[

Selected Reports

Talc Pleurodesis Through Indwelling Pleural

Catheters for Malignant Pleural Effusions
Retrospective Case Series of a Novel Clinical Pathway
Liju Ahmed, MBBS; Hugh Ip, MBBS; Deepak Rao, MBBS; Nishil Patel, MBBS; and Farinaz Noorzad, BSc

Malignant pleural eusions cause signicant morbidity, but there is no gold standard minimally invasive treatment. A new therapeutic approach combines talc pleurodesis and indwelling pleural catheters (IPCs) to enable outpatient management. This case series summarizes
the safety and ecacy data of all patients (24) with a symptomatic malignant pleural eusion
who underwent talc pleurodeses via IPCs between December 2010 and July 2013. Successful
pleurodesis was achieved in 22 procedures (92%). There was one empyema, one hydropneumothorax, one recurrent eusion, and two minor complications: one drain site wound
infection and one complaint of chest pain. Twenty-two procedures (92%) were performed in
the outpatient setting. This report conrms the safety and ecacy of administering talc slurry
through IPCs in an outpatient setting. Studies in a larger cohort are necessary to dene the
role of this novel approach in the treatment algorithm of patients with this condition.
CHEST 2014; 146 (6):e190-e194
ABBREVIATIONS:

IPC 5 indwelling pleural catheter; VATS 5 video-assisted thoracoscopic surgery

Malignant pleural effusions affect

. 150,000 patients in the United States each
year, reflecting advanced disease.1 In the
United Kingdom, the estimated incidence is
one new case per 1,000 population per year.2
Mean survival ranges from 3 to 12 months
after diagnosis3; the primary aim is palliation.
Talc poudrage via video-assisted thoracoscopic surgery (VATS) is generally the
preferred treatment.4,5 However, VATS is not
widely available, so talc slurry via chest tube
is a popular alternative. There is no evidence

Manuscript received February 14, 2014; revision accepted July 2, 2014.

AFFILIATIONS: From Guys and St Thomas NHS Trust (Drs Ahmed, Ip,
and Rao and Ms Noorzad); and Kings College London (Dr Patel),
London, England.
Drs Ahmed and Ip are joint first authors.
CORRESPONDENCE TO: Hugh Ip, MBBS, Chest Department, 1st Floor,
Lambeth Wing, St Thomas Hospital, Westminster Bridge Rd, London,
SE1 7EH, England; e-mail: Hughip@gmail.com

e190 Selected Reports

favoring talc administration via chest tube

or VATS; two randomized controlled trials
showed comparable outcomes.3,6,7
As an alternative to talc pleurodesis,
indwelling pleural catheters (IPCs) have
been used.8 IPCs allow long-term drainage
of effusions over periods of weeks to
months, useful especially in cases of trapped
lung, where talc pleurodesis is likely to fail.
IPCs can be inserted as day case procedures,
unlike chest drains, which usually require
hospital admission.

Reproduction of
this article is prohibited without written permission from the American
College of Chest Physicians. See online for more details.
DOI: 10.1378/chest.14-0394
2014 AMERICAN COLLEGE OF CHEST PHYSICIANS.

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A new therapeutic approach involves delivering talc

pleurodesis through an IPC. This exploits the strengths
of IPCs and the main benefit of talc pleurodesis, which
is preventing recurrence. This novel approach also
allows outpatient management.

This case series describes the initial experience of our

center. To our knowledge, there are no published data
on this approach. There is only one pilot study of
doxycycline, now superseded by graded talc, being given
through an IPC.9

Materials and Methods

Patients were reviewed 3 days later by a specialist pleural nurse. They

were assessed for lung reexpansion and resolution of effusion with thoracic ultrasound. Six areas of the hemithorax were assessed (Fig 2).
When at least five areas had good pleural approximation to the chest
wall, this was defined as . 90% of lung reexpansion. In the case of
uncertainty, chest radiographs or CT scans were used. If the lung had
not reexpanded, continued regular drainage (depending on fluid output)
was advised. If the lung was fully reexpanded in five or more areas on
ultrasound, and the drainage was , 200 mL/d, talc slurry was delivered
through the IPC. Twenty to 25 mL 1% lignocaine was given through
the IPC, along with 2.5 to 5 mg oral morphine, followed by 4 g graded
talc dissolved in 50 mL normal saline, and flushed with 50 mL normal
saline afterward. Patients were observed for at least 1 h following talc
instillation.

