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Talc Pleurodesis: Easy Alternative Solution

Khoja, Amir M MD, DTCD*; Amalnerkar, Dinesh P MSC, PHD; Mulik, Uttam P MSC, PHD; Seth, Tanay MSC, PHD

doi: 10.1097/01.lab.0000141898.96929.b3
Original Article
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Superiority of talc to cause obliteration of the pleural space over other agents has been well documented. Medical talc is difficult to obtain in many parts of India and hence talc pleurodesis is not performed, even in deserving cases. To overcome this difficulty, we compared the composition of the easily available inorganic talcum powder (face talc) with medical talc. Under 2000× magnification, it was observed that the size and the morphologic features of both talcs were similar. There was no difference in the elemental composition, and the face talc was also free of asbestos fibers. We used the face talc in 135 patients with symptomatic pleural effusion over the last 8 years and compared the outcome with that in 20 other patients who underwent pleurodesis using medical talc. There was no significant difference in the “pleurodesis failure” rate as well as that of recurrent pleural effusion between the 2 groups. Face talc is an easy, affordable, and safe alternative for pleurodesis in developing countries like India.

From the *Department of Chest Medicine and Thoracic Endoscopy, Ruby Hall Clinic; and the †Center for Materials for Electronics Technology (C-MET), Pune, India.

Received for publication January 22, 2004;

accepted July 27, 2004.

Reprints: Dr. Amir M. Khoja, Director and Head, Department of Chest Medicine and Thoracic Surgery, Ruby Hall Clinic, Pune, India (e-mail: amirkhoja@vsnl.com).

Lung cancer is the leading cause of malignant pleural effusion.1 When patients with lung cancer are first evaluated, approximately 15% have a pleural effusion.2 During the course of this disease, however, at least 50% of patients with disseminated lung cancer develop a pleural effusion. Pleural effusions occur with all the cell types of lung carcinoma but appear to be most frequent with adenocarcinoma.1,3 The incidence of pleural effusions in patients with small cell lung carcinoma is approximately 10%.4

Dyspnea appears to be the most common symptom in malignant pleural effusion occurring in more than 50%.3 Dull chest pain seems to be common in malignant pleural effusion as compared with those with benign pleural effusions (34% vs. 11%), whereas patients with benign disease are more likely to have pleuritic chest pain (51% vs. 24%).5

The prognosis of patients with malignant pleural effusions is grave. In a recent report, the median survival of 417 patients with malignant pleural effusions was only 4.0 months.6 This 4.0-month median survival is on the optimistic side because all 417 patients were judged to be fit enough to undergo pleurodesis.6

Patients with malignant pleural effusion who do not have a chylothorax should be considered for chemical pleurodesis. When managing such a patient, the first question to answer is whether the patient is symptomatic from the effusion. The only symptom likely to be relieved with pleurodesis is dyspnea. Probably this local therapy does not improve the duration of the patient’s life, but can definitely improve the quality of life.7

There are large numbers of methods, which can be used to obliterate the pleural space (pleurodesis), and accordingly, prevent the reaccumulation of the fluid. It is well known that the pleural space can be obliterated with talc. A recent review of 1200 procedures of talc pleurodesis reiterates the excellent success rates when talc is administered by slurry (87%) or by talc poudrage (93%) in the treatment of pneumothorax (91%) and pleural effusion (91%).8 The superiority of talc over other agents is also well documented.9

The availability of the talc is a problem in many cities in India and hence the talc pleurodesis is not done in many institutions. To overcome this problem, we have tried to find an alternative source for talc for pleurodesis. To our surprise, we found that face talc is a satisfactory alternative. The objective of this article is to report the results that we obtained with face talc in 135 cases over the last 8 years. This talc is commonly available in grocery stores. We hypothesized that the results with this face talc would be comparable to those with the commercial talc that is commonly used for pleurodesis. We have analyzed both the face talc powders (Cinthol and Johnson Baby talc) and imported talc (Steritalc, Novatech), and found that the contents are the same, only the coarseness differs, because the face talc is finer than the standard one (40–65 μm as compared with 40–75 μm).

