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Ann Thorac Surg 1996;62:1655-1658
© 1996 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Thoracoscopic Talc Insufflation Versus Talc Slurry for Symptomatic Malignant Pleural Effusion

Division of Cardiothoracic Surgery, Department of Surgery, and Department of Clinical Oncology, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong

Accepted for publication July 22, 1996.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Background. Talc has been generally accepted to be the most effective sclerosant for chemical pleurodesis, although the optimal route of administration remains unclear.

Methods. We designed a prospective, randomized study to compare video-assisted thoracoscopic talc insufflation with bedside talc slurry in the treatment of malignant pleural effusion. From September 1993 to November 1995, 57 patients were recruited and randomized to either video-assisted thoracoscopic talc insufflation under general anesthesia (n = 28) or talc slurry by the bedside (n = 29). Patients with poor general condition (Karnofsky score less than 30%), poor pulmonary function (forced expiratory volume in 1 second less than 0.5 L), or trapped lungs were excluded from this study. Five grams of purified talc was used for either video-assisted thoracoscopic talc insufflation or talc slurry.

Results. There was no statistically significant difference between the two groups of patients with respect to age, sex ratio, chest drainage duration, postprocedural hospital stay, parenteral narcotics requirement, complications, or procedure failure (ie, recurrence).

Conclusions. Video-assisted thoracoscopic talc insufflation has not been shown to be a superior approach compared with talc slurry in our study. Because the former demands more resources, we advocate that talc slurry should be considered as the procedure of choice in the treatment of symptomatic malignant pleural effusion in patients who do not have trapped lungs.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
See also page 1658.

Malignant pleural effusion is a common condition, which is often disabling and could be very difficult to treat. It represents a terminal condition with short median survival (in terms of months), and the goal of treatment is palliation [1]. Systemic chemotherapy is occasionally useful for breast and small cell lung carcinoma, but local therapy remains the mainstay of treatment. Talc has been identified as an effective sclerosant for chemical pleurodesis [2], although the optimal route of administration (dusting [3], "slurry" [4], "poudrage" [5]) remains unclear. More recently, video-assisted thoracoscopic talc insufflation (VT) has been shown to be a safe and effective approach in controlling malignant pleural effusion [6, 7]. We designed a prospective, randomized study to compare this approach with conventional bedside talc slurry (TS). Our results from a single institution form the basis of this article.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
From September 1993 to November 1995, 79 patients with established, symptomatic malignant pleural effusion were referred to us for treatment. Eleven patients, however, were excluded from this study because of either poor general condition (Karnofsky score less than 30%) [8] or poor pulmonary function (forced expiratory volume in 1 second less than 0.5 L). Seven patients were further excluded when trapped lung was revealed after either chest tube drainage or large-volume thoracocentesis. In addition, 4 patients who received chemotherapy or radiation therapy within 6 months before the diagnosis of malignant effusion were excluded from the study. This left 57 patients (20 men and 37 women with age ranging from 50 to 86 years) to be randomized for VT under general anesthesia (n = 28) or TS by the bedside (n = 29). We were careful in excluding patients whose dyspnea was due to tumor replacement of lung parenchyma rather than to effusion. We only selected those patients whose dyspnea improved after tube thoracostomy or large-volume thoracocentesis. Permission for the study was obtained from the Hospital Review Board, and full consent was obtained from the patients. Our techniques are briefly described below.

