Thorax (1969), 28, 788.

Chest wall tumour following iodized talc pleurodesisJOHN W. JACKSON and M. H. BENNETT

Thoracic Surgical Unit, Harefield Hospital, Harefield, Middlesexand Group Histopathology Department, Mount Vernon Hospital, Northwood, Middlesex

Jackson, J. W., and Bennett, M. H. (1973). Thorax, 28, 788-793. Chest wall tumour followingiodized talc pleurodesis. A man of 37 had an iodized talc pleurodesis carried out for recurrentspontaneous pneumothorax. There was no history of industrial exposure to asbestos. Twoyears latei he presented with pain in the right chest and radiographs at that time showedsome localized pleural thickening at the site of the thoracoscopy cannulation for introductionof talc.A provisional diagnosis of talc granuloma, chemical abscess or tumour was made and

exploratory thoracotomy revealed a tumour involving the chest wall, lung, and pleurawhich, on histological examination, showed adenocarcinoma of varying degrees of differen-tiation and in some parts also presenting a more squamoid appearance. Numerous doublyrefractile talc particles were intimately associated with the tumour and fibrous tissue. Shortlyafter excision the patient developed evidence of systemic dissemination of the disease anddied four months later. The possibility of this tumour being induced by the talc is discussed.A brief review is made of the various forms of talc used in surgery over the past 40 years

and attention is drawn to the significance of the proportion of asbestos mineral which ispresent in talc as mined in various parts of the world.We do not consider that this is a case of mesothelioma of the pleura.

For over 30 years iodized talc pleurodesis hasbeen a well tried and almost universally acceptedmethod of treating recurrent spontaneous pneumo-thorax. Gowar (1941), in searching for a materialto produce pleural symphysis, concluded that talcwas superior to all the other substances he hadinvestigated. The powder is most convenientlyintroduced using an insufflator and thoracoscope,a relatively minor procedure which may becarried out under local anaesthesia with a littlesedation: but, as the initial reaction may beextremely painful, general anaesthesia is to bepreferred.

After insertion of the thoracoscope and inspec-tion of the lung for cysts or bullae the visceraland parietal layers of the pleura are coated witha thin layer of talc. An intercostal tube is insertedand connected to an underwater seal to whichsuction may be applied. The tube is removedafter chest films have shown the lung to besatisfactorily expanded and bubbling has ceasedfor 24 hours.The failure rate following this method has been

extremely low. Two cases in a hundred required

Requests for reprints: J. W. Jackson, F.R.C.S., Thoracic SurgicalUnit, Harefield Hospital, Harefield, Middx

another poudrage because the lung had notbecome adherent. Both developed their recurrenceof pneumothorax before leaving hospital. Noneof the other cases required further attention tothe side treated. In a few patients the degrce ofpleural thickening was more than had beenexpected.

CASE REPORT

Mr. A. A. aged 37, a litho camera operator withthe Stationery Office, was admitted to hospital witha right-sided spontaneous pneumothorax in May1968. It resolved without treatment but recurredearly in July when iodized talc pleurodesis wasadvised and carried out. An apical intercostal tubewas inserted and 10 g of 1,/ iodized talc wasinsufflated through a separate cannula inserted fromthe right axilla. The lung expanded completelywithout air leak and the tube was removed afterfour days. The chest film was satisfactory in Sep-tember. He attended in January and September 1970because of chest pain 'localized to near the thoraco-scopy incision' and was given an intercostal blockwith no relief. Because his pain was so persistentand getting worse in spite of treatment he wasreadmitted to hospital in November 1970. He wasthin, drawn looking, and obviously in pain and

788

Chest wall tumour following iodized talc pleurodesis

(a)

FIG. 1. (a) PA chest radiograph; (b) IIcm.tomogram (AP projection) showing peripher-allesion in right upper zone.

