Talc is used intrapleurally as a sclerosing agent to prevent recurrence of malignant pleural effusions in symptomatic patients.1, 2, 3, 4, 5, 6, 7, 8, 9, 10 Intrapleural talc causes inflammation that results in fibrosis and adherence of serosal surfaces (pleurodesis), thereby obliterating the pleural space and reducing the chance of fluid reaccumulation. 1, 2, 4, 18, 19, 20
Safety and efficacy of talc administered via a chest tube as a suspension (slurry) or by insufflation during thoracoscopy or open thoracotomy for the treatment of malignant pleural effusions are based on data from published literature.1, 2, 3, 14 A review of published literature from 1966-1992 indicates that about 93% of patients with recurrent, symptomatic malignant pleural effusions were successfully treated (defined as absence of reaccumulation of the effusion as determined by clinical examination or chest radiograph) with talc pleurodesis.3, 14 When analyzed by method of administration, talc poudrage and slurry pleurodesis methods resulted in similar rates of success.3
Results of small randomized, comparative studies indicate that intrapleural talc (administered via a chest tube as a slurry or poudrage) may be at least as effective as intrapleural bleomycin,1, 2, 6, 7, 8, 9, 15, 16, 17 doxycycline,12 mustine (mechlorethamine),2, 11 or tetracycline2, 10 (parenteral formulation no longer commercially available in the US) and more effective than therapeutic thoracentesis1, 2, 4 in preventing recurrence of malignant pleural effusions (as observed on chest radiographs).4, 11 In these studies, clinical success was variably defined, but was based principally on an absence of reaccumulation of the effusion as determined by clinical examination or chest radiograph.1, 2, 6, 7, 8, 9 In some published studies of talc pleurodesis, complete and persistent absence of fluid was the determinant of response;10, 11 in one study, clinical success was defined as no further thoracentesis required for relief of dyspnea.5 Follow-up times were variable, and talc dosages ranged from 2.5-10 g.1, 4, 5, 7, 8, 9, 12, 13, 16
For additional information on the treatment of pleural effusions, see Uses: Pleural Effusions, in Bleomycin Sulfate 10:00 and Uses: Pericardial and Pleural Effusions, in Tetracyclines General Statement 8:12.24.
Talc is administered intrapleurally as an aerosol during thoracoscopy or open thoracotomy2 or as a slurry via a chest tube.1 Talc should not be administered IV.1
Prior to intrapleural administration of talc as an aerosol or slurry, effusions should be adequately drained from the pleural cavity.1, 2 Success of talc pleurodesis appears to be related to completeness of the drainage of pleural fluid and full reexpansion of the lung, both of which promote symphysis of pleural surfaces.1, 2
Intrapleural Administration as an Aerosol
For intrapleural administration as an aerosol, sterile talc is commercially available in single-use aluminum spray canisters containing 4 g of talc suspended in 25 g of inert propellant (1,1,1,2-tetrafluoroethane [HFA-134a]).2
The single-use spray canisters of talc should be stored at 20-25°C, but may be exposed to temperatures ranging from 15-30°C;2 freezing should be avoided.2 Because the canister contents are under pressure and the container could rupture, the canisters should not be exposed to temperatures above 49°C, should be protected from sunlight, and should not be punctured or incinerated.2
Prior to use, the spray canister should be shaken well and the actuator button with a delivery tube (15 or 25 cm) should be securely attached to the canister valve stem.2
The delivery tube should be inserted through the pleural trocar; the distal end of the tube should not be placed adjacent to lung parenchyma or directly against the chest wall.2 For optimal distribution, the spray canister should always be maintained in an upright position.2
While firmly holding the delivery tube and pleural trocar together in one hand, the actuator button on the canister should be pressed gently.2 While pointing the distal end of the delivery tube in several different directions, short bursts should be administered to distribute talc equally and extensively on all visceral and parietal pleural surfaces.2
The spray canister and delivery tube should be discarded after administration.2
