Best current therapy for patients with malignant pleural effusion.

slurry or thoracoscopic talc poudrage pleurodesis. Furthermore, it remains unclear whether spontaneous pleurodesis with TPC prolongs life. In survivors to 14 weeks, the mean time to pleurodesis was 54 days. One coauthor’s earlier study revealed that those with TPC who had spontaneous pleurodesis lived over 3 times as long as those who did not have pleurodesis [2] . If pleurodesis by itself prolongs life, why not use more rapid pleurodesis techniques, such as talc slurry or thoracoscopic talc poudrage in the best candidates for longer survival? The report of Sabur et al. [1] complements a recent RCT by Davies et al. [3] (TIME2) from 7 centers in the UK, which found that talc slurry pleurodesis was ‘not inferior’ to TPC in controlling dyspnea 42 days after randomization [3] . The median length of the initial hospitalization was shorter in the TPC group ( ! 1 day vs. 4 days) (shorter hospitalizations – a median of 3 days – have been reported with thoracoscopic talc poudrage) [4] . There was no significant difference in qol. The study by Davies et al. [3] was not powered to compare survival in the 2 groups and results from the 2 procedures were discordant for complications versus the need for subsequent procedures. These mixed results suggest that the choice of procedure may depend on the specific circumstances of each patient and local capabilities. The randomization process led to half A vexing problem for patients and physicians today is malignant pleural effusion. These patients’ generally short survivals may be managed with hospice care or chemotherapy and radiation therapy. Palliative options for dyspnea include repeated thoracenteses, placement of an indwelling plastic catheter for drainage at home, and pleurodesis. Little controlled data is available comparing these treatments. Fortunately, in this issue of Respiration, Sabur et al. [1] report on quality of life (qol) in 4 Canadian centers after insertion of a tunneled pleural catheter (TPC) left in place either for life or until ‘spontaneous’ pleurodesis occurred. This study indicates that patients surviving 14 weeks after TPC placement have improved mean qol, dyspnea scores, and patient satisfaction compared to baseline. Median dyspnea scores, which might have proved complementary, were omitted. However, 45% of patients were deceased at 14 weeks’ follow-up. No attempt was made to determine the qol and dyspnea from family members of the 45% who died between 2 and 14 weeks, roughly half the patients. So the qol/dyspnea results are based on the half of the patients with relatively long survival. Other information of interest would be a full accounting of lifetime medical events – qol, dyspnea, and otherwise – following TPC, in comparison with control groups of talc Published online: November 21, 2012