Video-Assisted Thoracoscopic Talc Insufflation
We modified the technique previously described using local anesthesia by Hartman and associates [6]. The procedure was performed under general anesthesia with selective one-lung ventilation and the patient in the lateral decubitus position with the table flexed at 30 degrees [9]. We routinely use a 10-mm operating telescope to minimize the number of ports made [10]. If the patient already came with a chest drain, we would use the drain site for the introduction of the telescope. Otherwise, needle aspiration was undertaken to determine the location of the fluid. We normally prefer to introduce the telescope low down in the chest (usually over the sixth or seventh intercostal space unless the diaphragm was shown or suspected to be elevated). Any residual pleural fluid was aspirated. Loculations were broken down. Fibrinous adhesions were taken down, whereas dense fibrous adhesions were selectively divided. Five grams of purified talc (Halewood Chemicals, Middlesex, UK) sterilized by dry heat was then insufflated into the chest to evenly cover the entire visceral and parietal surfaces. Initially we used a special talc atomizer (K. Storz, Culver City, CA), but we now prefer using a mucus extractor (UnoPlast, Hundested, Denmark) connected to a 50-mL syringe, which we have found to be simple, cheap, and reliable. A 28F chest drain was left in situ (placement of which was visually guided) and connected to 15 cm H₂O suction. The lung was confirmed to be fully reexpanded before withdrawal of the scope. The drain was connected to 15 cm H₂O suction and removed when the output was less than 50 mL in 24 hours.

Talc Slurry
Our technique was similar to that advocated by Webb and colleagues [4]. Five grams of purified talc (Halewood Chemicals) was mixed with 50 mL of normal saline solution and 10 mL of 2% lidocaine to form a suspension, which was then instilled through the chest drain. The drain was clamped for 2 hours and the patient turned in different positions. The drain was then reconnected to 15 cm H₂O suction and removed when the output was less than 50 mL in 24 hours.

Follow-up
All the patients were prospectively followed up. Particular attention was paid to the postprocedural chest drainage duration, hospital stay, parenteral meperidine requirement, and periprocedural complications. After discharge, the patients were regularly seen in the clinic at 6-week intervals for the first 4 months and then every 3 months. Any procedural failure in terms of radiologic evidence of fluid reaccumulation was noted. Telephone interviews with the patients were made as required to record changes in symptoms. Differences between the two groups were analyzed using Mann-Whitney U tests.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Our results are summarized in Table 1. There was no statistical difference in the demographics of the patients between the VT and TS groups in terms of age, sex ratio, and underlying pathology. There was no procedure-related mortality in either group. We found no differences between the two groups in terms of chest drainage durations, hospital stays, or parenteral meperidine requirement.

Two complications were encountered in the TS group: one acute transient respiratory failure and one wound infection. (1) Acute respiratory distress was encountered in a 73-year-old patient with chronic obstructive airway disease and stage IV lung carcinoma. It occured shortly after instillation of the talc slurry into the chest and clinically resembled exacerbation of chronic obstructive airway disease. The talc slurry was drained, and the patient improved on conservative management without needing ventilatory support. (2) The superficial wound infection resolved with local wound care.

Radiologic recurrence of effusion was noted in 1 patient 11 months after VT and in 3 patients after TS (at 6, 12, and 14 months, respectively). Nineteen patients died in the VT group, whereas 15 died in the TS group during follow-up without evidence of fluid reaccumulation. The mean follow-up is 10 months among the survivors (range, 4 to 16 months). Of the 4 patients with radiologic recurrence of effusion, only 1 patient (in the TS group) had her activity limited by dyspnea. She underwent repeat tube thoracostomy and TS treatment without further recurrence, until her death 2 months later.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
There is now a wealth of literature on the treatment of symptomatic malignant pleural effusion, although the optimal therapy remains unclear [1]. Options include repeated therapeutic thoracocentesis, tube thoracostomy and sclerotherapy, thoracoscopic talc insufflation, mechanical pleurodesis, pleuroperitoneal shunt, and pleurectomy. We normally reserve repeated thoracocentesis to those who are severely disabled and require continuous hospitalization (Karnofsky score less than 30%) [8] as rapid reaccumulation, protein depletion, and risk of empyema occur with this treatment. On the other hand, pleurectomy carries with it substantial morbidity and mortality [11] and is hard to justify for a palliative procedure. Pleuroperitoneal shunt has been shown to be effective [12], but it requires a very compliant patient who needs to manually pump 400 times a day. Moreover, there is a risk of shunt occlusion by blood clots or fibrin debris [13]. We therefore have reserved this approach to patients with severely (more than 25% fixed pneumothorax) trapped lung.

