Talc Insufflation Research Articles

A Randomized Controlled Study Evaluating the Efficacy and Safety of Silver Nitrates Injection Through Chest Tube Thoracostomy Versus Thoracoscopic Talc Insufflation for Pleurodesis in Cases of Malignant Pleural Effusion

A Randomized Controlled Study Evaluating the Efficacy and Safety of Silver Nitrates Injection Through Chest Tube Thoracostomy Versus Thoracoscopic Talc Insufflation for Pleurodesis in Cases of Malignant Pleural Effusion

Complications of thoracoscopic talc insufflation for the treatment of malignant pleural effusions: a meta-analysis

BackgroundTalc pleurodesis is an effective treatment for malignant pleural effusions (MPEs). This study was designed to estimate complication rates of thoracoscopic talc insufflation.MethodsLiterature search was conducted in electronic databases and studies were selected if they reported complication rates of thoracoscopic talc insufflation in cancer patients with MPEs. Meta-analyses of proportions were performed to obtain incidence rates of complications.ResultsTwenty-six studies (4482 patients; age 62.9 years [95% confidence interval (CI): 61.5, 64.4]; 50% [95% CI: 43, 58] females) were included. Intraoperative, perioperative, 30-day, and 90-day mortality rates were 0% [95% CI: 0, 1], 2% [95% CI: 0, 4], 7% [95% CI: 3, 13] and 21% [95% CI: 5, 43] respectively. Incidence rates [95% CI] of various complications were: pain (20% [1, 2]), fever (14% [3, 4]), dyspnea (13% [5, 6]), pneumothorax (6% [7, 8]) pneumonia (4% [0, 12]), emphysema (3% [3, 7]), prolonged air leakage (3% [0, 7]), prolonged drainage (3% [9, 10]), thromboembolism (3% [9, 11]), lung injury (2% [7, 12]), respiratory insufficiency (2% [0, 5]), re-expansion pulmonary edema (1% [0, 3]), empyema (1% [0, 2]), respiratory failure (0% [0, 1]), and acute respiratory distress syndrome (ARDS; 0% [0, 1].ConclusionsWhereas pain and fever were the most frequent complications of thoracoscopic talc insufflation, the incidence of ARDS was low. Pneumothorax, pneumonia, emphysema, prolonged air leakage, pulmonary embolism, arrythmia, re-expansion pulmonary edema, and empyema are important complications of thoracoscopic talc insufflation.

Thoracoscopic Talc Insufflation Versus Talc Slurry in Patients with Malignant Pleural Effusion

Background: Malignant Pleural Effusion (MPE) is defined as an accumulation of pleural fluid in which malignant cells are present. It is a poor clinical indicator as it represents an advanced stage neoplasm with median survival ranging from one to 12 months. Aim: We aimed at comparing Thoracoscopic Talc Insufflation with tube thoracostomy talc slurry pleurodesis in regard to the efficacy and complications in patients with MPE. Patients and Methods: 128 patients with MPE were divided into two groups, 64 in each. One group had tube thoracostomy talc slurry (TS) pleurodesis while the other had thoracoscopic talc insufflation (TTI) pleurodesis. Results: Talc slurry was associated with a longer hospital stay. Complications recorded included chest pain (TS 29%, TTI 25.4%), dry cough (TS 16%, TTI 39%), vomiting (TS 29%, TTI 13.6%), tachycardia (TS 16.13%, TTI 18.64%), surgical wound infection (TS 11.29%, TTI 10.17%), and respiratory failure complicating talc pneumonitis (TS 3.23%, TTI 0%). Pleurodesis success was enhanced by the presence of lung cancer (OR 2.34, p=0.02) or breast cancer (OR 2.55, p= 0.03) as the primary malignancy, the younger the patient's age at pleurodesis time (OR 1.004, p=0.89) and the higher the pleural fluid glucose content (OR 1.01, p=0.09). Pleurodesis failure was strongly correlated to the presence of any of the pre-procedural factors, female gender, hepatocellular carcinoma as the primary malignancy, and low pH pleural fluid. Conclusion: In MPE patients with no evidence of lung trapping, talc pleurodesis method used should depend on local expertise (availability of thoracoscopy), whether additional tissue is needed for molecular-marker analysis (would favor thoracoscopy), plus patient-related factors (operable or not). However, TTI has a significant irrefutable benefit in patients with adhesions and trapped lung.

