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(Chest. 2000;117:1404-1409.)
© 2000 American College of Chest Physicians

Successful Talc Slurry Pleurodesis in Patients With Nonmalignant Pleural Effusion*

Report of 16 Cases and Review of the Literature

Mendel Glazer, MD; Neville Berkman, MBBCh; Joel S. Lafair, MD and Mordechai R. Kramer, MD, FCCP

* From the Institute of Pulmonology (Drs. Glazer, Berkman, and Lafair), Hadassah University Hospital and Hebrew University-Hadassah Medical School, Jerusalem, and the Institute of Pulmonology (Dr. Kramer), Rabin Medical Center, Petach Tikvah, Israel.

Correspondence to: Mordechai R. Kramer, MD, Institute of Pulmonology, Rabin Medical Center, Petach Tikvah 49100, Israel; e-mail: kramerm{at}netvision.net


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Background: Chemical pleurodesis is an effective treatment for malignant pleural effusion and pneumothorax. This mode of therapy is, however, less widely accepted in the treatment of patients with refractory benign or undiagnosed pleural effusion.

Study objectives: To analyze the outcome of talc slurry pleurodesis in patients with nonmalignant pleural effusions.

Design: Retrospective and partly prospective analysis of clinical outcome.

Setting: Hadassah University Hospital, Jerusalem, Israel.

Patients and participants: Between 1992 and 1997, we treated 16 patients with nonmalignant pleural effusion using talc slurry pleurodesis. The cause of effusion was congestive heart failure in 6 patients, liver cirrhosis in 4 patients, yellow nail syndrome in 1 patient, systemic lupus erythematosus in 1 patient, chylothorax in 1 patient, and undiagnosed in 3 patients.

Interventions: Nine patients were hospitalized, and seven patients received treatment in a day-care setting. Follow-up ranged from 2 months to 3 years.

Results: Complete success was observed in 12 cases (75%), partial success in 3 cases (19%), and pleurodesis was ineffectual in 1 case (6%). There were no significant complications after the procedure in any of our patients. A review of the English-language medical literature revealed an additional 110 reported cases of nonmalignant pleural effusion that were treated with chemical pleurodesis. Of these cases, talc was used in 65% with a success rate of nearly 100%.

Conclusions: Chemical pleurodesis, and specifically talc slurry, is an effective treatment for recurrent benign or undiagnosed pleural effusion. This procedure is safe and easily performed and, in selected cases, can be performed in an outpatient day-care setting.

Key Words: cirrhosis • congestive heart failure • pleural effusion • talc slurry pleurodesis


   Introduction
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 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Talc pleurodesis is a common treatment modality for palliation of patients with malignant pleural effusion.1 2 3 4 5 6 7 The success rate in preventing recurrence of fluid accumulation is high (85 to 98%),1 4 5 6 7 thus alleviating dyspnea in these patients. Most patients, however, die within several months because of their underlying disease. Pleurodesis in nonmalignant cases of pleural effusion is less commonly performed or reported. We found reports of 110 cases of nonmalignant pleural effusion treated with chemical pleurodesis in the English-language literature between 1966 and 1997. This is a very small number if one considers the prevalence of refractory pleural effusion in conditions such as congestive heart failure (CHF) and cirrhosis.

We present our experience in 16 patients with nonmalignant effusion treated by chemical pleurodesis and review the cases reported previously.


   Materials and Methods
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 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Patients
From 1992 to 1997, we treated 16 patients with chemical pleurodesis (Table 1 ). Patients referred to the pulmonary clinic or seen as inpatients at Hadassah University Hospital, Jerusalem, Israel, were considered candidates for chemical pleurodesis if they had a large (usually one third of the pleural cavity) symptomatic effusion that required therapeutic thoracocentesis at least once a month.


