□ ORIGINAL ARTICLE □

Talc Pleurodesis for the Management of Malignant Pleural

Effusions in Japan

Takeo Inoue, Atsuko Ishida, Miho Nakamura, Hiroki Nishine,

Masamichi Mineshita and Teruomi Miyazawa

Abstract
Objective Malignant pleural effusions are commonly treated with tube drainage followed by chemical
pleurodesis to maintain the patient’s quality of life. While talc is now accepted to be a worldwide gold-
standard sclerosing agent for treating malignant pleural effusion, it is not yet approved in Japan. Instead,
many patients are administered OK-432 for pleurodesis, which carries the risk of complications such as high-
grade fever, chest pain, anaphylactic shock, interstitial pneumonia and acute renal failure. To assess the effi-
cacy and safety of talc as a sclerosing agent in the management of malignant pleural effusions in Japanese
patients.
Methods Pleurodesis was performed using 4 g of sterile talc with thoracoscopic talc poudrage or the ad-
ministration of talc slurry via a chest tube in patients with malignant pleural effusions.
Results A total of 57 patients were included. The success rate of pleurodesis assessed on chest radiography
at 30, 90 and 180 days was 90.6%, 80.9% and 76.1%, respectively. Complications occurring after talc
pleurodesis included fever in 10.5% of the patients and chest pain in 14.0% of the patients. No major com-
plications were reported.
Conclusion Talc pleurodesis is an effective and safe treatment for the management of malignant pleural ef-
fusion in Japanese patients.

Key words: malignant pleural effusion, talc poudrage, talc slurry, pleurodesis

(Intern Med 52: 1173-1176, 2013)

(DOI: 10.2169/internalmedicine.52.9281)

that intrapleural talc administration may cause acute respira-

Introduction
Malignant pleural effusion is a disease that is frequently
faced by pulmonologists in association with the increased
number of patients with malignant diseases. When treating
malignant pleural effusions, pleurodesis is commonly per-
formed in order to maintain the patient’s general condition.
In Japan, OK-432, a purified preparation derived from
Streptococcus pyogenes, is primarily used as a sclerosing
agent. In contrast, the worldwide standard therapy for con-
trolling malignant pleural effusions is pleurodesis with talc,
as talc has been reported to have a better success rate and a
lower incidence of side effects than other agents (1, 2).
Talc is a powder that includes various types of minerals
used for chalks and cosmetics. Concerns have been raised
tory distress syndrome; however, studies have revealed that
using talc with a large particle size does not lead to sys-
temic inflammation (3, 4). According to these reports, we
performed talc pleurodesis to treat malignant pleural effu-
sions in order to assess the efficacy and safety of talc in
Japanese patients using large particle sterile talc as a scle-
rosing agent.
Materials and Methods
Patients
Between May 2007 and April 2012, a prospective study
was performed in patients with uncontrolled and sympto-
matic malignant pleural effusions requiring pleurodesis at St.

Division of Respiratory and Infectious Diseases, Department of Internal Medicine, St. Marianna University School of Medicine, Japan
Received for publication November 6, 2012; Accepted for publication January 27, 2013
Correspondence to Dr. Teruomi Miyazawa, miyazawat@marianna-u.ac.jp

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 Intern Med 52: 1173-1176, 2013 DOI: 10.2169/internalmedicine.52.9281

A C D F

E
B

Figure. A: A sterile vial containing 4 g of sterile talc. B: Talc powder. C: A dedicated catheter con-
nected to a talc atomizer is inserted through the working channel of the flexi-rigid thoracoscope. D:
Endoscopic image during talc insufflation via a catheter under flexi-rigid thoracoscopy. Talc is in-
sufflated in a ‘blizzard’ manner into the pleural cavity. E: Endoscopic appearance of the pleural
surface following talc poudrage. Talc should be distributed thinly on the pleura. F: A syringe con-
taining 4 g of sterile talc mixed with 50 mL of sterile saline for talc slurry.

