Effusion recurrence and patient outcomes in malignant pleural effusion: a systematic review of pleurodesis and indwelling pleural catheters
Enzo Stella de Carvalho, Gustavo Pretel de Araujo, Heron Kairo Sabóia Sant’Anna Lima
Abstract
Objective: This review aimed to compare the efficacy and safety of these approaches. Methods: A systematic review was conducted in accordance with PRISMA 2020 guidelines. Studies published from 2014 to May 2025 were searched in PubMed, LILACS, and SciELO. After filtering and applying the inclusion criteria, 38 studies were selected for analysis. Results: A total of 3,088 patients were analyzed. Pleurodesis showed significantly lower recurrence rates compared to indwelling pleural catheters (IPC) (RR = 1.548; 95% CI: 1.31–1.80; p < 0.05). Among pleurodesis agents, 5% iodopovidone, doxycycline, and 0.3% silver nitrate were associated with the lowest recurrence rates. However, silver nitrate showed the highest incidence of severe adverse events. Talc poudrage and talc slurry were the most commonly used techniques, although they presented higher recurrence rates than the alternatives mentioned above. Daily or periodic drainage strategies demonstrated better outcomes than mixed-drainage strategies for IPC. Pleurodesis, especially with talc or iodopovidone, provided superior relief of dyspnea and better quality-of-life outcomes compared with IPC. Conversely, IPC was associated with shorter hospitalization periods and fewer immediate procedural complications, although it required prolonged catheter maintenance. Conclusions: Pleurodesis is more effective in reducing malignant pleural effusion recurrence and improving symptoms. IPC remains a useful option for selected patients, particularly those who are unsuitable for hospitalization or have non-expandable lungs.
Keywords
Referências
1. Scott H, Phil R. What you need to know about: the management of malignant pleural effusion. Br J Hosp Med. 2024;85(12):1-18. https://doi.org/10.12968/hmed.2024.0311 PMid:39831480.
2. Damaraju V, Sehgal IS, Muthu V, et al. Efficacy and safety of doxycycline versus iodopovidone for pleurodesis through an intercostal tube in malignant pleural effusions: a randomized trial. Support Care Cancer. 2023;31(8):454. https://doi.org/10.1007/s00520-023-07932-y PMid:37428348.
3. Cho JS, Na KJ, Lee Y, et al. Chemical pleurodesis using mistletoe extraction (ABNOVAviscum(R) injection) for malignant pleural effusion. Ann Thorac Cardiovasc Surg. 2016;22(1):20-6. https://doi.org/10.5761/atcs.oa.15-00230 PMid:26639937.
4. International Agency for Research on Cancer. Global Cancer Observatory: Cancer Today [Internet]. Lyon: IARC; 2022 [cited 2025 mar 24]. Available from: https://gco.iarc.fr/today/en/dataviz/bars?mode=cancer&group_populations=1&populations=76&sexes=1_2&key=total
5. Brasil. Departamento de Informação e Informática do Sistema Único de Saúde - DATASUS. Oncology pannel. Brasília: Ministério da Saúde; 2025.
6. Bhatnagar R, Piotrowska HEG, Laskawiec-Szkonter M, et al. Effect of thoracoscopic talc poudrage vs talc slurry via chest tube on pleurodesis failure rate among patients with malignant pleural effusions: a randomized clinical trial. JAMA. 2020;323(1):60-9. https://doi.org/10.1001/jama.2019.19997 PMid:31804680.
7. Thomas R, Fysh ETH, Smith NA, et al. Effect of an indwelling pleural catheter vs talc pleurodesis on hospitalization days in patients with malignant pleural effusion: the AMPLE randomized clinical trial. JAMA. 2017;318(19):1903-12. https://doi.org/10.1001/jama.2017.17426 PMid:29164255.
8. Haddaway NR, Page MJ, Pritchard CC, McGuinness LA. PRISMA2020: an R package and Shiny app for producing PRISMA 2020-compliant flow diagrams, with interactivity for optimised digital transparency and Open Synthesis. Campbell Syst Rev. 2022;18(2):e1230. https://doi.org/10.1002/cl2.1230 PMid:36911350.
9. Feller-Kopman D, Light R. Pleural disease. N Engl J Med. 2018;378(8):740-51. https://doi.org/10.1056/NEJMra1403503 PMid:29466146.
10. Kwok C, Thavorn K, Amjadi K, Aaron SD, Kendzerska T. Resource use and costs of indwelling pleural catheters versus pleurodesis for malignant pleural effusions: a population-based study. Ann Am Thorac Soc. 2024;21(6):940-8. https://doi.org/10.1513/AnnalsATS.202304-3330C PMid:38381853.
11. Penz ED, Mishra EK, Davies HE, Manns BJ, Miller RF, Rahman NM. Comparing cost of indwelling pleural catheter vs talc pleurodesis for malignant pleural effusion. Chest. 2014;146(4):991-1000. https://doi.org/10.1378/chest.13-2481 PMid:24832000.
12. Olfert JA, Penz ED, Manns BJ, et al. Cost-effectiveness of indwelling pleural catheter compared with talc in malignant pleural effusion. Respirology. 2017;22(4):764-70. https://doi.org/10.1111/resp.12962 PMid:27983774.
13. Fysh ETH, Bielsa S, Budgeon CA, et al. Predictors of clinical use of pleurodesis and/or indwelling pleural catheter therapy for malignant pleural effusion. Chest. 2015;147(6):1629-34. https://doi.org/10.1378/chest.14-1701 PMid:25474713.