Diagnostic Workup of Pleural Effusion and Medical Thoracoscopy –Current Status

Pleural effusion is a common clinical problem with diverse aetiologies accounting for around 4 patients in pulmonary practice. Pleural effusion results from an abnormal accumulation of fluid due to excessive production or decreased pleural fluid absorption and can be transudative or exudative depending on the fluid composition. Proper diagnostic workup of all pleural effusion cases must be done so that proper cause may be established and adequate treatment may then be started. About 20 to 25 of pleural effusion cases remain undiagnosed despite repeated thoracocentesis and closed pleural biopsies. Medical thoracoscopy is a minimally invasive procedure that allows complete visualization of the pleural space enabling the diagnostic and therapeutic procedures like pleural biopsy and talc insufflation for pleurodesis to be performed safely. Thoracoscopy increases the diagnostic yield in undiagnosed pleural effusion as it allows inspection of the pleural surfaces and permits pleural biopsy under direct visualization. The diagnostic yield of thoracoscopy in malignant and TB pleural effusion ranges from 91 to 95 and 93 to 100 respectively. The traditional instrument used for thoracoscopy has been the rigid thoracoscope. Development of the technique of semi-rigid thoracoscopy provided an alternate method to access the pleura using a scope which essentially resembles the flexible bronchoscope. Semi-rigid thoracoscopy is a safe and efficacious procedure in patients with undiagnosed pleural effusion. This article focuses on the simplified way on how to approach a case of pleural effusion with a simplified algorithm and also on the diagnostic and therapeutic utility of medical thoracoscopy.

ES 06.05 Approach to Malignant Pleural Effusions

The onset of an MPE usually indicates a significant reduction in prognosis, with a median life expectancy of 3 to 12 months from onset. MPE associated with breast cancer is usually associated with a better than average prognosis whilst lung cancer has the worst prognosis. Confirmation of malignancy and determination of the cell type may be established by increasingly invasive techniques; pleural aspiration cytology, facilitated by ultrasound guidance if the effusion is small or loculated, pleural biopsy, blind or image guided, thoracoscopy (usually now video-assisted) under local or general anesthesia. Whilst it is reasonable to start with the least invasive procedure suitable in the circumstances, in patients who are reasonably fit it is important to avoid an escalating cascade of failed procedures, each with the risk of causing pleural adhesions and clot formation, making effective palliation more difficult. There is much to commend early acceptance of an approach which combines the best chance of a tissue diagnosis with the best chance of effective palliation. This decision will be influenced by an assessment of prognosis. Prognosis once an MPE has been confirmed is dependent upon the extent of metastatic disease and associated co-morbidity. In a surgically palliated population in-hospital and 30-day mortality was statistically related to blood albumen levels, being 0% and 0.98% in those with normal albumen levels and 6.8% and 19% in those with hypoalbumenaemia (p =0.001).1 In a series of 278 patients referred to the Department of Thoracic Surgery at the Royal Brompton Hospital over a 72 month period 195 underwent thoracoscopic talc pleurodesis, 39 had a pleuro-peritoneal shunt inserted, 38 had pleurodesis through an intercostal drain, 29 had pleural biopsy alone and 9 were treated with long-term pleural drainage, a total of 310 surgical procedures. Overall median survival was 211 days post operatively. Survival was not significantly different for tumor type or method of palliation but was related to leucocytosis (p<0.0001), hypoxemia (p =0.014) and hypoalbumenaemia (p<0.0001).2 The summative effect of these factors is shown in the table. How this information might be used to personalize treatment options in patients for whom effective systemic therapy does not exist. Those whose prognosis is judged to be less than 2 months (having all 3 adverse prognostic factors) palliation may be achieved by repeated pleural aspiration. If prognosis is judged to be greater than 2 months, and especially if the patient is in a poor general condition, adequate palliation could be achieved by the insertion of an indwelling pleural catheter under local anesthesia. In fitter patients with an estimated survival greater than 6 months VATS insufflation of talc or the insertion of a pleuro-peritoneal shunt should be considered. The choice of talc or shunt will be dictated by the adequacy of lung expansion during positive pressure ventilation. In many respects these 2 techniques are complementary but having both of these techniques available at thoracoscopy allows affective long-term palliation to be achieved in 95% of patients.3 However pleuro-peritoneal shunts can be complicated by occlusion within 4 months in 15% of cases but spontaneous pleurodesis has usually been achieved by this time.4 Pleurectomy is rarely indicated in the palliation of MPE. 1. Pilling JE, Dusmet M, Ladas G, Goldstraw P. Predictors of early mortality and morbidity follwoing surgical palliation of malignant pleural effusion. Journal of Thoracic Oncology 2[8], s430. 2007. 2. Pilling JE, Dusmet ME, Ladas G, Goldstraw P. Prognostic Factors for Survival after Surgical Palliation of malignant Pleural Effusion. J Thorac Oncol 5, 1544-1550. 2010. 3. Petrou M, Kaplan D, Goldstraw P. The management of recurrent malignant pleural effusions: The complementary role of talc pleurodesis and pleuroperitoneal shunting. Cancer 75, 801-805. 1995. 4. Genc O, Petrou M, Ladas G, Goldstraw P. The long-term morbidity of pleuroperitoneal shunts in the management of recurrent malignant effusions. European Journal of Cardio-thoracic Surgery 18, 143-146. 2000. Malignant effusions, palliation, pleural malignancyTabled 1No of factorsnMedian survival (days)95% CIpNone39702473-931<0.00001One or two74200111-289Three234223-61 Open table in a new tab

