We retrospectively examined the use of tetracycline pleurodesis for the palliative treatment of malignant pleural effusions. Twenty-five patients (32 procedures) were identified for study. In contrast to higher success rates in prior reports, 13 procedures (40.6%) failed as repeated pleural drainage was required. Only five procedures (15.6%) achieved complete resolution of pleural fluid. In 14 procedures (43.8%) pleural effusions recurred but were not treated. In some of these cases the effusion may have been reduced sufficiently to relieve symptoms, while in others the high short-term mortality rate (29% in 30 days) and the development of loculated effusions (34%) may have led to the decision not to treat. Instillation of a larger dose of tetracycline (greater than or equal to 1 g) was associated with a better outcome. Although adequate pleural drainage and proper technique were used, other factors such as the presence of pleural masses, atelectasis, loculations, and patient performance status were not uniformly controlled. Greater attention to these factors and use of a larger dose of tetracycline (greater than or equal to 1 g) may increase the likelihood of a successful pleural symphysis.