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Background: Talc slurry pleurodesis (TSP) prevents recurrence of symptomatic malignant pleural effusion (MPE) in 71% to 78% patients. Nonexpansile lung (NEL) frequently accounts for TSP failure but is often occult predrainage, impairing selection of patients. NEL is associated with high pleural elastance (PEL), but technical limitations have hampered the development of PEL as a predictive NEL marker. We performed a single-center, randomized, controlled, open-label feasibility trial of EDIT (elastance-directed indwelling pleural catheter or TSP) management, using a novel digital manometer and a new definition of high PEL.Methods: Patients with symptomatic MPE were randomized 1:1 between EDIT and standard care (TSP). EDIT involved PEL assessment during large-volume thoracentesis; patients with high PEL (maximum PEL sustained over 250 mL [MaxPEL250] ≥ 14.5 cm H2O/L) were allocated to immediately receive an indwelling pleural catheter; the remainder underwent immediate drain placement for TSP. The primary outcome measure was recruitment feasibility, defined a priori as 30 patients over 12 months. Secondary outcomes included safety, technical reliability, and the aspiration volume required to detect high PEL. The accuracy of the PEL definition for NEL was analyzed post hoc.Results: Thirty-one patients were randomized (one allocation failure) over 12 months. PEL assessment (mean duration, 33 minutes) was successful in 13 of 15 patients (87%). No directly attributable serious adverse events occurred. High PEL was detected in seven of 13 patients (54%), associated with 100% sensitivity and 67% specificity for NEL, and was first detected at a median volume of 325 mL (range, 250-800 mL).Conclusions: A phase 3 trial testing the effect of EDIT management on symptomatic MPE recurrence following TSP is feasible.Trial Registry: ClinicalTrials.gov; No.: NCT03319186; URL: www.clinicaltrials.gov. [ABSTRACT FROM AUTHOR]

The article examines the implications of pleural adhesions following talc pleurodesis in rabbits. All adhesions being studied for one week are mesothelium-covered fibrovascular bands with well-developed blood and lymphatic vessels. Nerves are present in adhesions from 20% of the rabbits. The appearance of nerve fibers in pleural adhesions suggests that these adhesions are capable of conducting pain stimuli.

The article presents information on a study performed to investigate whether systemic inflammatory response is due to talc poudrage or to thoracoscopy. In the present study, two groups of patients were studied, in which, one group underwent thoracoscopic talc poudrage and the other group underwent only diagnostic thoracoscopy. These patients were also measured for WBC count and C-reactive protein levels. The results suggested that temperature and the WBC count increased significantly in the thoracoscopic talc poudrage group. So it was concluded that fever and systemic inflammatory reaction is due to talc poudrage and not to thoracoscopy.

The article presents a study examining the influence of antiinflammatory drugs on experimental pleurodesis induced by silver nitrate or talc. Chemical pleurodesis is used in the treatment of recurrent pleural diseases, especially in patients with malignant effusions when pleural symphysis is required. Two groups of 30 white New Zealand rabbits were used for the study. The results show that the sustained systemic administration of antiinflammatory agents, steroidal or nonsteroidal reduces the degree of pleural adhesions in animals with talc-induced pleurodesis but does not affect silver nitrate-induced pleurodesis.

This article reports that the combination therapy with intrapleural doxycycline and talc in reduced doses is effective in producing pleurodesis in rabbits. It is shown in this study that the injection of the half-dose combination was effective in producing a pleurodesis. The mean pleurodesis score in the half-dose combination group was significantly higher than that in the half-dose talc and half-dose doxycycline groups. For the purpose of this study a right hemothorax occupying 90 percent of the hemithorax was observed at autopsy in one rabbit in the half-dose combination group and this rabbit was excluded from the data analysis. The results support the hypothesis that combining two different agents that act through different pathways may generate additive effects in creating pleurodesis.

