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EPIToME (Early Pleurodesis via IPC with Talc for Malignant Effusion): Evaluation of a new management algorithm

Traditionally, most patients with malignant pleural effusion (MPE) have to undergo fluid drainage to assess if the underlying lung expands (or not) before being offered either pleurodesis or indwelling pleural catheter (IPC) respectively. Recent data suggest that talc can be safely instilled via IPC. Using IPC as a first-line definitive therapy for all MPE patients, followed by talc if suitable, will suit both subgroups and remove the need for prior assessment of expansion. This observational study enrolled 102 consecutive patients with symptomatic MPE (68% male) to assess the feasibility of EPIToME, a clinical algorithm incorporating results from AMPLE-1, -2, TIME-2, ASAP and IPC-Plus trials. All patients had IPC inserted and fluid evacuated. Those whose lung adequately expanded (n=47) underwent talc instillation and were discharged with daily vacuum drainages for 14 days or until pleurodesed. Using this protocol, 74% achieved pleurodesis after a median of 20 days. Patients unsuitable for talc pleurodesis (n=55) – trapped lung (n=31), prior failed pleurodesis, patient/oncologist preference - were discharged with symptom-guided drainage. All were followed for ≥120 days or till death. Only one patient needed further pleural drainage for fluid control in the first 12 months. Complications included symptomatic loculation (10%), IPC infection (7%) and reversible IPC blockage (3%). Conclusion: A high percentage of patients in the real-world unselected MPE population were not suitable for talc and first-line IPC offered optimal care. For those eligible, IPC combined with inpatient talc slurry pleurodesis, followed by daily home drainage provided good success rates.