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ORIGINAL ARTICLE
Year : 2022  |  Volume : 35  |  Issue : 2  |  Page : 704-708

Efficacy and safety of thoracoscopic talc pleurodesis in the treatment of malignant pleural effusion


Department of Cardiothoracic Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission07-Feb-2022
Date of Decision14-Mar-2022
Date of Acceptance29-Mar-2022
Date of Web Publication27-Jul-2022

Correspondence Address:
Mohamed S Abdelmotaleb
Yassin Abdelghafar Street, Shebin Elkoum, Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_50_22

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  Abstract 


Objective
To evaluate the efficacy and safety of thoracoscopic talc pleurodesis in the management of malignant pleural effusion (MPE).
Background
MPE is a common complication of advanced malignancy. Pleurodesis is a well-recognized treatment for the management of MPE. Talc is considered the most effective sclerosing agents used to produce pleurodesis.
Patients and methods
This is a retrospective chart review of all patients with MPE who underwent thoracoscopic talc pleurodesis for the management of MPE from April 2020 to December 2021.
Results
A total of 24 patients with MPE who underwent thoracoscopic talc pleurodesis for the management of MPE were included in the study. The mean age was 63 ± 8.35 years, and included 12 (50%) males and 12 (50%) females. Overall, low-grade fever was seen in four (16.67%) patients, pleuritic chest pain in three (12.5%) patients, and no complication in 17 (70.83%) patients. No recurrence of pleural effusion happened in 21 (87.5%) patients, recurrence in the form of localized effusion that did not need medical interference happened in two (8.33%), and recurrence in the form of diffuse effusion that needed medical interference happened in one (4.17%) patient. Operative time was 43.75 ± 6.63 min, duration of chest tube insertion was 3.25 ± 0.44 days, and hospital stay was 6 ± 0.72 days.
Conclusions
Thoracoscopic talc pleurodesis for the treatment of MPE is a feasible and effective treatment with short operative time, is a minimally invasive procedure, and has few adverse effects, making it a safe and effective option for managing patients with MPE.

Keywords: cancer, dyspnea, malignant pleural effusion, talc pleurodesis, thoracoscopy


How to cite this article:
Abdelmotaleb MS. Efficacy and safety of thoracoscopic talc pleurodesis in the treatment of malignant pleural effusion. Menoufia Med J 2022;35:704-8

How to cite this URL:
Abdelmotaleb MS. Efficacy and safety of thoracoscopic talc pleurodesis in the treatment of malignant pleural effusion. Menoufia Med J [serial online] 2022 [cited 2024 Mar 29];35:704-8. Available from: http://www.mmj.eg.net/text.asp?2022/35/2/704/352204




  Introduction Top


Malignant pleural effusion (MPE) is a common complication of advanced malignancy with a poor prognosis[1]. Progressive dyspnea is the most common symptom in patients with MPE followed by cough and chest pain that affect the quality of life[2]. Local palliative procedures are more required to relieve dyspnea, improve life quality, and avoid repeated thoracentesis for patients not responding to systemic treatment[3]. Current local managements include thoracentesis, pleurodesis, as well as chest tube drainage, indwelling pleural catheter drainage, pleurectomy, and pleuroperitoneal shunting[4]. Pleurodesis is a well-recognized treatment for the management of MPE aiming at the adhesion of the visceral and parietal pleura that prevents the accumulation of MPE and subsequently improves symptoms[5]. Pleurodesis can be completed by chemical sclerosants or by physical abrasion of pleural surfaces during thoracoscopy or thoracotomy[6]. Among the wide variety of sclerosing agents used to produce pleurodesis, talc is considered the most effective.

The aim of this study was to evaluate the efficacy and safety of thoracoscopic talc pleurodesis in the management of MPE.


  Patients and methods Top


This retrospective study was conducted in our tertiary university institute. Research Ethics Board approval was obtained for a retrospective chart review of all patients with MPE related to different malignancies who underwent thoracoscopic talc pleurodesis for the management of MPE from April 2020 to December 2021.