The article focuses on a study that aimed to assess the systemic response induced by low, nonpleurodesis-inducing doses of talc and silver nitrate in an experimental model in rabbits. The mechanism by which talc induces acute systemic effects is poorly understood. Talc particles have been demonstrated in several organs of animals that received doses of talc sufficient to produce a pleurodesis. There is also evidence that the risk of adverse effects after talc pleurodesis may be dose related. In fact, when a small dose of talc was injected in rabbits, talc particles were shown only in the ipsilateral lung and mediastinum.

This article cites a study comparing the efficacy and the safety of talc slurry and silver nitrate (SN) in the treatment of symptomatic malignant pleural effusions (MPE). It was hypothesized that the two agents would be equally effective. Sixty patients with unilateral MPEs were enrolled into this study. The patients were recruited between January 2000 and July 2002 from the following two hospitals: AVG Cancer Institute and Perola Byington Hospital. Eleven of the patients did not return for their follow-up visit and were excluded from the analysis. For the remaining 49 patients, a diagnosis of malignancy was obtained via cytology in 35 patients, by histologic examination of pleural biopsy specimens in 14 patients, and by both in 3 patients. In all patients, a chest tube was inserted using local anesthesia and parenteral meperidine. Findings of the study suggest that SN is an effective agent for producing a pleurodesis. The side effects of 0.5% SN appeared to be minimal.

Study objective: To demonstrate the efficacy, safety, and appropriate mode of instillation of talc for sclerosis in treatment of malignant pleural effusions (MPEs). Design: A prospective, randomized trial was designed to compare thoracoscopy with talc insufflation (TTI) to thoracostomy and talc slurry (TS) for patients with documented MPE. Measurements: The primary end point was 30-day freedom from radiographic MPE recurrence among surviving patients whose lungs initially re-expanded > 90%. Morbidity, mortality, and quality of life were also assessed. Results: Of 501 patients registered, those eligible were randomized to TTI (n = 242) or TS (n = 240). Patient demographics and primary malignancies were similar between study arms. Overall, there was no difference between study arms in the percentage of patients with successful 30-day outcomes (TTI, 78%; TS, 71%). However, the subgroup of patients with primary lung or breast cancer had higher success with TTI than with TS (82% vs 67%). Common morbidity included fever, dyspnea, and pain. Treatment-related mortality occurred in nine TTI patients and seven TS patients. Respiratory complications were more common following TTI than TS (14% vs 6%). Respiratory failure was observed in 4% of TS patients and 8% of TTI patients, accounting for five toxic deaths and six toxic deaths, respectively. Quality-of-life measurement demonstrated less fatigue with TTI than TS. Patient ratings of comfort and safety were also higher for TTI, but there were no differences on perceived value or convenience of the procedures. Conclusions: Both methods of talc delivery are similar in efficacy; TTI may be better for patients with either a lung or breast primary. The etiology and incidence of respiratory complications from talc need further exploration. [ABSTRACT FROM AUTHOR]

Study objectives: Patients with recurrent pleural effusions secondary to malignancy are subjected to pleurodesis if clinically indicated. Pleurodesis involves the introduction of a sclerosing agent into the pleural space. Talc is one of the most commonly used sclerosing agents in treating patients with recurrent, symptomatic malignant pleural effusions. However, the mechanisms whereby talc mediates pleural fibrosis remain unclear. We hypothesized that the intrapleural instillation of talc induces the pleural mesothelial production of basic fibroblast growth factor (bFGF), which is responsible for pleural fibrosis. Methods: Samples of pleural fluid collected from 23 patients with malignant pleural effusions and 6 patients with congestive heart failure (control group) were included in this study. A tumor grading scale (1 to 9) was used to demonstrate the extent of the tumor. In vitro pleural mesothelial cells (PMCs) were activated with talc, and the conditioned medium was collected to evaluate bFGF levels by enzyme-linked immunosorbent assay. The bFGF-induced proliferation of fibroblasts was studied by [3H]thymidine incorporation. The messenger RNA expression of bFGF in talc-activated PMCs was determined by Northern analysis. Results: In this study, we demonstrated that patients who have undergone successful pleurodesis following intrapleural talc insufflation have significantly higher levels of bFGF in their pleural fluid compared to those who do not respond to pleurodesis. In addition, we found a significant negative correlation between bFGF levels and tumor size. Talc-activated PMCs produce significantly higher levels of bFGF compared to control, which correlates with bFGF messenger RNA expression in PMCs stimulated with talc. The neutralization of pleural fluids and conditioned medium from talc-stimulated PMCs with bFGF antibodies significantly inhibits the bFGF-induced proliferation of pleural fibroblasts. Conclusions: An important outcome of this study was the finding that patients with extensive tumor involvement of the pleural mesothelium have a significantly lower pleural fluid bFGF response to talc compared to those who have limited involvement. Patients with limited pleural disease and higher bFGF responses go on to have successful pleurodesis, demonstrating that the presence of a mesothelium that is free of tumor enhances the possibility of success. In vitro PMCs stimulated with talc release biologically active bFGF. [ABSTRACT FROM AUTHOR]

