Optimising the management of malignant pleural effusion

Abstract

Introduction
Malignant pleural effusion (MPE) affects up to 15% of patients with cancer (1). Effective symptom control is paramount, given a median survival of 3 to 12 months (2). The mainstay of management relies on fluid drainage from the chest cavity for breathlessness relief, followed by attempted pleurodesis (to prevent fluid recurrence) or indwelling pleural catheter (IPC) placement. However, pleurodesis fails in approximately 20% of cases (3) and long-term IPC placement may be undesirable.
Methods
A systematic review and network meta-analysis (NMA) summarised current evidence and aimed to ascertain the most effective pleurodesis agent. Building on review findings, two studies aimed to characterise patients at risk of pleurodesis failure. Finally, a randomised controlled trial (RCT) was undertaken to determine whether existing interventions for MPE may be combined to provide more effective symptom control and reduced time in hospital compared to standard care. Qualitative interviews explored the patient experience of the interventions.
Results
In the systematic review and NMA, talc slurry and talc poudrage were both effective pleurodesis agents. A higher risk of pleurodesis failure was observed with IPC use, but reduced risk of requiring a repeat invasive procedure.
When seeking to characterise patients at risk of pleurodesis failure, no features were associated with non-expandable lung. A novel biomarker was not associated with an increased risk of MPE loculation.
Results from the TACTIC RCT are awaited. Recruitment is complete, with 124 participants randomised across 11 UK centres. Qualitative analysis is ongoing, but findings suggest that the combined procedure is acceptable to patients and that outpatient MPE management is preferred.
Discussion
The systematic review and NMA highlights that patients should have access to a range of interventions, including provision for daily IPC drainage. By combining diagnostic and therapeutic interventions in a single ambulatory procedure, a positive outcome from the TACTIC RCT could be practice changing.

Date of Award	18 Jun 2024
Original language	English
Awarding Institution	University of Bristol
Supervisor	Nick A Maskell (Supervisor) & Rahul Bhatnagar (Supervisor)