Lancet: Thoracic ultrasonography-guided pleurodesis effective in malignant pleural effusions

UK: A team of researchers led by Ioannis Psallidas conducted a study where they showed that thoracic ultrasonography-guided pleurodesis in patients with malignant pleural effusion (MPE) leads to a shorter hospital stay (as compared to the British Thoracic Society standard for pleurodesis) without affecting the procedure's success rate at 3 months. The findings of this study were published in the LANCET Respiratory Medicine.

Pleurodesis is an in-patient surgery that is used to treat symptomatic recurrent MPE and has a success rate of 75–80%. In a short trial, thoracic ultrasonography was proven to predict pleurodesis success early by indicating the cessation of lung sliding (a normal sign seen in healthy patients, lung sliding indicates a normal movement of the lung inside the thorax). The purpose of this study was to see if using thoracic ultrasonography in pleurodesis paths may reduce hospital stay in patients with MPE having pleurodesis.

The Efficiency of Biological Pleurodesis and Sonographic Indicators of Malignant Pleural Effusion (SIMPLE) experiment was conducted in 10 respiratory centers in the United Kingdom and one respiratory center in the Netherlands. Adult patients (over the age of 18) with proven MPE who needed talc pleurodesis through a chest tube or as poudrage during medical thoracoscopy were eligible. Using a minimization algorithm, patients were randomly randomized (1:1) to thoracic ultrasonography-guided treatment or routine care through an online portal. The primary objective was hospital stay length, and secondary outcomes were pleurodesis failure at 3 months, all-cause mortality, time to tube removal, symptoms and quality-of-life ratings, and the cost-effectiveness of thoracic ultrasonography-guided therapy.

The key findings are as follow:

1. Between December 31, 2015, and December 17, 2019, 778 individuals were evaluated for eligibility, and 313 people were recruited and randomly allocated to thoracic ultrasonography-guided care (n=159) or conventional treatment (n=154).

2. The median length of hospital stay in the intervention group was considerably shorter than in the standard care group in the modified intention-to-treat population.

3. In the per-protocol analysis, thoracic ultrasonography-guided care was shown to be non-inferior to standard care in terms of pleurodesis failure at 3 months, which happened in 27 (297%) of 91 patients in the intervention group against 34 (312%) of 109 patients in the standard care group.

4. The intervention group's mean time to chest tube removal was 24 days (SD 25) against 31 days (20) in the conventional care group.

5. Except for the EQ-5D visual analog scale, which was considerably lower in the usual care group at 3 months, there were no significant between-group differences in all-cause mortality, symptom ratings, or quality-of-life scores.

6. Although the expenses were comparable between the groups, thoracic ultrasonography-guided treatment was less expensive than conventional care.

In conclusion, the findings of this study support the routine use of thoracic ultrasonography in patients who are undergoing MPE-related pleurodesis.

Reference: 

Psallidas, I., Hassan, M., Yousuf, A., Duncan, T., Khan, S. L., Blyth, K. G., Evison, M., Corcoran, J. P., Barnes, S., Reddy, R., Bonta, P. I., Bhatnagar, R., Kagithala, G., Dobson, M., Knight, R., Dutton, S. J., Luengo-Fernandez, R., Hedley, E., Piotrowska, H., Brown, L., … Rahman, N. M. (2022). Role of thoracic ultrasonography in pleurodesis pathways for malignant pleural effusions (SIMPLE): an open-label, randomized controlled trial. The Lancet. Respiratory medicine, 10(2), 139–148. https://doi.org/10.1016/S2213-2600(21)00353-2

Keywords: thoracic ultrasonography, pleural effusion, pleurodesis, chest tube, malignancy, quality of life, LANCET, lung cancer, Ioannis Psallidas