Point: Should Thoracoscopic Talc Pleurodesis Be the First Choice Management for Malignant Effusion? Yes
2012; Elsevier BV; Volume: 142; Issue: 1 Linguagem: Inglês
10.1378/chest.12-1085
ISSN1931-3543
Autores Tópico(s)Trauma Management and Diagnosis
Resumoindwelling pleural catheter malignant pleural effusion talc slurry thoracoscopic talc poudrage Malignant pleural effusion (MPE) accounts for 22% of all pleural effusions, and in the United States >150,000 new cases are diagnosed annually.1American Thoracic Society Management of malignant pleural effusions.Am J Respir Crit Care Med. 2000; 162: 1987-2001Crossref PubMed Scopus (452) Google Scholar Carcinoma of any organ can metastasize to the pleura, and when malignant cells are detected in the pleural fluid or in pleural tissue they denote dissemination and poor prognosis. Median survival after the diagnosis of MPE is 4 to 6 months and is dependent on type of neoplasm.2Roberts ME Neville E Berrisford RG Antunes G Ali NJ BTS Pleural Disease Guideline Group Management of a malignant pleural effusion: British Thoracic Society pleural disease guideline 2010.Thorax. 2010; 65: ii32-ii40Crossref PubMed Scopus (602) Google ScholarDuring the course of disease, 50% of patients with breast cancer, 25% with lung cancer, and >90% with mesothelioma develop symptomatic MPE (Fig 1).2Roberts ME Neville E Berrisford RG Antunes G Ali NJ BTS Pleural Disease Guideline Group Management of a malignant pleural effusion: British Thoracic Society pleural disease guideline 2010.Thorax. 2010; 65: ii32-ii40Crossref PubMed Scopus (602) Google Scholar, 3Anderson CB Philpott GW Ferguson TB The treatment of malignant pleural effusions.Cancer. 1974; 33: 916-922Crossref PubMed Scopus (215) Google Scholar Although therapeutic thoracentesis provides effective symptom relief, most MPEs recur within a month, and it should not be the treatment of choice if patients have good Karnofsky Performance Scale scores (>30) or Eastern Cooperative Oncology Group Performance Status 1.4Burrows CM Mathews WC Colt HG Predicting survival in patients with recurrent symptomatic malignant pleural effusions: an assessment of the prognostic values of physiologic, morphologic, and quality of life measures of extent of disease.Chest. 2000; 117: 73-78Abstract Full Text Full Text PDF PubMed Scopus (174) Google Scholar, 5Ozyurtkan MO Balci AE Cakmak M Predictors of mortality within three months in the patients with malignant pleural effusion.Eur J Intern Med. 2010; 21: 30-34Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar In fact, repeated thoracentesis carries a risk of pneumothorax and empyema and impedes success with subsequent drainage procedures and thoracoscopy because of pleural adhesions.2Roberts ME Neville E Berrisford RG Antunes G Ali NJ BTS Pleural Disease Guideline Group Management of a malignant pleural effusion: British Thoracic Society pleural disease guideline 2010.Thorax. 2010; 65: ii32-ii40Crossref PubMed Scopus (602) Google ScholarMPE is effectively managed by complete drainage of fluid and administration of intrapleural sclerosant. For successful pleurodesis, the underlying lung must reexpand for apposition of the pleura to occur, and pleurodesis can be performed by instilling sclerosant into the pleural space via intercostal tube or small-bore catheter or by thoracoscopic talc poudrage (TTP).6Kennedy L Rusch VW Strange C Ginsberg RJ Sahn SA Pleurodesis using talc slurry.Chest. 1994; 106: 342-346Abstract Full Text Full Text PDF PubMed Scopus (188) Google Scholar, 7Steger V Mika U Toomes H et al.Who gains most? A 10-year experience with 611 thoracoscopic talc pleurodeses.Ann Thorac Surg. 2007; 83: 1940-1945Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar, 8Walker-Renard PB Vaughan LM Sahn SA Chemical pleurodesis for malignant pleural effusions.Ann Intern Med. 1994; 120: 56-64Crossref PubMed Scopus (356) Google Scholar Commonly used sclerosants are talc, tetracycline derivatives, and bleomycin.1American Thoracic Society Management of malignant pleural effusions.Am J Respir Crit Care Med. 2000; 162: 1987-2001Crossref PubMed Scopus (452) Google Scholar, 2Roberts ME Neville E Berrisford RG Antunes G Ali NJ BTS Pleural Disease Guideline Group Management of a malignant pleural effusion: British Thoracic Society pleural disease guideline 2010.Thorax. 