RESUMEN
OBJECTIVE: Talc pleurodesis is a widely used treatment option for malignant pleural effusion (MPE). However, the optimal form of administration remains controversial. Thus, we performed a systematic review and meta-analysis to assess the effectiveness of talc slurry (TS) in comparison with thoracoscopic talc insufflation/poudrage (TTI) for MPE treatment. METHODS: We searched PubMed, EMBASE, and Cochrane Library databases for studies that compared TS with TTI in patients with MPE. We used a random-effects model with a 95% CI to pool the data. Heterogeneity was assessed with I2 statistics. RESULTS: We included eight studies involving 1,163 patients, 584 of whom (50.21%) underwent TS. Pleurodesis failure rates were similar between the procedures (OR = 1.07; 95% CI: 0.56-2.06; p = 0.83; I2 = 62%); and 68% of patients (95% CI: 0.31-1.47; p = 0.33; I2 = 58%) had postoperative complications, which were lower in patients in the TS group than in the TTI group. In a subgroup analysis considering only randomized clinical trials, the failure rate was significantly lower in the TS treatment group (OR = 0.62; 95% CI: 0.42-0.90; p = 0.01; I2 = 0%). Similarly, dyspnea was less common in the TS group (OR = 0.74; 95% CI: 0.41-1.34; p = 0.32; I2 = 55%). Adverse effects were reported in 86 patients, and no significant difference was seen between the TS and TTI groups: empyema (OR = 1.43; 95% CI: 0.36-5.64; p = 0.86; I2 = 0%), pain (OR = 1.22 (95% CI: 0.67-2.21; p = 0.51; I2 = 38%), and pneumonia (OR = 1.15; 95% CI: 0.30-4.46; p = 0.86; I2 = 27%). CONCLUSIONS: Our findings suggest that TS is an effective treatment for MPE, with no significant increase in adverse events. Results suggest equivalent efficacy and safety for both procedures.
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Insuflación , Derrame Pleural Maligno , Pleurodesia , Talco , Toracoscopía , Humanos , Talco/administración & dosificación , Derrame Pleural Maligno/terapia , Pleurodesia/métodos , Insuflación/métodos , Insuflación/efectos adversos , Toracoscopía/métodos , Toracoscopía/efectos adversos , Resultado del Tratamiento , Reproducibilidad de los ResultadosRESUMEN
INTRODUCTION: The link between talcum powder use and cancer, particularly ovarian cancer, has been a topic of scientific research and legal debate for several years. Studies have suggested a potential association between long-term talcum powder use in the genital area and an increased risk of ovarian cancer. AREAS COVERED: The following report includes up-to-date evidence to support the potential link between talcum powder use and the risk of developing ovarian cancer. The International Agency for Research on Cancer, which is part of the World Health Organization, classified talc-based body powder as possibly carcinogenic to humans when used in the female genital area. However, other studies have not consistently supported this association, and thus more research is needed to establish a clear and definitive link between talcum powder use and cancer. Despite this, recent molecular-level data have linked talc to alterations in redox balance, gene mutations, and inflammatory responses. Specifically, we have identified a role for talc to induce the pro-oxidant state, inhibit apoptosis, and more importantly induced cellular transformation in normal ovarian cells. EXPERT OPINION: We presented unequivocal evidence to support our opinion that talc is not biologically inert and induces molecular changes that mimic the hallmarks of cancer.
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Neoplasias Ováricas , Estrés Oxidativo , Talco , Talco/efectos adversos , Talco/administración & dosificación , Humanos , Femenino , Neoplasias Ováricas/patología , Animales , Apoptosis , Polvos , Transformación Celular Neoplásica/inducido químicamente , Riesgo , Carcinógenos/toxicidadRESUMEN
Chemical pleurodesis is a technique in which an injurious and inflammatory substance is instilled into the pleural cavity to cause adhesion and fibrosis. It is commonly used in the management of recurrent malignant pleural effusions. Historically, many different types of sclerosants have been described, though only a few, including talc, the tetracycline derivatives, and anti-septic compounds such as silver nitrate and iodopovidone, have found their way into mainstream use. However, over the past several years, there has been increasing interest in alternative pleurodesis agents. In this review, we will explore future directions in the field, with an eye toward novel and investigational agents.