Marianna University Hospital. The enrollment criteria in-
cluded an age over 20 years, the presence of malignant cells
in the pleural effusion proven on cytology or the presence of
malignancy in a pleural biopsy and the ability to understand
and sign the informed consent forms. Patients were excluded
if the pleural effusion was recurrent after one or more at-
tempts of pleurodesis or when insufficient expansion of the
lung following pleural fluid drainage (trapped lung), inade-
quate lung function parameters and/or severe heart failure
were present. The Ethics Committee of St. Marianna Uni-
versity School of Medicine approved this study, and written
informed consent was obtained from all patients prior to en-
rollment in the study.
Methods
Sterile talc with a large particle size (SteritalcⓇ; Novatech;
La Ciotat, France) (Figure A, B) was used in this study. Talc
was administered with thoracoscopic talc poudrage or the
administration of talc slurry via a chest tube.
Thoracoscopic talc poudrage
Thoracoscopy was performed under local anesthesia at the
chest wall using 10 mL of 1% lidocaine, with an additional
10 mL if needed. Then, a flexible trocar (MAJ-1058; Olym-
pus; Tokyo, Japan) was placed, and a flexi-rigid thora-
coscope (LTF-240; Olympus) was inserted into the pleural
cavity. Any pleural fluid, if present, was aspirated through
the working channel of the scope under visual control. If
necessary, a pleural biopsy was performed. A catheter (K-
203; Olympus) connected to a talc atomizer (Wolf Com-
pany, Knittlingen, Germany) was inserted through the work-
ing channel of the flexi-rigid thoracoscope (Figure C). Un-
der direct visualization, 4 g of sterile talc was then insuf-
flated into the pleural cavity (Figure D, E). Following the
procedure, a 20-F chest tube was inserted, and chest radiog-
raphy was used to detect any acute adverse events and to
check the position of the chest tube. If no problematic find-
ings were found, the tube was subsequently connected to
-10 to -20 cm H2O suction for at least two days then re-
moved when less than 200 mL of fluid was drained per day.
Talc slurry administration via chest tube
Talc slurry was administered at the bedside via a chest
drainage tube placed in advance. The chest tube was
clamped, and 4 g of sterile talc mixed with 50 mL of sterile
saline (Figure F) was injected into the pleural cavity through
the chest tube. The tube was subsequently flushed with 50
mL of sterile saline. After being clamped for six hours, the
chest tube was opened again and connected to -10 to -20 cm
H2O suction for at least two days. The chest tube was re-
moved when less than 200 mL of fluid was drained per day.
Data collection and assessment
All data were collected prospectively. The primary end-
point was efficacy and the secondary endpoint was the
safety of the talc. We evaluated efficacy at 30, 90 and 180
days after talc pleurodesis using chest radiography. Cases in
which the chest tube was successfully removed when fluid
drainage decreased to less than 200 mL per day and in
which chest radiography showed a pleural effusion occupy-
ing less than one-third of the pleural space were considered
to be effective. Cases in which the chest tube could not be
removed because fluid drainage did not decrease to less than
200 mL per day or those with an increased pleural effusion
occupying one-third or more of the pleural space on chest
radiography were recorded as ineffective. Patients who died
due to progression of the underlying disease before 30 days
after pleurodesis or who did not show up for follow-up
chest radiography were excluded from the evaluation. Re-
garding complications, chest pain requiring a prescription