The commercially available single-use spray canister is fitted with a continuous spray valve that delivers talc at a rate of approximately 1.2 g per second, but is not considered to be a metered-dose delivery system.2 The dose delivered depends on the extent and duration of manual compression of the actuator button.2
Intrapleural Administration as a Slurry
For intrapleural administration as a slurry, sterile talc powder is commercially available in single-use 100-mL bottles containing 5 g of talc for extemporaneous preparation of slurry.1 The single-use bottles should be stored at 18-25°C and protected from sunlight.1
The talc slurry should be prepared in a laminar flow hood using aseptic technique.1
To prepare the slurry, a 16-gauge needle should be attached to a 60-mL Leur-Lok® syringe and 50 mL of 0.9% sodium chloride injection should be drawn into the syringe.1 The bottle containing talc should be vented with a needle and the 0.9% sodium chloride injection slowly added.1 The bottle should be swirled to disperse the talc powder; swirling should be continued to keep the powder from settling.1
The talc slurry should be divided into two 60-mL irrigation syringes by withdrawing 25 mL of slurry into each syringe with continuous swirling.1 An additional amount of 0.9% sodium chloride injection should then be drawn up so that the total volume in each syringe is 50 mL.1 Air should then be drawn into each syringe to the 60-mL mark to provide 10 mL of space to allow mixing prior to administration.1
Following mixing as described, each irrigation syringe will contain a talc slurry consisting of 2.5 g of sterile talc in 50 mL of 0.9% sodium chloride injection with an air headspace of 10 mL.1 The slurry should be administered within 12 hours after preparation;1 if not used within 12 hours, the slurry should be discarded.1
The manufacturer recommends that the irrigation syringes containing talc slurry be labeled with the expiration date and time, the statement “For Pleurodesis Only - NOT FOR IV ADMINISTRATION,” the identity of the patient intended to receive the slurry, and a cautionary statement to SHAKE WELL before use.1
Immediately prior to intrapleural administration, the irrigation syringes containing talc slurry must be completely and continuously agitated (to evenly redisperse the talc and avoid settlement) and the 10 mL of air (provided for mixing) must be vented.1
An adapter and syringe tip should be attached to the irrigation syrin continuous agitation of the syringe should be maintained.1 The talc slurry should be administered through the chest tube into the chest cavity by applying gentle pressure to the syringe plunger.1
Following administration of the talc slurry, the chest tube may be flushed with 10-25 mL of 0.9% sodium chloride solution and the drainage tube clamped.1 The patient should then be asked to move at 20- to 30-minute intervals from supine to alternating decubitus positions, so that over a period of about 2 hours the talc is distributed within the chest cavity.1 However, the manufacturer states that recent evidence suggests that this step may not be necessary.1 At the end of this period, the chest drainage tube should be unclamped, and excess saline removed by routine continual external suction on the tube.1
If talc is administered intrapleurally as the commercially available aerosol during thoracoscopy or open thoracotomy, the usual adult dose is 4-8 g given as a single dose and delivered intrapleurally from 1-2 spray canisters.2 The commercially available spray canisters deliver talc at a rate of approximately 1.2 g per second, but are not considered to be metered-dose delivery systems.2 The dose of talc delivered depends on the extent and duration of manual compression of the actuator button on the canister.2 The duration of chest tube drainage following talc sclerosis is dictated by the clinical situation.2 For information on administration of the commercially available talc aerosol, see Intrapleural Administration as an Aerosol under Dosage and Administration: Administration.
If talc is administered intrapleurally as an extemporaneously prepared slurry, the recommended adult dose is 5 g of talc dispersed in 50-100 mL of 0.9% sodium chloride injection and administered into the pleural cavity through a chest tube.1 Although the optimal dose for effective pleurodesis is not known, 5 g was the dose most frequently reported in the published literature.1 For information on preparation and administration of the talc slurry, see Intrapleural Administration as a Slurry under Dosage and Administration: Administration.