Asunto(s)
Pleurodesia , Soluciones Esclerosantes , Pleurodesia/métodos , Humanos , Soluciones Esclerosantes/administración & dosificación , Soluciones Esclerosantes/uso terapéutico , Derrame Pleural Maligno/terapia , Derrame Pleural Maligno/tratamiento farmacológico , Talco/administración & dosificaciónRESUMEN
BACKGROUND: Talc pleurodesis is an effective treatment for malignant pleural effusions (MPEs). This study was designed to estimate complication rates of thoracoscopic talc insufflation. METHODS: Literature search was conducted in electronic databases and studies were selected if they reported complication rates of thoracoscopic talc insufflation in cancer patients with MPEs. Meta-analyses of proportions were performed to obtain incidence rates of complications. RESULTS: Twenty-six studies (4482 patients; age 62.9 years [95% confidence interval (CI): 61.5, 64.4]; 50% [95% CI: 43, 58] females) were included. Intraoperative, perioperative, 30-day, and 90-day mortality rates were 0% [95% CI: 0, 1], 2% [95% CI: 0, 4], 7% [95% CI: 3, 13] and 21% [95% CI: 5, 43] respectively. Incidence rates [95% CI] of various complications were: pain (20% [1, 2]), fever (14% [3, 4]), dyspnea (13% [5, 6]), pneumothorax (6% [7, 8]) pneumonia (4% [0, 12]), emphysema (3% [3, 7]), prolonged air leakage (3% [0, 7]), prolonged drainage (3% [9, 10]), thromboembolism (3% [9, 11]), lung injury (2% [7, 12]), respiratory insufficiency (2% [0, 5]), re-expansion pulmonary edema (1% [0, 3]), empyema (1% [0, 2]), respiratory failure (0% [0, 1]), and acute respiratory distress syndrome (ARDS; 0% [0, 1]. CONCLUSIONS: Whereas pain and fever were the most frequent complications of thoracoscopic talc insufflation, the incidence of ARDS was low. Pneumothorax, pneumonia, emphysema, prolonged air leakage, pulmonary embolism, arrythmia, re-expansion pulmonary edema, and empyema are important complications of thoracoscopic talc insufflation.
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Complicaciones Intraoperatorias/etiología , Derrame Pleural Maligno/terapia , Pleurodesia/efectos adversos , Complicaciones Posoperatorias/etiología , Talco/administración & dosificación , Humanos , Insuflación/efectos adversos , Toracoscopía/efectos adversosRESUMEN
Talcum powder is recognized as the leading drug for pleurodesis, a treatment of choice for malignant pleural effusions. Recently, it was shown that hydrogel foam delivery systems significantly enhanced the number of adhesions between the chest wall and the lung in a New Zealand rabbit model due to the sol-gel transition. However, many questions still remain regarding the cause of improved efficacy, such as: (1) Would only hydrogel foams improve the efficacy of talc pleurodesis? (2) Is it possible to achieve the same efficacy of hydrogels using non-hydrogel foams? 3) What are the physicochemical properties that can be correlated to the efficacy of talc pleurodesis? In this study, we use non-hydrogel foam formulations to determine the efficacy of pleurodesis. Foam stability and rheology of the formulations were correlated to adhesion formation. The results clearly suggest a correlation of pleurodesis efficacy to the viscosity and modulus of the foam delivery system.
Asunto(s)
Hidrogeles/química , Pleurodesia/métodos , Talco/administración & dosificación , Animales , Química Farmacéutica , Estabilidad de Medicamentos , Conejos , Reología , Talco/uso terapéuticoRESUMEN
When powder is applied to the genital area, it has the potential to reach internal reproductive organs and promote carcinogenesis by irritating and inflaming exposed tissues. Although many studies have considered the association between genital powder use and ovarian cancer risk, the relationship between genital powder use and uterine cancer is less well-studied. We pooled data from four large, prospective cohorts (the Nurses' Health Study, the Nurses' Health Study II, the Sister Study and the Women's Health Initiative - Observational Study). We used Cox proportional hazards models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs), adjusting for prespecified confounders. In total, 209 185 women were included, with 37% reporting ever genital powder use. Over a mean 14.5 years of follow-up, 3272 invasive uterine cancers were diagnosed. There was no overall association between ever genital powder use and uterine cancer (HR = 1.01, 95% CI: 0.94-1.09), with little difference observed for frequent (≥1 times/week) vs never use (HR = 1.05, 95% CI: 0.95-1.16; P-for-trend = .46). Long-term use (>20 years; HR = 1.12, 95% CI: 0.96-1.31; P-for-trend = 0.14) was associated with a small, but not statistically significant, increase in risk, compared to never use. There were not clear differences by uterine cancer histologic subtypes or across strata of relevant covariates, including race/ethnicity, follow-up time, menopausal status and body mass index. The results of this large, pooled analysis do not support a relationship between the use of genital powder and uterine cancer, although the positive associations observed for long-term use may merit further consideration.