2010; 65: ii32-ii40Crossref PubMed Scopus (602) Google Scholar, 8Walker-Renard PB Vaughan LM Sahn SA Chemical pleurodesis for malignant pleural effusions.Ann Intern Med. 1994; 120: 56-64Crossref PubMed Scopus (356) Google Scholar Talc gives a success rate of 81% to 100%, which is in contrast to 65% to 76% achieved with tetracycline and its derivatives and 61% with bleomycin.1American Thoracic Society Management of malignant pleural effusions.Am J Respir Crit Care Med. 2000; 162: 1987-2001Crossref PubMed Scopus (452) Google Scholar, 2Roberts ME Neville E Berrisford RG Antunes G Ali NJ BTS Pleural Disease Guideline Group Management of a malignant pleural effusion: British Thoracic Society pleural disease guideline 2010.Thorax. 2010; 65: ii32-ii40Crossref PubMed Scopus (602) Google Scholar, 8Walker-Renard PB Vaughan LM Sahn SA Chemical pleurodesis for malignant pleural effusions.Ann Intern Med. 1994; 120: 56-64Crossref PubMed Scopus (356) Google Scholar, 9Heffner JE Diagnosis and management of malignant pleural effusions.Respirology. 2008; 13: 5-20PubMed Google Scholar Fever and pleuritic chest pain are more often observed with talc, and ARDS following talc slurry (TS) has been reported from the United Kingdom and United States, where nongraded talc (50% particle size 15 μm). In a multicenter trial of 558 patients with MPE who underwent TTP using graded talc, there was no occurrence of deaths, ARDS, or pneumonitis.13Janssen JP Collier G Astoul P et al.Safety of pleurodesis with talc poudrage in malignant pleural effusion: a prospective cohort study.Lancet. 2007; 369: 1535-1539Abstract Full Text Full Text PDF PubMed Scopus (248) Google ScholarCochrane database systematic review of 36 randomized controlled trials of 1,499 patients who underwent pleurodesis supports the use of intrapleural sclerosants to prevent recurrence, with talc as the sclerosant of choice and TTP as the preferred technique, which should be considered if patients have good performance status.14Shaw P Agarwal R Pleurodesis for malignant pleural effusions.Cochrane Database Syst Rev. 2004; 1: CD002916Google Scholar A systematic review also reported significant reduction in MPE recurrence following TTP rather than TS.15Tan C Sedrakyan A Browne J Swift S Treasure T The evidence on the effectiveness of management for malignant pleural effusion: a systematic review.Eur J Cardiothorac Surg. 2006; 29: 829-838Crossref PubMed Scopus (174) Google Scholar Although a phase III intergroup study showed comparable outcome between two groups randomized to receive TTP and TS, patients who underwent thoracoscopy reported greater comfort and safety. MPEs due to lung and breast cancers were also more effectively palliated with TTP.16Dresler CM Olak J Herndon II, JE Cooperative Groups Cancer and Leukemia Group B Eastern Cooperative Oncology Group North Central Cooperative Oncology Group Radiation Therapy Oncology Group et al.Phase III intergroup study of talc poudrage vs talc slurry sclerosis for malignant pleural effusion.Chest. 2005; 127: 909-915Abstract Full Text Full Text PDF PubMed Scopus (428) Google Scholar Stefani and colleagues,17Stefani A Natali P Casali C Morandi U Talc poudrage versus talc slurry in the treatment of malignant pleural effusion. A prospective comparative study.Eur J Cardiothorac Surg. 2006; 30: 827-832Crossref PubMed Scopus (117) Google Scholar who randomized 109 patients to TTP and TS, also demonstrated better immediate (87.5% vs 73%) and lifelong pleurodesis successes (82% vs 62%) in favor of TTP. When MPEs with low pH 8,300 pleurodesis annually for patients with pleural effusions were surveyed, the majority preferred talc over other agents because of its perceived efficacy, and TTP over TS.19Lee YC Baumann MH Maskell NA et al.Pleurodesis practice for malignant pleural effusions in five English-speaking countries: survey of pulmonologists.Chest. 2003; 124: 2229-2238Abstract Full Text Full Text PDF PubMed Scopus (149) Google Scholar Physicians have also observed prolonged survival in patients who experienced successful pleurodesis, including those with malignant mesothelioma.20Heffner JE Nietert PJ Barbieri C Pleural fluid pH as a predictor of pleurodesis failure: analysis of primary data.Chest. 