Is talc pleurodesis safe for young patients following primary spontaneous pneumothorax
http://www.100md.com
《血管的通路杂志》
a Department of Thoracic Surgery, Guy's Hospital, St Thomas Street, London, UK
b Library Services Manager, Royal Surrey County Hospital, Guildford, Surrey, UK
Abstract
A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether talc used for pleurodesis in young patients with a spontaneous pneumothorax has any long-term adverse effects. One hundred and eighty-one papers were identified using the search below. Eight papers presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of the papers are tabulated. We conclude that talc pleurodesis in young patients with a spontaneous pneumothorax appears to have minimal long-term adverse consequences.
Key Words: Evidence-based medicine; Thoracic surgery; Pneumothorax; Talc pleurodesis; Adverse events
1. Introduction
A Best Evidence Topic was constructed according to a structured protocol. This protocol is fully described in the ICVTS [1].
2. Clinical scenario
A 23-year-old man was due to undergo a VATS procedure with talc insufflation for recurrent spontaneous pneumothorax. While preparing the patient for theatre he asks you about how the talc that will be insufflated in the operation works. After explaining how the talc causes an inflammatory reaction that causes the pleura to adhere together, he asks that since the talc causes a reaction, can it cause any long-term problems.
3. Three-part question
In patients [with a pneumothorax] does [talc pleurodesis] cause [long term adverse effects]
4. Search strategy
Medline 1950–June 2006 and Embase 1974–June 2006 using the Dialog Datastar interface.
[Pneumothorax.W.DE. OR PNEUMOTHORAX#.W.DE.] AND [Talc.W.DE.]. Limit to English. This search was repeated in Cochrane Central Register of Controlled Trials.
5. Search outcome
A total of 181 papers were identified of which eight were deemed to be relevant. These are listed in Table 1.
6. Comments
The role of talc as the agent to achieve pleurodesis usually combined with a minimally invasive videothoracosopic approach (VATS) has become popular in treating patients with primary spontaneous pneumothorax (PSP) [2]. However, issues about the use of talc in young patients, the risk of carcinogenesis [9], and the development of restrictive lung pathology persist [7,8]. The review focuses on the long-term consequences of talc use in patients with PSP and will not consider early complications such as acute pneumonitits and ARDS or complications of talc used in older patients with malignant pleural effusions.
Concerns about the carcinogenic effect of talc are likely to have come originally from early reports in miners and processors exposed to impurities in talc dust resulting in malignant tumours of the lung and pleura [9]. In 1979 three centres in the UK retrospectively examined medical records to identify patients who had received pleurodesis with talc or kaolin at least 14 years earlier [9]. Two hundred and ten patients were identified. Once data were collated the authors concluded that there was no increased incidence of lung cancer (as compared to the general population) and no cases of mesothelioma. Furthermore, they speculated that the early reports suggesting talc may be carcino-genic may be due to asbestos-like contaminants present in the talc used. No other study identified an association between intrapleural talc use and increased incidence of subsequent lung or pleural cancer [2–9].
Two papers published in the late 1980s specifically examined patients for long-term evidence of respiratory compromise following talc pleurodesis [7,8]. One study measured static and dynamic lung function in PSP patients treated with talc pleurodesis or simple chest drainage. Patients who had undergone a talc pleurodesis some 22–35 years earlier showed a mild restrictive impairment of lung function (mean Total Lung Capacity, TLC 89% predicted) compared to those who had simple chest drainage (TLC 96%, predicted). One patient who had received talc pleurodesis had evidence of lung fibrosis and severe reduction in lung function (TLC, 58% predicted). No patient had developed mesothelioma [8]. In a paper published a year later by the same group X-ray, changes in the pleura was moderate with some thickening but no significant restriction in lung function [7]. Both studies concluded that in the long-term talc pleurodesis did not produce significant adverse effects on lung function. More recently, the largest series of VATS treated PSP using primarily talc pleurodesis was reported [2]. It showed a high success rate (98%) at 50 months follow-up, and with no reported deterioration in lung function in 26 patients followed-up over five years. Apart from the recent report from Italy [2], the other studies reviewed [3–6] comment on the absence of no long-term adverse effects without presenting any objective clinical, physiological or radiological evidence to support assertion.
Despite evidence dating back 20–25 years that talc as an agent for pleurodesis is likely to be safe and has few long-term adverse effects [6–9], recently concerns about the role of intrapleural talc and the generation of a systemic inflammatory response with systemic dissemination of talc particles beyond the pleural cavity have been reported [2]. This work has focused mainly on the immediate adverse effects of talc pleurodesis and the influence of dose and particle size on pulmonary inflammation. However, what influence the dissemination of talc has on long-term adverse effects remains unclear and no study dealing with this issue was identified.
