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Phase III Intergroup Study of Talc Poudrage vs Talc Slurry Sclerosis for Malignant Pleural Effusion
Open accessAbstract
Study objective To demonstrate the efficacy, safety, and appropriate mode of instillation of talc for sclerosis in treatment of malignant pleural effusions (MPEs).Design A prospective, randomized trial was designed to compare thoracoscopy with talc insufflation (TTI) to thoracostomy and talc slurry (TS) for patients with documented MPE.Measurements The primary end point was 30-day freedom from radiographic MPE recurrence among surviving patients whose lungs initially re-expanded > 90%. Morbidity, mortality, and quality of life were also assessed.Results Of 501 patients registered, those eligible were randomized to TTI (n = 242) or TS (n = 240). Patient demographics and primary malignancies were similar between study arms. Overall, there was no difference between study arms in the percentage of patients with successful 30-day outcomes (TTI, 78%; TS, 71%). However, the subgroup of patients with primary lung or breast cancer had higher success with TTI than with TS (82% vs 67%). Common morbidity included fever, dyspnea, and pain. Treatment-related mortality occurred in nine TTI patients and seven TS patients. Respiratory complications were more common following TTI than TS (14% vs 6%). Respiratory failure was observed in 4% of TS patients and 8% of TTI patients, accounting for five toxic deaths and six toxic deaths, respectively. Quality-of-life measurement demonstrated less fatigue with TTI than TS. Patient ratings of comfort and safety were also higher for TTI, but there were no differences on perceived value or convenience of the procedures.Conclusions Both methods of talc delivery are similar in efficacy; TTI may be better for patients with either a lung or breast primary. The etiology and incidence of respiratory complications from talc need further exploration.
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“thoracoscopic insufflation with talc ( poudrage) is more effective than talc slurry sclerosis [II, B] [145].”
From Metastatic non-small-cell lung cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up (2016) · cites this paper as [145]
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“The preferred sclerosing agent is talc, which is more effective than bleomycin or tetracycline [II, B] [144]; thoracoscopic insufflation with talc (poudrage) is more effective than talc slurry sclerosis [II, B] [145].”
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“Talc, the most effective and commonly used pleurodesis agent, has been shown to have multiple complications, including respiratory failure, pneumonia, and treatment-related death.(2,3) There is evidence that these serious risks are reduced through the use of more carefully regulated talc particles.”
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“[21] Dresler CM, Olak J, Herndon II JE, et al.”
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“By 6 months, talc pleurodesis had failed in approximately 50% of patients.(8) Fysh et al(3) showed, in 165 patients with mesothelioma, that talc pleurodesis was successful in life-time control of MPEs in about one-third of patients; 32% of all patients required further pleural intervention.”
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Penz, E. D., Watt, K. N., Hergott, C. A., Rahman, N. M., & Psallidas, I. (2017) · Cancer Management and Research · doi:10.2147/cmar.s95663 · Cited by 116
“…between treatment groups: • improved tiredness with mitoxantrone used over mepacrine 61 • improved fatigue in talc poudrage use over talc slurry 35 • improved EQ5D scores at 6 months over talc group, but no difference in QLQ-C30 scores 37 • improved performance scores at 1 week for patients…”
Use of tunnelled catheters for malignant pleural effusions in patients fit for pleurodesis
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“This compares very favourably to the results of the largest prospective study on TTI and TS for MPE, which found that patients with .90% lung re-expansion and still alive at 30 days had successful pleurodesis rates of 78 and 71% for TTI and TS, respectively [ 3 ].”
BackgroundResultInfluentialDiagnosis and management of malignant pleural effusions
Heffner, J. E. (2007) · Respirology · doi:10.1111/j.1440-1843.2007.01154.x · Cited by 115
Lee, P., Hsu, A. A. L., Lo, C. P. L., & Colt, H. G. (2007) · Respirology · doi:10.1111/j.1440-1843.2007.01144.x · Cited by 113
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“Subgroup Analysis Four studies involving 508 patients compared the efficacy of thoracoscopic talc poudrage with bedside talc slurry [33,40,42,44].”
BackgroundManagement of Malignant Pleural Effusions
Charpidou, A., Harrington, K. J., & Syrigos, K. N. (2006) · Springer eBooks · doi:10.1007/3-540-31040-1_49 · Cited by 109
“A large phase III study demonstrated that talc insufflation through thoracoscopy has higher success rates (82%) than the use of slurry through thoracostomy in the subgroup of patients with primary lung cancer [44] .”
