A Grocery Store Item for Pleurodesis?

Malignant pleural effusion is a common clinical problem worldwide.1 It is estimated that annually 200,000 patients in the United States have malignant pleural effusion.2 The most significant problem caused by malignant pleural effusion is dyspnea, which diminishes the quality of life of a patient with cancer with an expected lifetime of less than 6 months. Although the dyspnea can be relieved by therapeutic thoracentesis, the effusion often recurs rapidly. Thus far, pleurodesis appears to be the best option available to prevent recurrent malignant pleural effusions. Although it does not improve patient survival, it can significantly improve quality of life. Presently, talc is the preferred agent for pleurodesis in the United States and England.3 The reason for this preference is that talc, administered either by an aerosol (insufflation) or in suspension (slurry), is effective, inexpensive, widely available, and associated with minimal side effects in most reports. Methods of pleurodesis vary considerably among individual pulmonary physicians and among different countries. A recent investigation, The International Survey of Pleurodesis Practice (ISPP), surveyed pulmonary physicians in 5 different English-speaking countries (United States, Canada, United Kingdom, Australia, and New Zealand) regarding their management of malignant pleural effusions.3 This survey found significant variations in the practice of pleurodesis among physicians among and within the surveyed countries. The selection of a pleurodesing agent is one of the key questions in performing chemical pleurodesis today. Many different agents have been tried. However, none of the agents are ideal, each with a differing degree of efficacy and a variety of adverse effects.4,5 This is reflected in the results of the ISPP because responding physicians were only “somewhat satisfied” with the agents they used.3 There is, thus, no global consensus on the best pleurodesing agent. The 3 types of agents used most commonly in the 5 English-speaking countries surveyed by the ISPP were talc (either as poudrage or slurry), tetracycline (or its derivatives, especially doxycycline), and bleomycin.3 Other agents are commonly used in countries not represented in the survey include quinacrine, which has been used in Scandinavia6 for the last 3 decades, and OK-432 used in Japan7 for many years. Recently, the use of silver nitrate has been advocated in Brazil,8 whereas the use of iodopovidone has been advocated in Mexico.9 At the present time, there are considerable problems with using bleomycin and tetracycline derivatives for pleurodesis because bleomycin is expensive and relatively ineffective compared with other sclerosing agents, and tetracycline derivatives are not available in many countries. In addition, medical quality talc is not universally available. In this issue of the Journal of Bronchology, pages 226–232, Khoja and coworkers have been innovative in their endeavors to find a pleurodesis agent in a city where no such agent was readily available. They used face talc instead of commercially available medical talc as a pleurodesing agent in patients with malignant pleural effusions. The face talc they used is readily available in many of the grocery stores in India, and it is significantly cheaper than medical talc. They also compared these 2 agents in terms of contents, particle size, effectiveness, and side effects. Interestingly, they found that face talc content was nearly identical to the commercially available medical talc except for particle size, which was slightly different between the 2 agents (face talc, 40–65 μm vs. medical talc, 40–75 μm). However, particle sizes for both agents are still significantly larger than those of commercially available medical talc preparations in the United States (10.8–20.4 μm).10 In their study, all patients received a pleurodesing agent during videothoracoscopy under general anesthesia using bladder wash syringe. Although 135 patients received face talc, 20 patients received imported medical talc at a dose of 5–10 g. They found that the face talc was as effective as medical talc. More interestingly, they reported no incidence of adult respiratory distress syndrome (ARDS) even though the talc dose they used was 5 g or more. There is increasing debate concerning the safety of talc. At least 42 cases of ARDS after intrapleural talc administration exist in the literature, 24 after the use of talc slurry and the remaining 18 after talc insufflation.11–20 In some cases, the patients presented with respiratory failure and required mechanical ventilation. Eleven of the patients died.11,14,18–20 The mechanism responsible for ARDS after intrapleural talc administration is unknown, and the incidence of ARDS after intrapleural talc administration varies widely from study to study. Remarkably, most of the case series with number of patients who developed ARDS after intrapleural talc administration are from the United States, whereas some of the largest European case series reported no ARDS cases.21,22 A reasonable hypothesis to explain this disparity is that talc preparations with smaller median sizes are more likely to be absorbed and, therefore, would be more likely to produce ARDS. Indeed, we have shown previously that the mean diameter of the talc particles in 8 different talc preparations varied from 10.8 to 33.6 μm.10 Interestingly, talc preparations from the United States, the country with the highest incidence of ARDS after talc administration, have the smallest mean diameter. This hypothesis also could be the explanation why Khoja and coworkers report no ARDS cases after intrapleural talc administration, because each talc preparations used in their study had a particle size larger than those used in the United States. In a recent article, Maskell and coworkers23 investigated whether pleurodesis using mixed talc (containing small talc particles) produces greater lung and systemic inflammation and greater hypoxemia than graded talc (sorted during manufacture to exclude most particles less than 10 μm) or tetracycline. They found that pleurodesis with mixed talc causes a greater systemic inflammatory response than graded talc and tetracycline. In conclusion, the article by Khoja and coworkers in this issue of the Journal of Bronchology demonstrates that face talc can be used as an alternative pleurodesing agent in countries where the availability of other pleurodesing agents is limited. Out of curiosity, we visited 1 of the drug stores in Nashville, Tennessee, and found talc products in 2 differing forms: face powder and baby powder. The face powder had many ingredients in addition to talc, but the baby powder contained only fragrance in addition to the talc. It is important for physicians who obtain talc from nonmedical sources to pay close attention to all the ingredients of the talc preparation. It should be kept in mind that talc or any other product purchased at a grocery store needs to be sterilized appropriately before use. We also suggest that silver nitrate and iodopovidone be considered as possible alternative agents in countries where the usual pleurodesing agents are unavailable.

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