Pathway to Definitive Palliation of Malignant Pleural Effusions

SESSION TITLE: Impact of Pleural Disorders SESSION TYPE: Original Investigation Slide PRESENTED ON: Monday, October 24, 2016 at 07:30 AM - 08:30 AM PURPOSE: Malignant pleural effusions (MPE) are a common clinical problem. Definitive management strategies for symptomatic patients include chemical pleurodesis and indwelling pleural catheters. The clinical pathway that patients with symptomatic MPE experience prior to definitive palliation, including all procedures and hospital admissions, has not been systematically examined. METHODS: This was a retrospective study. Thoracoscopic talc insufflation and indwelling pleural catheter placement are performed at the Montreal Chest Institute for definitive palliation of patients with symptomatic MPE. The charts of all patients referred over a 2-year period were reviewed, with attention to the clinical course preceding definitive MPE palliation. The number of thoracenteses and chest tube insertions performed, ER visits and hospital admissions were tabulated over the interval from initial symptomatic MPE presentation to definitive palliation. RESULTS: Over a 2-year period, 99 patients underwent definitive interventions for MPE. Data on the clinical course leading to definitive palliation was available in 69 patients, who underwent 72 definitive procedures (68 indwelling pleural catheter insertions and 4 thoracoscopic talc insufflations). The clinical course leading to definitive palliation was considered “ideal” in 36/72 (50%) cases, with patients undergoing ≤ 2 therapeutic thoracenteses, no chest tube insertions, ≤ 1 ER visit, and no hospital admissions. In the remaining patients, a mean of 2.4 (SD 1.65) pleural procedures were performed during the period leading to definitive palliation. Tube thoracostomy (without pleurodesis) was performed in 27/72 (38%) cases, with the chest tubes remaining in place for an average of 3.7 days (SD 3.0). Hospitalization for symptomatic MPE preceded definitive palliative intervention in 28/72 (39%) cases. Patients who initially presented to the ER with symptomatic MPE were more likely to undergo chest tube insertion and hospital admission. CONCLUSIONS: There is significant variability in the clinical pathway of patients with symptomatic MPE, prior to definitive palliation. Half of the patients in this series underwent potentially avoidable procedures and/or hospital admissions. CLINICAL IMPLICATIONS: Increased awareness and accelerated referral for definitive palliation may avoid unnecessary pleural procedures and hospitalizations. DISCLOSURE: The following authors have nothing to disclose: Benjamin Shieh, Stephane Beaudoin, Anne Gonzalez No Product/Research Disclosure Information

Malign plevral efüzyonda yaklaşım tarzı nasıl olmalıdır?