Optimal Management of Malignant Pleural Effusions (Results of CALGB 30102)
Demmy, T. L., Gu, L., Burkhalter, J. E., Toloza, E. M., D’Amico, T. A., Sutherland, S., Wang, X., Archer, L. E., Veit, L. J., Kohman, L. J., et al. (2012) · Journal of the National Comprehensive Cancer Network · doi:10.6004/jnccn.2012.0102 · Cited by 108
Diagnóstico y tratamiento del derrame pleural
Garrido, V. V., Ferrer-Sancho, J., Blasco, L., Gafas, A. D. P., Rodríguez, E. P., Panadero, F. R., Candeira, S. R., Velázquez, Á. A. S., & Valdés, L. (2006) · Archivos de Bronconeumología · doi:10.1157/13090586 · Cited by 99
“…multicéntrico no se en-cuentran claras diferencias entre ambas técnicas de apli-cación, salvo en pleuritis metastásicas de cáncer de pul-món y mama 47 , un metaanálisis Cochrane evidencia que la aplicación de talco pulverizado en toracoscopia obtie-ne mejores resultados que en suspensión 48 (B),…”
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“The landmark study by Dresler et al. [78] demonstrated no differences between pleurodesis success at 30 days comparing talc slurry versus poudrage.”
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Advanced Malignant Lung Disease: What the Specialist Can Offer
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“Several studies comparing the effectiveness and safety of talc slurry through a chest tube thoracostomy with thoracoscopic talc poudrage revealed controversial results. In one prospective multicentre study [”
ResultWarren, W., KIM, A., & LIPTAY, M. (2007) · European Journal of Cardio-Thoracic Surgery · doi:10.1016/j.ejcts.2007.10.002 · Cited by 90
“More recently, surgeons have advocated video-assisted thoracoscopy to completely evacuate the effusion, break down adhesions and to insufflate talc evenly over the pleural surface [7,8].”
BackgroundPleural controversy: Closed needle pleural biopsy or thoracoscopy—Which first?
Koegelenberg, C. F. N., & Diacon, A. H. (2011) · Respirology · doi:10.1111/j.1440-1843.2011.01973.x · Cited by 88
Thoracoscopic Talc Versus Tunneled Pleural Catheters for Palliation of Malignant Pleural Effusions
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“The Cancer and Leukemia Group B (CALGB) 9334 trial did not find a difference in overall pleurodesis rate between VATS talc and talc slurry by chest tube, but a post-hoc subgroup analysis favored VATS in patients with near-complete lung reexpansion and in patients with breast and lung cancers [9].”
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Therapeutic thoracentesis: the role of ultrasound and pleural manometry
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Management of Malignant Pleural Effusion
Kastelik, J. A. (2013) · Lung · doi:10.1007/s00408-012-9445-1 · Cited by 79
“, insufflation 14% vs slurry 6%) [123].”
Diagnosis and Treatment of Pleural Effusion
Garrido, V. V., Ferrer-Sancho, J., Blasco, H., Gafas, A. D. P., Rodríguez, E. P., Panadero, F. R., Candeira, S. R., Velázquez, Á. A. S., & Valdés, L. (2006) · Archivos de Bronconeumología · doi:10.1016/s1579-2129(06)60545-4 · Cited by 78
“…MOC 31, or BG8 is The most commonly used of the many staging classifications that exist is the system proposed by the 52 very variable, with a mean of 9 to 12 months, and several prognostic factors have been described, mainly general * nuclear ribonucleoprotein; and GSR, global sedimentation rate.”
BackgroundDiagnosis and management of malignant pleural effusions: state of the art in 2017
Desai, N., & Lee, H. J. (2017) · Journal of Thoracic Disease · doi:10.21037/jtd.2017.07.79 · Cited by 76
Egan, A. M., McPhillips, D., Sarkar, S. A., & Breen, D. P. (2013) · QJM · doi:10.1093/qjmed/hct245 · Cited by 75
“A posthoc analysis suggested that insufflation may be better for patients with either a lung or breast primary.(35) Both methods of talc delivery require hospitalization and patients often experience pain and fever post-procedure.”
BackgroundInterventional therapies for malignant pleural effusions: The present and the future
Thomas, R., Francis, R. J., Davies, H. E., & Lee, G. (2014) · Respirology · doi:10.1111/resp.12328 · Cited by 71
Population based epidemiology and prognosis of mesothelioma in Leeds, UK
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Pleural controversies: image guided biopsy vs. thoracoscopy for undiagnosed pleural effusions?