The manufacturer states there are no known contraindications to intrapleural talc.1, 2
Potentially Curable Malignancies
Talc has no known antineoplastic activity and should not be used alone for potentially curable malignancies when systemic therapy would be more appropriate (e.g., malignant effusion secondary to a potentially curable lymphoma).1, 2
Implications for Future Procedures
Prior to intrapleural administration of talc for pleurodesis, clinicians should consider the possible need for future diagnostic and therapeutic procedures involving the hemithorax.1, 2
Sclerosis of the pleural space may preclude subsequent diagnostic procedures of the pleura on the treated side and may complicate or preclude future ipsilateral lung resective surgery, including pneumonectomy for transplantation purposes.1, 2
Acute pneumonitis and acute respiratory distress syndrome (ARDS) have rarely been reported in association with intrapleural talc administration;1, 2 a causal relationship has not been established.2 In 3 of 4 case reports, ARDS occurred after treatment with a relatively large talc dose (10 g) administered intrapleurally via chest tube.1, 2 One patient died 1 month after treatment and 2 patients recovered without further sequelae.1, 2 No reported cases involved talc administered thoracoscopically or by insufflation.2
IV† administration of talc is a well-recognized cause of pulmonary hypertension and lung parenchymal disease, but these complications have not been reported after intrapleural administration.2 Pulmonary diseases (e.g., silicosis or asbestosis-like diseases, chronic bronchitis, bronchogenic carcinoma, pleural plaques) have been reported in association with inhaled talc.2
The contents of commercially available spray canisters of talc are under pressure.2 The canisters must not be punctured and should not be used or stored near heat or open flame.2 (See Intrapleural Administration as an Aerosol under Dosage and Administration: Administration.)
Category B.1, 2 (See Users Guide.)
There are no adequate and well-controlled studies using intrapleural talc in pregnant women;1, 2 the drug should not be used during pregnancy unless benefits outweigh risks.1, 2
Safety and efficacy of intrapleural talc have not been established in pediatric patients.1, 2
Safety and efficacy of intrapleural talc in geriatric patients have not been studied specifically to date.1, 2
The estimated mean and median ages of patients treated with talc slurry administered via a chest tube in clinical studies (single-arm or randomized studies) were 60 and 62 years, respectively.1 In other clinical studies, the mean and median ages of patients treated with intrapleural talc ranged between 50 and 62 years of age.2
The most common adverse effects reported following intrapleural administration of talc are fever and pain.1, 2 Almost all reported cases of fever and over half of reported cases of pain occurred in patients who underwent diagnostic biopsies at the time of intrapleural administration of talc.2
It is not known whether the absorptive properties of talc would diminish the effectiveness of subsequent therapy with a second sclerosing agent.1, 2
Commercially available sterile talc powder for intrapleural administration is a white or off-white to light gray, asbestos- and brucite-free grade of talc that is of controlled particle size and contains at least 95% talc as hydrated magnesium silicate.1, 2 Sterile talc powder is commercially available in single-use pressurized spray canisters for intrapleural administration as an aerosol (see Intrapleural Administration as an Aerosol under Dosage and Administration: Administration).2 Each single-use canister contains 4 g of talc suspended in 25 g of 1,1,1,2-tetrafluoroethane (HFA-134a) aerosol propellant.2 Sterile talc powder also is commercially available in single-use bottles for preparation of a talc slurry for intrapleural administration via a chest tube (see Intrapleural Administration as a Slurry under Dosage and Administration: Administration).1
The mechanism of action of talc used as a sclerosing agent in the prevention of recurrent malignant pleural effusions is believed to involve induction of an inflammatory reaction that results in pleurodesis, thereby obliterating the pleural space and reducing the chance of pleural fluid reaccumulation.1, 2, 18, 19, 20
The extent of systemic absorption of talc following intrapleural administration has not been fully elucidated.1, 2 Systemic exposure to talc may be affected by the integrity of the pleural surface and, therefore, may be increased if the drug is administered immediately following lung resection or biopsy.1, 2
Importance of describing the intrapleural procedure to patients prior to administration of talc.1, 2
Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs, and any concomitant illnesses.1, 2
Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.1, 2
Importance of informing patients of other important precautionary information.1, 2 (See Cautions.)
Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.
Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.
1. Bryan Corporation. Sterile talc powder for intrapleural administration only prescribing information. Woburn, MA; 2003 Sep.