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Talco/administración & dosificación , Neoplasias Uterinas/epidemiología , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Persona de Mediana Edad , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Factores de Riesgo , Talco/efectos adversos , Neoplasias Uterinas/etiología , Salud de la MujerRESUMEN
OBJECTIVE: To compare the efficacy of chemical pleurodesis with talc and trichloroacetic acid during thoracoscopy. MATERIAL AND METHODS: Thoracoscopy with pleural biopsy was performed in 355 (83.5%) out of 424 patients with pleural effusion. Pleurodesis was ensured by intraoperative insufflation of talc powder (n=135) and application of 33% trichloroacetic acid solution to parietal and visceral pleura (n=19) in patients with malignant (125), inflammatory (6), post-traumatic (4), tuberculous (3), pancreatogenic (8) and hepatogenic (8) effusions. Drainage tubes were removed if daily drainage output volume was less than 100 ml or complete lung inflation was observed. RESULTS: Post-pleurodesis drainage took 7.1±5.4 days. Two patients developed bumpy rashes that were initially interpreted as carcinomatosis. However, these rashes were later identified as tuberculosis. Retrospectively, these patients were not good candidates for pleurodesis. Pleurodesis with talc suppressed exudation in 89.6% of cases. Complications developed in 4 cases (3%): pneumonia (1) and pleural empyema (3). These complications were associated with a violation of technical procedure of pleurodesis, i.e. procedure in rigid lung, atelectasis (1) and bronchopleural fistula (2). Mean duration of drainage after trichloroacetic acid-induced pleurodesis was 7.9±6.7 days. This procedure was effective in 84.2% of cases, and there were no complications. There are no previous reports on the use of this pleurodesis technique in the literature. Mean duration of drainage after talc-induced pleurodesis was decreased up to 6.9±5.4 days in patients with malignant pleural effusion (p<0.05), after trichloroacetic acid-induced pleurodesis - up to 7.5±8.1 days (p>0.05) compared to patients without pleurodesis (9.1±11.2 days). CONCLUSION: Pleurodesis with talc or trichloroacetic acid during thoracoscopy is effective for pleural effusions following malignancies, liver, kidney and cardiac diseases with decompensation. Essential requirements are adequate lung inflation, no atelectasis and bronchopleural fistula.
Asunto(s)
Derrame Pleural , Pleuresia , Pleurodesia/métodos , Soluciones Esclerosantes , Talco , Ácido Tricloroacético , Administración Tópica , Exudados y Transudados , Humanos , Derrame Pleural/diagnóstico , Derrame Pleural/etiología , Derrame Pleural/terapia , Pleuresia/etiología , Pleuresia/terapia , Estudios Retrospectivos , Soluciones Esclerosantes/administración & dosificación , Soluciones Esclerosantes/efectos adversos , Talco/administración & dosificación , Talco/efectos adversos , Toracoscopía , Ácido Tricloroacético/administración & dosificación , Ácido Tricloroacético/efectos adversosRESUMEN
Chemical pleurodesis, including talc pleurodesis, has been commonly used to prevent malignant pleural effusions and pneumothorax. This report describes a case of anaphylactic shock caused by talc pleurodesis. A 69-year-old woman who had prolonged air leakage after lobectomy underwent talc pleurodesis. Just after the talc administration, she went into shock. We immediately treated her for anaphylactic shock and simultaneously removed talc from the thoracic cavity through a thoracic tube. She subsequently recovered from shock. She had no further symptoms and was discharged 10 days after pleurodesis. Talc pleurodesis rarely causes severe complications, but it is necessary to treat these appropriately when they occur.