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MATERIALS AND METHODS

The 2 types of face talc (Cinthol made by Godrej, India, and Johnson Baby talc made by Johnson & Johnson, India) and imported talc (Steritalc, Novatech) were studied in detail in the laboratory, Center of Materials for Electronics Technology (C-MET, Pune, India). All patients had approximately 5 to 10 g of powder used through the bladder wash syringe with a needle attached to the tip so as to get the controlled spray of the powder. Failure meant no signs of pleurodesis in the form of regression of fluid on x-ray chest and stay of more than 10 days. The effect of autoclaving on the characteristics of the talc was also observed. The analysis was done to compare the contents of the face powder and the Steritalc; and in particular, the particle size of the powder (Figs. 1 and 2 and area analysis of the material was done with 2000× magnifications by the scientist of the laboratory. Thermal analysis was carried out on autoclaved samples of face powder and Steritalc to see if autoclaving affects their composition. The composition of the powder was studied by Energy Dispersive Analysis by x-rays (EDAX) and it was compared with that of asbestos because it is important to demonstrate the absence of asbestos (Figs. 3, 4, 5, and 6) in any talc used for medical purposes.

FIGURE 1.

FIGURE 1.

FIGURE 2.

FIGURE 2.

FIGURE 3.

FIGURE 3.

FIGURE 4.

FIGURE 4.

FIGURE 5.

FIGURE 5.

FIGURE 6.

FIGURE 6.

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Selection of Patients

A total of 207 patients with pleural effusions were studied at Ruby Hall Clinic, a 500-bed multispecialty hospital in Pune, India, between 1993 and 2001. The mean age of the patients was 40 years (Table 1). Those who had endoscopic and clinical features of malignancy and who had recurrent hemorrhagic effusions underwent talc pleurodesis. A total of 155 patients underwent the procedure; 20 were subjected to standard imported talc (Steritalc marketed by Novatech) and 135 were subjected to the pleurodesis with regular face talc of various available brands (Cinthol or Johnson (Table 2). Instead of a talc atomizer, a bladder wash syringe was used to insufflate the talc. Patients were included if they had dyspnea resulting from the effusion and recurrent exudative effusions. Patients were excluded from talc pleurodesis if they had a trapped lung or effusion with ipsilateral shift. Those with hemorrhagic effusion underwent pleurodesis and those with nonhemorrhagic effusions underwent pleurodesis only if there was a high index of suspicion of malignancy and abnormal nodules on the pleura on thoracoscopy. Three patients with transudative effusion underwent pleurodesis. All of them had liver cirrhosis.

Table 1

Table 1

Table 2

Table 2

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Procedure

All patients underwent videothoracoscopy in the operation room under general anesthesia with 1 lung ventilation. The lateral jackknife position was used. Usually 2 surgical ports were used. The telescope was passed through 1 port while the biopsy forceps and other instruments were passed through the other. The pleural cavity was emptied by aspirating the pleural fluid. Adhesions were lysed in patients with loculated effusion. Autoclaved talc (5–10 g) was insufflated through the second port with the help of the bladder wash syringe. In the case of Steritalc, the talc was sprayed through the container. After insufflation, the anesthetist inflated the lung and 1 chest tube was placed in the pleural space. Continuous negative suction was applied for at least 6 to 8 hours. Patients were shifted to the wards after the procedure and were ambulated the next day. A chest x-ray chest was taken the next day and another before the planned discharge. Additional x-rays were taken only when necessary. Chest tubes were removed when the drainage was less than 100 mL/24 hours. Patients were followed every month as outpatients with a chest x-ray.

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RESULTS

Of 207 patients with pleural effusion, 155 patients underwent talc pleurodesis. Patients not receiving pleurodesis had small effusions. Of 155 patients, face talc was used in 135 patients and Steritalc was used in 20 patients (Fig. 7) The results were comparable in both groups of patients.

FIGURE 7.

FIGURE 7.

Of 129 patients with hemorrhagic effusions, malignancy was seen in 110 patients (85%), tuberculosis in 9 patients (7%), and organizing pleuritis in 10 patients (8%). Of the 78 patients in the nonhemorrhagic group, 49 (62%) had tuberculosis, 18 (23%) had malignancy, and 11 (14%) had organizing pleuritis (Fig. 8). Of 128 malignant cases, 125 patients had metastasis, from the lung in 78 (62%), breast in 26 (21%), and 21 (16%) patients had no known primary. Only 3 (2%) cases of mesothelioma were seen (Table 3 and 4).

Table 3

Table 3

Table 4

Table 4

FIGURE 8.

FIGURE 8.