Study Design
A new treatment protocol was initiated in 2010. To assess outcomes, we
performed a retrospective review of procedure documentation, radiology data, and clinic letters. We collected data on the safety, complication rates, and success of talc pleurodesis through an IPC.
Participants
Details of all talc pleurodeses via IPCs between December 2010 and
July 2013 were reviewed. We included all procedures on patients with
a symptomatic malignant pleural effusion performed by the respiratory
department at St. Thomas Hospital. Histologic confirmation of the primary tumor was obtained in all cases. Patients were excluded from the
study if their primary tumor was small cell lung cancer or lymphoma or
if their World Health Organization performance status was . 1.
Interventions
All procedures were performed on an outpatient basis, unless the patient
had already been admitted to hospital. Figure 1 outlines the management protocol. Patients were initially assessed for trapped lung with the
help of chest radiographs and CT scans (where available), as well as with
pleural manometry. An IPC (PleurX) was inserted using a standard
technique.10 After the IPC insertion, pleural fluid was drained maximally, guided by pleural manometry and monitoring for chest pain.
Patients were then sent home with instructions to drain the IPC daily
for 3 days with 1-L vacuum bottles. When patients were unable to perform drainage themselves, district nurse visits were arranged. The volumes of fluid drained were recorded.

Results
During the study period, 57 IPCs were inserted for
patients with malignant pleural effusions. Thirty-three
procedures were excluded from the study because
there was no subsequent talc pleurodesis through the
IPC (reasons included trapped lung and performance
status . 1). The remaining 24 procedures fulfilling the
study criteria were analyzed.
The baseline patient characteristics are summarized
in Table 1. The median age was 70 y (range, 36-83 y),
and there was a predominance of women (58%). The
primary tumor was non-small cell lung cancer in
54% and breast cancer in 21%; the remaining 25% was
composed of ovarian cancer, rectal cancer, renal cell
cancer, tongue cancer, and thymic cancer. Eighteen
effusions (75%) were right sided.
The postpleurodesis outcomes are summarized in
Table 2. Successful pleurodesis was achieved in 22 procedures (92%).

They were then sent home with instructions to drain the IPC daily for
3 days with 1-L vacuum drainage bottles. District nurses assisted patients
when required. Three days later, pleural symphysis was assessed with
thoracic ultrasound. Pleurodesis is demonstrated by the absence of a
pleural sliding sign (sliding of the visceral pleura over the parietal pleura
during respiration). If there was good pleural approximation and loss of
pleural sliding in . 90% of the hemithorax, patients were advised to
stop drainage for 2 weeks. If there was no further fluid reaccumulation,
the IPC was removed.
Assessments
Complications and hospital admissions were documented on the electronic patient record system. Pleurodesis was assessed 3 days after talc
instillation. Pleurodesis success was determined for most patients at
14 days after talc instillation at the point of considering IPC removal.

Details of complications are summarized in Table 3. The

overall complication rate was 21% (five complications).
The major complications (making up 13%) were one
hydropneumothorax, one empyema, and one recurrent
effusion. The minor complications (making up 8%)
were one drain site wound infection and one patient
with chest pain.
One complication was not included in this analysis
because it was not attributable to the procedure being
investigated: talc slurry through an IPC. The patient
developed a pneumothorax after insertion of the IPC,
before talc pleurodesis.

Discussion
This case series of 24 procedures shows that talc
pleurodesis via IPC is effective, with successful
pleurodesis in 92% of procedures. The procedure is also
safe, with a major complication rate of only 12%.
Reactions to graded talc were not seen in these patients.

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e191

Figure 1 Flowchart of malignant

pleural effusion management at
Guys and St Thomas NHS Trust.
BTS 5 British Thoracic Society;
IPC 5 indwelling pleural catheter.

There were no IPC blockages following talc slurry

instillation. Twenty-two procedures (92%) were performed in the outpatient setting, and no problems

Figure 2 Diagram dividing each hemithorax into six areas for thoracic
ultrasound assessment.

e192 Selected Reports

resulted from discharging patients home the same day

(following talc instillation).
To our knowledge, these are the first published
safety and efficacy data on talc pleurodesis via an IPC.
The strength of the data is its real-world relevance.
Reasonably experienced pleural units should be able to
safely replicate this novel approach of talc pleurodesis
through an IPC for appropriate patients. Because of the
study design, we lacked a control group and objective
records of symptom improvement. There was also
variability in the timing of pleurodesis assessment
because of the limitations of the study design, and
clinical priorities. The review of our tertiary hospital
records did not capture data on patients when they were
admitted to other (eg, secondary) hospitals.
Patients with a performance status . 1 were excluded,
although they may have benefitted. We chose conservative

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TABLE 1

] Baseline Patient Characteristics (N 5 24)

Characteristics

TABLE 3

] Analysis of Complications

No.

Complications

Age, median (range), y

70 (36-83)

Total

Male (female)

10 (14)

42 (58)

Primary tumor

Age, median (range), y

Male (female)

Non-small cell lung

cancer

No.

100

71 (65-79)
3 (2)

60 (40)

13

54

21

Ovarian cancer

13

Thymic cancer

Rectal cancer

1 (4)

20 (80)

Renal cell cancer

Side of eusion,
left (right)

Thymic cancer

Pleurodesis, outpatient
(inpatient)

3 (2)

60 (40)

Successful pleurodesis

Breast cancer

Side of eusion, left

(right)
Pleurodesis, outpatient
(inpatient)

6 (18)

25 (75)

22 (2)

The next step is a multicenter randomized controlled trial.