Asunto(s)
Anafilaxia/etiología , Pleurodesia , Complicaciones Posoperatorias/terapia , Talco/efectos adversos , Anciano , Aire , Femenino , Humanos , Talco/administración & dosificaciónRESUMEN
BACKGROUND AND AIM: Talc poudrage has been used since many years for sclerosing chronic pleural effusion. Several reports have shown good results managing chronic seromas after breast, vascular, and incisional hernia surgeries. The purpose of this study is to determine the utility of talc seromadesis for the management of chronic seromas after incisional hernia surgery. MATERIALS AND METHODS: Multicentric prospective observational study including patients diagnosed of chronic seromas after incisional hernia surgery. Under local anesthesia and ultrasonographic control, two percutaneous trocars were placed in the seroma, washing the seroma cavity with 0.9% saline solution and aspirating the remaining liquid. A sample of 4 g of talcum powder was introduced in the seroma cavity, and a 15-F drain was left in place. Patients were followed each week during at least 4 weeks after drainage removal. RESULTS: Between January 2013 and December 2016, a total of six patients were enrolled in the study. Talc poudrage was performed without any complications. Drains were pulled out in a mean time of 3 (range: 2-4) weeks. One case of the chronic seromas was efficiently sclerosed with talc without recurrence in time. In three cases, the seroma recurred, and the final solution was surgical decortication of the seroma. In the other two cases, seroma also recurred and were managed with instillation of ethanol and iodine povidone. CONCLUSION: In our experience, the management of chronic seromas after incisional hernia repair with talc seromadesis is ineffective and is associated with a high rate of seroma recurrence.
Asunto(s)
Hernia Incisional/cirugía , Complicaciones Posoperatorias/tratamiento farmacológico , Seroma/tratamiento farmacológico , Anciano , Drenaje , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Talco/administración & dosificación , Insuficiencia del TratamientoRESUMEN
BACKGROUND: Hydroxyethyl Starch (HES) 130/0.4 (6%) is a commonly used intravascular volume expander with anti-inflammatory and antioxidant properties. In this study, we aimed to compare the histopathologic activity of HES 130/0.4 (6%) with various widely-used agents in pleurodesis. METHODS: Forty male Wistar-Albino rats were divided into five groups: controls, povidone-iodine recipients (PI group), sterile talcum recipients (Talcum group), autologous blood recipients (AB group) and HES 130/0.4 (6%) recipients (HES group). Thirty days after application of agents, pleural and lung tissues were resected. Evaluation was performed via macroscopic scoring (adhesion) and specimens were stained with H&E for microscopic examination (inflammation and fibrosis). RESULTS: HES recipients had significantly higher adhesion compared to controls (lower grade 0, higher grade 1 frequency vs. controls), they were found to have significantly lower frequency of grade 2 adhesion (vs. PI, Talc and AB) and grade 3 adhesion (vs. AB), indicating that the adhesion-generating properties of HES were only superior to the control group. HES recipients had significantly higher inflammatory grades compared to controls (lower grade 0, higher grade 1 frequency), while they had lower grades compared to the PI, Talc and AB groups. Although the PI, Talc and AB groups were statistically similar in most comparisons, we observed a trend towards higher success with the use of Talc and especially AB. CONCLUSION: Our results do not support a role for HES in pleurodesis. We believe that the autologous blood method remains as an effective and successful procedure without side effects.
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Derivados de Hidroxietil Almidón/administración & dosificación , Pleurodesia/métodos , Talco/administración & dosificación , Animales , Derivados de Hidroxietil Almidón/uso terapéutico , Masculino , Pleura/efectos de los fármacos , Pleura/patología , Ratas , Ratas Wistar , Talco/uso terapéutico , Toracotomía , Adherencias TisularesRESUMEN
We performed the midpoint transverse process to pleura (MTP) block in a patient with a recurrent pleural effusion requiring medical thoracoscopy, drainage of pleural effusion, talc poudrage, and placement of tunneled pleural catheter under sedation while in the left lateral decubitus position. Forty milliliters of a combination of bupivacaine hydrochloride and lidocaine, with dexamethasone and clonidine as adjuvants, was injected at the T6 level under ultrasound guidance with satisfactory intra- and postoperative analgesia.