Cateter and talc pleurodesis is strongly recomended for patients with symptomatic malignant pleural effusion. Large grade talc and thoracoscopic insufflation is recommended.

Case Series Report: The Novel Use of a Long Drain Line Post Intraoperative Talc Pleurodesis

First described in 1917, pleurodesis the fusing of visceral and parietal pleura, has a wide range of clinical applications. Talc pleurodesis is now widely used in the management of recurrent pneumothorax or malignant effusion, with a validated safety profile. As a result of chemical irritation to the pleural lining inflammation, adhesion and obliteration of the potential space results. Typically the procedure is completed at the bedside after chest drain insertion. However, the diagnosis is not clear operative pleural biopsy which is often required to be followed by on table talc insufflation. At this stage, once the port is closed and suction drainage commenced, large volumes of talc are lost from the thoracic space into the drain. In theory this reduces remaining intra-thoracic talc and thus potential for successful pleurodesis. Traditionally post procedure the drain is frequently removed within the first 24 hour period leaving the expanding lung at risk of developing an air leak. Described in this article is a technique we now use on all suitable talc pleurodesis patients. It employs a lengthened and raised drain line, allowing immediate ongoing suction drainage whilst minimising intrathoracic talc loss.

Interventional pulmonologist perspective: treatment of malignant pleural effusion.

The management of known malignant pleural effusions focuses around the initial thoracentesis and subsequent objective and subjective findings. A completely reexpanded lung after fluid removal and with symptomatic improvement predicts successful pleurodesis. Pleurodesis method depends on center expertise as well as patient preference. Medical thoracoscopy does not require the operating room setting and is performed on the spontaneously breathing patient with similar success rate to surgical thoracoscopy in the appropriately selected patients. However, it is not widely available. Talc insufflation is preferred for even distribution of sprayed particles to pleural surfaces. Most often, patients can be discharged home within 24 to 48 hours after continuous chest tube suction. Indwelling pleural catheter has become popular given the ease of insertion and patient centered home drainage. Coordinated care with good patient and family education and support is paramount to maximizing the beneficial potential of the catheter. Complications are minimal, and catheters are easily removed if patients can no longer benefit from drainage, or if pleurodesis has occurred. In the setting of trapped lung as a result of visceral pleura encasement from tumor, indwelling catheter can still be useful if the patient improves with thoracentesis. However, if no subjective improvement is seen after thoracentesis for trapped lung, then no procedure is recommended and other modes of palliation should be sought.

The dynamics of selected local inflammatory markers to talc in the treatment of malignant pleural effusions

Malignant pleural effusions accumulate in the space between the visceral (inner) layer covering the lungs and the parietal (outer) layer covering the chest wall. Larger effusions compress the pulmonary parenchyma resulting in increasing dyspnoea. Treatment is always local and palliative. Among others, chemical pleurodesis using talc can be performed in selected patients. Talc is hydrated magnesium silicate (chemically H₂Mg₃(SiO₃)₄) and has been used for pleurodesis since 1935. Videothoracoscopic talc powder insufflation (talc poudrage) is the most effective.However, markers of inflammatory reactions to extraneous substances like talc are not fully understood. The aim of this study was to assess the course of local inflammatory changes in the pleural cavity after talc insufflation. The Department of Cardiac Surgery of the Faculty of Medicine and University Hospital in Hradec Kralove, treated 47 patients aged 65 on average; 29 males and 18 females with proven recurrent malignant pleural effusion of various aetiologies from January 2009 to December 2010. They were retrospectively divided into group A (40 patients) without recurring effusion, and group B (7 patients) with recurring effusion and the need for thoracentesis or chest drainage during the 9-month monitoring. Major findings were made in soluble forms of cell receptors. Group B showed statistically higher levels of the anti-inflammatory form of sCD-163 receptor in pleural fluid before the talc poudrage. This showed limited ability to create an adequate inflammatory response to external stimuli. This group also showed lower levels of the inflammatory form of sTLR-2 receptor immediately after the talc insufflation. This revealed low local reactivity to external stimuli. The effect of the treatment was not influenced by morphologic tumour type. No statistically significant differences in postoperative complications were found. This confirmed the safety of both videothoracoscopy and treatment. There was no correlation between the type of malignant affection and the outcome of the chemical pleurodesis. Patients with relapsing effusion have higher values of concentration of anti-inflammatory sCD-163 in pleural fluid even before the application of talc, and lower levels of concentration of inflammatory sTLR-2 immediately after application of talc.

