Talc Pleurodesis for Malignant Pleural Effusions Is Preferred Over the Pleurx Catheter (Contrary Position)

The development of a clinically significant pleural effusion in a patient with an overlying malignancy often greatly affects the quality of life, as well as impacting on survival. The drainage of this fluid, with re-expansion of the underlying lung, can provide impressive relief of dyspnea, with resulting in an increase in energy level, improvement in appetite, and better overall sense of well-being. Over the last 50 years, several methods have been used to achieve the goal of complete evacuation of the pleural space, with partial or complete re-expansion of the lung. Repeated thoracentesis has been advocated by few since the incidence of recurrent effusions is high, the risk of pneumothorax is additive each time the procedure is performed, and the inconvenience to the patients to make multiple clinic visits. The insertion of a thoracoscopy tube alone has been equally ineffective in providing long-term control. Drainage with a chest tube with subsequent insertion of a chemical agent to fuse the pleural space has found favor and still widely used, although the agent and doses utilized are still matters of considerable controversy. Although clinical experience of using talc to induce pleural sclerosis dates back over 45 years, only recently has it been commercially available in the United States. Pleural sclerosis has been produced by instilling a slurry of talc through a chest tube with long-term control of the pleural effusion. However, there are several drawbacks to the above plan of action. For successful pleurodesis, the parietal and visceral pleural must be in apposition. In those cases where the lung incompletely re-expands (i.e. ‘‘trapped lung’’), this approach is doomed to failure, regardless of how much fluid is evacuated and how much better the patient breathes. Furthermore, it assumes that the patient is able to mount an inflammatory response sufficient to fuse the pleural space in the order of the few days the chest tube is left in place. It is not surprising, therefore, that the incidence of developing a recurrent, symptomatic pleural effusion within 6 months has been as high as 35%. Some have advocated instilling talc using a thoracoscopic approach, but the long-term results have not been demonstrated to be any better, and the cost of the admission is considerably higher. Either approach, almost by definition, requires an admission to the hospital for a period of 5–7 days, with the pain and limitations imposed by having a chest tube in place. Instillation of the sclerosing agent by itself is well known to induce pain, often requiring sedation and analgesics prior to the installation. Moreover, the instillation of talc in the pleural space has been cited to have precipititated an ARDS-type injury to the lung. An animal study has shown talc fibres in the pleural space to be disseminated to brain, lung, heart, spleen and kidneys presumably via the bloodstream. These concerns have led a prominent pulmonologist to challenge the choice of talc in the pleural space. An alternative approach has been sought to provide the goal of complete evacuation of pleural fluid on a purely outpatient basis. Although several methods have been tried, including repeated outpatient thoracentesis, placement of a Port-a-Cath in the pleural space (with at-home drainage provided by a nurse), the most practical and widely adopted is the outpatient placement of the Pleurx catheter under Received January 9, 2006; accepted April 18, 2006; published online: December 7, 2006. Address correspondence and reprint requests to: William Warren; E-mail: William_Warren@rush.edu