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An inflammatory reaction induced by the subcutaneous injection of talc embedded in a gel calcium phosphate increased resistance of mice challenged intravenously with Candida albicans. The relationship between the absolute number of polymorphonuclear phagocytes in the blood and this protective effect seems to indicate a major role of polymorphonuclear leukocytes following inflammation.
From May 1983 to June 1985 the authors performed a thoracoscopy as a diagnostic and therapeutic objective in 83 patients with chronic recurrent pleurisy; amongst these patients, 69 had know intra or extra thoracic cancer and the other 14 presented with an isolated pleurisy. Eight other patients had pleural carcinomatosis proven by needle biopsy and had pleural talc introduced by thoracoscopy. The examination was performed under local anaesthesia with neuroleptanalgesia; a rigid 7 mm diameter thoracoscope was used; the biopsies were performed uniquely on the parietal pleura using tropical forceps. The outcome was uncomplicated with no deaths nor any serious complications due to the method. The sensitivity of the pleural biopsy was 91.5% or 76 positive biopsies out of 83. 73 biopsies were metastatic and 3 were tuberculous pleurisies. The macroscopic appearance was strongly suggestive of malignancy in 78 patients and appeared inflammatory in 13, of whom 9 cases were positive on biopsy. The authors performed a pleural talcage in every case; a lasting pleural adhesion was obtained in 66 patients but regrettably there were 14 failures, the effusion recurring after removal of the drain. The authors stress the reduced number of incidents of pleural effusion, which confirms the good tolerance of pleural endoscopy.
We report a case of fatal fibrosing peritonitis in a 28-year-old drug abuser. The extensive fibrosis, which was limited to the abdominal cavity, contained birefringent material. Silica was identified by spectrophotometric analysis. Silica is a component of talc (magnesium silicate) used as a drug filler. Relatively small amounts are known to induce fibrosis. The manner of introduction of this material into the peritoneal cavity is hypothetical and includes accidental direct peritoneal contamination during subcutaneous injections, a method used by drug abusers.
Fibers having a diverse range of physical and chemical properties may be emitted into the atmospheric air mostly as a result of human activities. Because the inhalation by man of certain particles may under some circumstances pose a risk to health, this group of particulate matter has to be measured and identified. Because there is little information about the biological (predominantly carcinogenic) potential as yet, measuring techniques are non uniform as well. In this study, the fiber content of human lungdust specimens has been determined electronmicroscopically for 4 different groups: so called normal lungs (as a control), mesothelioma cases, which may have been spontaneous, or initiated by occupational exposure, fibrosis cases (without any lung tumour) after occupational exposure in coal- and talc-mines. In comparison to the mentioned groups some samples from the atmospheric air in the Ruhr District were analyzed for fibers with the aim of obtaining more information about the shape, length and diameter of this particle group. The data indicated that the size distribution of fibrous particles may be highly different depending upon the previous exposure. Furthermore, elongated particles with irregular shapes may confuse the counting and sizing results (preferentially those of the diameters). Based on the present study, fibrous particles greater than 1 micron in length with a length-to-breadth ratio greater than 10: 1 seem to be of increased biological relevance, if mesothelial risk is the main focus of the investigation.
The multiplication of Listeria monocytogenes in the spleen was decreased between the 3rd and the 11th day following the inflammatory reaction induced in Mice by subcutaneous implantation of talc embedded in a calcium phosphate gel into the dorsal area. A similar activity was observed after injection of SO4 (NH4)2 fractionated extracts from granuloma. The major activities were found in the 33% saturation precipitate and in the 80% saturation supernatant.
