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Metintas M, Ak G, Yildirim H, Dundar E, Aydin N, Erginel S, Alatas F, Yilmaz S, Metintas S. Image-Assısted Pleural Needle Biopsy or Medical Thoracoscopy: Which Method for Which Patient? A Randomızed Controlled Trial. Chest 2024; 166:405-412. [PMID: 38554817 DOI: 10.1016/j.chest.2024.03.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 03/22/2024] [Accepted: 03/23/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND Image-guided or assisted needle biopsies and the increasing use of medical thoracoscopy (MT) have increased the diagnostic accuracy of pleural diseases significantly. However, no consensus exists regarding which patients with pleural effusion should undergo MT and which patients should undergo image-guided or assisted needle biopsy as the first procedure to ensure greater diagnostic accuracy. RESEARCH QUESTION Which biopsy method is more appropriate for which patient to provide the highest diagnostic accuracy in the diagnosis of pleural effusion? STUDY DESIGN AND METHODS This prospective, randomized, parallel study included 228 patients with undiagnosed exudative pleural effusion. Patients were divided into two groups based on CT scan findings. Group 1 included patients with pleural effusion only. Group 2 included patients with pleural thickening or lesion in addition to pleural effusion. Patients in each group were assigned randomly to an image-assisted Abrams needle pleural biopsy (IA-ANPB) or MT arm. The diagnostic sensitivity, reliability, and safety were determined for both groups. RESULTS The false-negative rate was 30.3% for the IA-ANPB arm and 3.1% for the MT arm in group 1. The same rates were 11.9% for IA-ANPB and 4.7% for MT in group 2. In group 1, the sensitivity for the IA-ANPB arm was 69.7%, and the negative likelihood ratio was 0.30. The same rates for the MT arm were 96.9% and 0.03 (P = .009). In group 2, these values were 88.1% and 0.12 for the IA-ANPB arm and 95.4% and 0.05 for the MT arm (P = .207). The rate of complications between the two biopsy methods was not different (8.5% and 15.8%, respectively; P = .107). INTERPRETATION MT showed a high diagnostic success in all patients with pleural fluid. However, IA-ANPB showed similar diagnostic success as MT in patients with pleural effusion and associated pleural thickening or lesions. Therefore, in the latter case, IA-ANPB could be preferable to MT. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT05428891; URL: www. CLINICALTRIALS gov.
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Affiliation(s)
- Muzaffer Metintas
- Department of Chest Diseases, Eskisehir Osmangazi University Medical Faculty, Eskisehir, Turkey; Lung and Pleural Cancers Clinical and Research Center, Eskisehir Osmangazi University, Eskisehir, Turkey.
| | - Guntulu Ak
- Department of Chest Diseases, Eskisehir Osmangazi University Medical Faculty, Eskisehir, Turkey; Lung and Pleural Cancers Clinical and Research Center, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Huseyin Yildirim
- Department of Chest Diseases, Eskisehir Osmangazi University Medical Faculty, Eskisehir, Turkey
| | - Emine Dundar
- Department of Pathology, Eskisehir Osmangazi University Medical Faculty, Eskisehir, Turkey
| | - Nevin Aydin
- Department of Radiology, Eskisehir Osmangazi University Medical Faculty, Eskisehir, Turkey
| | - Sinan Erginel
- Department of Chest Diseases, Eskisehir Osmangazi University Medical Faculty, Eskisehir, Turkey
| | - Fusun Alatas
- Department of Chest Diseases, Eskisehir Osmangazi University Medical Faculty, Eskisehir, Turkey
| | - Senay Yilmaz
- Department of Chest Diseases, Eskisehir Osmangazi University Medical Faculty, Eskisehir, Turkey
| | - Selma Metintas
- Department of Public Health, Eskisehir Osmangazi University Medical Faculty, Eskisehir, Turkey
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Liang SH, Li C, Xie S. The diagnostic value of pleural effusion/serum ratio of carcinoembryonic antigen and pleural effusion/serum ratio of interferon-γ in classification of pleural effusion. Lab Med 2024:lmae050. [PMID: 39005192 DOI: 10.1093/labmed/lmae050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/16/2024] Open
Abstract
BACKGROUND Distinguishing between different types of pleural effusions (PEs) is crucial for clinical diagnosis and treatment. This study evaluates the diagnostic value of carcinoembryonic antigen (CEA) and interferon-gamma (IFN-γ) levels in PE and serum, as well as the PE/serum ratios of these markers, in classifying PE. METHODS We retrospectively analyzed 99 patients with PE, categorizing them into malignant pleural effusion (MPE), tuberculous pleural effusion (TPE), and benign PE groups. Levels of CEA and IFN-γ in PE and serum were quantified and their ratios were calculated. Diagnostic performance was assessed using receiver operating characteristic analysis, focusing on the area under the curve (AUC) to determine the efficacy of these biomarkers. RESULTS Significantly elevated levels of CEA in PE and serum were observed in the MPE group compared to the benign and TPE groups, with the PE/serum CEA ratio offering substantial diagnostic value (AUCs: PE = 0.843, serum = 0.744). Conversely, IFN-γ levels in PE and serum were markedly higher in the TPE group, demonstrating notable diagnostic accuracy (AUCs: PE = 0.970, serum = 0.917). CONCLUSION Both CEA and IFN-γ demonstrate high clinical utility in differentiating between MPE and TPE. The PE/serum ratio of these biomarkers enhances diagnostic accuracy, potentially facilitating earlier and more accurate therapeutic interventions.
