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Original Investigation
December 5, 2019

Effect of Thoracoscopic Talc Poudrage vs Talc Slurry via Chest Tube on Pleurodesis Failure Rate Among Patients With Malignant Pleural Effusions: A Randomized Clinical Trial

Author Affiliations
  • 1Academic Respiratory Unit, University of Bristol, Bristol, United Kingdom
  • 2North Bristol Lung Centre, North Bristol NHS Trust, Bristol, United Kingdom
  • 3Oxford Respiratory Trials Unit, Nuffield Department of Experimental Medicine, University of Oxford, United Kingdom
  • 4Pragmatic Clinical Trials Unit, Queen Mary University of London, London, United Kingdom
  • 5Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, United Kingdom
  • 6Somerset Lung Centre, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, United Kingdom
  • 7North West Lung Centre, Manchester University NHS Foundation Trust, Manchester, United Kingdom
  • 8Lungs for Living Research Centre, University College London, London, United Kingdom
  • 9Respiratory Medicine, Nottingham University Hospitals NHS Trust, United Kingdom
  • 10University of Nottingham, United Kingdom
  • 11Glasgow Pleural Disease Unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom
  • 12Institute of Infection, Immunity & Inflammation, University of Glasgow, Glasgow, United Kingdom
  • 13Respiratory Department, Sherwood Forest Hospitals Trust, United Kingdom
  • 14Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
  • 15Glan Clwyd Hospital, North Wales, United Kingdom
  • 16Lancashire Teaching Hospitals NHS, Foundation Trust, Preston, United Kingdom
  • 17Respiratory Department, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, United Kingdom
  • 18Respiratory Department, Guy's and St Thomas' NHS Trust, London, United Kingdom
  • 19Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees, United Kingdom
  • 20Medway NHS Foundation Trust, Gillingham, United Kingdom
  • 21Aintree University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
  • 22Milton Keynes University Hospital, Milton Keynes, United Kingdom
  • 23Croydon University Hospital, Croydon, United Kingdom
  • 24University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
  • 25Worcester Acute Hospitals NHS Trust, Worcester, United Kingdom
  • 26Cardiff and Vale University Health Board, Wales, United Kingdom
  • 27Department of Respiratory Medicine, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, United Kingdom
  • 28Institute for Global Health, University College London, London, United Kingdom
JAMA. 2020;323(1):60-69. doi:10.1001/jama.2019.19997
Key Points

Question  Is thoracoscopy with local anesthesia and administration of talc poudrage more effective than chest tube placement with local anesthesia and administration of talc slurry at inducing pleurodesis in individuals with malignant pleural effusion?

Findings  In this randomized clinical trial that included 330 patients, thoracoscopic talc poudrage, compared with chest tube insertion and talc slurry, resulted in no significant difference in the rate of pleurodesis failure at 90 days (22% vs 24%).

Meaning  Among patients with malignant pleural effusion, there was no significant difference in the rate of pleurodesis failure between the use of talc poudrage and talc slurry; however, the study may have been underpowered to detect small but potentially important differences.

Abstract

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

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