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  		Table 1.. Techniques and Results of Talc Pleurodesis in 16 Patients*

 
Pleurodesis Technique
A chest drain was inserted in all cases. On nine occasions, the patient was hospitalized for 2 to 5 days, and in most of them, a large-bore tube (26F to 30F) with underwater seal was placed in the fifth intercostal space, midaxillary line. Talc administration was performed only when there was no evidence of fluid in the pleural space as assessed by plain chest roentgenography. The other seven patients were admitted to a day-care facility, and a small (8F to 10F) intercostal drain (Cook Inc.; USA) was inserted in the morning and attached to underwater seal with suction. The patients were followed for 6 to 8 h in an ambulatory day care. If a repeat chest radiograph showed no residual effusion, talc was injected.

Two to three grams of asbestos-free talc were suspended in 50 mL of saline solution (0.9%) with 20 mL of 1% lidocaine and injected via the intercostal drain into the pleural space. An additional 20 mL of saline solution was used to flush the drain. The drain was then clamped, and the patient was asked to change position every 10 to 15 min to allow adequate distribution of talc. After an additional 2 h, the chest radiograph was performed to exclude pneumothorax, and the intercostal drain was removed. Dipyrone (1 g po) or pethidine (50 to 75 mg IM) was administered at the discretion of the treating physician to control pain.

Day-care patients were sent home after 1 to 2 h of observation.

In 15 cases, talc slurry was used as the initial sclerosing agent. In one patient, tetracycline was tried, and failed, and was followed by successful talc administration.

Pleurodesis was considered to be completely successful if there was no reaccumulation of pleural fluid in the same hemithorax. Reaccumulation of fluid was determined using plain x-ray films only (posteroanterior, lateral). The procedure was considered to be partially successful if there was accumulation of some fluid but the patient did not require repeated thoracocentesis and was considered a failure if the rate of fluid accumulation was unchanged after pleurodesis.


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
There were eight men and eight women, ages 21 to 87 years (median, 66 years) (Table 1) . The diagnosis for which pleurodesis was performed included CHF in 6 patients, liver cirrhosis in 4, systemic lupus erythematosus (SLE) in 1, yellow nail syndrome (YNS) in 1, chylothorax in 1, and in 3 patients, the cause of effusion was unknown. In five instances, the effusion was exudative, and in 11, it was transudative. All patients had multiple pleural taps (2 to 50; mean, 6) before pleurodesis. In 13 cases, there was right-sided effusion, and in 3, there was left-sided effusion.

In seven patients, pleurodesis was performed in a day-care setting, and nine patients were hospitalized. Day-care patients were kept in the hospital for 8 to 10 h but were not kept overnight.

A large-bore intercostal drain was used in eight patients, and a small Cook catheter was used in the remaining patients, including all ambulatory patients. Complete success rate of pleurodesis was greater with large-bore tubes (7 of 8 vs 5 of 8), although this difference was not significant. No difference between large and small tubes was noted when complete and partial successes were combined (7 of 8 vs 8 of 8).

Outcome
In 12 patients, pleurodesis was completely successful in preventing fluid accumulation (Table 1) . In three patients, the procedure was partially successful, including one patient with YNS who had a recurrence of effusion 2 months later. Thoracocentesis was repeated, and in 6 months of follow-up, he had no further recurrence of effusion. In the patient with chylothorax, pleurodesis was performed three times but was ineffectual. In no case was pleurodesis followed by worsening effusion in the contralateral chest cavity. There were no cases of trapped lung in our patient population. Both clinical and radiographic follow-up were obtained and ranged from 2 months to 3 years (mean, 8 months).

Complications
One patient experienced severe pleuritic pain lasting 3 days after pleurodesis. Five patients died of their underlying diseases 2 to 8 months after therapy. There was no difference in success or complication rate between hospitalized patients and outpatients.