2000; 117: 87-95Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar, 21Aelony Y Yao JF Prolonged survival after talc poudrage for malignant pleural mesothelioma: case series.Respirology. 2005; 10: 649-655Crossref PubMed Scopus (35) Google Scholar This could be attributed to other actions of talc, such as causing apoptosis of lung cancer and mesothelioma cells in vitro as well as altering the biologically active and angiogenic microenvironment of the pleural space to an angiostatic milieu due to endostatin induction.22Nasreen N Mohammed KA Dowling PA Ward MJ Galffy G Antony VB Talc induces apoptosis in human malignant mesothelioma cells in vitro.Am J Respir Crit Care Med. 2000; 161: 595-600Crossref PubMed Scopus (72) Google Scholar, 23Lee P Sun L Lim CK Aw SE Colt HG Selective apoptosis of lung cancer cells with talc.Eur Respir J. 2010; 35: 450-452Crossref PubMed Scopus (19) Google Scholar, 24Nasreen N Mohammed KA Brown S et al.Talc mediates angiostasis in malignant pleural effusions via endostatin induction.Eur Respir J. 2007; 29: 761-769Crossref PubMed Scopus (47) Google ScholarIt is arguable that since palliation is the primary objective, long-term indwelling pleural catheters (IPCs), originally designed for patients with trapped lungs (Fig 2), symptomatic loculated effusions from failed pleurodesis, and advanced cancers with short life expectancies, would represent a viable alternative to pleurodesis.9Heffner JE Diagnosis and management of malignant pleural effusions.Respirology. 2008; 13: 5-20PubMed Google Scholar, 25Tremblay A Michaud G Single-center experience with 250 tunnelled pleural catheter insertions for malignant pleural effusion.Chest. 2006; 129: 362-368Abstract Full Text Full Text PDF PubMed Scopus (312) Google Scholar An IPC is inserted in an ambulatory setting via tunneled technique and provides access to the pleural space for fluid drainage when symptoms recur. The majority of patients with MPEs derived immediate symptomatic relief regardless of primary neoplasm, which was sustained up to 30 days, and most did not require subsequent procedures. About 40% experienced spontaneous pleurodesis after 2 to 6 weeks of IPC, thereby allowing its removal.25Tremblay A Michaud G Single-center experience with 250 tunnelled pleural catheter insertions for malignant pleural effusion.Chest. 2006; 129: 362-368Abstract Full Text Full Text PDF PubMed Scopus (312) Google Scholar Malfunction of the catheter (9.1%), pneumothorax requiring chest tube (5.9%), pain (5.6%), and blocked catheter (3.7%) are complications commonly encountered, whereas empyema (2.8%), cellulitis (3.4%), and tumor metastases along the catheter tract (1%) were less common.26Van Meter ME McKee KY Kohlwes RJ Efficacy and safety of tunneled pleural catheters in adults with malignant pleural effusions: a systematic review.J Gen Intern Med. 2011; 26: 70-76Crossref PubMed Scopus (207) Google Scholar IPCs can fracture during removal, which can lead to iatrogenic severing of IPC; patients must learn to care for IPCs, and IPCs can be costly. In a cost analysis study, chest tube pleurodesis was found to be more cost-effective than IPC if patient survival was >6 weeks.27Olden AM Holloway R Treatment of malignant pleural effusion: PleuRx catheter or talc pleurodesis? A cost-effectiveness analysis.J Palliat Med. 2010; 13: 59-65Crossref PubMed Scopus (93) Google Scholar Cost will be an important consideration as effective chemotherapeutic agents targeting cancers at the molecular level are developed, which will translate to longer survival.28Langer CJ Besse B Gualberto A Brambilla E Soria JC The evolving role of histology in the management of advanced non-small-cell lung cancer.J Clin Oncol. 2010; 28: 5311-5320Crossref PubMed Scopus (222) Google Scholar The evidence presented lends impetus to TTP as the first choice in the management of patients with MPEs.Figure 2Trapped right lung after fluid drainage.