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Neoplasias de la Mama/secundario , Pleura/inervación , Derrame Pleural/cirugía , Toracoscopía/métodos , Neoplasias de la Mama/complicaciones , Catéteres/normas , Drenaje/métodos , Femenino , Humanos , Persona de Mediana Edad , Bloqueo Nervioso/instrumentación , Pleura/efectos de los fármacos , Pleura/patología , Derrame Pleural/etiología , Talco/administración & dosificación , Resultado del Tratamiento , Ultrasonografía Intervencional/métodosRESUMEN
BACKGROUND: There are around 40,000 new cases of malignant pleural effusion in the UK each year. Insertion of talc slurry via a chest tube is the current standard treatment in the UK. However, some centres prefer local anaesthetic thoracoscopy and talc poudrage. There is no consensus as to which approach is most effective. OBJECTIVE: This trial tested the hypothesis that thoracoscopy and talc poudrage increases the proportion of patients with successful pleurodesis at 3 months post procedure, compared with chest drain insertion and talc slurry. DESIGN: This was a multicentre, open-label, randomised controlled trial with embedded economic evaluation. Follow-up took place at 1, 3 and 6 months. SETTING: This trial was set in 17 NHS hospitals in the UK. PARTICIPANTS: A total of 330 adults with a confirmed diagnosis of malignant pleural effusion needing pleurodesis and fit to undergo thoracoscopy under local anaesthetic were included. Those adults needing a tissue diagnosis or with evidence of lung entrapment were excluded. INTERVENTIONS: Allocation took place following minimisation with a random component, performed by a web-based, centralised computer system. Participants in the control arm were treated with a bedside chest drain insertion and 4 g of talc slurry. In the intervention arm, participants underwent local anaesthetic thoracoscopy with 4 g of talc poudrage. MAIN OUTCOME MEASURES: The primary outcome measure was pleurodesis failure at 90 days post randomisation. Secondary outcome measures included mortality and patient-reported symptoms. A cost-utility analysis was also performed. RESULTS: A total of 166 and 164 patients were allocated to poudrage and slurry, respectively. Participants were well matched at baseline. For the primary outcome, no significant difference in pleurodesis failure was observed between the treatment groups at 90 days, with rates of 36 out of 161 (22%) and 38 out of 159 (24%) noted in the poudrage and slurry groups, respectively (odds ratio 0.91, 95% confidence interval 0.54 to 1.55; p = 0.74). No differences (or trends towards difference) were noted in adverse events or any of the secondary outcomes at any time point, including pleurodesis failure at 180 days [poudrage 46/161 (29%), slurry 44/159 (28%), odds ratio 1.05, 95% confidence interval 0.63 to 1.73; p = 0.86], mean number of nights in hospital over 90 days [poudrage 12 nights (standard deviation 13 nights), slurry 11 nights (standard deviation 10 nights); p = 0.35] and all-cause mortality at 180 days [poudrage 66/166 (40%), slurry 68/164 (42%); p = 0.70]. At £20,000 per quality-adjusted life-year gained, poudrage would have a 0.36 probability of being cost-effective compared with slurry. LIMITATIONS: Entry criteria specified that patients must be sufficiently fit to undergo thoracoscopy, which may make the results less applicable to those patients presenting with a greater degree of frailty. Furthermore, the trial was conducted on an open-label basis, which may have influenced the results of patient-reported measures. CONCLUSIONS: The TAPPS (evaluating the efficacy of Thoracoscopy And talc Poudrage versus Pleurodesis using talc Slurry) trial has robustly demonstrated that there is no additional clinical effectiveness or cost-effectiveness benefit in performing talc poudrage at thoracoscopy over bedside chest drain and talc slurry for the management of malignant pleural effusion. TRIAL REGISTRATION: Current Controlled Trials ISRCTN47845793. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 26. See the NIHR Journals Library website for further project information.
In patients with cancer, fluid can build up in the space between the chest wall and lung, causing breathlessness. The fluid can be drained using a small tube inserted between the ribs under local anaesthetic. However, it often recurs. To avoid this, doctors usually inject talc powder (mixed into a slurry) back down the drainage tube to try to 'stick' the lung to the inside of the chest wall. If successful, this prevents the fluid reforming. This procedure is called pleurodesis. An alternative is to insert a camera into the chest under light sedation and local anaesthetic (a 'thoracoscopy') and spray talc directly onto the inside of the chest wall (poudrage). This may be more effective, although this has not been proven and it is a slightly more complex procedure. Therefore, this trial was conducted to see if poudrage was more effective than slurry. A total of 330 patients were recruited from 17 UK hospitals who had chest fluid due to cancer. They were divided evenly, with half receiving standard drainage and slurry and the other half receiving a thoracoscopy and poudrage. They were followed up for 6 months. We measured how many experienced a recurrence in fluid build-up 3 months after treatment, as well as other impacts, including if there was any difference in the long-term costs. No difference in clinical effectiveness was found between talc poudrage and talc slurry. Poudrage was unlikely to be cost-effective. In summary, the researchers conclude that slurry is likely to be the preferable method.