Patients diagnosed to have MPE either proven histocytologically, an unexplained exudative effusion in advanced cancer, or suggested by radiological pleural changes consistent with malignancy were included.

Preoperative therapeutic thoracentesis was done before the operation to exclude trapped lung before transfer to operating room.

The patients received general anesthesia with one lung ventilation by double-lumen endotracheal intubation or single-lumen endotracheal intubation and bronchial blocker in the contralateral decubitus position.

Video-assisted thoracoscopy (VATS) was performed using one or two 5-mm port sites. The pleural cavity was explored, pleural fluid was drained fully, and adhesiolysis was performed using blunt and sharp dissection. Re-inflation of the lung excluded trapped lung. Multiple pleural biopsies were taken for histological confirmation. Patients received insufflation with 4 g of talc powder under thoracoscopic guidance. Once VATS intervention was complete and complete hemostasis achieved, one chest tube was placed through one of the intercostal access sites under the vision to facilitate proper drainage. The thoracic cavity was then closed in layers, and aseptic dressing was done.

Drains were removed if the chest radiograph confirmed satisfactory lung expansion and the drainage was less than 150 ml/24 h with no air leak. All patients were discharged on the same day when their chest tube was removed.

Gathered information included demographic characteristics (age and sex), mortality during 3 months of follow-up, coexisting comorbid conditions, primary tumor, histocytological study for pleural effusion, side of effusion, postoperative complication, recurrence of pleural effusion during 3 months of follow-up, operative time, chest tube duration, and hospital stay.

Statistical analysis of the data

Statistical analysis was performed via Statistical Package for the Social Sciences (SPSS) Computer Software (Version 20; IBM Software, Chicago, Illinois, USA). Descriptive statistics were expressed as mean and SD for numerical variables and as frequencies and percentages for categorical variables.


  Results Top


A total of 24 patients with MPE related to different malignancies who underwent thoracoscopic talc pleurodesis for the management of MPE from April 2020 to December 2021 were included in the study.

The overall mean age was 63 ± 8.35 years, and we had 12 (50%) males and 12 (50%) females [Table 1].
Table 1: Demographic data

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Total mortality during 3 months of follow-up was three (12.5%) patients.

There were 11 (45.83%) patients with no comorbidities; however, 13 (54.17%) patients had comorbidities in the form of diabetes mellitus in 9 (37.5%) patients, dyslipidemia in 4 (16.67%) patients, hypertension in 10 (41.67%) patients, chronic kidney disease in three (12.5%) patients, and liver cirrhosis in two (8.33%) patients [Table 2].
Table 2: Mortality and comorbidities

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Pleural effusion was on the right side in 12 (50%) patients and on the left side in 12 (50%) patients.

Regarding primary tumor, we had 12 (50%) patients with lung cancer, six (25%) patients with breast cancer, three (12.5%) patients with thyroid cancer, and three (12.5%) patients with ovarian cancer.

There were 19 (79.17%) patients with positive malignant cells in the histocytological study for pleural effusion and five (20.83%) patients with negative malignant cells [Table 3].
Table 3: Clinical data

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Regarding postoperative complications, we had low-grade fever in four (16.67%) patients, pleuritic chest pain in three (12.5%) patients, and no complication in 17 (70.83%) patients.

