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Anne V. Gonzalez, MD; Vishnu Bezwada, MD; John F. Beamis, Jr, MD, FCCP; Andrew G. Villanueva, MD, FCCP
Author and Funding Information

From the Department of Pulmonary and Critical Care Medicine, Lahey Clinic Medical Center.

Correspondence to: Anne V. Gonzalez, MD, McGill University Health Centre, Montreal Chest Institute, 3650 Saint-Urbain St, K1.09 Montreal, QC H2X 2P4, Canada; e-mail: anne.gonzalez@mcgill.ca


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2011 American College of Chest Physicians


Chest. 2011;139(2):478. doi:10.1378/chest.10-2737
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To the Editor:

We thank Dr Aelony for his interest in our recent article in CHEST (June 2010)1 on the occurrence of lung injury following thoracoscopic talc insufflation (TTI). We did not report on pleurodesis success rate because our goal was to determine the incidence of respiratory complications.

We acknowledge the design limitations of our retrospective study. We carefully assessed all cases of postprocedure respiratory insufficiency. Up to eight subjects may have had talc-related lung injury, but due to atypical features or because an alternate diagnosis was possible, we excluded four cases from the incidence calculation of 2.8%. Dr Aelony correctly notes that radiographic findings may be seen after pleural drainage or simple thoracoscopy. The occurrence of respiratory insufficiency was defined based on symptoms and increased oxygen requirements in addition to radiographic changes.

Dr Aelony states that we are inappropriately referencing two articles as showing complications of talc pleurodesis. Rehse et al2 reported the occurrence of ARDS in 9% of patients undergoing talc pleurodesis. He is correct in pointing out that three patients had undergone mechanical pleurodesis followed by poudrage; the other patients received talc slurry. Thus, ARDS was reported following simple talc exposure, albeit after administration as slurry. Dresler et al3 reported the results of a randomized trial comparing TTI with talc slurry for malignant pleural effusions. The complications reported included bronchopleural fistula (2% with talc slurry and 2.7% after TTI). Separately, the authors reported that respiratory failure was observed in 4% of patients after talc slurry and 8% following TTI. It is stated that the etiology of the respiratory complications was unclear but consistent with prior reports of respiratory failure following talc administration.

It is interesting that conversations with Bryan Corporation representatives would suggest that the current talc preparation is different from the original one. The four cases of talc-related lung injury we reported occurred in 2001, 2004, and 2007 (two cases). Dr Rodriguez-Panadero (personal communication, October 2009) recently compared Sclerosol (Bryan Corporation; Woburn, Massachusetts) with French-graded talc using laser diffraction and demonstrated that Sclerosol contains a larger proportion of small particles.

There are ample data from both animal studies and clinical trials to suggest that talc preparations that include small particles are associated with a higher risk of respiratory complications.4 We are delighted that Dr Aelony seconds our call for the US Food and Drug Administration to approve European-graded, large-particle talc for pleurodesis, given its established safety record.5

Gonzalez AV, Bezwada V, Beamis JF Jr, Villanueva AG. Lung injury following thoracoscopic talc insufflation: experience of a single North American center. Chest. 2010;1376:1375-1381. [CrossRef] [PubMed]
 
Rehse DH, Aye RW, Florence MG. Respiratory failure following talc pleurodesis. Am J Surg. 1999;1775:437-440. [CrossRef] [PubMed]
 
Dresler CM, Olak J, Herndon JE II, et al; Cooperative Groups Cancer and Leukemia Group B Cooperative Groups Cancer and Leukemia Group B Eastern Cooperative Oncology Group Eastern Cooperative Oncology Group North Central Cooperative Oncology Group North Central Cooperative Oncology Group Radiation Therapy Oncology Group Radiation Therapy Oncology Group Phase III intergroup study of talc poudrage vs talc slurry sclerosis for malignant pleural effusion. Chest. 2005;1273:909-915. [CrossRef] [PubMed]
 
Maskell NA, Lee YC, Gleeson FV, Hedley EL, Pengelly G, Davies RJ. Randomized trials describing lung inflammation after pleurodesis with talc of varying particle size. Am J Respir Crit Care Med. 2004;1704:377-382. [CrossRef] [PubMed]
 
Janssen JP, Collier G, Astoul P, et al. Safety of pleurodesis with talc poudrage in malignant pleural effusion: a prospective cohort study. Lancet. 2007;3699572:1535-1539. [CrossRef] [PubMed]
 

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References

Gonzalez AV, Bezwada V, Beamis JF Jr, Villanueva AG. Lung injury following thoracoscopic talc insufflation: experience of a single North American center. Chest. 2010;1376:1375-1381. [CrossRef] [PubMed]
 
Rehse DH, Aye RW, Florence MG. Respiratory failure following talc pleurodesis. Am J Surg. 1999;1775:437-440. [CrossRef] [PubMed]
 
Dresler CM, Olak J, Herndon JE II, et al; Cooperative Groups Cancer and Leukemia Group B Cooperative Groups Cancer and Leukemia Group B Eastern Cooperative Oncology Group Eastern Cooperative Oncology Group North Central Cooperative Oncology Group North Central Cooperative Oncology Group Radiation Therapy Oncology Group Radiation Therapy Oncology Group Phase III intergroup study of talc poudrage vs talc slurry sclerosis for malignant pleural effusion. Chest. 2005;1273:909-915. [CrossRef] [PubMed]
 
Maskell NA, Lee YC, Gleeson FV, Hedley EL, Pengelly G, Davies RJ. Randomized trials describing lung inflammation after pleurodesis with talc of varying particle size. Am J Respir Crit Care Med. 2004;1704:377-382. [CrossRef] [PubMed]
 
Janssen JP, Collier G, Astoul P, et al. Safety of pleurodesis with talc poudrage in malignant pleural effusion: a prospective cohort study. Lancet. 2007;3699572:1535-1539. [CrossRef] [PubMed]
 
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