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Tubos Torácicos , Drenaje , Derrame Pleural Maligno/terapia , Pleurodesia , Talco/administración & dosificación , Toracoscopía , Anciano , Análisis Costo-Beneficio , Femenino , Humanos , Masculino , Derrame Pleural Maligno/mortalidad , Resultado del Tratamiento , Reino UnidoRESUMEN
PURPOSE OF REVIEW: Malignant pleural effusion (MPE) is a common cause of breathlessness indicative of advanced disease. Treatment approaches focus on relief of breathlessness and optimizing quality of life. A number of recent, high-impact publications give further insight into the advantages of different treatment options. This article provides a summary of the most up-to-date evidence in this area. RECENT FINDINGS: Recent publications have demonstrated comparable pleurodesis outcomes of talc slurry to talc poudrage and explore strategies to combine the advantages of indwelling pleural catheters (IPCs) with a chemical pleurodesis. A daily IPC drainage regime improves the chances of pleurodesis success and early IPC removal in patients without significant trapped lung. SUMMARY: MPE is a diverse condition, with no one strategy representing the 'best' approach for all. Management decisions should be made in conjunction with the patient, taking their views and preferences into consideration.
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Manejo de la Enfermedad , Drenaje/métodos , Derrame Pleural Maligno/terapia , Pleurodesia/métodos , Calidad de Vida , Humanos , Talco/administración & dosificaciónRESUMEN
BACKGROUND: Malignant pleural effusions are a serious complication of many late stage cancers that adversely affect quality of life. Pleurodesis with talc slurry is a standard treatment option, but clinical failures occur, possible due to poor talc delivery. A novel drug-delivery system was developed that fills the entire thoracic cavity with a liquid foam containing talc. The foam is designed to gel and adhere to the tissue walls at body temperature, to improve talc deposition and efficacy. METHODS: Rheology, foam stability, and ex-vivo coating and bio-adhesion studies were performed on three concentrations of a novel hydrogel talc foam system that was developed to improve delivery of talc to the pleural surfaces. A New Zealand rabbit model of pleurodesis was used to evaluate effectiveness of the foams at inducing adhesion formation and compared to talc slurry. The rabbits were recovered after they had one of the test agents instilled into their pleura, and then sacrificed after 28 days. Pleurodesis was assessed by a blinded pathologist using a standardized pathological scoring system. RESULTS: All talc foam formulations produced foams that gelled at physiological temperatures and were relatively stable for at least two hours. As the concentration of the formulation increased the gelation temperature decreased and the foam adhesiveness increased. Rabbits that received talc foam had significantly greater adhesion formation than talc slurry (mean score of 2.21 vs. 1.18 (p < 0.05)). Rabbits that received the 20% foam developed the most adhesions. CONCLUSIONS: This study demonstrates that our triblock copolymer hydrogel foam delivery system enhances adhesion formation in an experimental model. This novel approach can have important clinical impact, potentially improving efficacy of existing therapies and reducing the need for more invasive treatments.
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Hidrogeles , Derrame Pleural Maligno/tratamiento farmacológico , Pleurodesia/métodos , Talco/administración & dosificación , Animales , Sistemas de Liberación de Medicamentos , Masculino , Conejos , Talco/uso terapéutico , Adherencias Tisulares/inducido químicamenteRESUMEN
Rationale: The likelihood of achieving pleurodesis after indwelling pleural catheter (IPC) placement for malignant pleural effusion varies with the specific drainage strategy used: symptom-guided drainage, daily drainage, or talc instillation through the IPC (IPC + talc). The relative cost-effectiveness of one strategy over the other is unknown.Objectives: We performed a decision tree model-based analysis to ascertain the cost-effectiveness of each IPC drainage strategy from a healthcare system perspective.Methods: We developed a decision tree model using theoretical event probability data derived from three randomized clinical trials and used 2019 Medicare reimbursement data for cost estimation. The primary outcome was incremental cost-effectiveness ratio (ICER) over an analytical horizon of 6 months with a willingness-to-pay threshold of $100,000/quality-adjusted life-year (QALY). Monte Carlo probabilistic sensitivity analysis and one-way sensitivity analyses were conducted to measure the uncertainty surrounding base case estimates.Results: IPC + talc was a cost-effective alternative to symptom-guided drainage, with an ICER of $59,729/QALY. Monte Carlo probabilistic sensitivity analysis revealed that this strategy was favored in 54% of simulations. However, symptom-guided drainage was cost effective for pleurodesis rates >20% and for life expectancy <4 months. Daily drainage was not cost effective in any scenario, including for patients with nonexpandable lung, in whom it had an ICER of $2,474,612/QALY over symptom-guided drainage.Conclusions: For patients with malignant pleural effusion and an expandable lung, IPC + talc may be cost effective relative to symptom-guided drainage, although considerable uncertainty exists around this estimation. Daily IPC drainage is not a cost-effective strategy under any circumstance.
