Pleurodesis

A pleurodesis is a surgical procedure used to treat pleural effusion in mesothelioma patients. It is not a curative treatment, but rather an approach that is recommended when symptoms like chest pain and shortness of breath are causing discomfort.

Pleural effusion is the buildup of excess fluid in the pleural space, the space between the visceral lining and parietal lining of the lungs. The goal of a pleurodesis is to eliminate the pleural space so that fluid can no longer accumulate.

Considered the best palliative treatment (which aims to ease symptoms rather than cure) for pleural effusions, this common procedure for mesothelioma patients is usually performed in a hospital and calls for a three- to five-day stay. The treatment is considered more effective than a thoracentesis, which drains the fluid of pleural effusions but does not close the pleural space and thus allows reaccumulation of fluid.

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Who Qualifies for a Pleurodesis

Not all mesothelioma patients are candidates for a pleurodesis. For example, if a patient has extensive tumor coverage of both the visceral and parietal linings, a pleurodesis is less effective at sealing the pleural space. Patients with a life expectancy of a few months may not undergo the procedure because they may want to avoid surgical procedures and any discomfort associated with recovery. If mesothelioma has progressed and the pleural cavity is compromised, a pleurodesis is no longer recommended and additional palliative treatments will be considered.

Mesothelioma patients diagnosed before stage IV will qualify for a pleurodesis, and some stage IV patients will qualify as well. Patients with a longer life expectancy and those in severe pain from pleural effusion may undergo a pleurodesis and will benefit from pain relief after the fluid is drained and tissues heal from the procedure. If a patient qualifies for a more aggressive surgery like a pleurectomy/decortication, a pleurodesis is not performed.

In many cases, mesothelioma patients first undergo a diagnostic thoracoscopy before a pleurodesis is considered. During the thoracoscopy, a biopsy is collected and pleural effusion fluid is drained. Quick recurrence of the effusion indicates that the patient will benefit from a pleurodesis.

The Procedure

The first step of a pleurodesis involves draining excess fluid from the pleural space. This is a very important step because the efficacy of the procedure will depend on whether the pleural space is free of fluid. Once the fluid is drained, there are two methods for producing inflammation on the pleural linings: chemical and mechanical. Before the procedure, patients will usually be medicated with a narcotic for pain and a benzodiazepine (such as Xanax) for comfort. Because of cheap cost and ease of the procedure, a chemical pleurodesis with talc is the most common pleurodesis method.

  • Chemical Pleurodesis

    Once all the fluid has been removed, asbestos-free talc will be inserted through a chest tube to cause inflammation in the chest cavity. After the talc has been administered, patients will be asked to lie down for a few hours and periodically change positions so that the talc is evenly distributed throughout the pleural space. Once sufficiently distributed, the talc will be removed via the same chest tube.

    As the talc is suctioned from the pleural cavity, the pleural space will become sealed with scar tissue and fluid won’t be able to accumulate in the future. Substances like bleomycin, tetracycline, nitrogen mustard and povidone iodine can also be used in substitute of talc, but talc is the most popular option. It’s also the least expensive to administer.

  • Mechanical Pleurodesis

    A pleurodesis can involve more invasive surgery if a doctor feels a different approach will present better results. In this scenario, a thoracoscopy is performed and inflammation is achieved by irritating the pleura with either a rough pad, gauze or a mechanical rotary brush. The two lung lining layers are then fused together to eliminate any space for fluid retention. Any suspicious tissue can also be removed during this type of pleurodesis.

Side Effects and Complications

The following side effects and complications have been reported with a pleurodesis:

  • Chest pain
  • Fever
  • Infection
  • Cardiovascular complications (rare)
  • Adult Respiratory Distress Syndrome (rare)

Chest pain and fever are the most common adverse effects of a pleurodesis. Some patients report a tight or burning feeling around the lungs, but this is usually eased with medication prior to the procedure. Because of the inflammatory response that helps to close the pleural space, a fever commonly develops about four to 12 hours after a talc pleurodesis.

Another possible complication of a pleurodesis is malignant growth at the site where the chest tube was inserted. This type of metastasis is referred to as seeding, but radiation therapy along the insertion site after the procedure can prevent seeding.

Treatment Results

After a short recovery from the procedure, patients should feel a big difference in their ability to breathe. More than 95 percent of patients with pleural effusion experience shortness of breath, cough, fever and pain. Following a pleurodesis, such symptoms should decrease.

In a trial on 33 patients with malignant pleural effusion, a talc pleurodesis controlled effusion in 90 percent of cases. A review of 1,168 malignant pleural effusion patients who underwent a pleurodesis showed the talc method was the most effective, with a 93 percent success rate.

Additional Resources

  1. Remedy’s Health Communities. (2011, Dec. 5). Pleural Effusion Treatment. Retrieved from http://www.healthcommunities.com/pleural-effusion/treatment.shtml
  2. Baldi, Alfonso. (2008). Mesothelioma from Bench Side to Clinic. Nova Science Publishers: New York.
  3. Ed. by O’Byrne, K. and Rusch, V. (2006). Malignant Pleural Mesothelioma. Oxford University Press: New York.
  4. Shahriyour, A. and Cameron, R. (2005). Management of Pleural Effusions in Mesothelioma. In Pass, H., Vogelzang, N. & Carbone, M. (Eds.), Malignant Mesothelioma (pp. 638-652). New York: Springer.
  5. American Thoracic Society. (1988). Management of Malignant Pleural Effusions. Retrieved from http://www.thoracic.org/statements/resources/respiratory-disease-adults/1987.pdf

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