R, Gatzemeier U. Intrapleural palliative treatment of malignant pleural effusions with talcum versus placebo (pleural tube alone). Lung Cancer 2000;29A:274.
  13. Hamed H, Fentiman IS, Chaudary MA, Rubens RD. Comparison of intracavitary bleomycin and talc for control of pleural effusions secondary to carcinoma of the breast. Br J Surg 1989;76:1266-1267.[Medline]
  14. Lynch T, Kalish L, Mentzer SJ, Decamp M, Strauss G, Sugarbaker DJ. Optimal therapy of malignant pleural effusions: report of a randomised trial of bleomycin, tetracycline, and talc and a meta-analysis. Int J Oncol 1996;8:183-190.
  15. Noppen M, Degreve J, Mignolet M, Vincken W. A prospective, randomised study comparing the efficacy of talc slurry and bleomycin in the treatment of malignant pleural effusions. Acta Clin Belg 1997;52:258-262.[Medline]
  16. Zimmer PW, Hill M, Casey K, Harvey E, Low DE. Prospective randomized trial of talc slurry vs bleomycin in pleurodesis for symptomatic malignant pleural effusions. Chest 1997;112:430-434.[Abstract/Free Full Text]
  17. Diacon AH, Wyser C, Bolliger CT, Tamm M, Pless M, Perruchoud AP, Soler M. Prospective randomized comparison of thoracoscopic talc poudrage under local anesthesia versus bleomycin instillation for pleurodesis in malignant pleural effusions. Am J Respir Crit Care Med 2000;162:1445-1449.[Abstract/Free Full Text]
  18. Ong KC, Indumathi V, Raghuram J, Ong YY. A comparative study of pleurodesis using talc slurry and bleomycin in the management of malignant pleural effusions. Respirology 2000;5:99-103.[CrossRef][Medline]
  19. Haddad FJ, Younes RN, Gross JL, Deheinzelin D. Pleurodesis in patients with malignant pleural effusions: talc slurry or bleomycin? Results of a prospective randomized trial. World J Surg 2004;28:749-753.[CrossRef][Medline]
  20. Fentiman IS, Rubens RD, Hayward JL. A comparison of intracavitary talc and tetracycline for the control of pleural effusions secondary to breast cancer. Eur J Cancer Clin Oncol 1986;22:1079-1081.[CrossRef][Medline]
  21. Fentiman IS, Rubens RD, Hayward JL. Control of pleural effusions in patients with breast cancer. A randomized trial. Cancer 1983;52:737-739.[CrossRef][Medline]
  22. Emad A, Rezaian GR. Treatment of malignant pleural effusions with a combination of bleomycin and tetracycline. A comparison of bleomycin or tetracycline alone versus a combination of bleomycin and tetracycline. Cancer 1996;78:2498-2501.[CrossRef][Medline]
  23. Kessinger A, Wigton RS. Intracavitary bleomycin and tetracycline in the management of malignant pleural effusions: a randomized study. J Surg Oncol 1987;36:81-83.[Medline]
  24. Martinez-Moragon E, Aparicio J, Rogado MC, Sanchis J, Sanchis F, Gil-Suay V. Pleurodesis in malignant pleural effusions: a randomized study of tetracycline versus bleomycin. Eur Respir J 1997;10:2380-2383.[Abstract]
  25. Patz Jr. EF, McAdams HP, Erasmus JJ, Goodman PC, Culhane DK, Gilkeson RC, Herndon J. Sclerotherapy for malignant pleural effusions: a prospective randomized trial of bleomycin vs doxycycline with small-bore catheter drainage. Chest 1998;113:1305-1311.[Abstract/Free Full Text]
  26. Ruckdeschel JC, Moores D, Lee JY, Einhorn LH, Mandelbaum I, Koeller J, Weiss GR, Losada M, Keller JH. Intrapleural therapy for malignant pleural effusions. A randomized comparison of bleomycin and tetracycline. Chest 1991;100:1528-1535.[Abstract/Free Full Text]
  27. Won SO, Choi J, Yong SK, Yong HD, Tae WJ, Mann HJ. Intrapleural doxycycline and bleomycin in the management of malignant pleural effusions: a randomised study. Tuberc Respir Dis 1997;44:85-92.
  28. Leahy BC, Honeybourne D, Brear SG, Carroll KB, Thatcher N, Stretton TB. Treatment of malignant pleural effusions with intrapleural Corynebacterium parvum or tetracycline. Eur J Respir Dis 1985;66:50-54.[Medline]
  29. Salomaa ER, Pulkki K, Helenius H. Pleurodesis with doxycycline or Corynebacterium parvum in malignant pleural effusion. Acta Oncol 1995;34:117-121.[Medline]
  30. Bayly TC, Kisner DL, Sybert A, Macdonald JS, Tsou E, Schein PS. Tetracycline and quinacrine in the control of malignant pleural effusions. A randomized trial. Cancer 1978;41:1188-1192.[CrossRef][Medline]
  31. Gust R, Kleine P, Fabel H. Fibrin glue and tetracycline pleurodesis in recurrent malignant pleural effusions. A randomized comparative study. Med Klin 1990;85:18-23.
  32. Loutsidis A, Bellenis I, Argiriou M, Exarchos N. Tetracycline compared with mechlorethamine in the treatment of malignant pleural effusions. A randomized trial. Respir Med 1994;88:523-526.[CrossRef][Medline]