During 3 months of follow-up, no recurrence in pleural effusion happened in 18 (85.71%) patients, recurrence in the form of localized effusion which did not need medical interference happened in two (9.52%), and recurrence in the form of diffuse effusion which needed medical interference happened in one (4.76%) patient [Table 4].
Table 4: Complications and recurrence

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Operative time was 43.75 ± 6.63 min, duration of chest tube insertion was 3.25 ± 0.44 days, and hospital stay was 6 ± 0.72 days [Table 5].
Table 5: Hospital stay, duration of chest tube insertion, and operative time

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  Discussion Top


Pleural effusion is a common debilitating complication of several types of advanced malignancy, and the presence of MPE indicates a poor prognosis[7]. Simple drainage of the pleural cavity has not proven to be sufficient for treatment of MPE, as 90% of patients will develop recurrent effusions within 30 days[8]. Drainage followed by obliteration of the pleural space has emerged as the procedure of choice for effective palliation of these patients[9]. Schulze et al.[10] reported that several methods and numerous sclerosing agents have been used because of their effectiveness and the low incidence of adverse effects associated with their use; talc has proved superior to other commonly used sclerosing agents, particularly the irritant chemotherapeutic agents.

In this study, the overall mean age was 63 ± 8.35 years, and we had 12 (50%) males and 12 (50%) females.

During 3 months of follow-up, three (12.5%) patients died during 3 months of follow-up as the presence of MPE indicates a poor prognosis.

Most patients in this study had comorbidities [13 (54.17%) patients] in the form of diabetes mellitus in nine (37.5%) patients, dyslipidemia in four (16.67%) patients, hypertension in 10 (41.67%) patients, chronic kidney disease in three (12.5%) patients, and liver cirrhosis in two (8.33%) patients.

Regarding the side of effusion, there was an equal number on both right and left sides.

The most frequent primary tumor was lung cancer in 12 (50%) patients followed by breast cancer in six (25%) patients. Most patients had positive malignant cells in the histocytological study of pleural fluid [19 (79.17%) patients].

In this study, the mean operative time was 43.75 ± 6.63 min and hospital stay was 6 ± 0.72 days with no complication in most of cases and mild complications in the rest of patients in the form of mild chest pain and low-grade fever.

During 3 months of follow-up, most patients had no recurrence [18 (85.71%) patients], and there was only one patient who had significant recurrence in the form of diffuse effusion, which needed drainage.

Basso and colleagues included 46 patients (28 men and 18 women; median age 67 years, range, 47–82 years) with MPE related to different malignancies who underwent VATS talc pleurodesis in their study. There were 26 (56.5%) patients with nonsmall cell lung cancer, eight (17.4%) with breast cancer, seven (15.2%) with pleural mesothelioma, and five (10.9%) with other malignancies. The average operative time was 28 ± 8 min, and the duration of chest tube drainage was 9.4 ± 4.1 days. Adverse effects were mild (temporary pain, fever for 2–3 days), affecting only three (12%) patients. Two (8%) patients died during hospitalization, due to progression of disease. The study concluded that VATS talc pleurodesis is a feasible and effective treatment for MPE and represents the method of choice for improving dyspnea and chest pain, which are the principal goals of care for such patients[1].

Love and colleagues conducted a retrospective review of outcomes for a consecutive series of 66 MPE cases (61 patients) treated over a 5-year period from 1995 to 2000. A standard operative technique involving a single-lung anesthetic and two-port thoracoscopy was employed. Outcomes were determined by contacting the referring practitioner or the patients themselves. Principal outcome measures included time to recurrence of the effusion and survival. Complete follow-up was achieved for 60 MPE cases (55 patients; five of whom were treated for metachronous, bilateral disease). The three most common primary sites were breast, lung, and mesothelial tissue. The planned procedure was not completed in two cases owing to encasement of the underlying lung by tumor. Primary failure (immediate recurrence of the effusion) occurred in six cases. Delayed recurrence of the effusion occurred in a further 23 MPE, resulting in complete control in 31 (52%) cases until death. Overall median survival was 220 days, and the 30-day mortality was 0. They concluded that management based on thoracoscopy and talc insufflation produces satisfactory results with an acceptable morbidity and no early mortality. The ability to inspect the pleural space, break down adhesions, and completely drain pockets of fluid to achieve complete lung expansion probably contributes to this[11].