7. Clinical bottom line
Talc pleurodesis in young patients with a primary pneumothorax appears to have minimal long-term adverse effects.
References
Dunning J, Prendergast B, Mackway-Jones K. Towards evidence-based medicine in cardiothoracic surgery: best BETS. Interact J Cardiovasc Thoracic Surg 2003; 2:405–409.
Cardillo G, Carleo F, Giunti R, Carbone L, Mariotta S, Salvadori L, Petrella L, Martelli M. Videothoracoscopic talc poudrage in primary spontaneous pneumothorax: a single-institution experience in 861 cases. J Thorac Cardiovasc Surg 2006; 131:322–328.
Ozcan C, McGahren ED, Rodgers BM. Thoracoscopic treatment of spontaneous pneumothorax in children. J Pediatr Surg 2003; 38:1459–1464.
Tschopp JM, Boutin C, Astoul P, Janssen JP, Grandin S, Bolliger CT, Delaunois L, Driesen P, Tassi G, Perruchoud AP. ESMEVAT team (European Study on Medical Video-Assisted Thoracoscopy). Talcage by medical thoracoscopy for primary spontaneous pneumothorax is more cost-effective than drainage: a randomised study. Eur Respir J Oct 2002; 20:1003–1009.
de Campos JRM, Vargas FS, Werebe EdC, Cardoso P, Teixeira LR, Jatene FB, Light RW. Thoracoscopy talc poudrage: a 15-year experience. Chest 2001; 119:801–806.
Milanez JR, Vargas FS, Filomeno LT, Fernandez A, Jatene A, Light RW. Intrapleural talc for the prevention of recurrent pneumothorax. Chest Oct 1994; 106:1162–1165.
Viskum K, Lang P, Mortensen J. Long term sequelae after talc pleurodesis for spontaneous pneumothorax. Pneumologie 1989; 43:105–106.
Lange P, Mortensen J, Groth S. Lung function 22–35 years after treatment of idiopathic spontaneous pneumothorax with talc poudrage or simple drainage. Thorax Jul 1988; 43:559–561.
Research committee of the British Thoracic Association and the Medical Research Council Pneumonconiosis unit. A long-term survey of the long-term effects of talc and kaolin pleurodesis. Br J Dis Chest 1979; 73:285–288.(Ian Hunta,, Brendan Barbera, Rachel Sout)
b Library Services Manager, Royal Surrey County Hospital, Guildford, Surrey, UK
Abstract
A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether talc used for pleurodesis in young patients with a spontaneous pneumothorax has any long-term adverse effects. One hundred and eighty-one papers were identified using the search below. Eight papers presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of the papers are tabulated. We conclude that talc pleurodesis in young patients with a spontaneous pneumothorax appears to have minimal long-term adverse consequences.
Key Words: Evidence-based medicine; Thoracic surgery; Pneumothorax; Talc pleurodesis; Adverse events
1. Introduction
A Best Evidence Topic was constructed according to a structured protocol. This protocol is fully described in the ICVTS [1].
2. Clinical scenario
A 23-year-old man was due to undergo a VATS procedure with talc insufflation for recurrent spontaneous pneumothorax. While preparing the patient for theatre he asks you about how the talc that will be insufflated in the operation works. After explaining how the talc causes an inflammatory reaction that causes the pleura to adhere together, he asks that since the talc causes a reaction, can it cause any long-term problems.
3. Three-part question
In patients [with a pneumothorax] does [talc pleurodesis] cause [long term adverse effects]
4. Search strategy
Medline 1950–June 2006 and Embase 1974–June 2006 using the Dialog Datastar interface.
[Pneumothorax.W.DE. OR PNEUMOTHORAX#.W.DE.] AND [Talc.W.DE.]. Limit to English. This search was repeated in Cochrane Central Register of Controlled Trials.
5. Search outcome
A total of 181 papers were identified of which eight were deemed to be relevant. These are listed in Table 1.
6. Comments
The role of talc as the agent to achieve pleurodesis usually combined with a minimally invasive videothoracosopic approach (VATS) has become popular in treating patients with primary spontaneous pneumothorax (PSP) [2]. However, issues about the use of talc in young patients, the risk of carcinogenesis [9], and the development of restrictive lung pathology persist [7,8]. The review focuses on the long-term consequences of talc use in patients with PSP and will not consider early complications such as acute pneumonitits and ARDS or complications of talc used in older patients with malignant pleural effusions.
