Pleurodesis

What Is a Pleurodesis?

Pleurodesis is a procedure to 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.

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 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 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.

Who Qualifies for a Pleurodesis?

Not all pleural mesothelioma patients are candidates for a pleurodesis.

If the cancer has progressed to an advanced stage and the patient has a trapped lung, meaning there is extensive tumor coverage of the pleural lining such that the lung cannot fully expand, 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.

Surgical Consultation for Pleurodesis

A surgical consultation is an important step to determine whether a patient is a good fit for a pleurodesis. During a consultation, patients meet with the surgeon and surgical team to discuss eligibility, risks, benefits and the potential for complications. The surgical team will review all medical records, including personal history and all records related to the mesothelioma diagnosis.

Consultations may be carried out in person or virtually through video conferencing. Patients may ask questions about the procedure, bring up any concerns or fears they may have and get to know more about the surgeon and the surgical team.

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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.

Before the actual pleurodesis procedure, excess fluid from the pleural space needs to be drained. 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 common 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. In either approach, a chest tube is left inserted until talc is sufficiently distributed and then removed.

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.

In a 2021 retrospective study, chemical pleurodesis was successful in over 31% of cases and had a significant contribution to patient survival.

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

Rapid Pleurodesis

One disadvantage of the talc pleurodesis procedure is the 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.

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

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 can develop 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.