(b)

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John W. Jackson and M. H. Bennett

movements of the right chest were considerablyrestricted. There was no inflammation in relationto the previous scars. He had pain and tendernessalong the right fourth intercostal space. He wasafebrile with a normal white cell count and asedimentation rate of 13. A chest film (Fig. la)showed an ill-defined triangular shadow at theperiphery of the right mid zone. Tomograms (Fig. lb)suggested a thickened pleura in this region andpossibly some rib erosion. A provisional diagnosisof talc granuloma, sterile chemical abscess or tumourwas made. In view of his persistent and increasingpain exploratory thoracotomy was advised.

At operation an apparent inflammatory reactionbetween the fourth and fifth ribs, suggesting anunderlying tumour or abscess, was found. Aspirationrevealed no pus. The chest was opened along theupper border of the sixth rib. The pleura wasadherent with plaques resembling iodized talc andwhat was described as a mild granulomatousreaction. The lung separated fairly easily from thechest wall except in relation to the main lesion whichlooked and felt more like tumour than abscess andappeared to be infiltrating lung. Frozen sectionsuggested a poorly differentiated squamous-cellcarcinoma. Excision of the chest wall with portionsof the fourth, fifth, and sixth ribs and a segment ofunderlying lung was carried out. The wound wasclosed with an underwater seal drain.

Histological examination of the resected specimenshowed carcinoma, predominantly clear-celled adeno-carcinoma, partly undifferentiated, with some areasof well-marked glandular and tubular differentiation(Fig. 2) and a few solid darkly staining foci ofmore squamoid appearance. The tumour appearedto have arisen in a portion of adherent lungassociated with an area of old fibrous scarring andextended through the chest wall tissues to theresection limits.At the margins of the tumour mass the pleura

showed a mild granulomatous reaction and numerousdoubly refractile talc particles which continued ina band of dense fibrous tissue running across thetumour corresponding to the plane of the invadedpleura. Talc particles also extended from this regioninto the scar tissue associated with the intrapulmonarypart of the tumour (Fig. 3).As the tumour reached to the inner and outer

limits of excision it was planned to give the patienta radical course of radiotherapy to the whole opera-tion area. Three weeks after operation a firm discretenodule was found in the anterior abdominal wall.It was removed and on section showed similarpoorly differentiated carcinoma. Further active treat-ment was deferred.He went home for a short while but was re-

admitted with severe pain and radiological evidenceof further tumour in the chest wall. This increased

FIG. 2. Photomicrograph of tumour showing a clear-celled adenocarcinoma with areasofglandular differentiation. H and E x 25.

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Chest wall tumour following iodized talc pleurodesis

(a)

(b)

FIG. 3 (a). Photomicrograph of undifferentiated carcinoma in scar tissue in lung.Hand E x50.(b) The samefield as in (a) photographed through polarizingfilters to show incorporateddoubly refractile talc particles.

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John W. Jackson and M. H. Bennett

V-

FIG. 4. Chest radiograph taken shortly before death showing the extentof recurrence of tumour.

in size rapidly (Fig. 4) until he died four monthsafter operation. No other clinical metastasesdeveloped.Necropsy showed a lobulated necrotic tumour.

involving the anterolateral chest wall and the under-lying lung with secondary deposits in the suprarenalglands.

DISCUSSION

To many surgeons 'talc' and 'glove powder' aresynonymous. Various substances have been usedand none has been entirely free from trouble.Antopol (1933) described peritoneal reaction tothe preparation that was being used as glovepowder up to that time. Lycopodium, a yellowtasteless and odourless dusting powder, had beenused for years in the pharmacy to prevent theagglutination of pills in a box. It is a vegetablesulphur derived from the spores of the clubmoss Lycopodium clavatum (wolf's foot). Its use

as a glove powder was abandoned in favour ofmineral talc which consists of:

Magnesium silicate 82-7%Calcium carbonate 8-7%Magnesium carbonate 766%

It is this preparation, to which iodine ({-1 %)is added, that has been used for pleurodesis.German (1943) described granuloma formation

from this form of talc and emphasized itsdangers. There were a number of similar articlespublished at that time.The modern Bisorb powder, introduced in

1947, is a mixture of amylose and amylopectins,derived from corn-starch and magnesium oxide.It was said to produce little foreign body reactionbecause, as its name indicates, the starchderivatives are in such a form that they arereadily absorbed. Neeley and Davies (1971) haveshown that it is not as harmless as expected andthey describe a granulomatous peritoneal reactionwhich develops within a few weeks of surgery.

