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cancers, which account for 50% to 65% of MPEs.4 Moreover, Aelony and Yao5 have demonstrated better survival after talc poudrage for mesothelioma, and 90% of patients with mesothelioma will develop symptomatic MPEs during the course of disease.6 The phase III intergroup study4 excluded patients with trapped lungs because of extensive intrapleural tumor load and pleural loculations, which occur in up to 30% of MPEs and are the main cause for pleurodesis failure. Thoracoscopy facilitates lysis of adhesions, which promotes drainage of pleural loculations to allow the underlying lungs to expand and enhances success of pleurodesis.7 Dr Light8 cited concern of talc and acute respiratory failure. I would reiterate that no respiratory failure was observed in 558 patients undergoing thoracoscopy with large-particle talc. The results reaffirm that respiratory failure is attributable to small-particle talc, which is an important consideration for safety.9 As there are few randomized controlled trials that compare different sclerosing agents, as pointed out by Dr Light,8 I conclude based on systematic reviews

by Cochrane and other investigators that talc is the most efficacious agent in inciting not only inflammation necessary to promote pleural fibrosis but also apoptosis of mesothelioma and lung adenocarcinoma cells in vitro.10,11 There is also no randomized controlled trial to date that compares talc pleurodesis (tube TS or thoracoscopy) with indwelling pleural catheters (IPCs), and one can only infer efficacy of the two methods from the reported pleurodesis rates. Pleurodesis occurs spontaneously with IPCs (46%) and TTP (. 80%). In addition, IPC use is associated with complications such as catheter malfunction (10%), empyema (3%), and catheter track metastases (1%).12 IPC is less cost-effective than chest tube pleurodesis if the patient survives . 6 weeks.13 Thus, we have to wait for randomized controlled trials of IPC with TTP or TS before any recommendation can be made in favor of IPC as the first choice in management of patients with MPE. Pyng Lee, MD, FCCP Singapore Affiliations: From the Division of Respiratory and Critical Care Medicine, National University Hospital, Yong Loo Lin School of Medicine, National University of Singapore.

Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Correspondence to: Pyng Lee, MD, FCCP, Division of Respiratory and Critical Care Medicine, National University Hospital, Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, Level 10, 1E Kent Ridge Rd, Singapore 119228; e-mail: pyng_lee@nuhs.edu.sg Š 2012 American College of Chest Physicians. 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.12-1086

References 1. Lee YC, Baumann MH, Maskell NA, et al. Pleurodesis practice for malignant pleural effusions in five English speaking countries. Chest. 2003;124(6):2229-2238.

2. Shaw P, Agarwal R. Pleurodesis for malignant pleural effusions. Cochrane Database Syst Rev. 2004;1(1):CD002916.

3. Tan C, Sedrakyan A, Browne J, et al. The evidence on the effectiveness of management for malignant pleural effusion: a systematic review. Eur J Cardiothorac Surg. 2006;29(5): 829-838.

4. 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.

5. Aelony Y, Yao JF. Prolonged survival after talc poudrage for malignant pleural mesothelioma: case series. Respirology.

2005;10(5):649-655.

6. 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.

7. Crnjac A, Sok M, Kamenik M. Impact of pleural effusion pH on the efficacy ofthoracoscopic mechanical pleurodesis in patients with breast carcinoma. Eur K Cardiothorac Surg.

2004;26:432-436.

8. Light RW. Counterpoint: should thoracoscopic talc pleurodesis be the first choice management for malignant pleural effusion? No. Chest. 2012;142(1):17-19.

9. Janssen JP, Collier G, Astoul P, et al. Safety of pleurodesis with talc poudrage in malignant pleural effusion: a prospective cohort study. Lancet. 2007;369(9572):1535-1539.

10. Nasreen N, Mohammed KA, Dowling PA, Ward MJ, Galffy G, Antony VB. Talc induces apoptosis in human malignant mesothelioma cells in vitro. Am J Respir Crit Care Med. 2000;161(2 pt 1):595-600.

11. Lee P, Sun L, Lim CK, Aw SE, Colt HG. Selective apoptosis of lung cancer cells with talc. Eur Respir J. 2010;35(2): 450-452.

12. Van Meter ME, McKee KY, Kohlwes RJ. Efficacy and safety of tunneled pleuralcatheters in adults with malignant pleural effusions: a systematic review. J Gen Intern Med. 2011;26(1): 70-76.

13. Olden AM, Holloway R. Treatment of malignant pleural effusion: PleuRx catheter or talc pleurodesis? A cost-effectiveness analysis. J Palliat Med. 2010;13(1):59-65.

