Pleurodesis

A pleurodesis is a surgical procedure used to treat and prevent pleural effusions, a major symptom of pleural mesothelioma and other asbestos-related diseases. If a patient is not eligible for tumor-removing surgery, a pleurodesis can still improve their quality of life by relieving pain and making it easier to breathe.

The coughing, chest pain and breathing difficulty associated with asbestos-related diseases are often caused by a buildup of excess fluid in the space between the inner and outer layers formed by the pleural lining around the lungs. This painful condition is called a pleural effusion, and it makes breathing difficult because it puts pressure on the lungs. If left untreated, it may lead to infection or the collapse of a lung.

Pleurodesis Facts

  • Removes excess fluid buildup, relieving pressure on lungs

  • Prevents future fluid buildup in most patients

  • Alleviates several pleural mesothelioma symptoms

  • Less invasive than major tumor-removing surgery

The goal of a pleurodesis procedure is to drain the excess fluid and then eliminate the pleural space so fluid can no longer accumulate there. Pleurodesis is a type of palliative treatment for pleural mesothelioma and many other cancers, meaning doctors perform it to relieve symptoms rather than kill or remove cancer cells.

Pleurodesis offers a more permanent solution than the other common procedures for treating pleural effusions. A thoracentesis procedure drains excess fluid but does not seal the pleural space, while the insertion of a pleural catheter requires regular home maintenance, potentially for the rest of a patient’s life.

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Who Qualifies for a Pleurodesis?

Not all pleural mesothelioma patients are candidates for a pleurodesis.

If the cancer has progressed to a late stage and the patient has a trapped lung, meaning there is extensive tumor coverage of the two layers of the pleural lining, a pleurodesis will not be effective at sealing the pleural space, according to a 2017 review of the procedure.

In addition, patients with a life expectancy of a few months may not undergo the procedure because they may want to avoid hospital stays and the discomfort associated with recovering from surgery. In these cases, doctors will consider other palliative treatments for mesothelioma.

On the other hand, if the patient is in good overall health and the cancer is still localized, they may be a candidate for a more aggressive tumor-removing surgery such as pleurectomy/decortication. Aggressive treatment of pleural mesothelioma usually involves removing the pleural lining rather than sealing it.

Jo D. is a mesothelioma survivor and was a candidate for having a pleurodesis procedure done.

“Attitude counts for a lot, and willingness to pursue the treatment recommendations all add up to a better chance for survival.”

Jo D. talc pleurodesis patient and pleural mesothelioma survivor diagnosed in 2009.

Pleurodesis Procedures

A pleurodesis procedure typically involves a hospital stay of three to seven days, though a newer method being tried by some specialists requires only a brief overnight stay. Before the procedure, patients are usually medicated with a narcotic for pain and a benzodiazepine, such as Xanax, for comfort.

The first step of a pleurodesis procedure is to drain the excess fluid from the pleural space. The next step is to irritate the two layers of the pleural lining, which provokes inflammation and scarring. The scar tissue fuses the two pleural layers together, eliminating the space between them.

There are two methods for producing inflammation in the pleural lining: chemical and mechanical. Because of its low cost and the ease of the procedure, the most common method is chemical pleurodesis with talc.

Chemical Pleurodesis

Talc is a type of clay mineral, and it has historically been the main ingredient in baby powder. The talc used for pleurodesis is medical grade, sterile and asbestos-free.

During chemical pleurodesis, talcum powder can be inserted into the pleura using thoracoscopy tools, or it can be mixed with fluid into a talc slurry and inserted through a chest tube. Once the talc is sufficiently distributed, the doctor then removes it.

Substances such as bleomycin, tetracycline, nitrogen mustard and povidone iodine can also be used for chemical pleurodesis, but talc is the most popular option because it is effective and the least expensive to administer.

A 2013 Australian review of pleurodesis for mesothelioma patients confirmed talc pleurodesis as the most effective treatment, and a 2016 Cochrane review also found talc pleurodesis the most effective for malignant pleural effusions.

Rapid Pleurodesis

One disadvantage of the common talc pleurodesis procedure is the week-long hospital stay often required for recovery. Many specialists recommend inserting a pleural catheter instead because it can be done as an outpatient procedure.

To find the best compromise between these two options, specialists have developed a “rapid pleurodesis” procedure that uses a pleural catheter and chemical pleurodesis. This method allows most patients to be discharged from the hospital within 48 hours.

A 2014 randomized trial and a 2016 retrospective analysis determined a rapid pleurodesis protocol can be as effective as the common chemical pleurodesis procedure most doctors currently follow.

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Mechanical Pleurodesis

Another way to cause the layers of the pleura to fuse together is to irritate them with a rough pad, gauze or a mechanical rotary brush instead of inserting a chemical substance.

Though this method may involve a more invasive surgical procedure, the results of a 2015 study suggest mechanical pleurodesis may provide greater symptom relief than chemical pleurodesis.

Pleurodesis Complications and Side Effects

Common side effects and complications of pleurodesis:

  • Chest pain

  • Fever

  • Infection

Chest pain and fever are the most common adverse effects of 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 seal the pleural space, a fever commonly develops about four to 12 hours after a talc pleurodesis.

As with any surgical procedure, there is a risk of infection that may need to be treated with antibiotics. In rare cases, pleurodesis may result in cardiovascular complications or acute respiratory distress syndrome.

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Karen Selby, RN and Patient Advocate at The Mesothelioma Center

Karen Selby joined Asbestos.com in 2009. She is a registered nurse with a background in oncology and thoracic surgery and was the director of a tissue bank before becoming a Patient Advocate at The Mesothelioma Center. Karen has assisted surgeons with thoracic surgeries such as lung resections, lung transplants, pneumonectomies, pleurectomies and wedge resections. She is also a member of the Academy of Oncology Nurse & Patient Navigators.

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Sources
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  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
  6. Fysh, E. et al. (2013). Pleurodesis outcome in malignant pleural mesothelioma. Retrieved from http://thorax.bmj.com/content/thoraxjnl/early/2013/01/07/thoraxjnl-2012-203043.full.pdf
  7. Clive, A. et al. (2016). Interventions for the management of malignant pleural effusions: a network meta-analysis. Cochrane Database Syst Rev. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/27155783
  8. Walker, S., Bibby, A. & Maskell, N. (2017). Current best practice in the evaluation and management of malignant pleural effusions. Therapeutic Advances in Respiratory Disease. Retrieved from http://journals.sagepub.com/doi/pdf/10.1177/1753465816671697

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