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Malignant pleural effusion (MPE) accounts for 22% of all pleural effusions, and in the United States >150,000 new cases are diagnosed annually.1American Thoracic Society Management of malignant pleural effusions.Am J Respir Crit Care Med. 2000; 162: 1987-2001Crossref PubMed Scopus (452) Google Scholar Carcinoma of any organ can metastasize to the pleura, and when malignant cells are detected in the pleural fluid or in pleural tissue they denote dissemination and poor prognosis. Median survival after the diagnosis of MPE is 4 to 6 months and is dependent on type of neoplasm.2Roberts ME Neville E Berrisford RG Antunes G Ali NJ BTS Pleural Disease Guideline Group Management of a malignant pleural effusion: British Thoracic Society pleural disease guideline 2010.Thorax. 2010; 65: ii32-ii40Crossref PubMed Scopus (602) Google Scholar During the course of disease, 50% of patients with breast cancer, 25% with lung cancer, and >90% with mesothelioma develop symptomatic MPE (Fig 1).2Roberts ME Neville E Berrisford RG Antunes G Ali NJ BTS Pleural Disease Guideline Group Management of a malignant pleural effusion: British Thoracic Society pleural disease guideline 2010.Thorax. 2010; 65: ii32-ii40Crossref PubMed Scopus (602) Google Scholar, 3Anderson CB Philpott GW Ferguson TB The treatment of malignant pleural effusions.Cancer. 1974; 33: 916-922Crossref PubMed Scopus (215) Google Scholar Although therapeutic thoracentesis provides effective symptom relief, most MPEs recur within a month, and it should not be the treatment of choice if patients have good Karnofsky Performance Scale scores (>30) or Eastern Cooperative Oncology Group Performance Status 1.4Burrows CM Mathews WC Colt HG Predicting survival in patients with recurrent symptomatic malignant pleural effusions: an assessment of the prognostic values of physiologic, morphologic, and quality of life measures of extent of disease.Chest. 2000; 117: 73-78Abstract Full Text Full Text PDF PubMed Scopus (174) Google Scholar, 5Ozyurtkan MO Balci AE Cakmak M Predictors of mortality within three months in the patients with malignant pleural effusion.Eur J Intern Med. 2010; 21: 30-34Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar In fact, repeated thoracentesis carries a risk of pneumothorax and empyema and impedes success with subsequent drainage procedures and thoracoscopy because of pleural adhesions.2Roberts ME Neville E Berrisford RG Antunes G Ali NJ BTS Pleural Disease Guideline Group Management of a malignant pleural effusion: British Thoracic Society pleural disease guideline 2010.Thorax. 2010; 65: ii32-ii40Crossref PubMed Scopus (602) Google Scholar MPE is effectively managed by complete drainage of fluid and administration of intrapleural sclerosant. For successful pleurodesis, the underlying lung must reexpand for apposition of the pleura to occur, and pleurodesis can be performed by instilling sclerosant into the pleural space via intercostal tube or small-bore catheter or by thoracoscopic talc poudrage (TTP).6Kennedy L Rusch VW Strange C Ginsberg RJ Sahn SA Pleurodesis using talc slurry.Chest. 1994; 106: 342-346Abstract Full Text Full Text PDF PubMed Scopus (188) Google Scholar, 7Steger V Mika U Toomes H et al.Who gains most? A 10-year experience with 611 thoracoscopic talc pleurodeses.Ann Thorac Surg. 2007; 83: 1940-1945Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar, 8Walker-Renard PB Vaughan LM Sahn SA Chemical pleurodesis for malignant pleural effusions.Ann Intern Med. 1994; 120: 56-64Crossref PubMed Scopus (356) Google Scholar Commonly used sclerosants are talc, tetracycline derivatives, and bleomycin.1American Thoracic Society Management of malignant pleural effusions.Am J Respir Crit Care Med. 2000; 162: 1987-2001Crossref PubMed Scopus (452) Google Scholar, 2Roberts ME Neville E Berrisford RG Antunes G Ali NJ BTS Pleural Disease Guideline Group Management of a malignant pleural effusion: British Thoracic Society pleural disease guideline 2010.Thorax. 2010; 65: ii32-ii40Crossref PubMed Scopus (602) Google Scholar, 8Walker-Renard PB Vaughan LM Sahn SA Chemical pleurodesis for malignant pleural effusions.Ann Intern Med. 1994; 120: 56-64Crossref PubMed Scopus (356) Google Scholar Talc gives a success rate of 81% to 100%, which is in contrast to 65% to 76% achieved with tetracycline and its derivatives and 61% with bleomycin.1American Thoracic Society Management of malignant pleural effusions.Am J Respir Crit Care Med. 2000; 162: 1987-2001Crossref PubMed Scopus (452) Google Scholar, 2Roberts ME Neville E Berrisford RG Antunes G Ali NJ BTS Pleural Disease Guideline Group Management of a malignant pleural effusion: British Thoracic Society pleural disease guideline 2010.Thorax. 