Survival in patients with malignant pleural effusion undergoing talc pleurodesis

Highlights

• Successful pleurodesis is associated with survival benefit in malignant effusion.

• The survival benefit is maintained after controlling for primary tumour type.

• Talc pleurodesis success rates vary between 50–80% according to setting.

Abstract

Objectives

Recent observations indicate a potential survival benefit in patients with malignant pleural effusion (MPE) who achieve successful pleurodesis in comparison to patients who experience effusion recurrence post pleurodesis. This study aimed to explore this observation using two datasets of patients with MPE undergoing talc pleurodesis.

Materials and Methods

Dataset 1 comprised patients who underwent talc pleurodesis at Oxford Pleural Unit for MPE. Dataset 2 comprised patients enrolled in the TIME1 clinical trial. Pleurodesis success was defined as absence of need for further therapeutic procedures for MPE in the three months following pleurodesis. Data on various clinical, laboratory and radiological parameters were collected and survival was compared according to pleurodesis outcome (success vs. failure) after adjusting for the aforementioned parameters.

Results

Dataset 1 comprised 60 patients with mean age 74.1±10.3 years. The most common primary malignancies were mesothelioma, breast and lung cancer. 29 patients (48.3%) achieved pleurodesis. The adjusted odds ratio (aOR) for poor survival with pleurodesis failure was 2.85 (95% CI 1.08–7.50, =p 0.034).

Dataset 2 comprised 259 patients from the TIME1 trial. The mean age was 70.8±10.3 and the most common primary malignancies were mesothelioma, lung and breast cancer. Pleurodesis was successful in 205 patients (79%). aOR for poor survival was 1.62 (95% CI 1.09–2.39, p = 0.015).

Conclusion

Achieving pleurodesis seems to impart a survival benefit in patients with MPE. Further studies are required to explore factors that may contribute to this phenomenon and to address the difference in survival between pleurodesis and indwelling pleural catheter interventions.

Introduction

Patients with malignant pleural effusion (MPE) are often symptomatic with breathlessness and their management is typically centred on palliation of their symptoms. [1] Therapeutic aspiration of the pleural fluid brings short-term benefit as the effusion tends to recur quickly and longer term palliative methods are frequently required [2]. The standard management in the UK for patients with MPE who do not have unexpandable lung is performing pleurodesis by applying talc to the pleural space [3].

The life expectancy of patients with MPE is usually expressed in months with median survival times ranging between 3–12 months. [1] It is common practice to reserve pleurodesis for patients with a good level of fitness commensurate with better performance status and to offer therapeutic thoracentesis to frailer patients with a more limited prognosis. A useful tool to predict survival in patients with MPE is the LENT score which is a robust method that provides important prognostic information, but it is yet to be prospectively validated [4]. The score utilises four readily available parameters namely; the pleural fluid LDH level, the Eastern Cooperative Oncology Group (ECOG) performance status, the serum neutrophil to lymphocyte ratio and the histology of the primary tumour to predict the survival of a given patient. More recently, a new tool has been devised to predict the mortality risk at three months in patients with MPE based on clinical and biochemical parameters and is called the PROMISE score [5].

It has been previously noted that in patients with mesothelioma, the survival of patients who undergo pleurodesis (regardless of the method used) is longer in comparison to patients who do not receive this treatment [6] and similar findings were noted in MPE secondary to non-pleural malignancies [7]. It could be argued that this survival difference is inherently related to the selection bias of better performance status patients who are offered pleurodesis; however, this difference was still observed when survival only in patients with higher performance status was studied [7]. Recent data suggest that a survival benefit is seen in MPE patients who have successful pleurodesis in comparison to those who fail pleurodesis and this has been reported in cohorts of patients with mesothelioma [8,9] and other malignancies [10] and where talc [9,11] or other substances such as bleomycin [10] were used to induce pleurodesis.

This study aimed to explore whether there was a difference in survival according to pleurodesis outcome in patients with MPE undergoing pleurodesis using large databases of prospectively collected data on patients with MPE undergoing talc pleurodesis.