Of all the sclerosants available, talc is generally considered the agent of choice because of its good track record (more than 90% success rate), wide availability, and low cost [2]. The possible harmful long-term effects of talc [14] seem academic in this group of patients with limited survival. Acute respiratory failure [15] and death [16] have been anecdotally reported with TS [15] or insufflation [16]. We encountered 1 case of acute respiratory failure with TS in this series. The exact underlying mechanism remains unclear, even though it may be dose related. Kennedy and Sahn [2] recommended a 5-g dose, which is what we use. In the past we tried thoracoscopic talc insufflation under local anesthesia [6] and found it to be fairly uncomfortable for the patients. In addition, it was difficult to carry out interventions like adhesiolysis in patients who were awake with ventilating lungs.

Patients with diffuse pleural metastasis are at risk of tumor seeding at thoracoscopy port sites. Fortunately, this is relatively uncommon: 6 of 215 patients reported by Boutin and associates [17], 2 of 30 patients reported by Davidson and colleagues [18], and 2 of our patients (1 is not in this series [19]). We recommend observation if the port site recurrence is asymptomatic in view of the patient's short life expectancy; otherwise, local irradiation has been shown to provide good palliation [18].

Video-assisted thoracic surgery has provided an alternative approach in the management of a variety of thoracic conditions. Thoracoscopic talc insufflation for malignant effusions under local [6] or general anesthesia [7] has been shown to be safe and effective; here we report a randomized, prospective comparison between this approach and conventional TS.

We have not shown in our study any statistically significant difference between TS and VT in terms of hospital stay, analgesic requirement, complications, or procedure failures. It is important to note that of the 4 patients who had fluid reaccumulation, only 1 was symptomatic enough to require further treatment. We acknowledge that our sample size is small, but we emphasize that we are comparing two treatment modalities with the goal of palliation for a condition with very limited survival. A multicenter trial is underway, and it will be interesting to see if the collective experience is in agreement with our own.

There are two further points of note. First, in this study, we are focusing only on those patients with no radiologic evidence of trapped lungs. For patients with a minor degree of trapped lungs (less than 25% fixed pneumothorax), thoracoscopic decortication has been shown to be useful in achieving lung reexpansion [7]. Second, we are aware of the weakness in our study in the lack of documentation of patients' quality of life after either procedure. We have encountered problems in using standard questionnaires for our patients: they require translation into Chinese; self evaluation and the visual linear analogue scale pose difficulties to those with a low level of education or low performance status [20]; functional status is closely influenced by social and psychological factors, which are difficult to quantify; and the questionnaires have not been externally validated. We are studying some of these problems.

We have changed our practice as a result of our findings. In view of VT demanding more resources (trained thoracoscopists, general anesthesia, operating room time), we now advocate TS to be considered as the procedure of choice for patients with symptomatic malignant effusion without trapped lungs. Pleuroperitoneal shunt should be considered for those with severely trapped lung who are likely to comply with handling the device. For those patients with minor degrees of trapped lungs (less than 25% fixed pneumothorax), the thoracoscopic approach should be selectively considered [7].

	Acknowledgments

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
We are grateful to Alex Fung, BA, for data collection and editorial assistance. This study was supported by University Funds (A/C 1635-23).

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Address reprint requests to Dr Yim, Division of Cardiothoracic Surgery, Department of Surgery, Prince of Wales Hospital, Shatin, NT Hong Kong.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Anthony P. C. Yim Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Yim, A. P. C. Articles by Ho, J. K. S. Search for Related Content PubMed PubMed Citation Articles by Yim, A. P. C. Articles by Ho, J. K. S. Related Collections Related Article