Malignancy is the most common cause of exudative pleural effusion in patients over the age of 60 years. Control of the effusion significantly reduces morbidity and improves quality of life. Tube thoracostomy with subsequent chemical pleurodesis is the treatment of choice for patients with tumors that are relatively insensitive to systemic chemotherapy. The agents most commonly used for chemical pleurodesis are tetracycline and bleomycin. A 13-center randomized trial compared tetracycline 1 g and bleomycin 60 U. Median time to recurrence or progression of the malignant effusion was 32 days for tetracycline and more than 46 days for bleomycin (P = .037). The recurrence rate within 30 days of instillation was 36% for bleomycin (10 of 28 patients) and 67% (18 of 27 patients) for tetracycline (P = .023). At 90 days, the recurrence rate was 30% (11 of 37) for bleomycin, and 53% (19 of 36) for tetracycline (P = .047). From this study, the authors concluded that intrapleural bleomycin appears superior to tetracycline for controlling malignant pleural effusions. Selected patients who fail tube thoracostomy and chemical pleurodesis should be considered for pleuroperitoneal shunting or pleurectomy.