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Chest wall tumour following iodized talc pleurodesis

It appears that this product does not have thelong-term problems of the earlier preparations.An increasing awareness of the problems of

asbestosis and its association with pleural meso-thelioma made us wonder if the chemical irritationcaused by the talc and iodine might induce apleural tumour. Such a probability was postulatedby Hinson at a meeting in 1966 and in the dis-cussion that followed Dr. P. J. Lawther reportedthat in the United States many toilet preparationsof talc contained chrysotile which had not beendeliberately added but occurred naturally in themineral deposit. Merliss (1971) likewise reportsthat very few mineral talcs are free of asbestosfibres. Talcs from Vermont mines are relativelypure but those from New York and Californiaare heavily contaminated.

Miller et al. (1971) drew attention to the signifi-cance of sublight microscopic mineral particlesin talc and described varying amounts of asbestosmineral, notably anthophyllite (Mg7 (Si8 O)(OH)2) and tremolite (Ca2, Mg5 (Si8 022 (OH)),that may be associated with the natural product.They describe talc pneumoconiosis in a man of70 who spent nine years cleaning ventilators ina factory using talc. The lungs showed fibrosisand granulomata with lymphocytes and epithelioidand giant cells.Hopkins and Taylor (1970) described two cases

of pulmonary talc granulomatosis associated withthe illicit use of methylphenidate hydrochloride(Ritalin). This drug is a mild stimulant and anti-depressant similar to the amphetamines, normallytaken by mouth but administered intravenouslyby addicts. Talc is used as a filler in the tabletform of the drug, and when introduced into thecirculation causes a granulomatous reaction inthe pulmonary vessels leading to intravascularthrombosis and pulmonary hypertension. One ofthe cases they describe also had a 'coin' lesionin the left upper lobe which turned out to bean undifferentiated malignant neoplasm with a

large area of central necrosis. The remainder ofthe lung showed a granulomatous reaction andbirefringent crystalline material with the typicalappearances of talc.We feel that our case was a 'scar carcinoma'

which became manifest after iodized talcpleurodesis. The tumour had apparently developedin close relation to the site of axillary cannulation.

Talc particles had become incorporated notonly in the invaded scarred pleura but also inthe scar tissue in the intrapulmonary part of thetumour. It seems unlikely that the talc played acausative role in the formation of the tumour butthere can be little doubt that the pleurodesisfacilitated the early spread of tumour to the chestwall along the cannula track.

It is possible that the tumour in Hopkins andTaylor's (1970) patient was provoked by a similarmechanism.

REFERENCESAntopol, W. (1933). Lycopodium granuloma. Archives of

Pathology, 16, 326.German, W. M. (1943). Dusting powder granulomas fol-

lowing surgery. Surgery Gynecology and Obstetrics, 76,501.

Gowar, F. J. S. (1941). The post-operative complications ofpulmonary lobectomy. British Journal of Surgery, 29, 3.

Hinson, K. F. W. (1966). Asbestosis and neoplasia. InSome Aspects of Carcinoma of the Bronchus and OtherMalignant Diseases of the Lung: A Symposium held atKing Edward VII Hospital, Midhurst, 4-5 July 1966,p. 19, edited by D. Teare and J. Fenning.

Hopkins, G. B. and Taylor, G. D. (1970). Pulmonary talcgranulomatosis. A complication of drug abuse. AmericanReview of Respiratory Diseases, 101, 101.

Merliss, R. R. (1971). Talc treated rice and Japanese stomachcancer. Science, 173, 1141.

Miller, A., Teirstein, A. S., Bader, M. E., Bader, R. A., andSelikoff, I. J. (1971). Talc pneumoconiosis: Significanceof sublight microscopic mineral particles. AmericanJournal of Medicine, 50, 395.

Neeley, J., and Davies, J. D. (1971). Starch granulomatosisof the peritoneum. British Medical Journal, 3, 625.

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