Indwelling pleural catheter: changing the paradigm of malignant effusion management.

Malignant pleural effusions (MPEs) affect as many as 150,000 patients with cancer in the United States1 and 100,000 patients with lung cancer2 in Europe each year. Inpatient care alone for MPE costs US$6 million per million population in Australia annually (data, the Western Australia Health Dept). The exciting advent of indwelling tunneled pleural catheters (IPCs) has critically challenged conventional approaches to MPE management, especially pleurodesis.3 IPCs offer ambulatory fluid drainage as the primary symptomatic therapy, thus prompting clinicians to redefine the goalposts of MPE care. Talc pleurodesis has been the mainstay of MPE management for decades, but its efficacy and safety have recently come under scrutiny.4 In the largest randomized trial in pleural disease (n 486),5 talc (poudrage or slurry) pleurodesis had a suboptimal success rate: only 75% of MPE patients at 1 month and 50% by 6 months had adequate fluid control. Adding the fact that many patients are unsuitable for pleurodesis (e.g., with trapped lungs), talc pleurodesis benefits only a subset of all MPE patients. Randomized trials have also shown that talc induces lung and systemic inflammation6 and killed 2.3% of patients in a Cancer and Leukemia Group B study through talc-induced respiratory failure.5 Although this acute lung injury can be avoided by using large particle size talc preparations,7 such products are not readily available in many countries, including the United States. These data have provoked debates and compelled the pleural community to revisit the principles of MPE care. The fundamental aim in MPE management is to improve dyspnea and quality of life, with minimal intervention and hospitalization. The timely introduction of IPCs which allow fluid evacuation from a single minimally invasive procedure serves exactly this purpose and explains its rapid rise in popularity (Suzuki et al estimated that 39,000 units sold in the United States per year8). Suzuki et al.8 in this issue of Journal of Thoracic Oncology reported the largest series of IPC (n 418) experience, providing corroborative evidence that IPCs are safe.9–12 A recent summary of all published reports on IPC complications revealed that most complaints were minor (e.g., mild pain after insertion). 13 A systematic review including 1370 patients has confirmed that serious complications, e.g., infection were uncommon ( 3%). 14 Other series have addressed specific concerns of IPC use: demonstrating safety records in patients undergoing chemotherapy15 and local radiotherapy16 with IPC in situ, and no significant protein loss results from regular drainage.17 IPC represents a new therapeutic ideology (not “yet another catheter”), and clinicians are still adapting to the specific changes needed to realize the full potential of this device. Suzuki et al.8 described a representative single-center review of IPC use, highlighting important contemporary issues of IPC management. First, the exact place of IPC in the paradigm of MPE management has yet to be defined. IPC is generally accepted for treatment of MPE patients in whom pleurodesis has failed or is contraindicated (especially trapped lungs). 18 Many specialist centers now offer