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In Reply

University Hospital, Ghent, Belgium

Andrew Bottomley

Quality of Life Unit, European Organisation for Research and Treatment of Cancer, Brussels, Belgium

Although we acknowledge the palliative effects on dyspnea by chemical pleurodesis, as described by Aelony in his letter, it is hazardous to compare data from small selected single institutional phase II series with those from large multicenter series. A recent meta-analysis on chemical pleurodesis concludes that talc is the better sclerosant agent and that thoracoscopic administration might be superior to bedside one.¹ In contrast, the Cancer and Leukemia Group B could not confirm the superiority of thoracoscopic instillation in a large prospective randomized trial.² There was a 6% incidence of treatment related death in this trial. Dr Aelony will be aware that pleurodesis is only effective in selected patients, in whom there is repetitive symptomatic pleural fluid accumulation and in whom the lung is re-expanding after thoracentesis. This is in fact the case in early stage disease. With disease progression, dyspnea becomes multifactorial (for example, by invasion of the chest wall, the mediastinum, or the presence of anemia or a trapped lung). The median interval between diagnosis and random assignment in our trial is 52 days, two thirds of patients had a WHO performance status of 1 to 2%, and 80% or more were in clinical stage III-IV.^3,4 These facts illustrate that these patients had more advanced disease. In fact, 20.4% of the patients in the cisplatin arm and 23.4% of the patients in the combined treatment arm actually had a pleurodesis with talc before being registered.

Most clinicians consider any kind of pleurodesis as part of active supportive care, delivered as needed. It is highly unlikely that pleurodesis will prolong survival in mesothelioma, as it is unlikely that single-agent cisplatin will shorten it.⁵ The Medical Research Council MS 01 study, that recently reached its planned accrual and has formal symptom and quality of life assessment included, will ultimately address the issue whether chemotherapy—platinum or nonplatinum containing—improves the different objective and subjective outcome parameters, as compared with active supportive care only.⁶ Analogous to what has been described in non–small-cell lung cancer, it is expected that this will be the case.⁷

In conclusion, conducting a randomized clinical trial comparing thoracoscopic talc poudrage with a cisplatin-antifolate regimen seems redundant in the current status of knowledge. Both treatments are to be considered complimentary to each other in the palliation of this dreadful and dismal disease.

Authors' Disclosures of Potential Conflicts of Interest

The authors indicated no potential conflicts of interest.

REFERENCES

1. Shaw P, Agarwal R: Pleurodesis for malignant pleural effusions. The Cochrane Database of Systematic Reviews, 2004, Issue 1

2. Dresler CM, Olak J, Herndon JE, et al: Phase III Intergroup study of talc poudrage vs talc slurry sclerosis for malignant pleural effusion. Chest 127:909-915, 2005[Abstract/Free Full Text]

3. Bottomley A, Gaafa R, Manegold C, et al: Short-term treatment-related symptoms and quality of life: Results from an international randomized phase III study of cisplatin with or without raltitrexed in patients with malignant pleural mesothelioma: An EORTC Lung-Cancer Group and National Cancer Institute, Canada, Intergroup study. J Clin Oncol 24:1435-1442, 2006[Abstract/Free Full Text]

4. Van Meerbeeck JP, Manegold C, Gaafar R, et al: A randomized phase III study of cisplatine with or without raltitrexed in patients with malignant pleural mesothelioma: An Intergroup study of the EORTC Lung Cancer Group and NCIC. J Clin Oncol 23:6881-6889, 2005[Abstract/Free Full Text]

5. Van Meerbeeck JP: Chemotherapy in malignant mesothelioma: What's up doc? J Thorac Oncol 1:279-280, 2006

6. National Cancer Res Networks: Trials portfolio: Mesothelioma trials. http://www.ctu.mrc.ac.uk/studies/meso_1.asp

7. Cullen MH, Billingham LJ, Woodroffe CM, et al: Mitomycin, ifosfamide, and cisplatin in unresectable non-small-cell lung cancer: Effects on survival and quality of life. J Clin Oncol 17:3188-3194, 1999[Abstract/Free Full Text]

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Related Correspondence

• Raltitrexed and Pemetrexed Studies in Mesothelioma Have Not Shown Improved Quality of Life nor Prolonged Survival Compared With Effective Pleurodesis With Thoracoscopic Talc Poudrage
  Yossef Aelony
  JCO 2006 24: 4667 [Full Text]

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