Thoracoscopy with a single opening was carried out under general anesthesia with a cold light thoracoscope of 7 mm in diameter. Biopsies were taken under visual control for optical and electron microscopic examination. In a series of 40 mesotheliomas, 30 patients with pleural effusion underwent 36 thoracoscopies. In 29 patients the macroscopic lesions were compatible with the diagnosis of mesothelioma. The most specific aspects consisted in white-yellowish nodules, almost translucent, arising from the parietal pleura (9 patients). Another typical pattern, a dense pleural thickening, was found in 10 patients. In the remaining patients, the lesions observed were less specific. The biopsy was positive in 35/36 thoracoscopies (97%). A talc poudrage was carried out in 10 patients: their mean survival was 458 days. In ten matched mesothelioma patients who underwent pleurectomy the mean survival was only 395 days. In 12 patients at an early stage, the visceral pleura was not involved by the tumor: their mean survival was 636 days. In 11 patients both parietal and visceral pleura were involved by the tumor: their mean survival was 138 days: (p less than 0,001). It is concluded that in mesothelioma pleural effusions, thoracoscopy is a safe and efficient procedure in order to reach a precise diagnosis, prognosis and efficient palliative treatment of the effusion.
Analyses of asbestos bodies from the general population have confirmed that these structures, like asbestos bodies from the lungs of asbestos workers, contain an asbestos core. In members of the general population this core is almost always an amphibole, whereas asbestos workers may have bodies formed on either amphibole or chrysotile. Most adults have a few bodies, and increasing numbers are seen in blue collar workers and others who handle small amounts of the fiber, with the highest levels being seen in asbestos workers. In men with minimal or extensive occupational exposure, asbestos bodies are formed on the commercial fibers, amosite and crocidolite, whereas women also form a significant number of bodies on the noncommercial fibers, anthophyllite and tremolite. These findings suggest that women may be exposed to specific asbestos-containing products, eg, cosmetic talc. The commercial fibers found in women and white collar men probably reflect atmospheric pollution with asbestos. At the highest levels of exposure, numbers of asbestos bodies correlate in a general way with the presence of asbestosis, although no precise value has been determined above which asbestosis is always found. In persons with much lower or environmental exposure, there does not appear to be any correlation between numbers of bodies and disease, in particular between numbers of bodies and carcinoma of the lung or gastrointestinal tract. The situation for mesothelioma is uncertain.
Cyclophosphamide (CY) increased whereas the talc embedded in a calcium phosphate gel (TCP) decreased the susceptibility of mice to systemic candidiasis estimated by measuring mean survival time and "renal infectivity" 12 h after challenge. Transfers of plasma from CY- and TCP-treated mice did not modify cnadidiasis susceptibility of recipient mice. Granulopenia and granulocytosis induced respectively by CY and TCP were significantly correlated with susceptibility or resistance to candidiasis. Nevertheless, TCP produced significant reticuloendothelial stimulation which could be also correlated with TCP protection. Reticuloendothelial stimulation with associated granulopenia in TCP-CY-treated mice gave protection against Listeria monocytogenes challenge but not against Candida albicans. Thus, blood polymorphonuclear leukocytes seem to play the main role in natural resistance of mice to candidiasis. This was corroborated after injection of immunostimulants; a good correlation was found between C. albicans resistance and the induced granulocytosis.
A patient had extensive foreign-body granulomatous inflammation of multiple skin sites and of the inguinal lymph nodes with splenomegaly, cutaneous anergy to common skin antigens, and peripheral blood eosinophilia. The patient had an elevated serum angiotensin-converting enzyme level. Histologically, the granulomas were of the foreign-body type with lymphocytes, histiocytes, eosinophils, and giant cells, some that contained doubly refractile crystalline material. Electron-probe x-ray microanalysis identified silicon, magnesium, iron, calcium, phosphorus, zinc, titanium, and chromium in the crystalline material. These findings suggest talc, cement, and inorganic pigment as possible sources of the crystals. This case is reported for its unusual clinical, laboratory, and morphologic features.