This would enable physicians to offer the best treatment
to alleviate suffering in this important patient group.15

Acknowledgments
Financial/nonfinancial disclosures: The authors have reported to
CHEST the following conflicts of interest: Dr Ahmed is a researcher
on a study site for the IPC-PLUS trial (ISRCTN73255764). Drs Ip,
Rao, and Patel and Ms Noorzad have reported that no potential conflicts

] Outcomes After Pleurodesis

Outcomes

No.

All
Procedures, %

Successful pleurodesis

22

92

Major

21

13

Hydropneumothorax

Empyema

Recurrent eusion

Drain site wound infection

Chest pain

Minor

80
20

80

of interest exist with any companies/organizations whose products or

services may be discussed in this article.

This study adds to the evidence that malignant pleural

effusions can be managed safely in an outpatient setting.
This allows patients to spend quality time at home rather
than in hospital and is likely to be cost effective. Previous studies involved outpatient pleurodesis through a
chest drain rather than an IPC.11-14 Furthermore, these
studies did not describe the use of graded talc, generally
accepted as the most effective sclerosant.4

Total complications

Non-small cell lung

cancer

92 (8)

exclusion criteria to ensure safety (in the outpatient

setting) during this study.

TABLE 2

Primary tumor

Other contributions: CHEST worked with the authors to ensure that

the Journal policies on patient consent to report information were met.

References
1. Haas AR, Sterman DH, Musani AI. Malignant pleural effusions:
management options with consideration of coding, billing, and a
decision approach. Chest. 2007;132(3):1036-1041.
2. Rahman NM, Ali NJ, Brown G, et al; British Thoracic Society
Pleural Disease Guideline Group. Local anaesthetic thoracoscopy:
British Thoracic Society Pleural Disease Guideline 2010. Thorax.
2010;65(suppl 2):ii54-ii60.
3. Roberts ME, Neville E, Berrisford RG, Antunes G, Ali NJ; BTS
Pleural Disease Guideline Group. Management of a malignant
pleural effusion: British Thoracic Society Pleural Disease Guideline
2010. Thorax. 2010;65(suppl 2):ii32-ii40.
4. Shaw P, Agarwal R. Pleurodesis for malignant pleural effusions.
Cochrane Database Syst Rev. 2004;(1)CD002916.
5. Tan C, Sedrakyan A, Browne J, Swift S, Treasure T. The evidence
on the effectiveness of management for malignant pleural effusion:
a systematic review. Eur J Cardiothorac Surg. 2006;29(5):829-838.
6. Dresler CM, Olak J, Herndon JE II, et al; Cooperative Groups
Cancer and Leukemia Group B; Eastern Cooperative Oncology
Group; North Central Cooperative Oncology Group; Radiation
Therapy Oncology Group. Phase III intergroup study of talc
poudrage vs talc slurry sclerosis for malignant pleural effusion.
Chest. 2005;127(3):909-915.
7. Yim AP, Chan AT, Lee TW, Wan IY, Ho JK. Thoracoscopic talc
insufflation versus talc slurry for symptomatic malignant pleural
effusion. Ann Thorac Surg. 1996;62(6):1655-1658.
8. Davies HE, Mishra EK, Kahan BC, et al. Effect of an indwelling
pleural catheter vs chest tube and talc pleurodesis for relieving
dyspnea in patients with malignant pleural effusion: the TIME2
randomized controlled trial. JAMA. 2012;307(22):2383-2389.
9. Wyckoff CC, Anderson ED, Read CA, Lee RE. The use of
intrapleural doxycycline via PleurX catheter in the treatment of
malignant pleural effusions: preliminary report. Chest. 2007;
132(4_MeetingAbstracts):432a.
10. Musani AI, Haas AR, Seijo L, Wilby M, Sterman DH. Outpatient
management of malignant pleural effusions with small-bore,
tunneled pleural catheters. Respiration. 2004;71(6):559-566.
11. Patz EF Jr, McAdams HP, Goodman PC, Blackwell S, Crawford J.
Ambulatory sclerotherapy for malignant pleural effusions.
Radiology. 1996;199(1):133-135.
12. Spiegler PA, Hurewitz AN, Groth ML. Rapid pleurodesis for
malignant pleural effusions. Chest. 2003;123(6):1895-1898.

journal.publications.chestnet.org

Downloaded From: http://journal.publications.chestnet.org/ by a Medical College of Wisconsin User on 01/14/2016

e193

13. Saffran L, Ost DE, Fein AM, Schiff MJ. Outpatient pleurodesis of
malignant pleural effusions using a small-bore pigtail catheter.
Chest. 2000;118(2):417-421.
14. Terra RM, Kim SY, Pego-Fernandes PM, Teixeira LR, Vargas FS,
Jatene FB. Is silver nitrate pleurodesis for patients with malignant

e194 Selected Reports

pleural effusion feasible and safe when performed in an outpatient

setting? Ann Surg Oncol. 2011;18(4):1145-1150.
15. Maskell NA. Treatment options for malignant pleural effusions:
patient preference does matter. JAMA . 2012; 307(22):
2432-2433.

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