  33. Tattersall M, Fox R, Woods R, Kefford R. Intracavitary adriamycin nitrogen mustard and tetracycline in the control of malignant effusions: a randomised study. Med J Aust 1980;2:447-448.[Medline]
  34. Koldsland S, Svennevig JL, Lehne G, Johnson E. Chemical pleurodesis in malignant pleural effusions: a randomised prospective study of mepacrine versus bleomycin. Thorax 1993;48:790-793.[Abstract/Free Full Text]
  35. Schmidt M, Schaarschmidt G, Chemaissani A. Pleurodesis in malignant pleural effusion: bleomycin vs. mitoxantrone. Pneumologie 1997;51:367-372.[Medline]
  36. Sartori S, Trevisani L, Nielsen I, Tassinari D, Abbasciano V. Intracavitary bleomycin vs interferon in the management of malignant pleural effusions. Chest 1998;113:1145-1146.[Free Full Text]
  37. Hillerdal G, Kiviloog J, Nou E, Steinholtz L. Corynebacterium parvum in malignant pleural effusion. A randomized prospective study. Eur J Respir Dis 1986;69:204-206.[Medline]
  38. Ostrowski MJ, Priestman TJ, Houston RF, Martin WM. A randomized trial of intracavitary bleomycin and Corynebacterium parvum in the control of malignant pleural effusions. Radiother Oncol 1989;14:19-26.[CrossRef][Medline]
  39. Luh KT, Yang PC, Kuo SH, Chang DB, Yu CJ, Lee LN. Comparison of OK-432 and mitomycin C pleurodesis for malignant pleural effusion caused by lung cancer. A randomized trial. Cancer 1992;69:674-679.[CrossRef][Medline]
  40. Nio Y, Nagami H, Tamura K, Tsubono M, Nio M, Sato M, Kawabata K, Hayashi H, Shiraishi T, Imai S, Tsuchitani T, Mizuta J, Nakagawa M, Fukumoto M. Multi-institutional randomized clinical study on the comparative effects of intracavital chemotherapy alone versus immunotherapy alone versus immunochemotherapy for malignant effusion. Br J Cancer 1999;80:775-785.[CrossRef][Medline]
  41. Masuno T, Kishimoto S, Ogura T, Honma T, Niitani H, Fukuoka M, Ogawa N. A comparative trial of LC9018 plus doxorubicin and doxorubicin alone for the treatment of malignant pleural effusion secondary to lung cancer. Cancer 1991;68:1495-1500.[CrossRef][Medline]
  42. Bo H, Yaohua W. Curative effect of highly agglutinative staphylococcin plus cisplatin in treatment of malignant pleural effusion and ascites. Chinese J Clin Oncol 1998;25:623-624.
  43. Bjermer L, Gruber A, Sue-Chu M, Sandstrom T, Eksborg S, Henriksson R. Effects of intrapleural mitoxantrone and mepacrine on malignant pleural effusion—a randomised study. Eur J Cancer 1995;31A:2203-2208.
  44. Manes N, Rodriguez-Panadero F, Bravo JL, Hernandez H, Alix A. Talc pleurodesis. Prospective and randomised study. Clinical follow-up. Chest 2000;118(4):131S.
  45. Yim AP, Chan AT, Lee TW, Wan IY, Ho JK. Thoracoscopic talc insufflation versus talc slurry for symptomatic malignant pleural effusion. Ann Thorac Surg 1996;62:1655-1658.[Abstract/Free Full Text]
  46. Evans TR, Stein RC, Pepper JR, Gazet JC, Ford HT, Coombes RC. A randomised prospective trial of surgical against medical tetracycline pleurodesis in the management of malignant pleural effusions secondary to breast cancer. Eur J Cancer 1993;29A:316-319.[CrossRef]
  47. Dryzer SR, Allen ML, Strange C, Sahn SA. A comparison of rotation and nonrotation in tetracycline pleurodesis. Chest 1993;104:1763-1766.[Abstract/Free Full Text]
  48. Mager HJ, Maesen B, Verzijlbergen F, Schramel F. Distribution of talc suspension during treatment of malignant pleural effusion with talc pleurodesis. Lung Cancer 2002;36:77-81.[CrossRef][Medline]
  49. Villanueva AG, Gray Jr. AW, Shahian DM, Williamson WA, Beamis Jr. JF. Efficacy of short term versus long term tube thoracostomy drainage before tetracycline pleurodesis in the treatment of malignant pleural effusions. Thorax 1994;49:23-25.[Abstract/Free Full Text]
  50. Davies CWH, Chapman S, Reza T, Thomas J. Efficacy of short (24 h) versus longer (72 h) chest drainage after talc pleurodesis for malignant pleural effusion. Eur Respir J 2003;22(Suppl. 45):192s.[CrossRef]
  51. Clementsen P, Evald T, Grode G, Hansen M, Krag JG, Faurschou P. Treatment of malignant pleural effusion: pleurodesis using a small percutaneous catheter. A prospective randomized study. Respir Med 1998;92:593-596.[CrossRef][Medline]
  52. Fry WA, Khandekar JD. Parietal pleurectomy for malignant pleural effusion. Ann Surg Oncol 1995;2:160-164.[CrossRef][Medline]