A 50-year-old man, a "mainline" heroin abuser for 25 years, with a five-year history of x-ray findings compatible with asbestosis is presented. Multiple open biopsies failed to prove a diagnosis of asbestosis. The microscopic analyses of tissues revealed the presence of granulomatosis, secondary to talc from chronic intravenous heroin abuse. The need for open lung biopsy in establishing a diagnosis is emphasized, as x-ray findings can be and often are misleading. A tissue diagnosis is necessary, particularly in cases in which drug abuse is suspected.
The methods used to induce pleural symphisis in recidivant malignant pleural effusions are reviewed. The most suitable for an average hospital are the intrapleural introduction of talc and tetracycline clorhydrate, of which the procedures are described.
The problems encountered in diagnosing the rare types of pneumoconiosis ( silicatosis other than asbestosis, aluminosis and hard metals fibrosis), result from the difficulties in realising a good occupational anamnese and from the disease pattern by itself. The classical examinations, (X-rays of the thorax and lung function measurements), are not able to detect the cause of these diseases, which are fundamentally characterised by an absence of specificity. These last years, new methods of diagnoses (angiotensin converting enzyme, gallium scan, transbronchial biopsies, mineralogical, cytological and histological examinations of the lung tissues and of the bronchial alveolar lavage) were developed and progressively introduced in the daily practice in pneumology. Only the examination of lung biopsies and of the products of bronchial alveolar lavage, in particular the mineralogical examinations, may usefully orientate the diagnosis. The bronchial alveolar lavage has the advantage of an easy repetition and of a small invasive character. Moreover this technique is of a rather low financial cost. However the results of these examinations must be interpreted with the greatest caution, in function of the complete medical and occupational data. The experience following more than 500 BAL shows that the discovery of talc and kaolin is very significant for an exposition since these minerals were never observed among not exposed subjects. The evidence of these minerals argues also for the diagnosis of talcosis or kaolinosis if there are radiological lesions that are compatible with these diseases. On the other hand a recent study suggests that the identification of multinuclear macrophages and of tungsten and/of tantalum in the bronchial alveolar lavage is pathognomonic of the pathology of the hard metals.
The insufflation of iodinised (1%) sterile talc in patients with spontaneous pneumothorax is presented as a safe and valuable method of treatment. A recidive pneumothorax occurs in 6.6% of the patients. This form of treatment should only be used in the forms of pneumothorax without bullous degeneration, which should be treated surgically. Pleural talcage can be performed under local anesthesia, without harmful repercussion on the patient or on the VC, FEV1, and diffusion capacity. In our experience, thoracoscopy provides the inestimable and necessary information for choosing the best way of treatment in patients with a spontaneous pneumothorax.
The immediate effects and long-term results are reported of thoracoscopic pleurodesis in 225 patients (158 men, 67 women) treated for persistent or recurrent spontaneous pneumothorax. The procedure was performed by combined local and neurolept analgesia with direct visual exploration of the pleural space through a rigid thoracoscope. The technique included electrocoagulation of small pleural blebs, followed by regional application of fibrin and insufflation of talc powder. The main indications were a first event which persisted more than 7 days despite chest-tube suction drainage in 27% (n = 61) or a recurrent event in 73% (n = 164). The procedure provided primary success in 96.4% of the patients. Only 8 patients (3.6%) required surgical intervention including parietal pleurectomy. Perioperative complications were pharmacologically induced respiratory failure (n = 5), generalized subcutaneous emphysema (n = 8), bleeding by cutting adhesions (n = 5) and Horner's syndrome (n = 2). However, no fatal complications occurred which could be ascribed to the procedure and all patients were discharged from the hospital after an average of 12.3 days except one who died of pulmonary embolism 5 days after thoracoscopy. Long-term follow-up over a mean period of 4.1 years revealed an ipsilateral recurrence rate of 10.2% (n = 24), 16% of the patients complained of sporadic pains at the site of insertion, 51% still had diffuse thoracic pains and 2.4% reported occasional attacks of dyspnea. Spirometric lung function tests showed normal values in 89%. The immediate and longterm results show thoracoscopic pleurodesis with fibrin and talcum to be a safe and effective method for treatment of patients with persistent or recurrent pneumothorax.
