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Early pleural effusion control in patients with lung cancer

We read with interest the article entitled ‘Role of early definitive management for newly diagnosed malignant pleural effusion related to lung cancer’ by Chiang et al. We have been particularly interested in the management of pleural effusion in patients with lung cancer, and we would like to raise four issues arising from the article by Chiang et al. First, in table 1 of Chiang et al.’s study, the authors showed that 154 patients had targetable oncogenic mutations (142 patients, excluding patients with uncommon epidermal growth factor receptor (EGFR) mutations). How did the authors treat the 12 patients with uncommon EGFR mutations? The authors stated that 57 patients received early malignant pleural effusion (MPE) control. However, figures 1 and 2 in Chiang et al.’s study indicated that 34 and 11 patients, respectively, had early fluid control measure. In the Results section of Chiang et al.’s study, 11 patients received control treatment in the best supportive care group, with the total being 56 patients. Was one patient lost to follow-up? Second, in table 2 of Chiang et al.’s study, the authors divided patients into two groups according to the ‘size’ of pleural effusion. Was there a difference in the need for MPE re-intervention between these two groups? Was pleurodesis required for patients with a smaller amount of pleural effusions, as the authors performed pleurodesis in 89.4% of patients? Third, according to figures 1 and 2 in Chiang et al.’s study, systemic anti-cancer therapy was performed after the early control of pleural effusion. We speculate that some patients may not be able to wait for the initiation of systemic anti-cancer therapy due to the speed of disease progression. We would like to know whether the authors think it worthwhile to wait for the start of systemic anti-cancer therapy, but whether treatment for targetable oncogenic mutations might be started. Fourth, we believe that the contribution of early pleural effusion control might be important to survival as the authors show the survival time in the Discussion section. As such, it would be of interest to know if early control of pleural effusion will significantly contribute to survival.