Malignant Pleural Effusions: Management Options

David J. McCracken, MRCP; Jose M. Porcel, MD; Najib M. Rahman, DPhil

Disclosures

Semin Respir Crit Care Med. 2018;39(6):704-712. 

In This Article

Indwelling Pleural Catheter Drainage and Autopleurodesis

Autopleurodesis, or spontaneous pleurodesis related to the catheter, is a recognized outcome of long-term catheter drainage, although the frequency with which this occurs varies from 23 up to 65%.[8,27,28]

A number of factors may influence IPC-related autopleurodesis.

  1. Drainage frequency: A lack of clarity persists with regard to the frequency with which drainage of an IPC should be performed. This has not been previously defined, but current standard practice is often characterized by alternate day drainage. Wahidi et al compared aggressive daily drainage with conventional treatment consisting of alternate day drainage using a multicenter randomized controlled trial. The ASAP trial, published in 2017, demonstrated aggressive management resulted in a statistically significant increase in the rate of autopleurodesis at 12 weeks as well as a reduction in the time taken for it to be achieved. Autopleurodesis was achieved in 47% of patients compared with 24% in the control arm (p = 0.003). The median time to autopleurodesis was significantly reduced from 90 to 54 days. There were no significant differences found in the frequency of adverse events seen. Quality of life and patient satisfaction measures between the two groups were also not significantly different.[27]

  2. Talc instillation: Although IPCs and talc pleurodesis are often presented as two distinct, mutually exclusive interventions, the IPC-PLUS trial, published by Bhatnagar et al in 2018, has demonstrated that instillation of a talc slurry through the IPC as a day case procedure in patients without evidence of lung entrapment is feasible and resulted in a pleurodesis rate of 43%. When compared with the autopleurodesis rate of 23% in the placebo group, this represented a statistically significant improvement (p = 0.008). There were also statistically significant improvements seen in quality of life measures and symptom scores in patients who received talc, with no significant difference observed in the number of adverse events.[28]

These two methods of IPC management allow patients the opportunity to be managed in an ambulatory or domiciliary setting, but also improve the likelihood of pleurodesis to prevent unnecessary ongoing burdensome treatment and reduce costs. The IPC-PLUS trial, in particular, challenges previously held positions of two distinct treatment modalities and represents a significant change in practice, establishing this combined treatment option as a valid treatment choice.

It may be possible to infer from the results of these two trials that consideration of a combined approach of daily drainage and talc instillation in IPC patients may be of value. It could be suggested that an even greater pleurodesis rate along with a further reduction in overall duration of treatment might be seen by way of a synergistic effect, but this has yet to be adequately tested by means of a randomized controlled trial.

This paradigm shift is important to consider. Even though rates of autopleurodesis are improved in IPC patients following either talc instillation or daily drainage, it should be noted that pleurodesis success is still significantly lower (at around 50%) when compared with conventional methods such as talc poudrage with an inpatient stay (around 80%). No direct comparison has been performed to date, but this conclusion may not be appropriate as the primary treatment goal of an IPC is long-term symptomatic management and not explicitly pleurodesis.

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