Thoracoscopic Talc Versus Tunneled Pleural Catheters for Palliation of Malignant Pleural Effusions

A malignant pleural effusion (MPE) is a late complication of malignancy that affects respiratory function and quality of life. A strategy for palliation of the symptoms caused by MPE should permanently control fluid accumulation, preclude any need for reintervention, and limit hospital length of stay (LOS). We compared video-assisted thorascopic (VATS) talc insufflation with placement of a tunneled pleural catheter (TPC) to assess which intervention better met these palliative goals. We conducted a retrospective chart review of consecutive MPE at a single institution from 2005 through June 2011. Primary a priori outcomes were reintervention in the ipsilateral hemithorax, postprocedure LOS, and overall LOS. One hundred nine patients with MPE were identified. Fifty-nine patients (54%) had TPC placed, and 50 (46%) were treated with VATS talc. Patients who underwent TPC placement had significantly fewer reinterventions for recurrent ipsilateral effusions than patients treated with VATS talc (TPC 2% [1 of 59], talc 16% [8 of 50], p=0.01). Patients treated with TPC had significantly shorter overall LOS (TPC LOS mean 7 days, mode 1 day; talc mean 8 day, mode 4 days, p=0.006) and postprocedure LOS (TPC post-procedure LOS mean 3 days, mode 0 days; talc mean 6 days, mode 3 days, p<0.001). Type of procedure was not associated with differences in complication rate (TPC 5% [3 of 59], talc 14% [7 of 50], p=0.18), or in-hospital mortality (TPC 3% [2 of 59], talc 8% [4 of 50], p=0.41). TPC placement was associated with a significantly reduced postprocedure and overall LOS compared with VATS talc. Also, TPC placement was associated with significantly fewer ipsilateral reinterventions. Placement of TPC should be considered for palliation of MPE-associated symptoms.

TLR2 in Pleural Fluid Is Modulated by Talc Particles during Pleurodesis

The aim of this study was to examine the role of TLR2 molecule in pleural space during thoracoscopic talc pleurodesis period in patients with malignant pleural effusion. We analyzed TLR2 molecule in soluble form as well as on membrane of granulocytes in pleural fluid. Pleural fluid examination was done at three intervals during pleurodesis procedure: 1st—before the thoracoscopic procedure, 2nd—2 hours after the terminating thoracoscopic procedure with talc insufflation, 3rd—24 hours after the thoracoscopic procedure. We reported significant increase of soluble TLR2 molecule in pleural fluid effusion during talc pleurodesis from preoperative value. This increase was approximately 8-fold in the interval of 24 hours. The changes on granulocyte population were quite different. The mean fluorescent intensity of membrane TLR2 molecule examined by flow cytometry on granulocyte population significantly decreased after talc exposure with comparison to prethoracoscopic density. To estimate the prognostic value of TLR2 expression in pleural fluid patients were retrospectively classified into either prognostically favourable or unfavourable groups. Our results proved that patients with favourable prognosis had more than 3-fold higher soluble TLR2 level in pleural fluid early, 2 hours after talc pleurodesis intervention.

Single center experience on talc poudrage morbidity: focus on high talc dosage

Malignant pleural effusion (MPE) is a common clinical problem of concern for most of the pneumologists and thoracic surgeons. A general consensus regarding the use of talc poudrage in treatment of MPE exists, but only few studies analyzed in detail talc insufflation related pulmonary morbidity. In particular, ARDS talc-related is caused by physical and chemical effects of the small talc particles (50% particle size <15 μm) and its occurrence is independent from the underlying disease, the quantity of talc used or the technique of talc instillation. In our series we observed 3 cases only (0.75%) of talc-related lung injury. This data strongly confirm the low rate of talc-related lung injury after talc poudrage in treatment of MPE regardless the amount of talc insufflated.