Concerns about the carcinogenic effect of talc are likely to have come originally from early reports in miners and processors exposed to impurities in talc dust resulting in malignant tumours of the lung and pleura [9]. In 1979 three centres in the UK retrospectively examined medical records to identify patients who had received pleurodesis with talc or kaolin at least 14 years earlier [9]. Two hundred and ten patients were identified. Once data were collated the authors concluded that there was no increased incidence of lung cancer (as compared to the general population) and no cases of mesothelioma. Furthermore, they speculated that the early reports suggesting talc may be carcino-genic may be due to asbestos-like contaminants present in the talc used. No other study identified an association between intrapleural talc use and increased incidence of subsequent lung or pleural cancer [2–9].
Two papers published in the late 1980s specifically examined patients for long-term evidence of respiratory compromise following talc pleurodesis [7,8]. One study measured static and dynamic lung function in PSP patients treated with talc pleurodesis or simple chest drainage. Patients who had undergone a talc pleurodesis some 22–35 years earlier showed a mild restrictive impairment of lung function (mean Total Lung Capacity, TLC 89% predicted) compared to those who had simple chest drainage (TLC 96%, predicted). One patient who had received talc pleurodesis had evidence of lung fibrosis and severe reduction in lung function (TLC, 58% predicted). No patient had developed mesothelioma [8]. In a paper published a year later by the same group X-ray, changes in the pleura was moderate with some thickening but no significant restriction in lung function [7]. Both studies concluded that in the long-term talc pleurodesis did not produce significant adverse effects on lung function. More recently, the largest series of VATS treated PSP using primarily talc pleurodesis was reported [2]. It showed a high success rate (98%) at 50 months follow-up, and with no reported deterioration in lung function in 26 patients followed-up over five years. Apart from the recent report from Italy [2], the other studies reviewed [3–6] comment on the absence of no long-term adverse effects without presenting any objective clinical, physiological or radiological evidence to support assertion.
Despite evidence dating back 20–25 years that talc as an agent for pleurodesis is likely to be safe and has few long-term adverse effects [6–9], recently concerns about the role of intrapleural talc and the generation of a systemic inflammatory response with systemic dissemination of talc particles beyond the pleural cavity have been reported [2]. This work has focused mainly on the immediate adverse effects of talc pleurodesis and the influence of dose and particle size on pulmonary inflammation. However, what influence the dissemination of talc has on long-term adverse effects remains unclear and no study dealing with this issue was identified.
7. Clinical bottom line
Talc pleurodesis in young patients with a primary pneumothorax appears to have minimal long-term adverse effects.
References
Dunning J, Prendergast B, Mackway-Jones K. Towards evidence-based medicine in cardiothoracic surgery: best BETS. Interact J Cardiovasc Thoracic Surg 2003; 2:405–409.
Cardillo G, Carleo F, Giunti R, Carbone L, Mariotta S, Salvadori L, Petrella L, Martelli M. Videothoracoscopic talc poudrage in primary spontaneous pneumothorax: a single-institution experience in 861 cases. J Thorac Cardiovasc Surg 2006; 131:322–328.
Ozcan C, McGahren ED, Rodgers BM. Thoracoscopic treatment of spontaneous pneumothorax in children. J Pediatr Surg 2003; 38:1459–1464.
Tschopp JM, Boutin C, Astoul P, Janssen JP, Grandin S, Bolliger CT, Delaunois L, Driesen P, Tassi G, Perruchoud AP. ESMEVAT team (European Study on Medical Video-Assisted Thoracoscopy). Talcage by medical thoracoscopy for primary spontaneous pneumothorax is more cost-effective than drainage: a randomised study. Eur Respir J Oct 2002; 20:1003–1009.
de Campos JRM, Vargas FS, Werebe EdC, Cardoso P, Teixeira LR, Jatene FB, Light RW. Thoracoscopy talc poudrage: a 15-year experience. Chest 2001; 119:801–806.
Milanez JR, Vargas FS, Filomeno LT, Fernandez A, Jatene A, Light RW. Intrapleural talc for the prevention of recurrent pneumothorax. Chest Oct 1994; 106:1162–1165.
Viskum K, Lang P, Mortensen J. Long term sequelae after talc pleurodesis for spontaneous pneumothorax. Pneumologie 1989; 43:105–106.
Lange P, Mortensen J, Groth S. Lung function 22–35 years after treatment of idiopathic spontaneous pneumothorax with talc poudrage or simple drainage. Thorax Jul 1988; 43:559–561.
Research committee of the British Thoracic Association and the Medical Research Council Pneumonconiosis unit. A long-term survey of the long-term effects of talc and kaolin pleurodesis. Br J Dis Chest 1979; 73:285–288.(Ian Hunta,, Brendan Barbera, Rachel Sout)