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I want you to know how much I appreciate all the kindness and support.  I have an appointment for next Tuesday with my oncologist.  The very kind respirologist asked me to come to his office tomorrow and hopefully we will have a better idea of what we are dealing with.

Historically, many chemical agents have been instilled into the pleural space and shown to have some effectiveness in controlling effusions, including tetracycline, doxycycline, minocycline, bleomycin, cisplatin, doxorubicin, etoposide, fluorouracil, mitomycin, mitoxantrone, interferon, Corynebacterium parvum, mepacrine, methylprednisolone, and talc.[6]

Chest tube drainage should be done by inserting the chest tube into the pleural cavity and draining the fluid. When the drainage reaches less than 50-100 milliliters in a 24 hour period, a sclerosing agent can be instilled.[2,5] Information on the recommended sclerosing agent is currently inconclusive. The few randomized studies on this topic are plagued by small numbers (all but one have fewer than 50 patients per arm), and relatively short follow-up. The single randomized study with more than 100 patients showed nearly twice as many patients had their pleural effusion controlled with bleomycin at 90 days (70%) than those treated with tetracycline.[7]

Large single-arm comparative studies [8-10] and very small randomized studies suggest advantages for talc as the sclerosing agent compared to tetracycline and bleomycin.[11,12] In these two randomized studies, thoracoscopy and insufflation of talc controlled the pleural effusions in twice as many patients as tetracycline or bleomycin (>90% versus 50%, respectively) in 63 patients with breast cancer. The comparative and single-arm studies suggest that talc provides control of approximately 90% of pleural effusions for 90 days or longer.[8-10] We await the results of two different large cooperative group randomized studies to help determine the appropriate sclerosing agent to use to treat patients with malignant pleural effusions. One compares intrapleural bleomycin, doxycycline, and talc as sclerosing agents.[13] Another compares the use of a talc slurry administered via chest tube to talc insufflated during thoracoscopy.[14] Another approach is appropriate for patients with a symptomatic malignant pleural effusion and good performance status (ECOG performance status of 0-2) who are capable of undergoing a procedure under local, regional, or general anesthesia. These patients can have thoracoscopy with biopsy of suspicious pleural lesions, lysis of adhesions, evaluation to see if the lung re-expands, and installation of the sclerosing agent during the same procedure.[4] This potentially shortens the hospitalization because the whole procedure can be done in the operating room in a single day.