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Treatment of Malignant Pleural Effusions
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Desmond J. Young, Pulmonary/Critical Care Fellow Associate, Gary Salzman, MD: Chairman, Division of Pulmonary and Critical Care, University of Missouri at Kansas City School of Medicine, Kansas City, Missouri
Send letter to journal:
youngdj{at}umkc.edu Desmond J. Young, et al.
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Letter to Editor, Much to our delight, in the March 2005 issue of Chest, Dresler and colleagues(1) completed an excellent large prospective study comparing talc slurry and talc poudrage in the management of symptomatic malignant pleural effusions. Much to our dismay, the authors did not report length of hospital stay and cost of treatment. Most patients with malignant pleural effusions want to go home as soon as possible. The role of talc pleurodesis is validated in the literature as the most successful agent for sclerosis in malignant pleural effusion. Talc via slurry or poudrage appears to be the most commonly use sclerosing agent used among pulmonologist practicing in the United States and a few other English-speaking countries.(2) Dresler et al. determined, "...equivalent efficacy of TS (thoracostomy and talc slurry) and TTI (thoracoscopy with talc insufflation)..."(1) The results are supported by a similar study(3) with slightly different methods and patient follow up. Reviewing both articles, there was no mention of cost analysis between the two patient populations of thoracoscopic talc insufflation and thorascopic talc slurry. In the smaller study, Yim and associates(3) did not find a significant difference in post procedural hospital stay between the two groups (7.6 ± 2.8 vs. 5.8 ± 3.1) Given the methodological differences and fewer number of patients, we can not assume this would apply to Dresler's prospective study. Rapid chemical pluerodesis has been successfully studied as perhaps the most convenient way to shorten the hospital stay of patients with limited life expectancy and symptomatic malignant pleural effusions without compromising success rates.(4,5,6) Usually, this was accomplished on average in 48 hours and as early as 24 hours. These studies were small and predominately did not use talc as a sclerosing agent due to talc's unknown efficacy and limited availability at the time. Since then, more studies are enforcing the superiority of talc as a sclerosing agent, however there is limited information on length of post procedure hospital stay and cost of treatment. There is even less information comparing the cost and hospital stay of different methods of instillation for talc in single head-to-head prospective studies. While thoracoscopic talc poudrage (TTP) was shown to be effective at a low pleural pH in malignant effusions by Aelony and associates(7), they also noted a short hospital stay (3.3 +/- 1.1 days). In that article, the authors proceed to reference other studies to support shorter chest tube drainage and hospital days with TTP compared with other previous studies using talc slurry. In a letter to the editor(8), Dr. Aelony admits his experience bias towards talc poudrage but states "further information needs to be available" prior to deciding the most cost-effective method for talc instillation. Dresler et al. fits our need for a properly powered, randomized prospective study to evaluate cost, hospital stay, and chest tube days. We are disappointed that the authors did not address these issues. We agree with their conclusion of "equivalent efficacy" especially from a clinician's view. However, what about the effectiveness of treatment to limit hospital days and cost for our patients? We believe that these are central issues for patients with symptomatic malignant pleural effusions in deciding how to spend their limited lives. It would be important to report data on length of hospital stay and cost from this excellent study. Patients would likely choose the technique with the shorter length of stay since other outcome measure were similar. References 1 Dresler CM, et al. Phase III intergroup study of talc poudrage vs talc slurry sclerosis for malignant pleural effusion. Chest 2005; 127:909- 915 2 Lee YCG, Baumann MH, Maskell NA, et al. Pleurodesis practice for malignant pleural effusions in five English-speaking countries: survey of pulmonologists. Chest 2003; 124(6): 2229 - 2238 3 Yim AP, Chan AT, Lee TW, et al. Thoracoscopic talc insufflation versus talc slurry for symptomatic malignant pleural effusion. Ann Thorac Surg 1996; 62:1655-1658 4 Spiegler PA, Hurewitz AN, Groth ML. Rapid pleurodesis for malignant pleural effusions. Chest 2003; 123:1895-1898 5 Villanueva AG, Gray AW Jr, Shahian DM, et al. Efficacy of short term versus long-term tube thoracostomy drainage before tetracycline pleurodesis in the treatment of malignant effusions. Thorax 1994; 49:23-25 6 Hsu WH, Chiang CD, Chen CY, et al. Ultrasound-guided small-bore Elecath tube insertion for the rapid sclerotherapy of malignant pleural effusion. Jpn J Clin Oncol 1998; 28:187-191 7 Aelony Y, King RR, Boutin C. Thoracoscopic talc poudrage in malignant pleural effusions: effective pleurodesis despite low pleural pH. Chest 1998; 113:1007 - 1012 8 Aelony Y. Cost-effective pleurodesis. Chest 1998; 1731b-1732b |
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