  53. Harvey JC, Erdman CB, Beattie EJ. Early experience with videothoracoscopic hydrodissection pleurectomy in the treatment of malignant pleural effusion. J Surg Oncol 1995;59:243-245.[Medline]
  54. Martini N, Bains MS, Beattie Jr. EJ. Indications for pleurectomy in malignant effusion. Cancer 1975;35:734-738.[CrossRef][Medline]
  55. Waller DA, Morritt GN, Forty J. Video-assisted thoracoscopic pleurectomy in the management of malignant pleural effusion. Chest 1995;107:1454-1456.[Abstract/Free Full Text]
  56. Soysal O, Karaoglanoglu N, Demiracan S, Topcu S, Tastepe I, Kaya S, Unlu M, Cetin G. Pleurectomy/decortication for palliation in malignant pleural mesothelioma: results of surgery. Eur J Cardiothorac Surg 1997;11:210-213.[Abstract]
  57. Genc O, Petrou M, Ladas G, Goldstraw P. The long-term morbidity of pleuroperitoneal shunts in the management of recurrent malignant effusions. Eur J Cardiothorac Surg 2000;18:143-146.[Abstract/Free Full Text]
  58. Petrou M, Kaplan D, Goldstraw P. Management of recurrent malignant pleural effusions. The complementary role talc pleurodesis and pleuroperitoneal shunting. Cancer 1995;75:801-805.[CrossRef][Medline]
  59. Reich H, Beattie EJ, Harvey JC. Pleuroperitoneal shunt for malignant pleural effusions: a one-year experience. Semin Surg Oncol 1993;9:160-162.[Medline]
  60. Schulze M, Boehle AS, Kurdow R, Dohrmann P, Henne-Bruns D. Effective treatment of malignant pleural effusion by minimal invasive thoracic surgery: thoracoscopic talc pleurodesis and pleuroperitoneal shunts in 101 patients. Ann Thorac Surg 2001;71:1809-1812.[Abstract/Free Full Text]
  61. Ferrer J, Villarino MA, Tura JM, Traveria A, Light RW. Talc preparations used for pleurodesis vary markedly from one preparation to another. Chest 2001;119:1901-1905.[Abstract/Free Full Text]
  62. Chen YM, Shih JF, Yang KY, Lee YC, Perng RP. Usefulness of pig-tail catheter for palliative drainage of malignant pleural effusions in cancer patients. Support Care Cancer 2000;8:423-426.[CrossRef][Medline]
  63. Parulekar W, Di Primio G, Matzinger F, Dennie C, Bociek G. Use of small-bore vs large-bore chest tubes for treatment of malignant pleural effusions. Chest 2001;120:19-25.[Abstract/Free Full Text]
  64. Pien GW, Gant MJ, Washam CL, Sterman DH. Use of an implantable pleural catheter for trapped lung syndrome in patients with malignant pleural effusion. Chest 2001;119:1641-1646.[Abstract/Free Full Text]
  65. Pollak JS, Burdge CM, Rosenblatt M, Houston JP, Hwu WJ, Murren J. Treatment of malignant pleural effusions with tunneled long-term drainage catheters. J Vasc Interv Radiol 2001;12:201-208.[Medline]
  66. Putnam Jr. JB, Walsh GL, Swisher SG, Roth JA, Suell DM, Vaporciyan AA, Smythe WR, Merriman KW, DeFord LL. Outpatient management of malignant pleural effusion by a chronic indwelling pleural catheter. Ann Thorac Surg 2000;69:369-375.[Abstract/Free Full Text]
  67. Smart JM, Tung KT. Initial experiences with a long-term indwelling tunnelled pleural catheter for the management of malignant pleural effusion. Clin Radiol 2000;55:882-884.[CrossRef][Medline]
  68. Morrison MC, Mueller PR, Lee MJ, Saini S, Brink JA, Dawson SL, Cortell ED, Hahn PF. Sclerotherapy of malignant pleural effusion through sonographically placed small-bore catheters. Am J Roentgenol 1992;158:41-43.[Abstract/Free Full Text]
  69. Seaton KG, Patz Jr. EF, Goodman PC. Palliative treatment of malignant pleural effusions: value of small-bore catheter thoracostomy and doxycycline sclerotherapy. Am J Roentgenol 1995;164:589-591.[Abstract/Free Full Text]
  70. Vazquez-Pelillo JC, Pena GE, Leon AP, Garcia FE, de Alvaro LJ, Folque GE. Malignant pleural effusions: a description of an alternative method of external drainage with a fine-caliber catheter. Arch Bronconeumol 1997;33:450-452.[Medline]
  71. Boland GW, Gazelle GS, Girard MJ, Mueller PR. Asymptomatic hydropneumothorax after therapeutic thoracentesis for malignant pleural effusions. Am J Roentgenol 1998;170:943-946.[Abstract/Free Full Text]
  72. Chang YC, Patz Jr. EF, Goodman PC. Pneumothorax after small-bore catheter placement for malignant pleural effusions. Am J Roentgenol 1996;166:1049-1051.[Abstract/Free Full Text]
  73. Dresler CM, Olak J, Herndon JE, Richards WG, Scalzetti E, Fleishmann SB, Hernstine KH, Demmy T, Jablons DM, Kohman L, Daniel TM, Haasler GB, Sugarbaker DJ. Phase III intergroup study of talc poudrage vs talc slurry sclerosis for malignant pleural effusion. Chest 2005;127:909-915.[Abstract/Free Full Text]