Rebuttal From Dr Light with a malignant effusion have a mean life Patients expectancy of only several months. It is, therefore,

incumbent upon physicians caring for these patients to manage their effusions in a manner that will provide them the most high-quality days during the remainder of their lives.

Dr Lee’s1 conclusion that the optimal treatment of pleural effusion is thoracoscopic talc pleurodesis appears to be based on two reviews, which were both published in 2006 and concluded that talc was the sclerosant of choice and that thoracoscopy was the preferred technique. Neither of these reviews included

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Point/Counterpoint Editorials

the article by Dresler et al,2 which showed that overall there was no difference in the percentage of successful pleurodesis whether the patient received talc via tube thoracostomy or via thoracoscopy. Lee goes on to note that in the study reported by Dresler et al,2 the pleurodesis was more successful in patients with breast and lung carcinoma subjected to thoracostomy.

This means that the patients with other malignancies who received thoracoscopy did worse. This study was not originally designed for subset analysis, so one must be careful of making conclusions from subset analysis.

As Davies et al3 point out, all randomized trials to date have failed to show a benefit of thoracoscopic talc poudrage over bedside chemical pleurodesis in the treatment of malignant pleural effusion.

In her article, Dr Lee1 states that the indwelling pleural catheter was originally designed for patients with trapped lungs. This is not accurate. I was involved in the initial study,4 which certainly was not restricted to patients with trapped lungs. Moreover, the majority of patients in the articles that I referred to in my counterpoint editorial did not have trapped lungs.5,6 Dr Lee maintains that the indwelling catheter is more expensive than talc pleurodesis. Interestingly, the article that she cites to support this position used tube thoracostomy rather than thoracoscopy. If the pleurodesis is done with thoracoscopy, the cost is probably higher than with tube thoracostomy. A large portion of the cost associated with the indwelling pleural catheter is for the suction bottles. It has been shown that the cost associated with the indwelling pleural catheter can be markedly reduced if a surgivac pump is used, rather than suction bottles. 7 The surgivac pump is reused, and the incidence of pleurodesis with it is at least as high as it is with suction bottles.

In conclusion, the best treatment of a malignant pleural effusion is not known. The treatment should be based on the clinical situation and patient preferences, as well as local expertise. Prospective randomized controlled studies are needed to identify the optimal treatment, taking into consideration the quality of life, success rates, complications, and cost. Until such studies are available, I believe that the best treatment of most patients is the implantation of an indwelling

journal.publications.chestnet.org

pleural catheter. I gave a talk at M.D. Anderson in 2010 on the treatment of malignant pleural effusions, discussing both the indwelling catheter and pleurodesis. I was surprised when one of the physicians in the audience asked me why I even discussed pleurodesis; virtually all malignant pleural effusions at that institution are treated with the indwelling catheter.

Richard W. Light, MD Nashville, TN Affiliations: From the Division of Allergy, Pulmonary, Immunology and Critical Care, Vanderbilt University.

Financial/nonfinancial disclosures: The author has reported to CHEST the following conflicts of interest: Dr Light has been on the advisory board of and is a consultant to CareFusion, which makes the Pleurx indwelling catheter, and CareFusion has provided support for some of his speaking engagements.

Correspondence to: Richard W. Light, MD, FCCP, Vanderbilt University, 2201 W End Ave, Nashville, TN 37235; e-mail: rlight98@ yahoo.com Š 2012 American College of Chest Physicians. 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.12-1088

References 1. Lee P. Point: should thoracoscopic talc pleurodesis be the first choice management for malignant effusion? Yes. Chest.

2012;142(1):15-17.

2. 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.

3. Davies HE, Rosenstengel A, Lee YC. The diminishing role of surgery in pleural disease. Curr Opin Pulm Med. 2011; 17(4):247-254.

4. Putnam JB Jr, Light RW, Rodriguez RM, et al. A randomized comparison of indwelling pleural catheter and doxycycline pleurodesis in the management of malignant pleural effusions.

Cancer. 1999;86(10):1992-1999.

5. Tremblay A, Michaud G. Single-center experience with 250 tunnelled pleural catheter insertions for malignant pleural effusion. Chest. 2006;129(2):362-368.

6. Warren WH, Kalimi R, Khodadadian LM, Kim AW. Management of malignant pleural effusions using the Pleur(x) catheter.

Ann Thorac Surg. 2008;85(3):1049-1055.

7. Al-Halfawy A, Light R. Safety and efficacy of using a surgivac pump for the drainage of chronic indwelling pleural catheters in malignant pleural effusions. Respirology. 2008;13(3):461-464.

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