Thoracoscopic Assessment of Pleural Tumor Burden in Patients with Malignant Pleural Effusion: Prognostic and Therapeutic Implications

Malignant pleural effusion (MPE) is encountered at an advanced stage of disease progression and often heralds a poor prognosis. The most reliable predictive factor of survival in such patients is the primary tumor. Thoracoscopy is often performed for accurate diagnosis and/or thoracoscopic talc insufflation as a therapeutic modality. It remains unknown whether pleural tumor burden, as visualized on thoracoscopy, has potential prognostic value. The objective of this study was to determine the prognostic accuracy of pleural tumor extent and localization (parietal, visceral, or diaphragmatic involvement), as assessed during medical thoracoscopy. Medical records of all patients who underwent thoracoscopy for suspicion of MPE between 2001 and 2008 at a tertiary care referral hospital were reviewed. Patients were included if pleural metastatic invasion was confirmed on tissue biopsy and survival status ascertained. Four hundred twenty-one patients underwent diagnostic or therapeutic medical thoracoscopy at our referral center. Among them, 122 had confirmed metastatic pleural spread, but survival data were lacking in 15. Primary tumor consisted of non-mall cell lung cancer in 56, breast cancer in 23, melanoma in eight, and other malignancies in 20. Median survival of the entire population was 9.4 months. On univariate analysis, the following variables were significantly associated with reduced median overall survival: pleural metastatic melanoma, age less than 60 years, bloody MPE, extensive pleural adhesions, and widespread visceral pleural nodules (p < 0.05). On multivariate analysis, only melanoma as a primary tumor, pleural fluid appearance and extent of pleural adhesions remained independent and significant predictors of survival. No significant association was found between the extent or localization of pleural tumor burden and overall survival.

Lung Injury Following Thoracoscopic Talc Insufflation: Experience of a Single North American Center

Lung Injury Following Thoracoscopic Talc Insufflation: Experience of a Single North American Center

Local iodine pleurodesis versus thoracoscopic talc insufflation in recurrent malignant pleural effusion: a prospective randomized control trial☆

To compare the efficacy, safety, and outcome of thoracoscopic talc poudrage (TTP) versus povidone-iodine pleurodesis (PIP) through a thoracostomy tube as a palliative treatment of pleural effusion due to metastatic breast carcinoma (MBC). A total of 42 MBC patients were prospectively enrolled in a randomized controlled trial. Twenty-two patients received TTP (group A), whereas 20 patients (group B) underwent pleurodesis by instilling povidone-iodine through a thoracostomy tube, as a bedside procedure. The mean age was 48.2 ± 9.9 (range: 29-64) years and 50.2 ± 7 (range: 32-62) years for groups A and B, respectively (p=ns). At presentation, all patients had moderate to severe dyspnea, New York Heart Association (NYHA)>II and Medical Research Council (MRC) dyspnea scale 3-5. Morbidity in both groups was low. Post-procedure analgesic requirements due to severe pleuritic chest pain were higher in group A (18% vs 0%, p=0.2). Four patients in group A (18%) and one in group B (5%) were febrile (>38°C) within 48 h of the procedure. Both groups achieved good symptom control, with improvement in MRC dyspnea scale (1-3). There were no in-hospital deaths. Post-procedure hospital stay was lower in group B (p=0.009). The mean progression-free interval was 6.6 (range 3-15) months. At follow-up (mean: 22.6 (range: 8-48) months), recurrence of significant pleural effusion requiring intervention was noted in two and three patients in group A and group B, respectively (p=ns). Povidone-iodine can be considered as a good alternative to TTP to ensure effective pleurodesis for patients with malignant pleural effusion due to MBC. The drug is available, cost effective and safe, can be given through a thoracostomy tube and can be repeated if necessary.