Schulze and colleagues conducted a retrospective study to evaluate the clinical outcome of 119 thoracoscopies in 101 patients (56 women, 45 men), from 42 to 91 years of age (mean, 68.69 years) with MPEs. VATS talc pleurodesis was done in 105 instances, and a pleuroperitoneal shunt was performed 14 times as an alternative when complete expansion of the lung could not be achieved due to tumor implants on the visceral pleura. The VATS talc pleurodesis resulted in clinically significant improvement of dyspnea in 92.2% of the patients. Thirty-day mortality was 2.8% and morbidity was 2.8%. The mean duration of postoperative survival was 6.7 months. Recurrent pleural effusion occurred in 5.7% of patients after a mean interval of 6 months. Clinical relief of dyspnea was obtained in 73% of the patients treated with pleuroperitoneal shunts. Thirty-day mortality in this group was 21% and morbidity was 14.3%. The mean duration of survival was 4.2 months. They concluded that VATS talc pleurodesis is appropriate for palliation of patients with MPEs and should be performed once the diagnosis has been confirmed. Patients with lungs trapped by visceral carcinomatosis may benefit from placement of a pleuroperitoneal shunt as an alternative[10].

Marrazzo and colleagues conducted a prospective study which was planned for a period of 3 years. Patients with an expected survival less than 3 months or who had a high anesthesiological risk were excluded. From January 2000 to June 2003, 76 patients underwent video-thoracoscopic chemical pleurodesis for MPE. Twenty-seven (35.5%) of these were men and 49 (64.5%) were women; the mean age was 63.3 years (SD 11.3). The primary tumor was breast in 32 (42.1%) cases, lung in 21 (27.7%), colorectal in four (5.2%) patients, and ovary in three (4.0%). The origin of neoplasm was unknown in six patients. The most common clinical finding was dyspnea. All patients underwent follow-up every month with physical examination, chest radiograph, and if necessary, computed tomography scan of the chest. Pleurodesis was successful in all patients, even though the effusion was loculated owing to numerous thoracenteses. The mean hospital stay was 4.5 days (SD 2.1). Drains were removed within a mean of 4.0 days (2.0). The morbidity rate was 2.6%. One patient had pleural empyema and another required postoperative mechanical ventilation in an ICU for development of acute respiratory failure. There was no perioperative mortality. A relapse of the pleural effusion requiring a second intervention 8 days after operation occurred in one case. Three (3.9%) patients underwent further thoracenteses for recurrence of pleural effusion within 2 months after talc poudrage. The average survival was 10 months. Overall survival was 72.3 and 34.2% at 6 and 12 months, respectively. A total of 16 patients are still living and six of them have survived 24 months after operation. The study suggested that VATS should replace conventional instillation of talc slurry through tube thoracostomy as the procedure of choice to achieve pleurodesis. The findings further suggest that early use of talc insufflated by video-thoracoscopic surgery is an effective and relatively safe method in treating and preventing recurrence of pleural effusion in a selected sample of patients with advanced cancer[12].

Leemans and colleagues conducted a retrospective observational analysis for all consecutive patients diagnosed with malignant pleuritis (confirmed by cytopathological or histopathological diagnosis) and subjected to thoracoscopic talc pleurodesis between January 2012 and December 2015. Of the 155 patients, 122 (78%) were classified as having a successful pleurodesis based on clinical and radiological criteria. Factors associated with unsuccessful pleurodesis were the presence of pleural adhesions, extensive spread of pleural lesions, the use of systemic corticosteroids, and a prolonged time period between the clinical diagnosis of the pleural effusion and the moment of pleurodesis. This study concluded that there should be early referral for talc pleurodesis in symptomatic patients with malignant pleurisy and the use of thoracic ultrasound before the procedure, as both potentially enhance the success rate of pleurodesis through medical thoracoscopy[13].

From all of the data, thoracoscopic talc pleurodesis seems to be a good choice for management of MPE owing to effective palliation and low risk of recurrence and considered a safe procedure with short operative time and mild adverse effects.