The average stay in the hospital was 6 days. Patients with large effusions of more than 2 L needed more days as compared with those with smaller effusions (less than 1 L) (average 10 days vs. 5 days). The recurrence rate after 3 months was studied; there were 6 (4%) patients in the face talc group and 1 (5%) patient in the Steritalc group. There were 5 (4%) failures in the face talc group and 1 (5%) failure in the Steritalc group (Fig. 7). Only 13 patients returned for follow up after 6 months and had no recurrence. The remaining were either lost to follow up or were dead. Results of imported talc and the face talc were compared and except for the particle size, the composition, elements, thermal stability, and asbestos-free nature were the same (Fig. 9). There was no difference in the results of the 2 face powders also.

FIGURE 9.

FIGURE 9.

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DISCUSSION

Malignant disease involving the pleura is the third leading cause of exudative pleural effusions after tuberculosis and parapneumonic effusions. Because many parapneumonic effusions are small and are not subjected to thoracentesis, tuberculosis and malignancy are probably the leading causes of exudative effusions subjected to thoracentesis. In the series from Baltimore, 42% of 102 exudative pleural effusions were the result of malignant disease.10 In an epidemiologic study from the Czech Republic, malignancy accounted for 24% of all the pleural effusions.11 In our study, in the hemorrhagic effusion group, malignancy was the most common cause, whereas in the nonhemorrhagic effusion group, tuberculosis was the most common cause.

Carcinomas of the lung and breast and lymphomas account for approximately 75% of malignant pleural effusions. Metastatic ovarian carcinoma is the fourth leading cause of malignant pleural effusions, whereas sarcomas, particularly melanoma, account for a small percentage of malignant pleural effusions. No other single tumor accounts for more than 1% of malignant pleural effusions. In approximately 6% of patients with malignant pleural effusions, the primary tumor is not identified.12,13

In our study, metastasis of adenocarcinoma of the lung was the most common finding followed by breast carcinoma. Incidence of mesothelioma was somehow very low in our series.

Pleurodesis was the most appropriate procedure for the patients with recurrent large effusions. Before a pleurodesis is attempted, the position of the mediastinum on the chest radiograph should be evaluated, because its position tells much about the pleural pressure on the side of the effusion. If the mediastinum is shifted toward the side of the effusion, the pleural pressure is more negative on the side of the effusion. Pleurodesis is then unlikely to be successful because the ipsilateral lung is unable to expand. In such patients, a bronchoscopic examination should be performed to assess the patency of the major bronchi. If neoplastic obstruction of the bronchi is discovered, radiotherapy, laser therapy, or an endobronchial stent should be considered for relief of the bronchial obstruction. If no obstructing lesion is found, the lung is probably encased by the tumor, and a pleurectomy should be considered.

Patients with a trapped lung rarely benefit with pleurodesis. Only those with rapid accumulation of the fluid of 2 to 3 L undergo pleurodesis.14 These criterions not only apply to the malignant effusions,15 but also to the transudates of cardiac and cirrhotic patients who do not respond to the aggressive therapy.16

All the substances used to induce pleurodesis are pleural irritants, which produce inflammation and a sclerosing effect. They destroy the mesothelial layer17 and induce pleural fibrosis,18 which binds the visceral and the parietal surfaces together. This process stops the constant dripping of fluid from the pleural surface. In the trapped lung syndrome, surgical decortication with or without pleurectomy could be considered.19 Sclerosants are sometimes injected at the surgeon’s discretion.

At the present time, the agents that are most commonly recommended are the tetracycline derivatives (minocycline or doxycycline), talc (either insufflated or as a slurry), the antineoplastics bleomycin, or mitoxantrone and silver nitrate.

During the 1980s, tetracycline was probably the agent most commonly used for creating a pleurodesis. Tetracycline at a dosage of 35 mg/kg is effective in creating a pleurodesis in rabbits.20 Tetracycline is also effective in treating malignant pleural effusions. Sherman and coworkers21 reported that 1500 mg tetracycline effectively controlled 94.4% of 108 malignant pleural effusions. In a review of 11 reports involving 359 patients, the success rate with tetracycline was 67%.22

Doxycycline and minocycline are effective at producing pleurodesis in patients with malignant pleural effusion. The usual dose of doxycycline is 500 mg. There has also been 1 report in which the administration of 300 to 500 mg minocycline produced a complete response at 30 days in 62.5% of patients and a partial response (no need for further thoracentesis) in an additional 25%.23 The primary side effect when pleurodesis is performed with a tetracycline derivative is severe chest pain.24

Talc can be instilled into the pleural space either as an aerosol (insufflation) or suspended in saline (slurry). The disadvantage of the insufflation methods is that it must be done in conjunction with either thoracoscopy or thoracotomy, whereas the talc slurry can be administered through chest tubes. Insufflated talc was first used in 1935 by Bethune25 to produce a pleurodesis. Subsequent studies have shown that insufflated talc is very effective for creating a pleurodesis.