Lung Injury Following Thoracoscopic Talc Insufflation: Experience of a Single North American Center

Thoracoscopic talc insufflation (TTI) has been used to obliterate the pleural space and prevent recurrent pleural effusions or pneumothorax. Reports of acute pneumonitis and ARDS after the use of talc raised concern about its safety. Differences in particle size of various talc preparations may explain the variable occurrence of pneumonitis. We sought to determine the incidence of lung injury after TTI over a 13-year period at our institution. Patients who underwent TTI between January 1994 and July 2007 were identified from a prospectively maintained logbook. The talc used was commercially available sterile talc (Sclerosol). The hospital course was reviewed in detail, and all cases of respiratory insufficiency were examined with regard to onset, suspected cause, and outcome. Talc-related lung injury was defined as the presence of new infiltrates on chest radiograph and increased oxygen requirements, with no other identifiable trigger than talc exposure. A total of 138 patients underwent 142 TTIs for recurrent pleural effusions or spontaneous pneumothorax. TTI was performed most frequently for malignant pleural effusions (75.5% of effusions). The median dose of talc was 6 g (range, 2-8 g). Dyspnea with increased oxygen requirements developed within 72 h postprocedure for 12 patients. Four patients (2.8%) had talc-related lung injury, and talc exposure may have contributed to the respiratory deterioration in four additional patients. We report the occurrence of lung injury after TTI using the only talc approved by the US Food and Drug Administration. These results reinforce previous concerns regarding the talc used for pleurodesis in North America.

Early and late morbidity and mortality and life expectancy following thoracoscopic talc insufflation for control of malignant pleural effusions: a review of 400 cases

BackgroundMalignant pleural effusion is a common sequelae in patients with certain malignancies. It represents a terminal condition with short median survival (in terms of months) and the goal is palliation. Aim of our study is to analyze morbidity, mortality and life expectancy following videothoracoscopic talc poudrage.Materials and methodsFrom September 2004 to October 2009, 400 patients underwent video-assisted thoracic surgery (VATS) for malignant pleural effusion. The conditions of patients were assessed and graded before and after treatment concerning morbidity, mortality, success rate of pleurodesis and median survival.ResultsThe median duration of follow up was 40 months (range 4-61 months). All patients demonstrated notable improvement in dyspnea. Intraoperative mortality was zero. The procedure was well tolerated and no significant adverse effects were observed. In hospital mortality was 2% and the pleurodesis success rate was 85%. A poor Karnofsky Performance Status and delay between diagnosis of pleural effusion and pleurodesis were statistically significant factors for in-hospital mortality. The best survival was seen in breast cancer, followed by ovarian cancer, lymphoma and pleural mesothelioma.ConclusionsVideo-assisted thoracoscopic talc poudrage is an effective and safe procedure that yields a high rate of successful pleurodesis and achieves long-term control with marked dyspnea decrease.

Minimally Invasive Talc Insufflation

Talc insufflation is usually performed by thoracic surgeons in the operating room through video-assisted thoracoscopic surgery (VATS) or by pulmonologists in a specially equipped suite (medical thoracoscopy). These techniques can cause postoperative pain, require placement of port sites through small incisions, and increase waiting time and cost for patients who have no need for visual inspection of the pleura, biopsy, or apical bleb resection. Poudrage (French for powdering) with asbestos-free talcum powder (talc) is a proven technique with wide acceptance for treatment of pneumothorax. Use of a small, 4 g, canister of talc under pressure is a commonly used method to aerosolize and apply it using the supplied Teflon catheters. This report describes a patient who was too ill for almost any formal procedure in whom we performed talc poudrage by an even less invasive technique, using controlled permissive pneumothorax in the radiology suite by using a small needle, guide wire, and dilator with no thoracoscopy ports. Given the increased expense, frequent waiting time delay, and diminished access to care, we believe this technique deserves consideration in patients who are poor surgical candidates and perhaps in the young patient with no computed tomography evidence that might suggest the need for apical bleb resection, biopsy, or additional investigation.

Management of malignant pleural effusion

Malignant pleural effusion (MPE) often presents in patients with cancer at an advanced stage and thus carries a poor prognosis. This review updates the current knowledge on the management of MPE, focusing on recent literature about the efficacy and safety of the most common methods, including pleurodesis by either thoracoscopy with talc insufflation or thoracostomy with talc slurry, use of an indwelling pleural catheter, and intrapleural chemotherapy. Talc remains the agent of choice in pleurodesis, although the use of alternative agents continues to be explored. The choice of procedure to achieve pleurodesis depends on careful patient selection based on predictive factors and individual characteristics. Talc pleuro-desis is relatively well tolerated and safe, as is an indwelling pleural catheter, in an appropriate patient population. Because MPE is a common problem in cancer patients, future research with more randomized, prospective designs and innovative interventions is needed.