Further studies with a larger number of patients are needed to prove that thoracoscopic talc pleurodesis is the first choice for the management of MPE in all surgically fit patients.


  Conclusions Top


Thoracoscopic talc pleurodesis for the treatment of MPE is a feasible and effective treatment with short operative time, is a minimally invasive procedure, and has a few adverse effects, making it a safe and effective option for managing patients with MPE.

Further studies should be done to prove that early thoracoscopic talc pleurodesis should be a first choice to achieve pleurodesis.

Declaration of patient consent

The authors declare that they have obtained consent from patients. Patients have given their consent for their images and other clinical information to be reported in the journal. Patients understand that their names will not be published and due efforts will be made to conceal their identity but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Basso S, Mazza F, Marzano B, Santeufemia D, Chiara G, Lumachi F. Improved quality of life in patients with malignant pleural effusion following video assisted thoracoscopic talc pleurodesis: preliminary results. Anticancer Res 2012; 32:5131–5134.  Back to cited text no. 1
    
2.
Pilling JE, Dusmet ME, Ladas G, Goldstraw P. Prognostic factors for survival after surgical palliation of malignant pleural effusion. J Thorac Oncol 2010; 5:1544–1550.  Back to cited text no. 2
    
3.
Saffran L, Ost DE, Fein AM, Schiff MJ. Outpatient pleurodesis of malignant pleural effusions using a small-bore pigtail catheter. Chest 2000; 118:417–421.  Back to cited text no. 3
    
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Kastelik JA. Management of malignant pleural effusion. Lung 2013; 191:165–175.  Back to cited text no. 4
    
5.
Rodriguez-Panadero F, Montes-Worboys A. Mechanisms of pleurodesis. Respiration 2012; 83:91–98.  Back to cited text no. 5
    
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Khaleeq G, Musani AI. Emerging paradigms in the management of malignant pleural effusions. Respir Med 2008; 102:939–948.  Back to cited text no. 6
    
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Lombardi G, Zustovich F, Nicoletto MO, Donach M, Artioli G, Pastorelli D. Diagnosis and treatment of malignant pleural effusion: a systematic literature review and new approaches. Am J Clin Oncol 2010; 33:420–423.  Back to cited text no. 7
    
8.
Agarwal R, Paul AS, Aggarwal AN, Gupta D, Jindal SK. A randomized controlled trial of the efficacy of cosmetic talc compared with iodopovidone for chemical pleurodesis. Respirology 2011; 16:1064–1069.  Back to cited text no. 8
    
9.
Kolschmann S, Ballin A, Gillissen A. Clinical efficacy and safety of thoracoscopic talc pleurodesis in malignant pleural effusions. Chest 2005; 128:1431–1435.  Back to cited text no. 9
    
10.
Schulze M, Boehle AS, Kurdow R, Dohrmann P, Henne-Bruns D. Effective treatment of malignant pleural effusion by minimal invasive thoracic surgery: thoracoscopic talc pleurodesis and pleuroperitoneal shunts in 101 patients. Ann Thorac Surg 2001; 71:1809–1812.  Back to cited text no. 10
    
11.
Love D, White D, Kiroff G. Thoracoscopic talc pleurodesis for malignant pleural effusion. ANZ J Surg 2003; 73:19–22.  Back to cited text no. 11
    
12.
Marrazzo A, Noto A, Casà L, Taormina P, Lo Gerfo D, David M, et al. Video-thoracoscopic surgical pleurodesis in the management of malignant pleural effusion: the importance of an early intervention. J Pain Symptom Manage 2005; 30:75–79.  Back to cited text no. 12
    
13.
Leemans J, Dooms C, Ninane V, Yserbyt J. Success rate of medical thoracoscopy and talc pleurodesis in malignant pleurisy: a single-centre experience. Respirology 2018; 23:613–617.  Back to cited text no. 13
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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