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“com potentially harmful intervention (61).”
Advanced medical interventions in pleural disease
Bhatnagar, R., Corcoran, J. P., Maldonado, F., Feller-Kopman, D. J., Janssen, J. P., Astoul, P. J., & Rahman, N. M. (2016) · European Respiratory Review · doi:10.1183/16000617.0020-2016 · Cited by 66
Management of malignant pleural effusions
Davies, H. E., & Lee, G. (2013) · Current Opinion in Pulmonary Medicine · doi:10.1097/mcp.0b013e3283615b67 · Cited by 66
“50% of patients have adequate fluid control from talc treatment [16].”
InfluentialIs Full Postpleurodesis Lung Expansion a Determinant of a Successful Outcome After Talc Pleurodesis?
Terra, R. M., Junqueira, J. J. M., Teixeira, L. R., Vargas, F. S., Pêgo‐Fernandes, P. M., & Jatene, F. B. (2009) · CHEST Journal · doi:10.1378/chest.08-2448 · Cited by 66
Boshuizen, R. C., Noort, V. V. D., Burgers, J. A., Herder, G. J. M., Hashemi, S. M. S., Hiltermann, T. J. N., Kunst, P. W. A., Stigt, J. A., & van den Heuvel, M. M. (2017) · Lung Cancer · doi:10.1016/j.lungcan.2017.01.019 · Cited by 66
Sebastian, M., Kiewe, P. M., Schuette, W., Brust, D., Peschel, C., Schneller, F., Rühle, K.-H., Nilius, G., Ewert, R., Lodziewski, S., et al. (2009) · Journal of Immunotherapy · doi:10.1097/cji.0b013e318195b5bb · Cited by 65
“Both methods showed similar efficacy, however, in patients with breast and lung cancer, thoracoscopy with talc insufflation had a higher success rate of 82% versus 67%.(19) Nevertheless, prognosis of patients with MPEs still remains poor, with a mean survival of 3 months after diagnosis and a 30-day mortality of 30%,…”
MethodContemporary best practice in the management of malignant pleural effusion
Koegelenberg, C. F. N., Shaw, J. A., Irusen, E. M., & Lee, G. (2018) · Therapeutic Advances in Respiratory Disease · doi:10.1177/1753466618785098 · Cited by 64
Mesothelioma and Asbestos-Related Pleural Diseases
Greillier, L., & Astoul, P. J. (2008) · Respiration · doi:10.1159/000127577 · Cited by 64
Who Gains Most? A 10-Year Experience With 611 Thoracoscopic Talc Pleurodeses
Steger, V., Mika, U., Toomes, H., Walker, T., Engel, C., Kyriss, T., Ziemer, G., & Friedel, G. (2007) · The Annals of Thoracic Surgery · doi:10.1016/j.athoracsur.2007.02.061 · Cited by 62
Assessment of Pleural Pressure in the Evaluation of Pleural Effusions
Feller-Kopman, D. J., Parker, M. J., & Schwartzstein, R. M. (2009) · CHEST Journal · doi:10.1378/chest.08-1788 · Cited by 62
Rahman, N. M., & Gleeson, F. V. (2008) · Current Opinion in Pulmonary Medicine · doi:10.1097/mcp.0b013e3282fe9a04 · Cited by 62
Talc mediates angiostasis in malignant pleural effusionsviaendostatin induction
Nasreen, N., Mohammed, K. A., Brown, S. C., Su, Y., Sriram, P., Moudgil, B., Loddenkemper, R., & Antony, V. B. (2007) · European Respiratory Journal · doi:10.1183/09031936.00061606 · Cited by 59
“However, recent concerns about adverse events have tempered its use [ 14 , 15].”
BackgroundMalignant Pleural Effusion: Diagnosis and Management
Ferreiro, L., Antelo, J. S., Álvarez-Dobaño, J. M., Toubes, M. E., Riveiro, V., & Valdés, L. (2020) · Canadian Respiratory Journal · doi:10.1155/2020/2950751 · Cited by 58
“However, when patients who died within 30 days or failed to achieve lung reexpansion were included, success rates decreased to 53% and 60%, respectively [60].”
BackgroundMethodYoshida, K., Sugiura, T., Takifuji, N., Kawahara, M., Matsui, K., Kudoh, S., Takada, M., Fukuoka, M., Ariyoshi, Y., Fukuda, H., et al. (2007) · Lung Cancer · doi:10.1016/j.lungcan.2007.07.009 · Cited by 58
Management of malignant pleural effusions
Bennett, R., & Maskell, N. A. (2005) · Current Opinion in Internal Medicine · doi:10.1097/01.mcp.0000166495.71574.46 · Cited by 57
Danson, S. J., Conner, J., Edwards, J. G., Blyth, K. G., Fisher, P. M., Muthana, M., Salawu, A., Taylor, F., Hodgkinson, E., Joyce, P., et al. (2020) · Lung Cancer · doi:10.1016/j.lungcan.2020.10.007 · Cited by 56
Casal, R. F., Eapen, G. A., Morice, R. C., & Jiménez, C. A. (2009) · Current Opinion in Pulmonary Medicine · doi:10.1097/mcp.0b013e32832b8b2d · Cited by 56
Bhatnagar, R., Laskawiec-Szkonter, M., Piotrowska, H., Kahan, B. C., Hooper, C. E., Davies, H. E., Harvey, J., Miller, R. F., Rahman, N. M., & Maskell, N. A. (2014) · BMJ Open · doi:10.1136/bmjopen-2014-007045 · Cited by 55
“045).(4) The role of talc poudrage for the induction of pleurodesis and the prevention of fluid recurrence in MPE”
BackgroundThoracoscopy: medical versus surgical-in the management of pleural diseases.
Shojaee, S., & Lee, H. J. (2015) · PubMed Central · doi:10.3978/j.issn.2072-1439.2015.11.66 · Cited by 57
“Interestingly, 9 of 16 patients came from a single large randomized trial for talc insufflation when nongraded talc was used (51).”
BackgroundFrom “awake” to “monitored anesthesia care” thoracic surgery: A 15 year evolution
Mineo, T. C., & Tacconi, F. (2013) · Thoracic Cancer · doi:10.1111/1759-7714.12070 · Cited by 54
Agarwal, R., PAUL, A. S., Aggarwal, A. N., Gupta, D., & Jindal, S. K. (2011) · Respirology · doi:10.1111/j.1440-1843.2011.01999.x · Cited by 54
The management of benign non-infective pleural effusions
Bintcliffe, O. J., Lee, G., Rahman, N. M., & Maskell, N. A. (2016) · European Respiratory Review · doi:10.1183/16000617.0026-2016 · Cited by 54
Lung Injury Following Thoracoscopic Talc Insufflation
Gonzalez, A. V., Bezwada, V., Beamis, J. F., & Villanueva, A. G. (2010) · CHEST Journal · doi:10.1378/chest.09-2020 · Cited by 53
Medical thoracoscopy and its evolving role in the diagnosis and treatment of pleural disease
Murthy, V., & Bessich, J. L. (2017) · Journal of Thoracic Disease · doi:10.21037/jtd.2017.06.37 · Cited by 53
“Several trials comparing talc slurry and thoracoscopic poudrage have shown a slight advantage to the thoracoscopic approach, during which adhesiolysis can be performed to improve pleural contact and pleurodesis (60,61).”
BackgroundAli, M. S., Light, R. W., & Maldonado, F. (2019) · Journal of Thoracic Disease · doi:10.21037/jtd.2019.03.86 · Cited by 52
Management of Malignant Pleural Mesothelioma
West, S. D., & Lee, G. (2006) · Clinics in Chest Medicine · doi:10.1016/j.ccm.2006.01.004 · Cited by 52
“In a large randomized trial, talc pleurodesis by slurry was as effective as thoracoscopic poudrage for malignant pleural effusions [99].”
BackgroundHaas, A. R., Sterman, D. H., & Musani, A. I. (2007) · CHEST Journal · doi:10.1378/chest.06-1757 · Cited by 52
Pleural controversies: indwelling pleural catheter vs. pleurodesis for malignant pleural effusions.
Fortin, M., & Tremblay, A. (2015) · Europe PMC (PubMed Central) · doi:10.3978/j.issn.2072-1439.2015.01.51 · Cited by 52
“For example, a phase III trial reported a 78% success rate following thoracoscopic talc pleurodesis, but if all enrolled subjects had been included, only 60% would have been alive and recurrence free at 30 days and an additional 33% would have experienced late recurrence beyond that time point (23).”
BackgroundFreeman, R. K., Ascioti, A. J., & Mahidhara, R. S. (2013) · The Annals of Thoracic Surgery · doi:10.1016/j.athoracsur.2013.03.063 · Cited by 50
“In a recent multicenter study in which talc was used for pleurodesis using VATS or a slurry using tube thoracostomy, the overall incidence of respiratory complications was 10%, resulting in 11 (2%) pulmonary-related deaths [13].”
BackgroundMineo, T. C., Sellitri, F., Tacconi, F., & Ambrogi, V. (2014) · Journal of Palliative Medicine · doi:10.1089/jpm.2013.0617 · Cited by 50
Fibrin turnover and pleural organization: bench to bedside
Komissarov, A. A., Rahman, N. M., Lee, G., Florova, G., Shetty, S., Idell, R. D., Ikebe, M., Das, K. C., Tucker, T. A., & Idell, S. (2018) · American Journal of Physiology-Lung Cellular and Molecular Physiology · doi:10.1152/ajplung.00501.2017 · Cited by 50
Multidisciplinary management of malignant pleural effusion
Kaifi, J. T., Toth, J. W., Gusani, N. J., Kimchi, E. T., Staveley-O’Carroll, K. F., Belani, C. P., & Reed, M. F. (2011) · Journal of Surgical Oncology · doi:10.1002/jso.22100 · Cited by 48
Kitamura, K., Kubota, K., Ando, M., Takahashi, S., Nishijima, N., Sugano, T., Toyokawa, M., Miwa, K., Kosaihira, S., Noro, R., et al. (2012) · Cancer Chemotherapy and Pharmacology · doi:10.1007/s00280-012-2026-4 · Cited by 47
Talc Pleurodesis Through Indwelling Pleural Catheters for Malignant Pleural Effusions
Ahmed, L., Ip, H., Rao, D., Patel, N., & Noorzad, F. (2014) · CHEST Journal · doi:10.1378/chest.14-0394 · Cited by 46
Koegelenberg, C. F. N., & Diacon, A. H. (2013) · Current Opinion in Pulmonary Medicine · doi:10.1097/mcp.0b013e32835f4c23 · Cited by 46
Pleural procedural complications: prevention and management.
Corcoran, J. P., Psallidas, I., Wrightson, J., Hallifax, R., & Rahman, N. M. (2015) · Europe PMC (PubMed Central) · doi:10.3978/j.issn.2072-1439.2015.04.42 · Cited by 49
“If talc poudrage pleurodesis is performed then graded talc is recommended due to an increased risk of respiratory failure and acute respiratory distress syndrome with non-graded talc (81,85-87).”
Background
Metadata
- Authors
- Dresler, C. M., Olak, J., Herndon, J. E., Richards, W. G., Scalzetti, E., Fleishman, S. B., Kernstine, K. H., Demmy, T., Jablons, D. M., Kohman, L., Daniel, T. M., Haasler, G. B., & Sugarbaker, D. J.
- Affiliations
- Centre international de recherche sur le cancer (FR)
- Advocate Lutheran General Hospital (US)
- Brigham and Women's Hospital (US)
- SUNY Upstate Medical University (US)
- University of Iowa (US)
- Roswell Park Comprehensive Cancer Center (US)
- University of California, San Francisco (US)
- University of Virginia Health System (US)
- Medical College of Wisconsin (US)
- Corresponding author
- Dresler, Carolyn M
- Venue
- Chest
- Publisher
- Elsevier BV
- Published
- 2005-03
- Volume
- 127
- Issue
- 3
- Pages
- 909-915
- ISSN
- 0012-3692 (ISSN-L)
- PMC
- PMC4644736
- OpenAlex
- W2147481343
- Cited by
- 578
- References
- 39
- Citations by year
- 2026: 10 · 2025: 20 · 2024: 24 · 2023: 12 · 2022: 27 · 2021: 26 · 2020: 40 · 2019: 23 · 2018: 38 · 2017: 31 · 2016: 32 · 2015: 34 · 2014: 32 · 2013: 33 · 2012: 35
- FWCI
- 22.73
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- CHEST Journal (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Cancer Institute (2 U01 CA65170, R01CA093708, U01CA065170)
- Topics
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Pleural and Pulmonary Diseases
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Lung Cancer Diagnosis and Treatment
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Pericarditis and Cardiac Tamponade
- Keywords
- malignant pleural effusion, talc poudrage, talc slurry, talc pleurodesis, thoracostomy, pleural effusion recurrence, respiratory complications, non-relapse mortality, quality of life, lung cancer, breast cancer
- MeSH terms
- Adult, Aged, Aged, 80 and over, Female, Humans, Insufflation, Male, Middle Aged, Quality of Life, Recurrence, Talc, Thoracoscopy, Thoracostomy, Pleural Effusion, Malignant, Pleurodesis
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