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Affiliation(s)
- Shu-Hui Liang
- Clinical Laboratory, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Cui Li
- Clinical Laboratory, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Si Xie
- Clinical Laboratory, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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Yan Z, Wen JX, Niu Y, Jiang TW, Huang JH, Chen H, Chen Q, Wang YF, Yan L, Hu ZD, Zheng WQ. Diagnostic accuracy and cellular origin of pleural fluid CXCR3 ligands for tuberculous pleural effusion. Cytokine 2024; 179:156618. [PMID: 38663252 DOI: 10.1016/j.cyto.2024.156618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 04/06/2024] [Accepted: 04/12/2024] [Indexed: 05/21/2024]
Abstract
BACKGROUND Pleural biomarkers represent potential diagnostic tools for tuberculous pleural effusion (TPE) due to their advantages of low cost, short turnaround time, and less invasiveness. This study evaluated the diagnostic accuracy of two CXCR3 ligands, C-X-C motif chemokine ligand 9 (CXCL9) and CXCL11, for TPE. In addition, we investigated the cellular origins and biological roles of CXCL9 and CXCL11 in the development of TPE. METHODS This double-blind study prospectively enrolled patients with undiagnosed pleural effusion from two centers (Hohhot and Changshu) in China. Pleural fluid on admission was obtained and levels of CXCL9 and CXCL11 were measured by an enzyme-linked immunosorbent assay (ELISA). The receiver operating characteristic (ROC) curve and the decision curve analysis (DCA) were used to evaluate their diagnostic accuracy and net benefit, respectively. THP-1 cell-derived macrophages were treated with Bacillus Calmette-Guérin (BCG), and quantitative real-time PCR (qRT-PCR) and ELISA were used to determine the mRNA and protein levels of CXCL9 and CXCL11. The chemoattractant activities of CXCL9 and CXCL11 for T helper (Th) cells were analyzed by a transwell assay. RESULTS One hundred and fifty-three (20 TPEs and 133 non-TPEs) patients were enrolled in the Hohhot Center, and 58 (13 TPEs and 45 non-TPEs) were enrolled in the Changshu Center. In both centers, we observed increased CXCL9 and CXCL11 in TPE patients. The areas under the ROC curves (AUCs) of pleural CXCL9 and CXCL11 in the Hohhot Center were 0.70 (95 % CI: 0.55-0.85) and 0.68 (95 % CI: 0.52-0.84), respectively. In the Changshu Center, the AUCs of CXCL9 and CXCL11 were 0.96 (95 % CI: 0.92-1.00) and 0.97 (95 % CI: 0.94-1.00), respectively. The AUCs of CXCL9 and CXCL11 decreased with the advancement of age. The decision curves of CXCL9 and CXCL11 showed net benefits in both centers. CXCL9 and CXCL11 were upregulated in BCG-treated macrophages. Pleural fluid from TPE and conditioned medium from BCG-treated macrophages were chemotactic for Th cells. Anti-CXCL9 or CXCL11 neutralizing antibodies could partly block the chemotactic activity. CONCLUSIONS Pleural CXCL9 and CXCL11 are potential diagnostic markers for TPE, but their diagnostic accuracy is compromised in elderly patients. CXCL9 and CXCL11 can promote the migration of peripheral Th cells, thus representing a therapeutic target for the treatment of TPE.