2010; 65: ii32-ii40Crossref PubMed Scopus (602) Google Scholar, 8Walker-Renard PB Vaughan LM Sahn SA Chemical pleurodesis for malignant pleural effusions.Ann Intern Med. 1994; 120: 56-64Crossref PubMed Scopus (356) Google Scholar, 9Heffner JE Diagnosis and management of malignant pleural effusions.Respirology. 2008; 13: 5-20PubMed Google Scholar Fever and pleuritic chest pain are more often observed with talc, and ARDS following talc slurry (TS) has been reported from the United Kingdom and United States, where nongraded talc (50% particle size 15 μm). In a multicenter trial of 558 patients with MPE who underwent TTP using graded talc, there was no occurrence of deaths, ARDS, or pneumonitis.13Janssen JP Collier G Astoul P et al.Safety of pleurodesis with talc poudrage in malignant pleural effusion: a prospective cohort study.Lancet. 2007; 369: 1535-1539Abstract Full Text Full Text PDF PubMed Scopus (248) Google Scholar Cochrane database systematic review of 36 randomized controlled trials of 1,499 patients who underwent pleurodesis supports the use of intrapleural sclerosants to prevent recurrence, with talc as the sclerosant of choice and TTP as the preferred technique, which should be considered if patients have good performance status.14Shaw P Agarwal R Pleurodesis for malignant pleural effusions.Cochrane Database Syst Rev. 2004; 1: CD002916Google Scholar A systematic review also reported significant reduction in MPE recurrence following TTP rather than TS.15Tan C Sedrakyan A Browne J Swift S Treasure T The evidence on the effectiveness of management for malignant pleural effusion: a systematic review.Eur J Cardiothorac Surg. 2006; 29: 829-838Crossref PubMed Scopus (174) Google Scholar Although a phase III intergroup study showed comparable outcome between two groups randomized to receive TTP and TS, patients who underwent thoracoscopy reported greater comfort and safety. MPEs due to lung and breast cancers were also more effectively palliated with TTP.16Dresler CM Olak J Herndon II, JE Cooperative Groups Cancer and Leukemia Group B Eastern Cooperative Oncology Group North Central Cooperative Oncology Group Radiation Therapy Oncology Group et al.Phase III intergroup study of talc poudrage vs talc slurry sclerosis for malignant pleural effusion.Chest. 2005; 127: 909-915Abstract Full Text Full Text PDF PubMed Scopus (428) Google Scholar Stefani and colleagues,17Stefani A Natali P Casali C Morandi U Talc poudrage versus talc slurry in the treatment of malignant pleural effusion. A prospective comparative study.Eur J Cardiothorac Surg. 2006; 30: 827-832Crossref PubMed Scopus (117) Google Scholar who randomized 109 patients to TTP and TS, also demonstrated better immediate (87.5% vs 73%) and lifelong pleurodesis successes (82% vs 62%) in favor of TTP. When MPEs with low pH 8,300 pleurodesis annually for patients with pleural effusions were surveyed, the majority preferred talc over other agents because of its perceived efficacy, and TTP over TS.19Lee YC Baumann MH Maskell NA et al.Pleurodesis practice for malignant pleural effusions in five English-speaking countries: survey of pulmonologists.Chest. 2003; 124: 2229-2238Abstract Full Text Full Text PDF PubMed Scopus (149) Google Scholar Physicians have also observed prolonged survival in patients who experienced successful pleurodesis, including those with malignant mesothelioma.20Heffner JE Nietert PJ Barbieri C Pleural fluid pH as a predictor of pleurodesis failure: analysis of primary data.Chest. 2000; 117: 87-95Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar, 21Aelony Y Yao JF Prolonged survival after talc poudrage for malignant pleural mesothelioma: case series.Respirology. 