Study Objective: s: To determine whether talc (TL) and silver nitrate (SN), two effective pleurodesis agents, induce a systemic inflammatory response in the acute phase of experimental pleurodesis in rabbits.Design: Samples of blood and pleural fluid were collected after 6, 24, and 48 h from rabbits injected intrapleurally with 3 mL saline solution, TL (400 mg/kg), or 0.5% SN, and were assayed for WBC count, percentage of neutrophils, and levels of lactate dehydrogenase (LDH), interleukin (IL)-8, and vascular endothelial growth factor (VEGF). The pleural liquid production was compared in the three different groups. A sample of blood collected from animals preinjection was used as the control.Results: At 6 h after pleural injection, the mean blood WBC count and percentage of neutrophils were significantly elevated in the TL group, whereas the mean LDH and IL-8 levels were significantly increased in the SN group. VEGF was undetectable in the preinjection serum and saline solution-injected animals, but was increased in the serum after the pleural injection of both TL and SN to a comparable degree. SN elicited a more intense acute pleural inflammation reaction than did TL, with higher WBC count and IL-8 levels found in the pleural fluid, mainly within the first 6 h. LDH and VEGF levels, and pleural liquid production were also higher for SN, and they increased with time.Conclusions: In the acute phase of pleural injection, TL induced a transient increase in blood WBC count and percentage of neutrophils, while SN induced increases in blood LDH and IL-8 levels. Both TL and SN induced significant increases in blood VEGF levels. SN induced an earlier and more intense acute pleural inflammation than TL. Pleural liquid VEGF levels were higher after SN injection and increased, as did pleural liquid production. These findings suggest that the intrapleural injection of TL and SN produce a systemic inflammatory response that may have a role in the pathogenesis of fever and ARDS, which occur with pleurodesis. [ABSTRACT FROM AUTHOR]

To prospectively study all patients with COPD and spontaneous pneumothorax (SP) who underwent thoracoscopic talc poudrage (TP) under local anesthesia to determine its efficacy and safety in recurrence prevention. Forty-one patients (38 men and 3 women) with a mean (±SD) age of 70.7 ± 7.2 years were treated. All patients had COPD, with a mean FEV1 of 41 ± 14% predicted. The majority of SPs measured 20 to 50% in size, and 34% were recurrent. Three grams of talc were insufflated into the pleural cavity without complications. Thirteen patients (32%) complained of pain, 5 (12%) developed fever, 27 (66%) had subcutaneous emphysema, and 7 (17%) had prolonged air leaks. Postoperative chest tube drainage and hospital stay were 4 and 5 days, respectively. Success was 95% after a median follow-up of 35 months. Four patients with FEV1 of < 40% predicted died within 30 days of the procedure, yielding a mortality rate of 10%. FEV1 (in liters), FEV1 (in % predicted), and ischemic heart disease were risk factors that influenced early mortality. Thoracoscopic TP is effective for pneumothorax prevention and can be performed with acceptable mortality in patients with advanced COPD. [ABSTRACT FROM AUTHOR]