Insufflated talc is very effective at creating a pleurodesis in patients with malignant pleural effusion. Ribas and associates26 treated 383 patients with malignant pleural effusions with 2 g insufflated talc and reported a success rate of 93.4%. Hartman and associates27 reported that the intrapleural insufflation of 3 to 6 g aerosolized talc controlled malignant pleural effusions in 37 of 39 (95%) patients for 90 days.

It appears that talc slurry is also very effective at producing a pleurodesis. Adler and Sayet28 treated 44 hemothoraces with malignant pleural effusion with 10 g talc in 250 mL saline and reported control of the effusion in 41 (93%). Webb and coworkers29 reported a 100% success rate in 28 patients with malignant effusions who were given 5 g talc and 3 g thymol iodine in 50 mL saline. Kennedy and co-workers30 reported that 10 g talc mixed in 150 to 250 mL of normal saline solution effectively controlled 38 of 47 (81%) malignant pleural effusions.

Antineoplastics, including bleomycin,31 nitrogen mustard and mitoxantrone, cisplatin, doxorubicin, etoposide, fluorouracil, and mitomycin-C have been evaluated for the treatment of pleural effusions, and the response rates have been less than 50% for almost all.22 Therefore, their use cannot be recommended.

Silver nitrate was probably the first agent used to produce a pleurodesis and is very effective.32

Talc pleurodesis is in the practice since 1935. Its usefulness was documented on many occasions. Its superiority over tetracycline and bleomycin was heavily debated. However, those in whom tetracycline failed, talc worked. Hence, many authors claimed talc as the superior agent. There have been several reports of adult respiratory distress syndrome (ARDS), 32 cases of acute pneumonitis, 15 after talc instillation either by insufflation33,34 and 17 after slurry,35,36 but most of the patients who developed ARDS received talc from the United States, and 2 large series from Israel37 and Europe38 reported no instances of acute respiratory distress. The differences in opinion are such that certain authors doubt whether talc should be used for pleurodesis.39 In our series, there was no incidence of ARDS. The varying prevalence in different countries of ARDS suggests that the syndrome could be dependent on the talc preparation and probably the particle size and impurities. However, there are no published data on the physical and chemical characteristics of various preparation of talc.40 The mechanism by which talc produces lung injury is unknown. It has been postulated that the injury is the result of impurities like dolomite, quartz, kaoline, calcite, or chlorite. It is probably the systemic absorption of the talc with subsequent liberation of the inflammatory mediators. This hypothesis was reported by Rinaldo et al. that there was a large amount of talc in the bronchoalveolar lavage fluid of the patients underwent talc pleurodesis.

Availability of talc was a problem, and we found inorganic-based talcum powder, eg, face talc, was also an alternative solution because the content of face talc and that of Steritalc was the same as magnesium trisilicate hydroxide Mg3 (Si205) 2(OH) 2. Autoclaving of the talc was well discussed by Kennedy et al,41 in which it was found out that various methods like dry heat, ethylene oxide, and gamma ray sterilization can be used with almost comparable results. Absence of asbestos was demonstrated by showing totally different behavior of asbestos and talc. Similarly, imported talc and inorganic-based talc also showed the same composition of magnesium trisilicate hydroxide. Hence, we feel that inorganic-based talc like face talc can be a good alternative to the conventional imported talc with nearly the same effectiveness for pleurodesis.

Inpatient pleural sclerosis is very similar to outpatient pleural sclerosis. One option available if the pleural sclerosis is done as an inpatient is thoracoscopy. The results with thoracoscopy overall are probably better than the results with tube thoracostomy because patients with trapped lungs can be identified (and therefore do not receive a pleural sclerosant), and loculated pleural effusions can be completely drained.

The keys to the success of this procedure are the pleuritis produced by the sclerosant and the approximation of the visceral and the parietal pleura by the chest tubes so that a pleural symphysis can occur and the quality of life can improve in the patients with malignant pleural effusions.

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Keywords:

talc pleurodesis; face talc; thoracoscopy; India

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