2005; 10: 649-655Crossref PubMed Scopus (35) Google Scholar This could be attributed to other actions of talc, such as causing apoptosis of lung cancer and mesothelioma cells in vitro as well as altering the biologically active and angiogenic microenvironment of the pleural space to an angiostatic milieu due to endostatin induction.22Nasreen N Mohammed KA Dowling PA Ward MJ Galffy G Antony VB Talc induces apoptosis in human malignant mesothelioma cells in vitro.Am J Respir Crit Care Med. 2000; 161: 595-600Crossref PubMed Scopus (72) Google Scholar, 23Lee P Sun L Lim CK Aw SE Colt HG Selective apoptosis of lung cancer cells with talc.Eur Respir J. 2010; 35: 450-452Crossref PubMed Scopus (19) Google Scholar, 24Nasreen N Mohammed KA Brown S et al.Talc mediates angiostasis in malignant pleural effusions via endostatin induction.Eur Respir J. 2007; 29: 761-769Crossref PubMed Scopus (47) Google Scholar It is arguable that since palliation is the primary objective, long-term indwelling pleural catheters (IPCs), originally designed for patients with trapped lungs (Fig 2), symptomatic loculated effusions from failed pleurodesis, and advanced cancers with short life expectancies, would represent a viable alternative to pleurodesis.9Heffner JE Diagnosis and management of malignant pleural effusions.Respirology. 2008; 13: 5-20PubMed Google Scholar, 25Tremblay A Michaud G Single-center experience with 250 tunnelled pleural catheter insertions for malignant pleural effusion.Chest. 2006; 129: 362-368Abstract Full Text Full Text PDF PubMed Scopus (312) Google Scholar An IPC is inserted in an ambulatory setting via tunneled technique and provides access to the pleural space for fluid drainage when symptoms recur. The majority of patients with MPEs derived immediate symptomatic relief regardless of primary neoplasm, which was sustained up to 30 days, and most did not require subsequent procedures. About 40% experienced spontaneous pleurodesis after 2 to 6 weeks of IPC, thereby allowing its removal.25Tremblay A Michaud G Single-center experience with 250 tunnelled pleural catheter insertions for malignant pleural effusion.Chest. 2006; 129: 362-368Abstract Full Text Full Text PDF PubMed Scopus (312) Google Scholar Malfunction of the catheter (9.1%), pneumothorax requiring chest tube (5.9%), pain (5.6%), and blocked catheter (3.7%) are complications commonly encountered, whereas empyema (2.8%), cellulitis (3.4%), and tumor metastases along the catheter tract (1%) were less common.26Van Meter ME McKee KY Kohlwes RJ Efficacy and safety of tunneled pleural catheters in adults with malignant pleural effusions: a systematic review.J Gen Intern Med. 2011; 26: 70-76Crossref PubMed Scopus (207) Google Scholar IPCs can fracture during removal, which can lead to iatrogenic severing of IPC; patients must learn to care for IPCs, and IPCs can be costly. In a cost analysis study, chest tube pleurodesis was found to be more cost-effective than IPC if patient survival was >6 weeks.27Olden AM Holloway R Treatment of malignant pleural effusion: PleuRx catheter or talc pleurodesis? A cost-effectiveness analysis.J Palliat Med. 2010; 13: 59-65Crossref PubMed Scopus (93) Google Scholar Cost will be an important consideration as effective chemotherapeutic agents targeting cancers at the molecular level are developed, which will translate to longer survival.28Langer CJ Besse B Gualberto A Brambilla E Soria JC The evolving role of histology in the management of advanced non-small-cell lung cancer.J Clin Oncol. 2010; 28: 5311-5320Crossref PubMed Scopus (222) Google Scholar The evidence presented lends impetus to TTP as the first choice in the management of patients with MPEs. Supplementary Material/cms/asset/1c3cf559-9cfe-4384-a867-2d8ce9b9dfdc/mmc1.mp3Loading ... Download .mp3 (20.58 MB) Help with .mp3 files Supplementary audioValue of Thoracoscopic Talc Pleurodesis for Management of Malignant Pleural EffusionDuration: 44:57 minModerator: D. Kyle Hogarth, MD, FCCP, Podcast Editor, CHESTParticipants: Pyng Lee, MD, FCCP, Richard W. Light, MD, FCCP /cms/asset/1c3cf559-9cfe-4384-a867-2d8ce9b9dfdc/mmc1.mp3Loading ... Download .mp3 (20.58 MB) Help with .mp3 files Supplementary audioValue of Thoracoscopic Talc Pleurodesis for Management of Malignant Pleural EffusionDuration: 44:57 minModerator: D. Kyle Hogarth, MD, FCCP, Podcast Editor, CHESTParticipants: Pyng Lee, MD, FCCP, Richard W. Light, MD, FCCP
Referência(s)