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 Intern Med 52: 1173-1176, 2013
Table 1. Effective Pleurodesis and Success
Rates after 30, 90, and 180 Days
30 days 90 days 180 days
Evaluable cases, n 53 47 46
Effective pleurodesis, n 48 38 35
Success rate, % 90.6 80.9 76.1
for pain control, a temporary fever over 38.0℃ and the oc-
currence of any complications requiring additional treatment
or procedures within 30 days after talc pleurodesis were
noted.
Results
A total of 57 patients, including 39 women and 18 men
with a mean age of 68.1±10.5 years (range, 43 to 92 years),
participated in this study. There were 28 patients with lung
cancer (26 cases of non-small cell lung cancer and two
cases of small cell lung cancer), three patients with malig-
nant pleural mesothelioma, 15 patients with breast cancer,
four patients with ovarian cancer, three patients with renal
cell carcinoma, one patient with endometrial cancer, one pa-
tient with pancreatic cancer, one patient with malignant
melanoma and one patient with leiomyosarcoma. Eight pa-
tients underwent thoracoscopic talc poudrage and 49 patients
received talc slurry. Removal of the chest tube was unsuc-
cessful in three patients because the fluid drainage did not
decrease to less than 200 mL per day. Among the remaining
patients, the mean duration of chest tube drainage after talc
pleurodesis was 4.4±2.2 days (range, 2 to 12). Thirty-seven
patients (64.9%) received subsequent systemic therapy for
underlying diseases after talc pleurodesis.
Table 1 shows the efficacy results for talc pleurodesis.
Four patients died due to the progression of the underlying
disease before 30 days after pleurodesis and were excluded
from the evaluation for efficacy. The success rate (effective
cases/evaluable cases) of talc pleurodesis among all patients
at 30, 90 and 180 days was 90.6% (48/53), 80.9% (38/47)
and 76.1% (35/46), respectively. Among the eight patients
who underwent thoracoscopic talc poudrage, the success rate
(effective cases/evaluable cases) remained 100% (8/8) until
180 days after the procedure. The success rate (effective
cases/evaluable cases) at 30, 90 and 180 days among the pa-
tients who received talc slurry was 88.9% (40/45), 76.9%
(30/39) and 71.1% (27/38), respectively.
Table 2 shows the complications observed after the proce-
dures. Temporary fevers over 38.0℃ were observed in six
patients (10.5%). Eight patients (14.0%) complained of
chest pain requiring a prescription for pain control and, of
these, two patients (3.5%) had accompanying temporary
dyspnea without desaturation. No major complications oc-
curred as a result of the procedures.
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DOI: 10.2169/internalmedicine.52.9281
Table 2. Complications
Grade* Grade 1 Grade 2 Grade 3 or severer
Fever 6 0 0
Chest pain 0 8 0
Dyspnea 1 1 0
* Scored according to Common Terminology Criteria for Adverse
Events (CACAE) version 4.0
Discussion
For uncontrolled and symptomatic malignant pleural effu-
sions, pleurodesis is commonly performed to maintain the
patient’s quality of life. In Japan, OK-432 is primarily used
as the sclerosing agent. While the efficacy of OK-432 is ac-
ceptable, with a reported success rate of 73%, the high inci-
dence of high-grade fever and chest pain is problematic (5).
In Western countries, on the other hand, talc pleurodesis has
been the gold standard treatment for malignant pleural effu-
sions for many years (6). In this study, we applied talc in 57
Japanese patients with malignant pleural effusions in order
to assess the efficacy and safety of this compound. The suc-
cess rate at 30 days after talc pleurodesis was 90.6%, which
is similar to the findings of previous reports (7-9).
Regarding complications, our study showed that only a
small number of patients complained of fever and/or chest
pain after talc pleurodesis, while OK-432 is associated with
high incidences of fever, chest pain and dyspnea. For exam-
ple, we reported that only 10.5% of the patients complained
of a fever over 38.0℃, which is considerably lower than a
previous finding of 76.9% for OK-432 (5). Although the
number of patients evaluated in this study was limited, the
complications resulting from talc pleurodesis are considered
to be acceptable. It is important for patients with malignant
pleural effusions to maintain a reasonable quality of life, as
many already suffer from a poor general condition.
In order to administer talc into the pleural space, we per-
formed both thoracoscopic talc poudrage and talc slurry
through a chest tube. In general, a rigid thoracoscope is
commonly used for talc poudrage (10). We used a flexi-rigid
thoracoscope in this study, which has the advantage of being
able to reach narrow spaces more easily with its bidirec-
tional flexible tip that allows for pleural fluid aspiration and
biopsy under visualization from a single port of entry. Flexi-
rigid thoracoscopy is primarily performed to diagnose pleu-
ral effusions of unknown cause (11-13). Previously, we de-
scribed the use of thoracoscopic talc poudrage under flexi-
rigid thoracoscopy with one port of entry and a dedicated
catheter (14). In this report, we revealed that all nine proce-
dures, including those performed in three patients over 75
years of age and two patients with a Karnofsky Performance
Status Scale of 50, were performed safely and effectively
and concluded that this technique is useful, even in elderly
patients or those with a relatively low performance status. In
the present study, the success rate at 180 days after
pleurodesis was 100% for talc poudrage and 71.0% for talc
 Intern Med 52: 1173-1176, 2013
slurry. In fact, some previous reports have shown higher
success rates for thoracoscopic talc poudrage (7, 8). This is
most likely because thoracoscopic talc poudrage can confirm
talc distribution throughout the entire pleural cavity under
visualization, while the administration of talc slurry is per-
formed blindly. Therefore, performing thoracoscopic talc
poudrage is recommended, even though it requires special
equipment and operator skill.
In conclusion, talc is acceptable in terms of both efficacy
and safety as a sclerosing agent for pleurodesis in Japanese
patients. As for the administration of talc, depending on the
skill of the pulmonologist and whether the facility can per-
form thoracoscopic talc poudrage, it is better to administer
talc under thoracoscopy, otherwise talc slurry should be se-
lected.
The authors state that they have no Conflict of Interest (COI).
Acknowledgement
The authors are indebted to Mr. Jason Tonge for his English
review of this manuscript.
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