Should we really compare indwelling pleural catheters to any pleurodesis?

ation of the fluid and adhesiolysis during thoracoscopy, showed excellent immediate (>90%) and 1-year (85%) results [6] , with few side effects, producing better quality and quantity of pleural symphysis compared to talc slurry [7] . Talc seems to have another interesting local antitumor effect, the induction of apoptosis of cancer cells [4, 8] . Iodopovidone is an interesting alternative to talc for pleurodesis as it is cheap, safe and showed high efficacy rates (90%) [9] . Many chemotherapeutic agents, such as bleomycin, cisplatin and taxanes, which have lower efficacy but at the same time highest costs, have been tested [10] . New molecules such as cytokines (transforming growth factor-β), which are involved in the coagulation cascade [11] , are expensive, and data in humans are still lacking. To date, thoracoscopy with Luzenac talc poudrage remains the most effective low-cost method of pleurodesis in patients with MPE, a good performance status and long life expectancy [12–14] . Studies reporting data from patients with recurrent non-MPE are mainly retrospective or include only a small number of patients with many different causes of their disease (inhomogeneous population) [15–17] . Frequently, benign diseases necessitating an intervention in case of refractory pleural effusion are congestive heart failure, renal failure and hepatic cirrhosis [15, 16] . Patients with Pleural effusion is a common manifestation of malignancies, which either reveals the disease or occurs during the course of the disease. Overall, 150,000 new cases of malignant pleural effusions (MPE) are reported every year in the USA. Any neoplasm may lead to this manifestation: in primary tumors of the pleura (mesothelioma), it occurs in up to 95% of the cases, whereas in metastatic neoplasms in males lung carcinomas account for 40% and in females breast carcinomas account for 30% [1, 2] . Although the survival of patients with MPE is globally reported to be poor, we have to differentiate between patients with MPE as an initial manifestation of the disease, who are naïve to any treatment, and patients with MPE occurring during disease progression, who are relapsing and/or resisting to treatment [3] . Pleurodesis is a process involving multiple inflammatory cells recruited by cytokines, which leads to a coagulation-fibrinolysis imbalance and finally a development of adhesions between visceral and parietal pleurae in order to obliterate the pleural space to palliate effusion and symptoms [4] . Relief of dyspnea may be obtained regardless of radiographic findings. For pleurodesis, many compounds have been tested. The cheapest compound providing long-lasting pleurodesis is sterile, asbestos-free, calibrated Luzenac talc [5] . Talc insufflation, after evacuPublished online: May 6, 2014