Patients will be randomised to undergo either chest drain insertion followed by 4 g talc slurry instillation,

or to undergo medical thoracoscopy with 4 g talc poudrage. The study flow diagram is shown in figure 1. Figure 1 Trial flow chart (BTS, British Thoracic Society; CI, chief investigator; CXR, chest X-ray; QoL, quality of life; VAS, visual assessment selleck kinase inhibitor scale; PA, pleural apposition; SOB, shortness of breath). Subject screening and selection Patients with MPE will be identified following early discussion at each centre’s cancer multidisciplinary team meetings (MDT), at routine outpatient appointments and during inpatient reviews. Eligible patients will be invited to participate on a consecutive basis, and will be provided with a patient information leaflet at the earliest opportunity (see online supplementary appendix 2). Patients can be enrolled only once into the TAPPS trial. Inclusion criteria Clinically confident diagnosis of MPE requiring pleurodesis, defined as: Pleural effusion with histocytologically proven pleural malignancy; or Pleural effusion in the context of histocytologically proven malignancy elsewhere, without a clear alternative cause for fluid; or Pleural

effusion with typical features of malignancy with pleural involvement on cross-sectional imaging without a clear alternative cause for fluid. Fit enough to undergo local anaesthetic thoracoscopy. Expected survival >3 months. Written informed consent to trial participation. Exclusion criteria Patients in whom thoracoscopy is the only reasonable approach to making a diagnosis, and in whom such a diagnosis would significantly influence further management; Age <18 years; Females who are pregnant or lactating; Evidence of extensive lung entrapment on CXR or a CT scan, or significant

fluid loculation on an ultrasound scan, to a level which would normally be a contraindication to attempted talc pleurodesis; Insufficient volume or position of pleural fluid on lateral decubitus thoracic ultrasound to safely perform local anaesthetic thoracoscopy without further intervention being necessary; Previously documented adverse AV-951 reaction to talc; Clear contraindication to thoracoscopy or chest tube insertion. Informed consent A doctor will confirm patient eligibility prior to consent being taken. Participation in the trial will be discussed with the patient by a medical or nursing member of the local trial team. Patients will be given sufficient time (in their own opinion) to fully consider trial entry, as well as to ask questions of investigators.