To provide information about available agents for chemical pleurodesis.

MEDLINE was searched from 1966 to October 1992 for English language medical literature; an additional reference was translated from Japanese.

Study designs of evaluations included in the review

Controlled and uncontrolled trials reporting the results of chemical pleurodesis in patients with recurrent, symptomatic, malignant pleural effusions. The following agents were not included: Calmette-Guerin bacillus cell-wall skeleton, nitrogen mustard, quinacrine and thiotepa.

Specific interventions included in the review

Agents used for chemical pleurodesis for malignant pleural effusions: doxycycline, minocycline, tetracycline, bleomycin, cisplatin, doxorubicin, etoposide, fluorouracil, interferon-beta, mitomycin-c, Corynebacterium parvum, methylprednisolone and talc.

Participants included in the review

Patients with recurrent, symptomatic, malignant pleural effusions.

Outcomes assessed in the review

Complete responses as defined by the absence of reaccumulation of the effusion, determined by clinical examination or chest radiograph. Side-effects were also assessed.

How were decisions on the relevance of primary studies made?

The authors do not state how the papers were selected for the review, or how many of the authors performed the selection.

The authors do not state that they assessed validity.

The following information was extracted from each article by three independent observers: pleurodesis regimen, number of patients, success rate and adverse effects.

How were the studies combined?

The overall rate of complete response for each agent was simply calculated using the number of patients who responded and the total number of patients treated.

How were differences between studies investigated?

The studies were grouped according to different pleurodesis agents, but differences with each agent were not investigated.

Forty-three studies involving 1,168 patients were included. Only 4 agents (tetracycline, bleomycin, Corynebacterium parvum and talc) were studied in more than 100 patients.

The complete response rate after treatment with chemical pleurodesis was, on average, 64%, i.e. 752 out of 1,168 patients. The success rate of the pleurodesis agents was 0, 54, 67, 76 and 93% with etoposide, bleomycin, tetracyclines, Corynebacterium parvum and talc, respectively. Pain (23%) and fever (19%) were the most commonly reported adverse effects.

The prices of the agents were tabulated.

Doxycycline and minocycline appear to be effective tetracycline-replacement agents in the small number of patients studied. Talc appears to be the most effective and least expensive agent; however, insufflation has the disadvantages of the need for expensive thoracoscopy and the usual need for general anaesthesia. Bleomycin appears to be less effective than talc and the tetracyclines, and is substantially more expensive.

The authors discussed the limitations of evidence; these include the lack of direct comparability of different agents, differences in patient case-mix and follow-up, and variation in technique. Most agents were only studied on a few patients.

Clear implications cannot be drawn without larger-scale randomised controlled trials.

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.