   Discussion
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 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
The present study demonstrates that the intrapleural administration of 2 to 3 g of talc in a slurry was an effective treatment for nonmalignant recurrent pleural effusion. In previous studies, talc slurry has been very effective in treating malignant pleural effusion and pneumothorax. There are > 600 reported cases of talc used in the treatment of pneumothorax and > 650 in primary or secondary malignant pleural effusion.2 3 4 8 9 10 Talc has been used less frequently for the treatment of benign effusion. In animal studies, there appears to be no difference between slurry and poudrage talc pleurodesis in malignant and nonmalignant effusion,11 12 13 although data in human studies are as yet inconclusive.14 In all our patients, slurry talc pleurodesis was used.

In our study, half the patients were treated using a small-bore Cook catheter. We observed no difference between small and large catheters in successful drainage of fluid, although more patients with large-bore tubes achieved complete success after pleurodesis. We do not think that this was related to the size of the tube. The small-bore tube is associated with less patient discomfort and is less traumatic.

A large number of our patients were treated in an ambulatory setting, with complete success achieved in five of eight cases and partial success in a further three cases. We believe that ambulatory management of these patients with benign effusion is an acceptable therapeutic option. It is obviously necessary to observe standard practice as regards talc pleurodesis, including the use of asbestos-free talc to avoid potential carcinogenesis, to ascertain that the lung has fully expanded before talc insertion, and to maintain sterile conditions before and during talc injection.

Reports from the English-language literature that described the use of chemical pleurodesis for nonmalignant pleural effusion and comparison of various agents are summarized in Table 2 .


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  		Table 2.. Literature Review of Pleurodesis in Cases of Benign Effusion

 
CHF
CHF is the most common cause of all pleural effusions. Usually the effusion is bilateral, but it may be unilateral (more frequently the right side). Occasionally, the effusion is refractory to commonly used treatment including repeated taps.

Several authors have reported successful pleurodesis using various sclerosing agents,15 16 although recurrence in the other chest cavity may occur.17 In our series, we treated six cases of recurrent pleural effusion caused by CHF, all of which had a successful outcome. In no cases in our series was the procedure followed by worsening contralateral effusion.

Liver Cirrhosis
Pleural effusion occurs in approximately 6% of patients with cirrhosis of the liver and clinical ascites.18 Pleural fluid results from movement of ascitic fluid through diaphragmatic defects or via diaphragmatic lymphatics because of increased intra-abdominal pressure. Hypoalbuminemia with decreased intravascular oncotic pressure predisposes to increased pleural interstitial liquid pressure with subsequent entry into the pleural space. In 70% of cases, effusion occurs on the right side, in 15%, on the left side, and in 15%, the effusion is bilateral.18 Occasionally, hepatic cirrhosis may produce a pleural effusion without associated clinical ascites.19 We found reports of 24 cases of liver cirrhosis with pleural effusion that were treated by pleurodesis. In 14 patients, talc was used, in 7, tetracycline, in 1, Atabrine (quinacrine), and in 2, the name of the drug was not reported.

Vargas et al20 used talc in six patients. Five treatments were completely successful, and one patient needed repeat pleurodesis 4 months later. Falchuk et al21 reported two patients successfully treated with tetracycline. In contrast, Ikard and Sawyers22 reported two cases in which pleurodesis using tetracycline and quinacrine were unsuccessful. Runyon et al23 reported a patient in whom pleurodesis was unsuccessful and was followed by severe complications (hypotension, oliguria). They concluded that hepatic hydrothorax with congenital diaphragmatic defects is a contraindication to chest tube insertion. Mouroux et al24 attained complete resolution of pleural effusion using surgical video thoracoscopy with thoracoscopic closure of diaphragmatic defects and talc pleurodesis in six of eight cases.

Our study includes four patients with resistant pleural effusion because of liver cirrhosis. In all cases, pleurodesis was successful (three complete and one partial).

