Small Particle-Size Talc Is Associated with Poor Outcome and Increased Inflammation in Thoracoscopic Pleurodesis

Abstract

Rationale: Talc is very effective for pleurodesis, but there is concern about complications, especially acute respiratory distress syndrome. Objectives: It was the aim of this study to investigate if talc with a high concentration of small particles induces greater production of cytokines, and if pleural tumor burden has any influence on the local production and spillover of cytokines to the systemic circulation and eventual complications. Methods: We investigated 227 consecutive patients with malignant effusion submitted to talc pleurodesis. One hundred and three patients received ‘small-particle talc' (ST; containing about 50% particles <10 µm) and 124 received ‘large-particle talc' (with <20% particles <10 µm). Serial samples of both pleural fluid and blood were taken before and 3, 24, 48 and 72 h after thoracoscopy. Also, mesothelial cells were stimulated with both types of talc in vitro. Measurements and Results: Interleukin-8, tumor necrosis factor-α, vascular endothelial growth factor, basic fibroblast growth factor and thrombin-antithrombin complex were measured in all samples. Early death (<7 days after talc) occurred in 8 of 103 patients in the ST and in 1 of 124 in the ‘large-particle talc' group (p = 0.007). Patients who received ST had significantly higher proinflammatory cytokines in pleural fluid and serum after talc application, and also in supernatants of the in vitro study. Pleural tumor burden correlated positively with proinflammatory cytokines in serum, suggesting that advanced tumor states induce stronger systemic reactions after talc application. Conclusions: ST provokes a strong inflammatory reaction in both pleural space and serum, which is associated with a higher rate of early deaths observed in patients receiving it.

Can EGFR-Tyrosine Kinase Inhibitors (TKI) Alone Without Talc Pleurodesis Prevent Recurrence of Malignant Pleural Effusion (MPE) in Lung Adenocarcinoma

“…The most common adverse events occurring after talc pleurodesis are fever (10-17%), pain, and gastrointestinal symptoms. Rarely, a systemic inflammatory response syndrome and/or adult respiratory distress syndrome develop; these complications are generally preventable by avoiding small particle size talc and not administering more than 5 g of talc at a time [22]. However, graded (large size talc) may not be available everywhere.…”

Safety Profile of the Use of Iodopovidone for Pleurodesis in Patients with Malignant Pleural Effusion

“…Inflammatory response promoted by pleurodesis is described for the use of many sclerosing agents, and inflammation itself is probably the main cause of all these metabolic consequences [4,5,6,7,8,9,10,11,14,29]. We recommend a cautious approach with pleurodesis, whatever agent is used.…”

“…Nevertheless, talc pleurodesis is related to some severe complications such as hypoxia and acute respiratory distress syndrome [4,5,6,7]. These complications are less frequent after the use of talc with large particles [8,9,10,11]. Unfortunately, talc with large particles is not widely available.…”

Tunneled Pleural Catheters in the Management of Chylothorax from Central Venous Catheter-Related Superior Vena Cava Obstruction

“…Typically, thoracic duct ligation is first considered, but talc pleurodesis, pleurectomy, or pleuroperitoneal shunts are further options in case thoracic duct ligation fails [9]. Talc pleurodesis has been reported to be successful [10], but excessive inflammation and acute respiratory distress syndrome may also be encountered, particularly with small particle talc [11,12]. …”