Study objective: Many reports have shown that talc is the most effective and least expensive agent for the creation of a pleural symphysis. However, its use still remains controversial due to severe acute respiratory side effects possibly related to the systemic dissemination of talc particles. The purpose of this study was to assess the distribution of calibrated talc after intrapleural administration in rats. Material and methods: Thirty-seven Wistar male rats were randomly assigned to undergo pleurodesis by talc slurry (33 rats) or by simple chest tube drainage (control group; 4 rats). Forty milligrams of calibrated talc suspended in 1 mL sterile saline solution was injected into rats in the treated group. The animals were randomly assigned for autopsy at 24 or 72 h after pleural injection. Lungs, parietal pleura, diaphragm, liver, kidneys, spleen, pericardium, brain, and blood were assessed by polarized light for birefringent talc particle detection and counting. Results: No deaths were observed. The autopsies showed no pleurodesis at 24 and 72 h. Despite high doses of talc (extrapolated from the dose of 10 g in a 70-kg adult man), few talc particles were found in the liver of two rats, in the spleen of one rat, and only one particle of talc was observed at the brain surface of the rat studied by scanning electron microscopy. No particles were found in the other organs, in particular in the contralateral lung and blood, contrasting with previously published results using noncalibrated tale particles. Conclusions: The lack of systemic dispersion of talc particles, with the packaging talc we currently use in our clinical practice, is probably due to the size of the talc particles, which are larger than the other talc preparations. Calibrated tale is required in ease of intrapleural administration for pleurodesis to avoid systemic dissemination and potential secondary acute respiratory failures. [ABSTRACT FROM AUTHOR]

Background: Cases of acute respiratory failure reported after talc pleurodesis have raised concerns about its safety. It has been speculated that this pulmonary inflammatory syndrome is secondary to the extrapleural dissemination of the talc particles.Study Objectives: To test the hypothesis that particle size influences extrapleural talc deposition and pleural inflammation after talc slurry pleurodesis.Design: Thirty rabbits underwent pleurodesis as follows: 10 rabbits received 200 mg/kg of the talc used for human pleurodesis, normal talc (NT); 10 rabbits received 200 mg/kg of talc with particles of larger size, large talc (LT); and 10 rabbits received saline solution. Samples from the ipsilateral lung, chest wall, diaphragm, mediastinal pleura, heart, liver, spleen, and right kidney were obtained at 24 h and 7 days and processed for optic and electron microscopy and energy-dispersive x-ray analysis.Results: Visceral pleural thickening was greater with NT than with LT, but no differences were observed in the macroscopic score of adhesions. There was more talc in the lungs of the rabbits that received NT than in those that received LT. Talc particles were detected in mediastinum (100%) and pericardium (20%), irrespective of the talc used. Three animals, all receiving NT, had talc particles in the liver.Conclusions: Our study shows that while both talcs were equally effective in achieving pleurodesis, the intrapleural injection of NT elicits greater pulmonary and systemic talc particle deposition than LT. Moreover, pleural inflammation was greater with NT than with LT. [ABSTRACT FROM AUTHOR]

Background: At the present time, talc is the one of the agents most commonly used for the production of a pleurodesis. However, there have been several recent reports of acute pneumonitis developing after the intrapleural administration of talc. The incidence of pneumonitis has varied markedly from center to center. Objective: To compare the physical characteristics of talc used for the production of pleurodesis in various localities. Design: Eight tale preparations (four from the United States, and one each from Brazil, France, Spain, and Taiwan) were analyzed for the distribution of the particle size and the type and amount of impurities. Measurements: The physical characteristics of the tale specimens were determined using radiograph diffraction and scanning electron microscopy. Results: The mean and median particle size varied by more than a factor of three among the eight different tale preparations. In addition, the impurities of the different tale preparations were quite varied. Conclusions: We conclude that there is marked variation in the physical characteristics of the tale preparations used intrapleurally for the production of a pleurodesis. We speculate that different incidences of acute pneumonitis at various centers after intrapleural administration of talc may be due to differences in the physical characteristics of the talc preparations used for pleurodesis. [ABSTRACT FROM AUTHOR]