SLE
Pleural effusion is common in SLE. The fluid is usually exudative, containing a high concentration of immunoglobulins and a low concentration of complement. Classically, the effusion responds to steroid therapy. Six cases of refractory pleural effusion secondary to SLE treated with pleurodesis are described in the English-language literature. Two reported attempts at pleurodesis using tetracycline were unsuccessful.25 26 In these cases, subsequent treatment with talc poudrage was effective, and in one,25 a second dose of tetracycline was instilled. In contrast, Gilleece et al27 reported successful pleurodesis using tetracycline. Our study includes one case of pleural effusion secondary to SLE that was treated successfully with talc sclerotherapy.

Chylothorax
Our study included one patient with posttraumatic chylothorax in whom two attempts at talc pleurodesis were unsuccessful.

A nonmalignant chylothorax may result from thoracic surgery, trauma, or movement of chylous ascites to the pleural space. Twenty-six cases of nonmalignant chylothorax treated with pleurodesis were found in our literature survey. Vargas et al20 successfully treated five patients by using talc for this purpose. Gingell28 reported the same results in 3 patients, Adler and Levinsky29 in 1, Weissberg and Kaufman30 and Weissberg31 in 7, and Fairfax et al32 in 3. Robinson33 and Lieberman and Agliozzo34 described two patients in whom effusion was completely controlled by intrapleural insufflation of nitrogen mustard. Strausser and Flye35 obtained positive results in treating chylothorax in a case of lymphangiomatosis.

Le Coultre et al36 described 24 cases of postoperative chylothorax in children of whom 4 were successfully treated by pleurodesis. No details regarding method of pleurodesis are provided.

YNS
YNS is rare disorder that presents with lymphedema and pleural effusion with or without yellow nails. The pleural fluid is usually exudative. The lymphedema and pleural effusion are chronic and persistent, and spontaneous recovery has not been reported.18 Chemical pleurodesis has been successful in controlling effusion. There are 3 reports of effective talc pleurodesis,8 37 3 reports of successful tetracycline pleurodesis,38 39 and 1 with quinacrine.40 In contrast, others reported failure of pleurodesis using tetracycline, cyclophosphamide, and Atabrine for this purpose.26 41 Our study included one patient with YNS in whom talc pleurodesis was partially successful.

Nephrotic Syndrome
The mechanism for pleural fluid accumulation in nephrotic syndrome is decreased oncotic pressure in the pleural microvascular circulation due to hypoalbuminemia. Increased hydrostatic pressure from salt and water overload may be contributory.18 Pulmonary thromboembolism is a common complication in nephrotic patients. The presence of hemorrhagic pleural fluid would suggest thromboembolic disease. Occasionally, large unilateral or bilateral effusions occur. Jenkins and Shelp42 reported a case of recurrent pleural transudate in a patient with nephrotic syndrome in whom intrapleural insufflation of tetracycline was successful in preventing recurrence.

Peritoneal Dialysis
Although peritoneal dialysis frequently is associated with small bilateral effusion, massive unilateral effusion (usually right-sided) is seen occasionally.43 Five cases of treatment with pleurodesis have been described in the literature. Tetracycline was used in 2 patients,44 talc in 2 patients,36 45 and autologous blood instillation in 1 case.46 Successful pleurodesis was achieved in all cases.

Other Causes
There are other reports describing the treatment of six patients with empyema with talc pleurodesis,30 37 five patients with AIDS,15 one patient with Dressler’s syndrome,47 two cases of recurrent effusion after radiotherapy,8 47 three cases of asbestos injury,47 and one of macroglobulinemia.8 All patients were treated successfully with talc.

In conclusion, refractory or recurrent nonmalignant pleural effusion can be successfully treated by pleurodesis. In our series and the reported literature, the use of talc slurry is convenient and is associated with excellent outcome and minimal complications. In selected patients, this procedure can be performed in an ambulatory setting.


   Footnotes
 
Abbreviations: CHF = congestive heart failure; SLE = systemic lupus erythematosus; YNS = yellow nail syndrome

Received for publication January 29, 1999. Accepted for publication November 5, 1999.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

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