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Catéteres de Permanencia/economía , Árboles de Decisión , Derrame Pleural Maligno/terapia , Pleurodesia/métodos , Talco/administración & dosificación , Anciano , Anciano de 80 o más Años , Análisis Costo-Beneficio , Femenino , Humanos , Masculino , Medicare , Modelos Teóricos , Derrame Pleural Maligno/economía , Pleurodesia/economía , Años de Vida Ajustados por Calidad de Vida , Ensayos Clínicos Controlados Aleatorios como Asunto , Talco/economía , Estados UnidosRESUMEN
PURPOSE: Many patients diagnosed with advanced cancer have malignant pleural effusion that does not respond to chemotherapy or radiation therapy. These patients often have respiratory symptoms, especially dyspnea. In order to relieve these symptoms, various procedures including chemical pleurodesis have been performed. Although talc is the most widely used and effective sclerosing agent, there it has various adverse effects. The objective of this study was to determine whether Viscum (ABNOVA Viscum® Fraxini Injection, manufactured by ABNOVA GmbH, Germany) could be used as an agent to replace talc in clinical practice. METHODS: Data of 56 patients with malignant pleural effusion who received chemical pleurodesis after tube thoracostomy from January 2003 to December 2017 were retrospectively reviewed to analyze clinical course and response after pleurodesis with each agent. RESULTS: After pleurodesis, changes in numeric rating scale (NRS) was 1.4 ± 1.6 in the talc group and 0.5 ± 1.5 in the Viscum group (p = 0.108). Changes in white blood cell counts after pleurodesis were 4154.8 ± 6710.7 in the talc group and 3487.3 ± 6067.7 in the Viscum group (p = 0.702). Changes in C-reactive protein (CRP) were 9.03 ± 6.86 in the talc group and 6.3 ± 7.5 in the Viscum group (p = 0.366). The success rate of pleurodesis was 93.3% in the talc group and 96% in the Viscum group (p = 0.225). CONCLUSION: Viscum pleurodesis showed comparable treatment results with talc pleurodesis while its adverse effects such as chest pain and fever tended to be relatively weak.
Asunto(s)
Neoplasias/terapia , Extractos Vegetales/administración & dosificación , Derrame Pleural Maligno/terapia , Pleurodesia/métodos , Viscum/química , Adulto , Anciano , Tubos Torácicos , Disnea/tratamiento farmacológico , Femenino , Alemania , Humanos , Masculino , Persona de Mediana Edad , Neoplasias/patología , Extractos Vegetales/efectos adversos , Derrame Pleural Maligno/patología , Pleurodesia/efectos adversos , Estudios Retrospectivos , Talco/administración & dosificación , Talco/efectos adversos , Resultado del TratamientoRESUMEN
Objectives: Pleurodesis is an important management option to palliate breathlessness in patients with malignant pleural effusion (MPE). This systematic review aimed to examine available literature for studies investigating factors that predict pleurodesis outcome.Methods: The healthcare databases advanced search (HDAS) Medline and Embase in addition to Cochrane Database of Systematic Reviews were searched on for publications reporting on pleurodesis for MPE in English language. All study types reporting previously unpublished data on predictors of pleurodesis success were included. Thirty-four studies involving 4626 patients were included in the systematic review.Results: The most common pleurodesis agent used was talc which was used in 27 studies. Meta-analyses demonstrated that the strongest predictors of pleurodesis success were higher pleural fluid pH, smaller volume of effusion pre-pleurodesis and full lung re-expansion post effusion drainage. Shorter duration of tube drainage, higher pleural fluid glucose, lower LDH, and lower pleural tumor burden all seem to favor pleurodesis success, but with considerable statistical heterogeneity between studies. Available data do not suggest that chest tube size affects pleurodesis outcome.Conclusion: Overall, available results are difficult to interpret due to evidence quality. Prospective studies are needed to further explore these factors.Protocol registration: CRD42018115874 (Prospero database of systematic reviews).