Study Objective: To compare the pleurodesis results from the intrapleural injection of silver nitrate and talc slurry over an observation period of 12 months in rabbits.Design: Rabbits were randomized to receive 2 mL of 0.5% silver nitrate or 400 mg/kg of talc slurry in 2 mL intrapleurally. Ten rabbits in each group were killed at 1 month, 2 months, 4 months, 6 months, 8 months, 10 months, and 12 months after intrapleural injection. The degree of gross pleurodesis and the amount of microscopic pleural fibrosis and inflammation were graded on a scale of 0 to 4.Results: The mean +/- SEM gross pleurodesis score in the 70 rabbits that received silver nitrate was 3.34 +/- 0.08, which was significantly higher than the score of 2.32 +/- 0.09 in the 70 rabbits that received talc. The mean gross pleurodesis score was significantly higher at each of the observation times (p < 0.05), except at 2 months, in the rabbits that received silver nitrate. The pleurodesis was distributed throughout the thorax in the rabbits that received silver nitrate, while it was only in the ventral thorax in the rabbits that received talc slurry. The gross pleurodesis scores showed no tendency to decrease during the 12-month observation period in either treatment group. The persistence of talc in the pleural space did not lead to chronic inflammatory changes because the inflammation scores were similar in both groups at all observation times. The microscopic pleural fibrosis score tended to decrease with time in the silver nitrate group but not in the talc slurry group.Conclusions: The intrapleural injection of 2 mL of 0.5% silver nitrate produces a better pleurodesis than does the intrapleural injection of 400 mg/kg of talc slurry in rabbits. The pleurodesis induced by silver nitrate persists for at least 1 year. The efficacy of silver nitrate as a sclerosing agent in humans should be evaluated. [ABSTRACT FROM AUTHOR]

Examines experience with thoracoscopy and talc poudrage during the previous 15 years with regards to efficacy, side effects, morbidity, and mortality. Indication that thoracoscopy with talc poudrage is effective in producing a pleurodesis in malignant and benign pleural effusion and in spontaneous pneumothorax; Systemic distribution of the insufflation of talc associated with a low rate of morbidity.

Study Objective: The ideal agent for producing pleurodesis has not been identified. Although talc is the agent most commonly used at the present time, there are concerns about its safety. Silver nitrate is a possible alternative agent. The purpose of the present study was to compare the effectiveness of intrapleural silver nitrate and talc slurry in producing pleurodesis in rabbits. Additionally, the total amount of pleural collagen and the distribution of thick and thin collagen fibers were studied.Design: Two groups of 10 rabbits received either 0.50% silver nitrate or 400 mg/kg talc in a total volume of 2 mL intrapleurally. The animals were killed 28 days after injection, and the pleural spaces were assessed grossly for evidence of pleurodesis and microscopically for evidence of inflammation and fibrosis. Collagen was assessed with the van Gieson's and picrosirius stains.Results: The macroscopic pleurodesis (scale, 0 to 4; mean +/- SEM) resulting from the intrapleural injection of silver nitrate (3.4+/-0.2) was significantly better (p<0.001) than that resulting from talc (1.6+/- 0.1). The mean degree of microscopic pleural fibrosis induced by silver nitrate (3.3+/-0.3) was significantly higher (p = 0.003) than that induced by talc (1.8+/-0.1). The mean amount of microscopic pleural collagen (van Gieson's) was significantly greater (p<0.001) in the rabbits that received silver nitrate (3.0+/-0.2) than in those that received talc (1.6+/-0.2). The distribution of thick and thin collagen fibers did not differ between the groups.Conclusions: We conclude that, in our rabbit model, intrapleural silver nitrate was more effective than talc in producing a pleurodesis. [ABSTRACT FROM AUTHOR]

