CHAPTER (3): TALC PLEURODESIS Historical Background

Bethune in 1935 first introduced talc in the pleural space to produce pleural adhesions preliminary to lobectomy. Subsequently, Chambers in 1958 suggested that intrapleural talc could be used for the palliative treatment of malignant pleural effusions. Since then, many authors have reported their results with this agent and have concluded that it is one of the most effective, simplest, and cheapest methods to produce pleurodesis. (Emad Ibrahim, Marc Noppen; 2010)

Structure
Steritalc is non-soluble and induces permanent pleurodesis. It is guaranteed asbestos and latex free. Steritalc is supplied sterile and has the perfectly adapted and controlled granulometry to minimise the risk of migration across the parietal pleura. Steritalc has side effects similar to cyclines. Any pain occurring can be reduced by using xylocaine 1% administered directly in the pleura or via the slurry. (Emad Ibrahim, Marc Noppen; 2010)

Indications
1. Chronic pleurisy, principally malignant. 2. Spontaneous pneumothorax. 3. Other cases in which a pleurodesis is indicated. (Kolschmann S, 2005)

Contraindications
Steritalc should not be used if the patient cannot undergo thoracoscopy. In order to avoid systemic migration of the talc, Steritalc should not be applied after a mechanical abrasion of the pleura. Steritalc should not be applied in case of pregnancy or breast -feeding. (Kolschmann S, 2005)

Dosage
Malignant Pleural Effusion Talc pleurodesis is used to be indicated as a sclerosing agent to decrease malignant pleural effusion recurrence in symptomatic patients. It is administered intrapleurally via chest tube after adequate drainage of the effusion. *Sclesol: 4-8 g (1-2 canisters); deliver by manually pressing actuator button; dist al end of the delivery tube should be pointed in several different directions, while short bursts are administered to distribute talc powder equally and extensively on all visceral and parietal pleural surfaces. *Sterile Talc Powder dosage is 5 g dissolved in 50-100 mL 0.9% NaCl.

Instructions for use

Contents are sterile unless package is damaged or opened. Remove contents from inner packaging only immediately before use. The respective asepsis standards have to be adhered to when removing the content from the inner packaging. (M. Tschopp, Boutin C, 2002)

Technique
There are many technical differences in thoracoscopic talc pleurodesis but the outcomes usually the same. One method is adopted for pneumothorax by Tschopp et al, where thoracoscopy was carried out in the lateral decubitus position under local anesthesia with 1% lignocaine. A 7-mm trocar was inserted into the fourth or fifth intercostal space in midaxillary line. A 0 optical telescope was inserted and connected to a video camera and monitor. The visceral pleura were carefully inspected using supplemental air insufflation where necessary. No electrocoagulation, stapling or ligation of any

parenchymal lesions was carried out. Sterile asbestos -free talc (2 g) was insufflated particularly to the apex. At the end of the procedure a drain (2428 French gauge) was inserted through the sixth intercostal space in the midaxillary line and connected to underwater seal suction with a negative pressure of 20 cmH2O for 2 days or until air leakage stopped. When an air leak persisted for >7 days, another procedure was perfomed and the case was considered as an immediate failure. The authors waited 1 week before proposing a second intervention in order to optimise the chances of success in both groups and to avoid overtreating failed cases of conservative treatment. (M. Tschopp, Boutin C, 2002) Kolschmann et al, used medical thoracoscopy by a pulmonary physician in an endoscopy suite assisted by two trained nurses for pleurodesis in MPE. Patients were placed in the lateral decubitus position. The patients BP, pulse rate, and oxygen saturation were monitored continuously. Supplemental oxygen was given to the patients to maintain oxygen saturation. Lidocaine 2% was used for local anesthesia and sedation was achieved by a combination of midazolam and fentanyl. They used a 6.5 -mm thoracoscope (0 and 30; Karl Storz; Tuttlingen, Germany) with a single 7-mm trocar. After complete aspiration of all of the remaining fluid, a thorough inspection of the pleural surface was made. The adhesions were taken down with the biopsy forceps, if possible. Biopsy specimens were made for histopathologic examination, if necessary. Under visual control, an average of 8 g of sterile asbestos-free talc (Steritalc; Novatech; France) was distributed onto the pleural surface. After removal of the thoracoscope, a thoracostomy tube was inserted. Suction (20 cm H2O) was started after 1 h, and the chest tube was left in place until < 100 mL of fluid was drained in 24 h. Chest radiography was performed the same day after the procedure and before discharge. (Kolschmann S, 2005) Despite the safety of talc pleurodesis still some reported side effects have to be mentioned. Fever up to 102.4 F after talc pleurodesis has been reported to occu r in 16

69% of patients. Fever characteristically occurs 412 h after talc instillation and may last for 72 h. Empyema has been reported with talc slurry in 011% of procedures, whereas talc poudrage is associated with an incidence rate of 03% of patients. Local site infection is uncommon, and the degree of pain associated with talc has reportedly ranged from nonexistent to severe. Cardiovascular complications such as arrhythmias, cardiac arrest, chest pain, myocardial infarction, or hypotension have been noted; whether these complications result from the procedures or are related to talc per se has not been determined. Acute respiratory distress syndrome (ARDS), acute pneumonitis, and respiratory failure have also been reported to occur after both talc poudrage and slurry. (Kennedy L, 1994) Milanez de Campos et al, reported empyema in 4%, re -expansion pulmonary edema in 2.2%, and respiratory failure 1.3% in talc pleurosesis. Kolschmann et al ; studied survival curves after 180 days after talc pleurodesis in MPE and showed significant differences, with best survival in mesothelioma and shortest life expectancy in lung cancer (p = 0.005). Adverse effects included empyema in one case and malignant invasion of the scar. No episode of talc-induced ARDS was observed. (Milanez de Campos JR, 2001)

Safety
Talc powder is a household item, sold globally for use in personal hygiene and cosmetics. Some suspicions have been raised about the possibility its use promotes certain types of diseases, mainly cancers of the ovaries and lungs. The studies reference, showed its usage in pulmonary issues, lung cancer, skin cancer and ovarian cancer. One of these, published in 1993, was a US National Toxicology Program report, which found that cosmetic grade talc containing no asbestos-like fibers was correlated with tumors

formation in rats (animal testing) forced to inhale talc for 6 hours a day, five days a week over at least 113 weeks. (National Toxicology Program 1993) The US Food and Drug Administration (FDA) considers talc (magnesium silicate) to be generally recognized as safe (GRAS) for use as an anti-caking agent in table salt in concentrations smaller than 2%. (U.S. Food and Drug Administration. 2009)

Adverse effects
They are frequency not defined. It is difficult to distinguish adverse effects of talc from adverse effects of procedures associated with talc administration: 1. Empyema 2. Hypoxemia 3. Dyspnea 4. Unilateral pulmonary edema 5. Pneumonia 6. ARDS 7. Bronchopleural fistula 8. Hemoptysis 9. Pulmonary emboli 10. Tachycardia 11. Myocardial infarction 12. Hypotension 13. Hypovolemia 14. Asystolic arrest 15. Adverse reactions due to the delivery procedure and chest tube may include pain, infection at the site of thoracostomy or thoracoscopy, localized bleeding, and subcutaneous emphysema (Talc powder, sterile (Rx) 2011)