Management of malignant pleural effusion

We were surprised that the review entitled ‘Interventional therapy for malignant pleural effusion’ by Thomas et al.1 made no mention of medical thoracoscopy. While surgical video-assisted thoracoscopic surgery does require general anaesthesia and single lung ventilation, medical thoracoscopy is performed with local anaesthesia and mild sedation and involves only a single sub 1-cm skin incision. In the investigation of suspected malignant pleural effusion, medical thoracoscopy offers the ability to obtain a definite histological diagnosis and talc pleurodesis in a single procedure. The authors state that ‘recent data have established that talc pleurodesis will fail in about 30% of patients’. We assume that this refers to the study by Fysh in Western Australia2 in malignant mesothelioma, although no reference is given. In that study, the talc pleurodesis was performed in a wide variety of institutions and very few patients had medical thoracoscopy. Our own single-centre series shows a 90% success rate for talc pleurodesis at medical thoracoscopy with no difference between mesothelioma and other malignancies. Success was defined as no need for further pleural intervention.3 While indwelling pleural catheters (IPC) clearly have a place, the quoted reduction in hospital admission days is balanced by the necessity of repeated and in some cases frequent drainage though the IPC and requirement for a fairly specialized support team to perform this. IPC may have become the preferred modality in many centres because of the lack of access to medical thoracoscopy rather than for any other reason, and this is certainly the situation in the United States. We feel that a single 45-min procedure followed by an average of 2–3 days in hospital offering definitive diagnosis and a 90% chance of no further intervention being required may be preferable to many patients to the prospect of having an indwelling chest tube with repeated aspirations for the rest of their lives. Patients being treated for malignant pleural effusion would benefit from centres offering a choice of treatment options.