This article has been cited by other articles:


Home page
 ChestHome page
R. M. Terra, J. J. M. Junqueira, L. R. Teixeira, F. S. Vargas, P. M. Pego-Fernandes, and F. B. Jatene
Is Full Postpleurodesis Lung Expansion a Determinant of a Successful Outcome After Talc Pleurodesis?
Chest, August 1, 2009; 136(2): 361 - 368.
[Abstract] [Full Text] [PDF]

Home page
 Mayo Clin Proc.Home page
J. E. Heffner and J. S. Klein
Recent Advances in the Diagnosis and Management of Malignant Pleural Effusions
Mayo Clin. Proc., February 1, 2008; 83(2): 235 - 250.
[Abstract] [Full Text] [PDF]

Home page
 ThoraxHome page
British Thoracic Society Standards of Care Committ
BTS statement on malignant mesothelioma in the UK, 2007
Thorax, November 1, 2007; 62(Suppl_2): ii1 - ii19.
[Full Text] [PDF]

Home page
 The OncologistHome page
P. Solli and L. Spaggiari
Indications and Developments of Video-Assisted Thoracic Surgery in the Treatment of Lung Cancer
Oncologist, October 1, 2007; 12(10): 1205 - 1214.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
V. Steger, U. Mika, H. Toomes, T. Walker, C. Engel, T. Kyriss, G. Ziemer, and G. Friedel
Who Gains Most? A 10-Year Experience With 611 Thoracoscopic Talc Pleurodeses
Ann. Thorac. Surg., June 1, 2007; 83(6): 1940 - 1945.
[Abstract] [Full Text] [PDF]

Home page
 JRSMHome page
C. Tan, T. Treasure, J. Browne, M. Utley, C. W H Davies, and H. Hemingway
Seeking consensus by formal methods: a health warning
J R Soc Med, January 1, 2007; 100(1): 10 - 14.
[Full Text] [PDF]

Home page
 DTBHome page
Can {blacktriangledown}pemetrexed help in malignant mesothelioma?
DTB, October 1, 2006; 44(10): 77 - 80.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Carol Tan
Artyom Sedrakyan
Tom Treasure
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Tan, C.
Right arrow Articles by Treasure, T.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Tan, C.
Right arrow Articles by Treasure, T.
Related Collections
Right arrow Pleura

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS