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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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BackgroundResultInfluentialPercutaneous Management of Malignant Fluid Collections
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“Respiratory failure has been reported in 4% of patients after slurry and 8% after poudrage.(6) The incidence of respiratory complications appears to be dose related, with most cases involving doses > 5 g.”
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Pleural LDH as a prognostic marker in adenocarcinoma lung with malignant pleural effusion
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BackgroundInterleukin-2 reverses CD8+ T cell exhaustion in clinical malignant pleural effusion of lung cancer
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“Nine of the 16 deaths occurred in a single trial where talc particle size was not taken into account.[48]”
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“Chemical pleurodesis occasionally causes marked discomfort in patients, such as severe chest pain and a fever, and there are several reports of severe complications [12–14].”
BackgroundThoracic Ultrasound as an Early Predictor of Pleurodesis Success in Malignant Pleural Effusion
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“slurry pleurodesis, except with regard to fatigue, where poudrage was superior [37].”
BackgroundInfluentialVEGF and sVEGFR-1 in malignant pleural effusions: Association with survival and pleurodesis outcomes
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“In fact, Dresler et al (19) reported late recurrence of a pleural effusion”
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Balassoulis, G., Sichletidis, L. T., Spyratos, D. G., Chloros, D. A., Zarogoulidis, K., Kontakiotis, T., Bagalas, V., Porpodis, K., Manika, Κ., & Patakas, D. (2008) · American Journal of Clinical Oncology · doi:10.1097/coc.0b013e318165c061 · Cited by 30
“A recent multicentered prospective, randomized trial of 482 patients showed no difference between talc insufflation and talc slurry in success rates at 30 days.(34) However, the subgroup of patients with primary lung or breast cancer had higher success with insufflation than with slurry.”
BackgroundAcute inflammatory response secondary to intrapleural administration of two types of talc
Rossi, V. F., Vargas, F. S., Marchi, E., Acencio, M. M. P., Genofre, E. H., Capelozzi, V. L., & Antonângelo, L. (2009) · European Respiratory Journal · doi:10.1183/09031936.00039209 · Cited by 30
Point: Should Pleural Manometry Be Performed Routinely During Thoracentesis? Yes
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“Superiority of one method over the other is not clear [4–6].”
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Pleural manometry in patients with pleural diseases – the usefulness in clinical practice
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“Three randomised studies comparing VATS to chest tube and talc pleurodesis did not demonstrate any significant benefits with VATS [104, 147, 148].”
BackgroundResultInfluentialFysh, E. T. H., Thomas, R., Read, C., Lam, B. C. H., Yap, E., Horwood, F., Lee, P., Piccolo, F., Shrestha, R. L., Garske, L. A., et al. (2014) · BMJ Open · doi:10.1136/bmjopen-2014-006757 · Cited by 28
Frost, N., Brünger, M., Ruwwe‐Glösenkamp, C., Raspe, M., Tessmer, A., Temmesfeld‐Wollbrück, B., Schürmann, D., Suttorp, N., & Witzenrath, M. (2019) · BMC Pulmonary Medicine · doi:10.1186/s12890-019-1002-8 · Cited by 28
Treatment Options for Malignant Pleural Effusions
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Diagnosis and Management of Malignant Pleural Effusion: A Decade in Review
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“The question of the effectiveness of talc poudrage administered via thoracoscopy versus talc slurry administered via chest tube has been investigated in multiple studies, often with a statistically insignificant trend toward improved pleurodesis rate with talc poudrage but with a trend towards more adverse events [6,6…”
BackgroundLaisaar, T. (2006) · Interactive Cardiovascular and Thoracic Surgery · doi:10.1510/icvts.2005.118018 · Cited by 27
Antonângelo, L., Vargas, F. S., Teixeira, L. R., Acencio, M. M. P., Vaz, M. A. C., Filho, M. T., & Marchi, E. (2006) · Lung · doi:10.1007/s00408-005-2569-9 · Cited by 27
“Although the effectiveness of talc is higher than 70% [4, 7, 11, 14, 25] irrespective of the method used, its use is restricted because of the possible development of respiratory distress syndrome, which is lethal in many cases [19].”
MethodPleurodesis for malignant pleural effusion: talc, toxicity and where next?
Davies, H. E., Lee, G., & Davies, R. J. O. (2008) · Thorax · doi:10.1136/thx.2007.092940 · Cited by 27
“failure in over 2% of patients when used for pleurodesis in a large US clinical trial.(8) Preparations with the smallest talc particles”
Chest Tubes and Pleural Drainage: History and Current Status in Pleural Disease Management
Sorino, C., Feller-Kopman, D. J., Mei, F., Mondoni, M., Agati, S., Marchetti, G., & Rahman, N. M. (2024) · Journal of Clinical Medicine · doi:10.3390/jcm13216331 · Cited by 32
“Two large randomized trials have not shown a difference between slurry and poudrage [35,36].”
BackgroundQuality of life after interventions for malignant pleural effusions: a systematic review
Sivakumar, P., Saigal, A., & Ahmed, L. (2019) · BMJ Supportive & Palliative Care · doi:10.1136/bmjspcare-2018-001610 · Cited by 26
Bedside Talc Pleurodesis for Malignant Pleural Effusion: Factors Affecting Success
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Efficacy of pleurodesis for malignant pleural effusions in breast cancer patients
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The diminishing role of surgery in pleural disease
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Iodopovidone is as effective as doxycycline in producing pleurodesis in rabbits
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Indwelling Pleural Catheter Drainage Strategy for Malignant Effusion: A Cost-Effectiveness Analysis
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Diagnostics in Pleural Disease
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“Nine out of sixteen were seen in a single randomised control trial, attributed to the use of non-graded talc leading to unintended absorption and toxicity, with resultant acute respiratory distress syndrome and respiratory failure [74].”
BackgroundSwitching off malignant pleural effusion formation-fantasy or future?
Spella, M., Giannou, A. D., & Stathopoulos, G. (2015) · Journal of Thoracic Disease · doi:10.3978/j.issn.2072-1439.2015.05.20 · Cited by 25
“This figure increases to 50% of patients at 6 months after pleurodesis, despite guideline implementation (20).”
BackgroundCurrent Status of Medical Pleuroscopy
Medford, A. R. L., BENNETT, J. A., FREE, C. M., & Agrawal, S. (2010) · Clinics in Chest Medicine · doi:10.1016/j.ccm.2009.10.001 · Cited by 24
“Although a recent randomized trial did not show an overall superiority for thoracoscopic talc poudrage over talc slurry via chest drain, a subgroup of patients with lung and breast cancer had greater success with talc poudrage (82% vs 67% success at 30 days).(31) In the same study, the proportion of patients with talc…”
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Management of Malignant Pleural Effusions—What Is New
Thomas, R., Roy, B., Maldonado, F., & Lee, G. (2019) · Seminars in Respiratory and Critical Care Medicine · doi:10.1055/s-0039-1698285 · Cited by 24
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Malignant Pleural Effusion: Still a Long Way to Go
Meriggi, F. A. (2018) · Reviews on Recent Clinical Trials · doi:10.2174/1574887114666181204105208 · Cited by 23
Bhatnagar, R., Luengo-Fernández, R., Kahan, B. C., Rahman, N. M., Miller, R. F., & Maskell, N. A. (2020) · Health Technology Assessment · doi:10.3310/hta24260 · Cited by 26
“Characteristic Treatment arm, summary measure Treatment arm, number with missing data Thoracoscopy and poudrage Chest drain and slurry Thoracoscopy and poudrage (N= 166) Chest drain and slurry (N= 164) Age (years), mean (SD) 68 (11) 68 (12) 0 (0) 0 (0) Chest pain (VAS), mean (SD) 17 (23) 18 (25) 1 (1) 1 (1) Breathless…”
BackgroundDiagnostic value of ultrasound-guided needle biopsy in undiagnosed pleural effusions
Lin, Z., Wu, D., Wang, J., Wang, C., & Huang, M. (2020) · Medicine · doi:10.1097/md.0000000000021076 · Cited by 25
Malignant pleural disease in primary lung cancer
Mishra, E., Davies, H., & Lee, G. Y. C. (2009) · European Respiratory Society eBooks · doi:10.1183/1025448x.00044019 · Cited by 21
“Talc acts by inducing an acute inflammatory response, which, if sufficiently intense, results in eventual pleural fibrosis and adhesion formation [85].”
BackgroundMethodRe-expansion pulmonary oedema: a novel emergency therapeutic option
Sunderland, N. P., Maweni, R. M., Akunuri, S., & Karnovitch, E. (2016) · BMJ Case Reports · doi:10.1136/bcr-2016-215076 · Cited by 23
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Bhatnagar, R., & Maskell, N. A. (2013) · Clinics in Chest Medicine · doi:10.1016/j.ccm.2013.04.001 · Cited by 23
“Mortality associated with pleuroscopy is extremely uncommon, with most deaths seemingly caused by pre-existing medical factors or as a result of reactions unrelated to the procedure itself.(17) In combined data from 5054 patients, the total number of deaths was 17 (0.”
BackgroundWang, J., Zhou, X., Xie, X., Tang, Q., Shen, P., & Zeng, Y. (2016) · BMC Pulmonary Medicine · doi:10.1186/s12890-016-0318-x · Cited by 22
Zhang, W., Zhao, Y.-L., Li, S., Zhao, Y.-N., Guo, N., & Liu, B. (2021) · Journal of Cardiothoracic Surgery · doi:10.1186/s13019-021-01475-1 · Cited by 22
“It is suggested that the risk of acute respiratory complications should not be underestimated and a close monitoring of up to 72 h post-pleurodesis should be considered [21, 24].”
BackgroundFitzgerald, D. B., Sidhu, C., Budgeon, C. A., Tan, A. L., Read, C., Kwan, B. C. H., Smith, N. A., Fysh, E. T. H., Muruganandan, S., Saghaie, T., et al. (2022) · Trials · doi:10.1186/s13063-022-06405-7 · Cited by 22
Petersen, J. K., Fjællegaard, K., Rasmussen, D. B., Alstrup, G., Høegholm, A., Sidhu, J. S., Sivapalan, P., Gerke, O., Bhatnagar, R., Clementsen, P. F., et al. (2024) · Diagnostics · doi:10.3390/diagnostics14020204 · Cited by 22
“%) patients with suspected or known MPE being diagnosed with NEL is consistent with the results of other studies [5,35].”
