Elsevier

The Lancet

Volume 369, Issue 9572, 5–11 May 2007, Pages 1535-1539
The Lancet

Articles
Safety of pleurodesis with talc poudrage in malignant pleural effusion: a prospective cohort study

https://doi.org/10.1016/S0140-6736(07)60708-9Get rights and content

Summary

Background

Talc is the most effective chemical pleurodesis agent for patients with malignant pleural effusion. However, concerns have arisen about the safety of intrapleural application of talc, after reports of development of acute respiratory distress syndrome in 1–9% of treated patients. Our aim was to establish whether use of large-particle-size talc is safe in patients with malignant pleural effusion.

Methods

We did a multicentre, open-label, prospective cohort study of 558 patients with malignant pleural effusion who underwent thoracoscopy and talc poudrage with 4 g of calibrated French large-particle talc in 13 European hospitals, and one in South Africa. The primary endpoint was the occurrence of acute respiratory distress syndrome after talc pleurodesis.

Findings

No patients developed acute respiratory distress syndrome (frequency 0%, one-sided 95% CI 0–0·54%). 11 (2%) patients died within 30 days. Additionally, seven patients had non-fatal post-thoracoscopy complications (1·2%), including one case of respiratory failure due to unexplained bilateral pneumothorax.

Interpretation

Use of large-particle talc for pleurodesis in malignant pleural effusion is safe, and not associated with the development of acute respiratory distress syndrome.

Introduction

Talc is hydrated magnesium silicate, and was first used for pleurodesis in 1935 by the surgeon Norman Bethune.1 In the second half of the 20th century, talc became increasingly popular for induction of pleurodesis in many pleural diseases—eg, spontaneous pneumothorax, benign pleural effusion, and malignant pleural effusion.2, 3, 4, 5, 6 Compared with other agents for chemical pleurodesis, talc seemed to give the best results in terms of effectiveness, with least recurrence of effusion, after both talc poudrage, and instillation of talc slurry through a chest tube.7 The effectiveness of talc pleurodesis compared with other forms of pleurodesis has also been supported by animal studies.8 Additionally, talc is inexpensive and widely available.

However, the safety of intrapleural application of talc has been debated since cases of respiratory failure and acute respiratory distress syndrome after talc pleurodesis were reported.4, 9, 10, 11 Other authors noted no complications at all, even in large series of patients.6, 12, 13 The occurrence of acute respiratory distress syndrome in some series and its absence in others was independent of the underlying disease (malignant pulmonary effusion or pneumothorax),6, 10, 11 the quantity of talc used (2–10 g),4, 6, 10, 11, 12 or the technique of talc instillation (slurry or poudrage).4, 6, 10, 11, 12 Several researchers have reported results that suggest that acute respiratory distress syndrome after talc pleurodesis is mainly related to the particle size of the talc used.14, 15

Our aim was to assess the safety of large-particle talc applied as poudrage for pleurodesis in patients with malignant pleural effusion.

Section snippets

Patients

We did a prospective cohort study to measure the side-effects of thoracoscopy and pleurodesis by poudrage with large-particle talc for treatment of recurrent malignant pleural effusions. 14 centres (all departments of pulmonary diseases) participated in the study, 13 in Europe and one in South Africa, between Oct 1, 2002, and Oct 31, 2005. Our primary endpoint was the occurrence of acute respiratory distress syndrome after talc pleurodesis. Secondary endpoints were other side-effects (eg,

Results

558 patients aged 30–96 years, (mean 64·4 years) were recruited. Table 1 shows the patients' baseline characteristics and the contribution of each institution. Table 2 shows details of the thorascopic procedures. Non-steroidal anti-inflammatory drugs were used in 178 (32%) patients. Parietal pleural biopsies were obtained in 475 (85%) patients (range 1–30, mean 6·3, mode 5 per patient). Visceral biopsies (range 1–10, average 3·7, mode 3) were obtained in 23 (4%) patients. If no biopsy sample

Discussion

The absence of acute respiratory distress syndrome in patients with malignant pulmonary effusion supports our hypothesis that pleurodesis with large-particle talc is safe. Side-effects from thoracoscopic pleurodesis were mild in our study. The small increases in temperature and oxygen use after talc pleurodesis were not clinically significant, and might be due to mild systemic and lung inflammation caused by talc.14, 19 Our results also accord with the hypothesis that acute respiratory distress

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