Malignant pleural effusion (MPE) is defined as the presence of malignant cells in the pleural fluid, generally secondary to primary or metastatic neoplasms involving the pleura.1
In lung cancer, MPE is present in approximately 15% of patients at the time of diagnosis, and up to 40% will develop it during the course of the disease, where it is associated with poor prognosis and high mortality.2
The main symptom reported by patients with MPE is dyspnea; therefore, treatment is primarily focused on symptomatic relief. In some cases, clinical improvement may also allow continuation of systemic oncologic treatment. For this reason, therapeutic indication is based more on the clinical impact than on the volume of the effusion.
The therapeutic strategies available for its management include:
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Therapeutic thoracentesis, although the frequent recurrence of the effusion limits its use as a definitive treatment, and it is therefore reserved for patients with limited survival expectancy.
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Pleural drainage with instillation of sclerosing agents (talc slurry) has success rates of approximately 65–90%.
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Likewise, thoracoscopy allows the combination of diagnosis and treatment through pleural biopsy and talc instillation (talc poudrage) in a single procedure, with success rates close to 80%.
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However, these strategies are less effective in patients with non-expandable lung. In such cases, indwelling pleural catheters (IPCs) represent an effective outpatient alternative. Nevertheless, they are associated with lower rates of spontaneous pleurodesis (≈40%) and require frequent home drainage, which may impose a significant burden on frail patients or those with limited home support.3
The combination of thoracoscopy and talc poudrage with the simultaneous placement of an IPC has been studied in small prospective studies with good results.4,5
The study by Dipper et al. represents the first randomized clinical trial comparing medical thoracoscopy with talc poudrage alone versus its combination with an IPC in patients with symptomatic malignant pleural effusion. It is a well-designed multicenter randomized trial that evaluated two clinically relevant co-primary endpoints: total hospital length of stay during the first 4 weeks after the procedure, including the index admission and any readmissions, and dyspnea control over the same period, assessed using a 100-mm visual analogue scale (VAS). The intervention group had a median hospital stay of 1 day compared with 2 days in the standard care group (p=0.26), while median dyspnea scores at 4 weeks were 14.0mm versus 19.6mm, respectively (p=0.26). Although neither co-primary endpoint reached statistical significance, the observed results numerically favored the combined strategy, particularly with respect to hospital stay, but the trial did not demonstrate a significant benefit over standard care.
Despite this, the study demonstrated a clinically relevant finding in one of the secondary outcomes, with a significant reduction in the need for additional pleural procedures in the intervention group compared with the control group (3% vs 34%; p<0.0001), which could help reduce future hospitalizations and invasive interventions in palliative care patients.
Among the main limitations were the impossibility of blinding due to the presence of the IPC and protocol deviations, particularly early hospital discharges in the control group related to organizational changes following the COVID-19 pandemic. These issues led to the performance of post-hoc per-protocol analyses, partially reducing the statistical robustness of the results.
Overall, although the combination of medical thoracoscopy, talc poudrage, and IPC did not demonstrate benefits in the primary outcomes, it may represent a useful alternative in selected patients in whom minimizing the need for additional pleural procedures is a priority.6
Current evidence positions medical thoracoscopy as a highly valuable tool in the management of MPE; however, the ultimate goal is no longer limited to achieving effective radiological pleurodesis. In an increasingly older, frail, and multimorbid population, true success lies in minimizing procedures, reducing hospital stay, and controlling symptoms with the lowest possible healthcare burden.
Recent evidence also compels us to move away from dogmatic positions, such as the dichotomy between talc poudrage and talc slurry, and to advance toward a comprehensive approach focused on delivering the greatest possible clinical value to the patient.7,8 Many of these patients prioritize an outpatient approach that enables both diagnosis and treatment to be performed within a single procedure.8 In this context, medical thoracoscopy is becoming established as a strategy for individualized pleural management, characterized by a reduction in reinterventions, optimization of pleural device use, and potentially earlier removal of the pleural catheter.6
In this setting, the analyzed study provides a snapshot of contemporary pleural units, characterized by a high proportion of patients with mesothelioma, advanced disease, and associated comorbidities. In this context, the absence of significant differences in hospital stay or dyspnea control should not be interpreted as a failure of the combined strategy, but rather the opposite. The reduction in the need for additional pleural interventions represents the finding with the greatest practical relevance: avoiding repeated thoracenteses, as well as reducing physical suffering, anxiety, and functional decline in these patients.
At the same time, the IPC is progressively no longer considered a tool reserved for trapped lung or pleurodesis failure, but rather is becoming integrated into hybrid strategies capable of combining symptomatic control, lower reintervention rates, and outpatient management.
This shift reflects a profound transformation in interventional pleural pulmonology: the goal is no longer solely to achieve technical success, but to maximize time spent outside the hospital and minimize healthcare burden.6 Modern interventional pulmonology requires specialized training in advanced pleural ultrasound and comprehensive IPC management. However, the real challenge is probably no longer exclusively technical, but organizational. It is essential to establish structured pleural units, efficient home follow-up programs, and close coordination with oncology and palliative care services.
Ethical considerationsThis study did not require ethical approval because it did not involve experiments on humans or animals, nor did it include identifiable personal data.
Declaration of generative AI and AI-assisted technologies in the writing processDuring the preparation of this work the author(s) did not use generative AI or AI-assisted technologies in the writing or editing of the manuscript.
Informed consentThis study did not require informed consent, as it did not involve human participants or the collection of identifiable personal data.
FundingWe declare that there is no funding received for this work.
Authors’ contributionsAll authors contributed to the conception, writing, and revision of the manuscript. All authors have read and approved the final version.
Conflicts of interestWe declare that there is no conflict of interest related to this work.