Study objective: To determine indications, limitations, morbidity and mortality of surgical thoracoscopy for management of hepatic hydrothorax, a rare, but often recurrent, complication in cirrhotic patients. Patients and methods: From May 1985 through May 1999, 10 men and 8 women, with a mean age of 57.6 years (range, 26 to 76 years), underwent 21 therapeutic thoracoscopies to achieve pleurodesis by application of talc. Results: The procedure was effective in 10 of 21 procedures. There were four recurrences (19.1%) that were retreated, with only one being successful. In this specific group, we detected high morbidity (57.1%) and mortality (38.9%) during the follow-up period of 3 months. Diaphragmatic defects were localized and closed five times (23.8%). Hospital stay was approximately 15 days (range, 5 to 41 days). Conclusion: The procedure appears to be indicated for these fragile patients, especially when medical therapy fails. Immediate efficacy was 47.6%, increasing to 60% with videothoracoscopy and suture of the diaphragmatic defect. However, morbidity and mortality were high. [ABSTRACT FROM AUTHOR]

Treatment for malignant pleural effusions with expandable lung would favor treatment with talc pleurodesis and often requires days of inpatient hospitalization for management and observation3. B DISCUSSION: b We demonstrate a validated alternative treatment strategy in a patient with bilateral malignant pleural effusions. [Extracted from the article]

Follow-up CT chest revealed bilateral enlargement in the pulmonary nodules identified in the right lung. Therefore, a CT/PET scan was recommended which revealed several nodules with pleural thickening throughout the right lung with multiple areas that were FDG positive. B CONCLUSIONS: b Pulmonary foreign body granulomatosis is a diagnosis that needs to be considered on granulomatous and malignant lung disease differential diagnosis, specially after the presence of risk factors on the initial assessment. [Extracted from the article]

The article presents a case study of a 70-year-old female nonsmoker who experienced shortness of breath and nonproductive cough. Findings of computed tomography (CT) of thorax revealed the collapse of right upper lobe with occlusion of the right upper lobe, while severe endobronchitis with thickened mucosa was showed during bronchoscopy. It notes that the patient was diagnosed with talc-associated airway granulomatosis.

B TYPE: b Abstract Publication B TOPIC: b Procedures B PURPOSE: b Malignant pleural effusion (MPE) is a common condition, representing an advanced state of disease with poor survival. Other malignancies included were 14.3% gastro-intestinal tumors, 8.2% breast tumors, 8.2% urologic tumors, 4% hematologic tumors and 2% laryngeal tumors. In post-pleurodesis relapse group, the average survival estimated was 186 days and for non-relapse group was 405 days. [Extracted from the article]

Points out that most reported trials agree in the concept that well-selected patients with severe emphysema derive benefit from lung volume reduction surgery (LVRS), but there has been debate regarding the optimal surgical approach. Surgical LVRS by sternotomy or thoracoscopy using stapling devices for the resection of diseased portions; Laser therapy; Bilateral LVRS preferred to sequential unilateral LVRS; Results from the National Emphysema Treatment Trial.

Expresses concerns about the safety of talc. Reasons why chest physicians prefer it for pleurodesis; Development of adult respiratory distress syndrome following intrapleural talc administration; Cause of acute pneumonitis.

Consumers of adulterated drugs may present with talc-induced interstitial lung disease. A transbronchial biopsy specimen showing granulomas with intracellular talc crystals is necessary to confirm this diagnosis. In patients infected with HIV, such a condition can be indistinguishable at first glance from opportunistic infections or other pulmonary diseases. A case is presented of a seropositive patient whose chest radiographs showed a diffuse interstitial pattern. [ABSTRACT FROM AUTHOR]

Pulmonary talc granulomatosis is a rare disease entity classically described in intravenous injection of talc-containing substances intended for oral use. She underwent a bronchoscopy with bronchioalveolar lavage and trans bronchial lung biopsy which revealed multinucleate foreign body giant cells and fibrosis, compatible with talc granulomatosis. B DISCUSSION: b There are 4 types of pulmonary disease associated with talc: Talco-silicosis, talco-asbestosis, talcosis, and pulmonary talc granulomatosis. [Extracted from the article]