Asunto(s)
Derrame Pleural Maligno/tratamiento farmacológico , Pleurodesia , Anciano , Tubos Torácicos , Drenaje , Femenino , Humanos , Masculino , Persona de Mediana Edad , Talco/administración & dosificación , Resultado del TratamientoRESUMEN
Importance: Malignant pleural effusion (MPE) is challenging to manage. Talc pleurodesis is a common and effective treatment. There are no reliable data, however, regarding the optimal method for talc delivery, leading to differences in practice and recommendations. Objective: To test the hypothesis that administration of talc poudrage during thoracoscopy with local anesthesia is more effective than talc slurry delivered via chest tube in successfully inducing pleurodesis. Design, Setting, and Participants: Open-label, randomized clinical trial conducted at 17 UK hospitals. A total of 330 participants were enrolled from August 2012 to April 2018 and followed up until October 2018. Patients were eligible if they were older than 18 years, had a confirmed diagnosis of MPE, and could undergo thoracoscopy with local anesthesia. Patients were excluded if they required a thoracoscopy for diagnostic purposes or had evidence of nonexpandable lung. Interventions: Patients randomized to the talc poudrage group (n = 166) received 4 g of talc poudrage during thoracoscopy while under moderate sedation, while patients randomized to the control group (n = 164) underwent bedside chest tube insertion with local anesthesia followed by administration of 4 g of sterile talc slurry. Main Outcomes and Measures: The primary outcome was pleurodesis failure up to 90 days after randomization. Secondary outcomes included pleurodesis failure at 30 and 180 days; time to pleurodesis failure; number of nights spent in the hospital over 90 days; patient-reported thoracic pain and dyspnea at 7, 30, 90, and 180 days; health-related quality of life at 30, 90, and 180 days; all-cause mortality; and percentage of opacification on chest radiograph at drain removal and at 30, 90, and 180 days. Results: Among 330 patients who were randomized (mean age, 68 years; 181 [55%] women), 320 (97%) were included in the primary outcome analysis. At 90 days, the pleurodesis failure rate was 36 of 161 patients (22%) in the talc poudrage group and 38 of 159 (24%) in the talc slurry group (adjusted odds ratio, 0.91 [95% CI, 0.54-1.55]; P = .74; difference, -1.8% [95% CI, -10.7% to 7.2%]). No statistically significant differences were noted in any of the 24 prespecified secondary outcomes. Conclusions and Relevance: Among patients with malignant pleural effusion, thoracoscopic talc poudrage, compared with talc slurry delivered via chest tube, resulted in no significant difference in the rate of pleurodesis failure at 90 days. However, the study may have been underpowered to detect small but potentially important differences. Trial Registration: ISRCTN Identifier: ISRCTN47845793.
Asunto(s)
Derrame Pleural Maligno/terapia , Pleurodesia/métodos , Talco/administración & dosificación , Anciano , Tubos Torácicos , Drenaje , Femenino , Humanos , Masculino , Persona de Mediana Edad , Toracoscopía , Insuficiencia del TratamientoRESUMEN
BACKGROUND AND OBJECTIVE: Chemical pleurodesis is performed for patients with MPE with a published success rate of around 80%. It has been postulated that inflammation is key in achieving successful pleural symphysis, as evidenced by higher amounts of pain or detected inflammatory response. Patients with mesothelioma are postulated to have a lower rate of successful pleurodesis due to lack of normal pleural tissue enabling an inflammatory response. METHODS: The TIME1 trial data set, in which pleurodesis success and pain were co-primary outcome measures, was used to address a number of these assumptions. Pain score, systemic inflammatory parameters as a marker of pleural inflammation and cancer type were analysed in relation to pleurodesis success. RESULTS: In total, 285 patients were included with an overall success rate of 81.4%. There was a significantly higher rise in CRP in the Pleurodesis Success group compared with the Pleurodesis Failure group (mean difference: 19.2, 95% CI of the difference: 6.2-32.0, P = 0.004) but no significant change in WCC. There was no significant difference in pain scores or analgesia requirements between the groups. Patients with mesothelioma had a lower rate of pleurodesis success than non-mesothelioma patients (73.3% vs 84.9%, χ2 = 5.1, P = 0.023). CONCLUSION: Change in CRP during pleurodesis is associated with successful pleurodesis but higher levels of pain are not associated. Patients with mesothelioma appear less likely to undergo successful pleurodesis than patients with other malignancies, but there is still a significant rise in systemic inflammatory markers. The mechanisms of these findings are unclear but warrant further investigation.