When to perform pleurodesis for malignant pleural effusion (MPE)?

From the Guidelines

Pleurodesis for malignant pleural effusion should be performed when a patient has a symptomatic, recurrent effusion that has been confirmed as malignant, the lung fully expands after drainage, and the patient has a reasonable life expectancy. The decision to perform pleurodesis is based on the patient's overall clinical condition, including their performance status, life expectancy, and the presence of symptoms such as dyspnea. According to the most recent and highest quality study 1, in patients with malignant pleural effusion (MPE) with known or suspected expandable lung and no prior definitive therapy, either indwelling pleural catheters (IPCs) or chemical pleurodesis can be used as first-line definitive intervention for management of dyspnea. Some key points to consider when deciding on pleurodesis include:

• The patient's lung must be able to fully expand after drainage, as pleurodesis is not effective if the lung is trapped due to adhesions or other conditions.
• The patient should have a reasonable life expectancy, generally more than 1-3 months, to benefit from the procedure.
• Complete drainage of the pleural space is necessary before pleurodesis, usually via chest tube or indwelling pleural catheter.
• Common sclerosing agents include talc, doxycycline, and bleomycin, with talc showing the highest success rates.
• Pleurodesis should not be performed if the patient has a very limited life expectancy or cannot tolerate the procedure due to poor performance status. The procedure works by creating an inflammatory reaction between the pleural surfaces, leading to adhesion and preventing fluid reaccumulation, thereby providing long-term symptom relief and avoiding repeated thoracentesis procedures. It is also important to consider the patient's values and preferences when choosing between IPCs and chemical pleurodesis, as IPCs reduce time in hospital but are associated with an increased risk of cellulitis 1. In patients with limited life span, serial thoracentesis can be considered as an alternative to pleurodesis 1.

From the Research

Indications for Pleurodesis in Malignant Pleural Effusion

• Malignant pleural effusion is a common complication of metastatic cancer, occurring in approximately half of all patients, and can significantly reduce quality of life due to symptoms such as dyspnea and cough 2.
• Pleurodesis is a procedure aimed at preventing re-accumulation of the effusion and thereby reducing symptoms and the need for repeated hospitalization for thoracocentesis 2.
• The decision to perform pleurodesis should be based on the patient's overall condition, life expectancy, and the presence of symptoms such as dyspnea, cough, and chest pain 3, 4.

Optimal Timing for Pleurodesis

• Pleurodesis is typically considered for patients with a life expectancy of more than 30 days, as indicated by a Karnofsky Performance Scale score of 40 or higher 3.
• For patients with a shorter life expectancy (less than 6 weeks), the use of a Pleurx catheter may be a more cost-effective option 4.
• The optimal timing for pleurodesis may also depend on the patient's clinical situation, local expertise, and success rates of the procedures 4.

Efficacy and Safety of Talc Pleurodesis

• Talc pleurodesis has been shown to be an effective and safe method for inducing pleurodesis in patients with malignant pleural effusion, with a success rate of over 90% 3, 5.
• Thoracoscopic talc poudrage is considered the most effective technique for pleurodesis, with a higher success rate compared to bedside talc slurry 2, 5.
• The incidence of adverse events, such as chest pain, fever, and empyema, is relatively low and mostly related to the therapeutic procedure itself 3, 5.

Alternative Options for Pleurodesis

• The use of a Pleurx catheter is an alternative option for patients with malignant pleural effusion, particularly those with a shorter life expectancy or who are not candidates for talc pleurodesis 4, 6.
• Rapid pleurodesis protocols, which combine chemical pleurodesis and indwelling pleural catheter drainage, may also be an effective option for patients with recurrent symptomatic pleural effusion 6.