The authors report about one case of respiratory distress occurring after pleural talcage for pneumothorax. Although few cases have been published, this complication is known, and it should lead to carefully consider the indication of this technique and to limit the total amount of talc used.
Thoracoscopy has been around for decades, advocated by some, but until recently, ignored by many. Not surprisingly, its diagnostic and therapeutic efficacy in patients with suspected or proven malignant pleural effusions has withstood the test of time. Today, the potential benefits of thoracoscopy must be weighed against its cost in patients with limited life expectancy. Although diagnostic thoracoscopy requires only overnight hospitalization, pleurodesis imposes a longer hospital stay. The discomfort of an indwelling chest tube, the need for hospitalization, and the financial burden of thoracoscopic procedures compared with less-invasive means of pleural investigation and pleurodesis must be taken into account on an individual basis. Thoracoscopy should not be performed for the sake of intervention. Its indications and all diagnostic or therapeutic alternatives should always be carefully examined. Its role, however, in the diagnosis and treatment of patients with malignant pleural effusions is undeniable. The diagnostic accuracy of thoracoscopic pleural biopsy is excellent. Several studies demonstrate that thoracoscopic talc pleurodesis is more frequently successful than other methods of pleurodesis. As a staging procedure, thoracoscopy helps determine extent of disease, and possibly, prognosis in patients with metastatic pleural carcinomatosis, lung cancer, and malignant mesothelioma. As this procedure is increasingly rediscovered by our medical and surgical communities, greater clinical and experimental investigation aimed at establishing successful management strategies in patients with malignant pleural effusions will hopefully occur.
To assess the value of thoracoscopy in spontaneous pneumothorax, the procedure and results of thoracoscopy by using fiberoptic bronchoscope and rigid cold-light thoracoscope in 50 patients with persistent or recurrent pneumothorax were reported. We found subpleural blebs or bullae in 35 cases and adhesions preventing lung expansion in 10 cases. The histologic diagnosis following thoracoscopic biopsy in 13 patients showed non-specific inflammation in 12 cases and tuberculosis in one case. The overall diagnostic rate was 92% (46/50). 5 cases were cured with transendoscopical Nd-YAG laser cauterisation of the blebs or bullae not exceeding 1 cm in diameter. There were no side effects after the procedure, and no recurrence was observed in a follow-up of 24 months. 40 patients were treated with intrapleural talcum power under thoracoscopic control. The postoperative complications were transient fever and chest pain and recurrence was observed in two cases only (5%) during 2-7 years of follow-up. It is concluded that thoracoscopy enables accurate assessment of the causes of pneumothorax, talc pleurodesis is a very effective method of controlling recurrent and persistent pneumothorax, and laser therapy can play an important role in selected patients with spontaneous pneumothorax.
To assess the value of thoracoscopy in malignant pleural effusions, the procedure and results of thoracoscopy by using a fiberoptic bronchoscope and a rigid cold-light thoracoscope in 130 cases with malignant pleural effusion are reported. The overall diagnostic rate was 91.5% (119/130). The malignant pleural mesothelioma in 24 cases and metastatic cancers in 95 cases were histopathologically confirmed. Talcum powder, tetracycline and Corynebacterium parvum were separately sprayed through thoracoscope into pleural cavity in 69, 10 and 10 patients, and the success rates of complete and lasting pleurodesis were 87.0%, 5/10 and 8/10 respectively. Postoperative complications included transient fever and chest pain, local subcutaneous emphysema in 6 cases and tumor seeding at thoracoscopy site in 4 cases. It is concluded that thoracoscopy is simple, safe, reliable and of high practical value in the diagnosis of malignant pleural effusions and in assessment before exploratory thoracotomy, and that transendoscopical administration of drugs for pleurodesis is a very effective method for controlling malignant pleural effusions. The efficacy of the talc poudrage is better than tetracycline and Corynebacterium parvum.