The choice of a sclerosing agent is determined by the agent’s efficacy, accessibility, safety, ease of administration, number of administrations to achieve a complete response, and cost, as well as by the treating physician’s personal preference [2]. A variety of sclerosing agents have been used to treat MPE, but many have proved less than optimal because of poor efficacy, a high incidence of adverse effects, difficulty in administration, or costs.

A recent Cochrane review concluded that talc is probably the optimal agent for chemical pleurodesis [13]. When comparing different sclerosants, talc was found to be the most efficacious, with overall success rate of approximately 80 %. Thoracoscopic talc pleurodesis yielded a success rate of 96 %. The relative risk (RR) of effusion non-recurrence was 1.34 (95 % confidence interval (CI) 1.16–1.55) in favor of talc compared with bleomycin, tetracycline, or tube drainage alone. This view is supported by a more recent systematic review [14], in which the authors found that talc tended to be associated with fewer recurrences when compared to bleomycin (RR, 0.64; 95 % CI 0.34–1.20) and, with less certainty, to tetracycline (RR, 0.50; 95 % CI, 0.06–4.42).

A serious complication associated with the use of talc is adult respiratory distress syndrome or acute pneumonitis leading to acute respiratory failure. There have been many reports of pneumonitis associated with talc pleurodesis, predominantly from the UK and the USA where, historically, talc of mixed particle sizes has been used. Maskell and colleagues undertook two studies to assess the association of talc particle grade and respiratory failure [15, 16]. In the first study, they concluded mixed talc worsened gas exchange and induced more systemic inflammation than talc restricted to large grade. In a subsequent cohort study of 558 patients who underwent thoracoscopic pleurodesis using large grade talc, there were no episodes of pneumonitis [16].

In the USA, bleomycin is also a more expensive sclerosant than talc, and tetracycline is no longer available for use as a sclerosant. Talc is an effective and safe sclerosant and should be the agent of choice for pleurodesis.

Talc is administered in two ways: insufflated at thoracoscopy as dry particles using an atomizer (poudrage) or via an intercostal tube in the form of a suspension of talc particles in fluid (slurry). Four studies have directly compared talc slurry (TS) with talc poudrage (TP) [17–20].

Yim et al. [17] in 1996 designed a prospective, randomized study to compare talc slurry with thoracoscopic talc poudrage for the first time, and did not find any superiority of poudrage over slurry. One shortcoming of the study was the small sample size, and study also lacked documentation of patients’ quality of life after the procedures. Data from another randomized study are available only in abstract form [18]. That study suggests superiority of poudrage over slurry, but limited data are available to validate this conclusion. More recently Stefani et al. [20] compared thoracoscopy and talc poudrage with talc slurry in a non-randomized manner. Their results suggest superiority of poudrage over slurry, but the two groups were not equivalent with respect to performance status. In the largest randomized study, Dresler et al. [19] compared talc poudrage with talc slurry. Although the study concluded that the two methods were equivalent, the subgroup of patients with primary lung or breast cancer had higher success with talc poudrage than with TS (82 % vs 67 %). Quality-of-life measurement also favored talc poudrage. Patient ratings of comfort and safety were also higher for talc poudrage (Table 49.2).

In addition to the slight superior efficacy of TS to TP, thoracoscopy also affords an opportunity to directly inspect the pleura and to address adhesions and loculations. This may be indicated for patients who have had prior ipsilateral surgery or attempted pleurodesis, or for whom there is a significant possibility of a trapped lung. TP is also perceived by patients to afford greater comfort and medical safety, as well as causing less fatigue relative to TS. These factors may importantly impact treatment preferences for patients who rank quality of life as a principal goal of care.

Several prospective or retrospective trails have compared IPC and talc pleurodesis for the management of MPE in recent years [4, 21–27]. In a randomized controlled trail (TIME2), Davies et al. [22] compared IPC (Rocket ^®) to chest tube and talc pleurodesis. They demonstrated dyspnea improvement in both groups, with no significant difference in the first 42 days. But there was a statistically significant improvement in dyspnea in the IPC group at 6 months. The duration of initial hospitalization was significantly shorter in the IPC group, with a median of 0 days compared to 4 days for the talc group. There was no significant difference in quality of life. More patients in the talc group required further pleural procedures compared with in the IPC group (22 % vs 6 %).

Another prospective randomized trial concluded that IPC (PleurX^®) achieved superior palliation of unilateral MPEs than bedside talc pleurodesis, particularly in patients with trapped lungs [23].

Hunt and his colleagues also compared thoracoscopic talc to IPC. The trial included 109 patients: 59 patients had IPC placed, and 50 were treated with video-assisted thoracic surgery (VATS) and talc. Patients who underwent IPC placement had significantly fewer reinterventions for recurrent ipsilateral effusions than patients treated with VATS talc (IPC 2 % vs. talc 16 %, p = 0.01), and had significantly shorter overall length of stay (LOS) (7 days vs. 8 days, p = 0.006) and post procedure LOS (3 days vs. 6 days, p <0.001). Complication rates and in-hospital mortality were not significantly different. They concluded that placement of a IPC is superior to VATS talc for palliation of MPE-associated symptoms [24].

A retrospective propensity score-matched comparison of talc pleurodesis and IPC in patients undergoing diagnostic thoracoscopy also demonstrated that IPC provided palliation of patients’ malignant pleural effusions and freedom from reintervention equal to that of talc pleurodesis after thoracoscopy, while resulting in a shorter mean length of hospital stay and interval to the initiation of systemic therapy. Lower rates of operative morbidity were also seen in the IPC treatment group [25].

As listed in Table 49.3, an indwelling pleural catheter is therefore an effective option for controlling symptomatic malignant effusions. It is particularly useful when length of hospitalization is to be kept to a minimum, for patients who are known or are suspected to have a trapped lung, and in situations in which expertise and facilities exist for out-patient management of these catheters.