Talc Pleurodesis: A Medical, Medicolegal, and Socioeconomic Review

Our plain-English summary of Talc Pleurodesis: A Medical, Medicolegal, and Socioeconomic Review, by I. Baiu, E. Yevudza, J.B. Shrager (The Annals of Thoracic Surgery, 2020).

The study

• Authors: I. Baiu, E. Yevudza, J.B. Shrager
• Journal: The Annals of Thoracic Surgery
• Published: 2020;109(4):1294-1301
• Type of article: Systematic review
• Cited by: 23 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: Talcum has been used in pleurodesis for more than 8 decades. Despite a wealth of research, controversy remains over the optimal sclerosant for pneumothorax and pleural effusions. Talc's historical primacy has been challenged because of its potential for pulmonary toxicity, possible carcinogenicity, and recent concerns surrounding availability and legal liability, thus making this an ideal time for a review.

Methods: This systematic review of the talc literature, focused on publications after the year 2000, evaluated mechanism of action, efficacy, side effect profile, and alternative sclerosants; included is an overview of current socioeconomic and legal controversies.

Results: The data support talc as the most effective agent for pleurodesis. There is evidence to suggest that mean particle size has a direct relationship with the side effect profile and that significant hypoxemic events after talc administration are exceedingly rare when using available graded talc preparations. Concerns regarding the development of malignant diseases after topical talc application remain incompletely resolved but appear related to cosmetic powder preparations that were contaminated with asbestos. Purified talc in the pleural space has not been implicated. Recent difficulties accessing commercial talc preparations have been solved. Although safe and effective talc alternatives do exist, these agents are not as well studied.

Conclusions: Talc pleurodesis with modern, purified, graded talc preparations is safe and highly effective. Talc is an inexpensive and accessible option that remains appropriate for pleurodesis despite existing controversies.

Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

In plain English

This article was a review, not a new study. The authors searched PubMed for research on agents used for pleurodesis (sealing the space around the lung) in pleural effusion and pneumothorax, focusing on work published after 2000. They also reviewed publicly available legal documents and media. Drawing on the studies they reviewed, they reported that talc was the most effective agent and that particle size and dose affected how much inflammation spread through the body. One cited multicenter cohort using graded talc reported no cases of acute respiratory distress syndrome (ARDS). The authors noted that talc was often contaminated by asbestos before 1970, but they found no reports of talc causing malignant mesothelioma. Cited studies of perineal talc powder showed small increases in ovarian cancer risk, which the authors called weak statistical evidence. The authors concluded that purified graded talc is the most reliable pleurodesis agent and that there is neither evidence for, nor reason to believe, that talc pleurodesis causes mesothelioma. They noted that ARDS definitions and talc doses varied across studies, and that no study had specifically examined ovarian cancer after pleurodesis.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Literature review, which the authors describe as a systematic review, plus a review of legal and socioeconomic issues based on public documents and media
• Who was studied: Published systematic reviews and original research on pleurodesis agents, limited to case series of at least 30 subjects published after 2000 (except papers establishing 'firsts'). The legal and socioeconomic part used publicly available documents and media. No count of included studies is given.
• Exposure: Medical talc (hydrated magnesium silicate, purified to more than 95% talcum) placed in the pleural space for pleurodesis, compared with alternative agents. The authors also discussed perineal cosmetic talc and asbestos contamination of talc before 1970.
• Main results:
  • From the literature reviewed, the authors reported that talc was the most effective agent for pleurodesis.
  • The authors reported strong animal and clinical evidence that mean particle size and dose determine how widely talc spreads in the body and how much inflammation follows pleurodesis.
  • A cited multicenter prospective cohort study using graded talc (mean particle size 24.5 µm) reported an ARDS incidence of zero. A cited study using non-graded talc reported a 1.3% incidence of ARDS, with 50% mortality.
  • The authors reported that talc was frequently contaminated by asbestos before 1970. Since then, talc for cosmetic powders or any medical use has undergone purification intended to remove such contamination.
  • The authors found no reports of talc causing malignant mesothelioma and no literature linking talc placed in the pleural space to non-thoracic cancers.
  • In the cited Nurses' Health Study (121,700 women), perineal talc use was associated with a small increase in risk of invasive serous ovarian cancer (RR 1.4, 95% CI 1.02-1.92). A cited meta-analysis reported OR 1.31 (95% CI 1.24-1.39) for ovarian cancer.
  • The authors described the evidence linking perineal talc use to ovarian cancer as weak statistical evidence.
  • The only long-term outcome study after talc pleurodesis (118 months) showed no increased risk of cancer. The authors noted that this study was underpowered and had insufficient follow-up.
• The authors' conclusion: The authors concluded that, among the agents available for pleurodesis, purified graded talc is the most reliable and efficacious. They also concluded that there is neither evidence for, nor reason to believe, that talc pleurodesis causes mesothelioma.
• Limitations the authors state:
  • Definitions of ARDS, talc doses and particle sizes varied across the literature, making the incidence of ARDS difficult to establish.
  • No studies have specifically evaluated the risk of ovarian cancer after talc pleurodesis.
  • How side effects change with talc dose has not been systematically studied in humans.
  • Alternative agents have not been studied well enough in prospective, randomized trials for the authors to recommend any of them over talc.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Pleural plaques and thickening, Talc and vermiculite.

Medical terms in this study, explained in our Lexicon: Talc Pleurodesis, Pleurodesis, Pneumothorax, Pleural Effusion, Talc, Systematic Review.

Related studies

• A randomized controlled trial of the efficacy of cosmetic talc compared with iodopovidone for chemical pleurodesis — R. Agarwal, A.S. Paul, et al. (2011)
• Medical thoracoscopic talc pleurodesis for chylothorax due to lymphoma: a case series — D.C. Mares, P.N. Mathur (1998)
• Success rate of medical thoracoscopy and talc pleurodesis in malignant pleurisy: A single-centre experience — J. Leemans, C. Dooms, et al. (2018)
• Intrapleural talc for the prevention of recurrent pneumothorax — J.R. Milanez, F.S. Vargas, et al. (1994)
• CT appearances of talc pleurodesis — S. Narayanaswamy, S. Kamath, et al. (2007)
• Pleural granuloma mimicking malignancy 42 years after slurry talc injection for primary spontaneous pneumothorax — S. Tenconi, L. Luzzi, et al. (2010)

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