14. Salamonsen MR, Lo AKC, Ng ACT, Bashirzadeh F, Wang WYS, Fielding DIK. Novel use of pleural ultrasound can identify malignant entrapped lung prior to effusion drainage. Chest. 2014;146(5):1286-93. https://doi.org/10.1378/chest.13-2876 PMid:25010364.
15. Psallidas I, Hassan M, Yousuf A, et al. Role of thoracic ultrasonography in pleurodesis pathways for malignant pleural effusions (SIMPLE): an open-label, randomised controlled trial. Lancet Respir Med. 2022;10(2):139-48. https://doi.org/10.1016/S2213-2600(21)00353-2 PMid:34634246.
16. Omoregbee BI, Okugbo S. Pleurodesis with povidone iodine in patients with malignant pleural effusion in a tertiary center in Nigeria. Pan Afr Med J. 2021;38:169. https://doi.org/10.11604/pamj.2021.38.169.2 PMid:33995776.
17. Ershadi R, Vahedi M, Zadeh HK, et al. Subcutaneous octreotide therapy for malignant pleural effusion after pleurodesis with talc powder: a placebo-controlled, triple-blind, randomized trial. Support Care Cancer. 2022;30(12):9833-40. https://doi.org/10.1007/s00520-022-07440-5 PMid:36357795.
18. Rahman NM, Pepperell J, Rehal S, et al. Effect of opioids vs NSAIDs and larger vs smaller chest tube size on pain control and pleurodesis efficacy among patients with malignant pleural effusion: the TIME1 randomized clinical trial. JAMA. 2015;314(24):2641-53. https://doi.org/10.1001/jama.2015.16840 PMid:26720026.
19. Andrade Neto JD, Terra RM, Teixeira RM, Pereira SV, Pego-Fernandes PM. Safety profile of the use of iodopovidone for pleurodesis in patients with malignant pleural effusion. Respiration. 2015;90(5):369-75. https://doi.org/10.1159/000440727 PMid:26439936.
20. Martin GA, Tsim S, Kidd AC, et al. Pre-EDIT: a randomized feasibility trial of elastance-directed intrapleural catheter or talc pleurodesis in malignant pleural effusion. Chest. 2019;156(6):1204-13. https://doi.org/10.1016/j.chest.2019.07.010 PMid:31374208.
21. Peddle-McIntyre CJ, Muruganandan S, McVeigh J, et al. Device assessed activity behaviours in patients with indwelling pleural catheter: a sub-study of the Australasian Malignant PLeural Effusion (AMPLE)-2 randomized trial. Respirology. 2023;28(6):561-70. https://doi.org/10.1111/resp.14451 PMid:36642702.
22. Iglesias Heras M, Juárez Moreno E, Ortiz de Saracho Bobo J, et al. Usefulness of thoracic ultrasound in the assessment of removal of indwelling pleural catheter in patients with malignant pleural effusion. Radiologia (Engl Ed). 2024;66(Suppl Suppl 1):S24-31. https://doi.org/10.1016/j.rxeng.2023.04.008 PMid:38642957.
23. Shafiq M, Simkovich S, Hossen S, Feller-Kopman DJ. Indwelling pleural catheter drainage strategy for malignant effusion: a cost-effectiveness analysis. Ann Am Thorac Soc. 2020;17(6):746-53. https://doi.org/10.1513/AnnalsATS.201908-6150C PMid:32125880.
24. Feller-Kopman DJ, Reddy CB, DeCamp MM, et al. Management of malignant pleural effusions. An official ATS/STS/STR clinical practice guideline. Am J Respir Crit Care Med. 2018;198(7):839-49. https://doi.org/10.1164/rccm.201807-1415ST PMid:30272503.
25. Thomas R, Francis R, Davies HE, Lee YC. Interventional therapies for malignant pleural effusions: the present and the future. Respirology. 2014;19(6):809-22. https://doi.org/10.1111/resp.12328 PMid:24947955.
26. Sivakumar P, Douiri A, West A, et al. OPTIMUM: a protocol for a multicentre randomised controlled trial comparing Out Patient Talc slurry via Indwelling pleural catheter for Malignant pleural effusion vs Usual inpatient Management. BMJ Open. 2016;6(10):e012795. https://doi.org/10.1136/bmjopen-2016-012795 PMid:27798020.
27. Bhatnagar R, Kahan BC, Morley AJ, et al. The efficacy of indwelling pleural catheter placement versus placement plus talc sclerosant in patients with malignant pleural effusions managed exclusively as outpatients (IPC-PLUS): study protocol for a randomised controlled trial. Trials. 2015;16(1):48. https://doi.org/10.1186/s13063-015-0563-y PMid:25880969.
28. Fitzgerald DB, Sidhu C, Budgeon C, et al. Australasian Malignant Pleural Effusion (AMPLE)-3 trial: study protocol for a multi-centre randomised study comparing indwelling pleural catheter (±talc pleurodesis) versus video-assisted thoracoscopic surgery for management of malignant pleural effusion. Trials. 2022;23(1):530. https://doi.org/10.1186/s13063-022-06405-7 PMid:35761341.
29. Lau EPM, Ing M, Vekaria S, et al. Australasian Malignant Pleural Effusion (AMPLE)-4 trial: study protocol for a multi-centre randomised trial of topical antibiotics prophylaxis for infections of indwelling pleural catheters. Trials. 2024;25(1):249. https://doi.org/10.1186/s13063-024-08065-1 PMid:38594766.
Submetido em:
02/03/2026
Revisado em:
30/04/2026
Aceito em:
25/05/2026
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