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An unplanned subgroup analysis suggested a better successful pleurodesis rate with thoracoscopic poudrage in patients with lung or breast cancer.[5] This is being evaluated in a randomized trial (ISRCTN47845793) in the United Kingdom. A smaller randomized study involving 60 patients showed that full lung re-expansion was more common after thoracoscopic pleurodesis but did not change patient outcomes[38] with no difference in QoL, hospitalization or pleurodesis success rates Entinostat chemical structure when compared with talc slurry. The third randomized study comparing thoracoscopic pleurodesis with talc slurry pleurodesis in 57 patients also reported similar findings with no significant difference in pleurodesis success or hospitalization rates.[39] The lack of research on MPE is highlighted in the case of talc pleurodesis. Despite its use worldwide over many decades, its usefulness and harm have only been uncovered by research studies in recent years. In some countries, talc was licensed as a device rather than a drug and avoided the scrutiny of pharmaceutical safety.[60] Only in recent years had it come to light that many ��talc�� preparations used around the world contained largely other compounds or even no talc at all. Even within genuine talc preparations, significant heterogeneity exists in their physical properties in different commercial products.[61] Talc of small particle size can be systemically absorbed, presumably via parietal lymphatics, as shown in human and animal studies.[62, 63] This induces systemic and lung inflammation. Dresler et?al.[5] showed that 2.3% of patients died of the resultant respiratory failure, irrespective of whether talc was insufflated SCR7 or administered as slurry. Large particle size talc preparations (median particle size >25??m) are not available in some parts of the world; this becomes an important factor in the choice of MPE treatment. There are wide variations in how talc slurry pleurodesis is performed. No consensus exists on the ideal timing for pleurodesis. The reported success rate for pleurodesis attempted at the time of initial MPE diagnosis is similar to pleurodesis deferred for symptomatic recurrence.[53, 64, 65] Early intervention may reduce the risk of trapped Mianserin HCl lung that could preclude pleurodesis[66] (Fig.?5). Conversely, nearly half of all MPEs may not recur and cause significant symptoms, thus arguing against routine pleurodesis on all new patients. The exact timing of instillation of sclerosant is unknown; few data support the traditional practice to defer instillation till daily fluid output falls below a specified rate (e.g.