BackgroundResultTerra, R. M., Bellato, R. T., Teixeira, L. R., Chate, R. C., & Pêgo‐Fernandes, P. M. (2015) · Respiration · doi:10.1159/000371470 · Cited by 22
Verma, A., Chopra, A., Lee, Y. W., Bharwani, L. D., Asmat, A., Ahmed, D. B. A., Akbar, F. A., Lim, A. Y. H., Chotirmall, S. H., & Abisheganaden, J. A. (2016) · Current Drug Discovery Technologies · doi:10.2174/1570163813666160524142846 · Cited by 22
Fortin, M., Taghizadeh, N., & Tremblay, A. (2018) · Respiration · doi:10.1159/000485934 · Cited by 22
Management of malignant pleural effusions
Rodríguez‐Panadero, F., & Romero‐Romero, B. (2011) · Current Opinion in Pulmonary Medicine · doi:10.1097/mcp.0b013e3283474015 · Cited by 22
Myers, R. L., & Michaud, G. C. (2013) · Clinics in Chest Medicine · doi:10.1016/j.ccm.2012.12.003 · Cited by 21
Kapp, C. M., & Lee, H. J. (2021) · Clinics in Chest Medicine · doi:10.1016/j.ccm.2021.08.004 · Cited by 21
Mummadi, S. R., Kumbam, A., & Hahn, P. Y. (2014) · F1000Research · doi:10.12688/f1000research.5538.1 · Cited by 21
Beyea, A., Winzelberg, G. S., & Stafford, R. E. (2012) · Journal of Pain and Symptom Management · doi:10.1016/j.jpainsymman.2012.05.002 · Cited by 21
“This improvement correlated with significant reductions in the size of the MPE.”
BackgroundMethodInfluentialPatient evaluation for rapid pleurodesis of malignant pleural effusions
Krochmal, R. L., Reddy, C., Yarmus, L. B., Desai, N., Feller-Kopman, D. J., & Lee, H. J. (2016) · Journal of Thoracic Disease · doi:10.21037/jtd.2016.08.55 · Cited by 21
“Despite a longer time to pleurodesis in our study, talc insufflation via thoracoscopy has previously been demonstrated to be highly successful amongst lung or breast cancer patients (16).”
BackgroundTalc Pleurodesis for the Management of Malignant Pleural Effusions in Japan
Inoue, T., Ishida, A., Nakamura, M., Nishine, H., Mineshita, M., & Miyazawa, T. (2013) · Internal Medicine · doi:10.2169/internalmedicine.52.9281 · Cited by 20
“6%, which is similar to the findings of previous reports (7-9).”
BackgroundResultA prospective study of patient-centred outcomes in the management of malignant pleural effusions
Walker, S., Zubrinic, M., Massey, C., Shargall, Y., Bédard, E. L. R., & Darling, G. E. (2016) · International Journal of Palliative Nursing · doi:10.12968/ijpn.2016.22.7.351 · Cited by 20
Boshuizen, R. C., Onderwater, S., Burgers, S. J. A., & van den Heuvel, M. M. (2013) · Respiration · doi:10.1159/000351796 · Cited by 20
Quality assessment of the guidelines for the management of malignant pleural effusions and ascites
Li, J., Shi, Y., An, L., Yang, J.-X., Qi, Y., Yang, T., Cen, Y., Lin, Y., & Sun, D. (2020) · World Journal of Surgical Oncology · doi:10.1186/s12957-020-02097-y · Cited by 19
Summary for Clinicians: Clinical Practice Guideline for Management of Malignant Pleural Effusions
Reddy, C. B., DeCamp, M. M., Diekemper, R. L., Gould, M. K., Henry, T. S., Iyer, N. P., Lee, G., Lewis, S. Z., Maskell, N. A., Rahman, N. M., et al. (2018) · Annals of the American Thoracic Society · doi:10.1513/annalsats.201809-620cme · Cited by 19
Medical thoracoscopy in an Australian regional hospital
Simpson, G. (2007) · Internal Medicine Journal · doi:10.1111/j.1445-5994.2007.01312.x · Cited by 19
Image-Guided Palliative Care Procedures
Requarth, J. A. (2011) · Surgical Clinics of North America · doi:10.1016/j.suc.2010.12.009 · Cited by 18
Advances in pleural infection and malignancy
Bedawi, E. O., Guinde, J., Rahman, N. M., & Astoul, P. J. (2021) · European Respiratory Review · doi:10.1183/16000617.0002-2020 · Cited by 18
Putting evidence into practice: Palliative care
Brunnuber, K., Nash, S., Meier, D. E., Weissman, D. E., & Woodcock, J. (2012) · LSHTM Research Online (London School of Hygiene and Tropical Medicine) · doi:10.17037/pubs.00021010 · Cited by 18
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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