2. Bryan Corporation. Sclerosol® intrapleural aerosol (sterile talc powder) prescribing information. Woburn, MA; 2012 Oct.
3. American Thoracic Society. Management of malignant pleural effusions. Am J Respir Crit Care Med . 2000; 162:1987-2001. [PubMed 11069845]
4. Sorensen PG, Svendsen TL, Enk B. Treatment of malignant pleural effusion with drainage, with and without instillation of talc. Eur J Respir Dis . 1984; 65:131-5. [PubMed 6365578]
5. Aelony Y, King R, Boutin C. Thoracoscopic talc poudrage pleurodesis for chronic recurrent pleural effusions. Ann Intern Med . 1991; 115:778-82. [PubMed 1929026]
6. Hamed H, Fentiman IS, Chaudary MA et al. Comparison of intracavitary bleomycin and talc for control of pleural effusions secondary to carcinoma of the breast. Br J Surg . 1989; 76:1266-7. [PubMed 2481558]
7. Ong KC, Indumathi V, Raghuram J et.al. A comparative study of pleurodesis using talc slurry and bleomycin in the management of malignant pleural effusions. Respirology . 2000; 5:99-103. [PubMed 10894097]
8. Zimmer PW, Hill M, Casey K et al. Prospective randomized trial of talc slurry vs bleomycin in pleurodesis for symptomatic malignant pleural effusions. Chest . 1997; 112:430-4. [PubMed 9266880]
9. Noppen M, Degreve J, Mignolet M et al. A prospective, randomised study comparing the efficacy of talc slurry and bleomycin in the treatment of malignant pleural effusions. Acta Clin Belg . 1997; 52:258-62. [PubMed 9489119]
10. Fentiman IS, Rubens RD, Hayward JL. A comparison of intracavitary talc and tetracycline for the control of pleural effusions secondary to breast cancer. Eur J Cancer Clin Oncol . 1986; 22:1079-81. [PubMed 3536525]
11. Fentiman IS, Rubens RD, Hayward JL. Control of pleural effusions in patients with breast cancer. A randomized trial. Cancer . 1983; 52:737-9. [PubMed 6190551]
12. Kuzdzal J, Sladek K, Wasowski D et al. Talc powder vs doxycycline in the control of malignant pleural effusion: a prospective, randomized trial. Med Sci Monit . 2003; 9:PI72-9. [PubMed 12824959]
13. Yim AP, Chan AT, Lee TW et al. Thoracoscopic talc insufflation versus talc slurry for symptomatic malignant pleural effusion. Ann Thorac Surg . 1996; 62:1655-8. [PubMed 8957368]
14. Walker-Renard PB, Vaughan LM, Sahn SA. Chemical pleurodesis for malignant pleural effusions. Ann Intern Med . 1994; 120:56-64. [PubMed 8250457]
15. Noppen M, Degreve J, Mignolet M et al. A prospective, randomised study comparing the efficacy of talc slurry and bleomycin in the treatment of malignant pleural effusions. Acta Clin Belg . 1997; 52:258-62. [PubMed 9489119]
16. Zimmer PW, Hill M, Casey K et al. Prospective randomized trial of talc slurry vs bleomycin in pleurodesis for symptomatic malignant pleural effusions. Chest . 1997; 112:430-4. [PubMed 9266880]
17. Hamed H, Fentiman IS, Chaudary MA et al. Comparison of intracavitary bleomycin and talc for control of pleural effusions secondary to carcinoma of the breast. Br J Surg . 1989; 76:1266-7. [PubMed 2481558]
18. Ruckdeschel JC. Management of malignant pleural effusion: an overview. Semin Oncol . 1988; 15(Suppl 3):24-8. [PubMed 3293215]
19. Andrews CO, Gora ML. Pleural effusions: pathophysiology and management. Ann Pharmacother . 1994; 28:894-903. [PubMed 7524816]
20. Hausheer FH, Yarbro JW. Diagnosis and treatment of malignant pleural effusion. Semin Oncol . 1985; 12:54-75. [PubMed 2579439]