Elsevier

Lung Cancer

Volume 36, Issue 1, April 2002, Pages 77-81
Lung Cancer

Distribution of talc suspension during treatment of malignant pleural effusion with talc pleurodesis

https://doi.org/10.1016/S0169-5002(01)00475-5Get rights and content

Abstract

Talc pleurodesis is an effective technique for the management of symptomatic malignant pleural effusions. It is assumed that a good dispersion of talc suspension contributes to the final success of this treatment. For this purpose, guidelines often advise to rotate the patient after intra-pleural instillation of the sclerosant. This prospective, randomized study analyses the dispersion of talc suspension and the overall success rate in patients with malignant effusions. After instillation of 99mTc-sestamibi-labeled talc suspension ten subjects were rotated for 1 h, while the ten other patients remained in a stable supine body position. Scintigraphic imaging was done in two directions immediately after instillation and after 1 h with a clamped drain. The overall success of the treatment was assessed 1 month after the pleurodesis. The dispersion of talc was limited and unequal in 75% of the subjects. In two patients with apparently good distribution on anterior views, the lateral views of the scintigraphy showed only limited distribution. Rotation of the patients did not influence the dispersion of sludge after 1 min or 1 h. Pleurodesis was successful in 85% of the patients after 1-month follow-up. Standard rotation protocols for patients with malignant pleural effusion do not affect the overall dispersion of talc suspension and should be abolished because of the discomfort caused to the patients.

Introduction

Malignant pleural effusion is caused by tumor growth in the pleural cavity [1]. It is often recurrent and pleurodesis is usually necessary for effective symptom control. Talc is the most effective sclerosant agent used to treat malignant pleural effusions, with reported success rates of 87–93% [1], [2]. A comparison of talc poudrage versus talc suspension did not show a significant difference in success rate [3].

Little is known about the mechanisms contributing to the final success of pleurodesis [4]. It is assumed that proper deposition of the sclerosant is needed for good symphysis [5] and rotation of patients after instillation of the sclerosant is regularly applied. However, radiolabeled tetracycline instilled through a chest tube has been demonstrated to be rapidly and completely dispersed into the pleural space without patient repositioning [6], and rotational manoeuvres seemed to offer no benefit to the success of pleural symphysis [7]. Similar studies with talc have not been published yet and patient rotations are still used as part of the treatment protocol. We studied the intrapleural dispersion of talc suspension after instillation in patients with symptomatic malignant pleuritis and analyzed the influence of rotation on the distribution pattern of talc in the pleural cavity, and the effect of a rotational protocol on the overall success of talc pleurodesis.

Section snippets

Subjects

Twenty consecutive subjects, 13 male and seven female, who underwent chemical pleurodesis for symptomatic malignant pleural effusion were included in the study. Their mean age was 67 years (range 42–88). The diagnosis of malignant pleural effusion was confirmed by cytological or histological specimens. Thirteen patients had non-small cell lung carcinoma (NSCLC), three had a breast cancer, and in one patient the primary tumor was an ovarian cancer. In the three remaining subjects the primary

Results

In general, the distribution of talc suspension was poor, as shown in Fig. 1. A distribution of sludge covering less than 50% of the pleural cavity was seen in 75% of the treated patients. No differences were found between rotated and non-rotated patients (Mann–Whitney test, P=0.58). Only two patients seemed to have a good and equal dispersion (≥75% of the thoracic cavity) on the posterior scintigram but the lateral views revealed poor distribution of the talc, which was located only at the

Discussion

Effusions of malignant origin are by far the most common indication for pleurodesis [8]. Talc is the most effective sclerosing agent used for this purpose, when compared with bleomycin, tetracycline, mustine, quinacrine, mitoxantrone, and tube thoracostomy alone [1], [2], [9]. It is assumed that the contact area of talc with the pleural surfaces should be extensive to achieve successful and complete pleural symphysis [5]. Since insufflation of talc powder causes an optimal dispersion of the

Conclusion

Distribution of talc suspension used for pleurodesis is poor. Rotation does not influence the dispersion or the overall effectiveness of pleurodesis with talc suspension. Furthermore, rotation can cause severe discomfort to the patients and is time consuming for the nursing personnel. On the basis of this study, we advise not to use rotation protocols after pleurodesis with talc suspension.

Acknowledgements

We want to thank Dr P. Zanen for his statistical analysis.

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