Recurrent and symptomatic pleural effusions are common in patients with malignancy. Up to 25% of patients with lung cancer and 50% of patients with breast cancer will develop a pleural effusion. Overall, mesothelioma, breast and lung cancer, account for the majority of malignant pleural effusions. According to underlying disease, many patients with malignant pleural effusion may live for months or even years. These patients’ quality of life is therefore of much importance and the aim of treatment should be beside the management of the primary disease, is to relieve symptoms, and to decrease the discomfort of the patient [10]. The necessity for repeated aspirations to relieve dyspnea is both physically and psychologically traumatic to the patient and a burden to the healthcare system. Therefore, the majority of patients will need a procedure to remove the fluid and prevent recurrence [11]. Treatment options for malignant pleural effusions are determined by several factors: symptoms and performance status of the patient, the primary tumor and its response to systemic therapy, and lung re-expansion following pleural fluid evacuation [12].
Pleurodesis is considered the best palliative therapy for the treatment of recurrent malignant pleural effusions [13]. Several techniques and various agents have been used for this purpose, with variable efficacy and safety [14]. Talc, tetracycline and bleomycin have been widely used for pleurodesis. Many studies have shown the effectiveness and safety of Povidone-iodine as an agent for pleurodesis with achieving very good results [3,15].
Our study included 39 cases divided into two groups; group A had talc pleurodesis and group B had povidone-iodine pleurodesis. They were 11 males (28.2%) and 28 females (77.8%) with no statistical significant difference between both groups regarding sex. Our study patients’ ages ranged from 65–80 years. Mean ± SD (71.0 ± 5.0 for group A and 70.9 ± 5.1 for group B).
Regarding patients’ complaints: the most common symptom in our study was dyspnea (100% of cases), followed by cough which occurred in 15 cases, and chest pain that occurred in 19 cases. Occurrence of dyspnea can be explained as moderate to massive pleural effusion causing compression on the lung. Also presence of cough and chest pain in some cases can be explained by the massive effusion, pleural irritation and chest infection with no statistical significant difference between both groups.
Regarding the response to treatment in group A there was complete response with no fluid re-accumulation in 15 patients (71.4%), and partial response in two patients (9.5%) with radiologically detected re-accumulation of minimal to mild amount at 2 months post procedure but never developed any clinical dyspnea during the follow-up and failure in 4 cases (19%) with recurrence of dyspnea and radiologically detected re-accumulation of moderate to massive pleural effusion. In group B, there was complete response with no fluid re-accumulation in 12 patients (66.7%), and partial response in one case (5.6%) who developed re-accumulation of fluid but never developed any clinical dyspnea, and failure in 5 cases (27.8%) with recurrence of dyspnea and radiologically detected re-accumulation of moderate to massive pleural effusion with no statistically significant difference between both groups.
In a prospective randomized study, Agarwal R. and colleagues randomly assigned patients with pleural effusion or pneumothorax, to receive chemical pleurodesis with either iodopovidone or cosmetic talc. They studied 38 patients with pleural effusions, who required pleurodesis, with the common pleural diseases being lung cancer and pulmonary tuberculosis. They observed complete success with absence of re-accumulation of fluid on CXR at 30 days in 16/19 (84.2%) in the iodopovidone group and 15/19 (78.9%) patients in the talc groups [16].
Mohsen et al. studied 44 patients with malignant pleural effusion secondary to breast cancer, divided into 2 groups using VATS talc pleurodesis in one group and bedside povidone-iodine in the other group. His study results match with our study regarding the success rate between both groups [4]. They reported no fluid re-accumulation in 19 patients (87%), and partial response in one patient (4%) and failure in two patients (9%) in the talc pleurodesis group. In the Povidone-iodine pleurodesis group, they found that there was complete response with no fluid re-accumulation in 17 patients (85%) at the early post-procedure follow-up, and failure response in three patients (15%) with no statistically significant difference between both groups which agrees with our study [4].
In a systematic review and meta-analysis on the efficacy and safety of iodopovidone pleurodesis, Agarwal R. and colleagues found that the success rate of iodopovidone pleurodesis varied from 70 to 100 per cent in different studies with the pooled success rate being 88.7 per cent (95% CI, 84.1 to 92.1) by the random effects model. The success rate was not significantly different whether tube thoracostomy or thoracoscopy was used for pleurodesis (P = 0.13) [17].
In another systematic review that included 1,168 patients, Walker-Renard PB and colleagues found that the complete success rate of talc was 93 per cent compared with Corynebacterium parvum (76%), tetracycline (67%), doxycycline (72%) and bleomycin (54%) [18].
Regarding the complications of our procedure, Chest pain and fever were the most common adverse effects in both groups. In our study, chest pain was recorded in 14 cases of group A and 9 cases of group B. Fever was the second most common complication; 4 cases in each group and anti-pyretic was given with close follow-up and fever subside with no more side effects until removal of the drain and discharge, with no statistically significant difference between both group. There was no other complication reported in our study. There was one case of mortality recorded in group A with the cause of death related to the primary tumor and not the pleurodesis. No mortality detected in group B.
In Agarwal R. and colleagues study, all patients experienced chest pain with median (IQR) Visual Analogue Scale of 20 (10–30) mm and a range of 10–90 mm. Fever occurred in nine patients (four in the iodopovidone group and five in the talc group) and was self-limited. Two patients (one in each group) developed empyema, which was treated with antibiotics. None of the patients, in their study, developed ARDS, visual loss or hypotension associated with administration of either agent [16].
Mohsen et al. agree with our results regarding post-operative complications as chest pain was the most common complications (4 cases only with talc pleurodesis) followed by fever (4 cases with talc pleurodesis, a single case with Povidone-iodine pleurodesis) but without a significant difference [4].
In their systematic review and meta-analysis, Agarwal R. and colleagues found that there were no deaths, acute respiratory distress syndrome (ARDS) or visual loss related with iodopovidone pleurodesis. They found that the complications reported of iodopovidone pleurodesis included chest pain and systemic hypotension [17].
Concerns that Povidone-iodine might be associated with visual loss were reported by Wagenfeld et al. in three cases during VATS [19]. However, authors used an unusual large amount of 200–500 ml of 10% Povidone-iodine [19]. They also noted that the safe amount to be used is 20 ml of 10% iodine, which is the amount that we have used in our study. As an additional safety precaution, we administered this dose in a diluted form (in normal saline).
The limitations of our study included the small sample size and not measuring the pH of the pleural fluid which can affect the success of pleurodesis as reported by some authors [20].