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Affiliation(s)
- Zhi Yan
- Department of Laboratory Medicine, the Affiliated Hospital of Inner Mongolia Medical University, Hohhot 010050, China; School of Medical Laboratory & Department of Cell Biology, Tianjin Medical University, Tianjin 300203, China
| | - Jian-Xun Wen
- Department of Medical Experiment Center, the Basic Medical Sciences College of Inner Mongolia Medical University, Hohhot 010050, China
| | - Yan Niu
- Department of Medical Experiment Center, the Basic Medical Sciences College of Inner Mongolia Medical University, Hohhot 010050, China
| | - Ting-Wang Jiang
- Department of Key Laboratory, the Affiliated Changshu Hospital of Nantong University, Changshu 215500, China
| | - Jin-Hong Huang
- Department of Pulmonary and Critical Care Medicine, the Affiliated Changshu Hospital of Nantong University, Changshu 215500, China
| | - Hong Chen
- Department of Pulmonary and Critical Care Medicine, the Affiliated Changshu Hospital of Nantong University, Changshu 215500, China
| | - Qi Chen
- The Third Clinical Medical College of Ningxia Medical University, Yinchuan 750004, China
| | - Ya-Fei Wang
- Department of Laboratory Medicine, the Affiliated Hospital of Inner Mongolia Medical University, Hohhot 010050, China; Key Laboratory for Biomarkers, Inner Mongolia Medical University, Hohhot 010050, China
| | - Li Yan
- Key Laboratory for Biomarkers, Inner Mongolia Medical University, Hohhot 010050, China; Department of Respiratory and Critical Care Medicine, the Affiliated Hospital of Inner Mongolia Medical University, Hohhot 010050, China
| | - Zhi-De Hu
- Department of Laboratory Medicine, the Affiliated Hospital of Inner Mongolia Medical University, Hohhot 010050, China; Key Laboratory for Biomarkers, Inner Mongolia Medical University, Hohhot 010050, China
| | - Wen-Qi Zheng
- Department of Laboratory Medicine, the Affiliated Hospital of Inner Mongolia Medical University, Hohhot 010050, China; Key Laboratory for Biomarkers, Inner Mongolia Medical University, Hohhot 010050, China.
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Okorie IJ, Atere M, Fernando A, Ugwendum D, Nfonoyim J, Nfonoyim J. Re-enforcing High-Risk Acute Pericarditis Requiring Hospital Admission: An Unusual Case of Critical Idiopathic Acute Pericarditis Presenting As Tamponade and Pleuro-Pericardial Complications in a Patient Presenting With Flu-Like Symptoms. Cureus 2024; 16:e58147. [PMID: 38741856 PMCID: PMC11089582 DOI: 10.7759/cureus.58147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2024] [Indexed: 05/16/2024] Open
Abstract
Pericarditis is an inflammatory process that affects the pericardium, the fibrous sac surrounding the heart. Acute pericarditis accounts for approximately 0.1% of inpatient admissions and 5% of non-ischemic chest pain visits to the emergency departments (EDs). Most patients who present with acute pericarditis have a benign course and good prognosis. However, a rare percent of the patients develop complicated pericarditis. Examples of complications include pericardiac effusion, cardiac tamponade, constrictive pericarditis, effusive and constrictive pericarditis and, even more rarely, large pleural effusion The occurrence of complicated pericarditis can lead to high morbidity and mortality if not urgently managed in most patients. Our case presents a 60-year-old male that presented to the emergency room with flu-like symptoms. However, the viral panel test was negative. He initially got discharged with supportive care but was brought back to the ED by his wife in a critical, life-threatening state due to pericarditis symptoms complicated by tamponade and shock. His condition required urgent intervention and critical level of care. The patient's course was also complicated by myopericarditis and recurrent bilateral pleural effusions, which required therapeutic interventions. This unique case presents the patient group that develop multiple life-threatening complications of acute pericarditis, including cardiac tamponade and shock, affecting several end organs. This case also highlights clues to the predisposing factors to complications of acute pericarditis. Patients who present with high-risk signs and symptoms indicating poorer prognosis warrant further observation and admission. This will also add to the literature reviews regarding the risk factors associated with development of complicated acute pericarditis. This will also serve as a review of pathophysiology, etiology, current diagnosis and available novel treatment for such patients.
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Affiliation(s)
| | - Muhammed Atere
- Cardiology, Richmond University Medical Center, New York, USA
| | - Annmarie Fernando
- Internal Medicine, Richmond University Medical Center, New York, USA
| | - Derek Ugwendum
- Internal Medicine, Richmond University Medical Center, New York, USA
| | - Jay Nfonoyim
- Pulmonary and Critical Care, Richmond University Medical Center, New York, USA
| | - Jay Nfonoyim
- Pulmonary and Critical Care, Richmond University Medical Center, New York, USA
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Bodtger U, Porcel JM. TARGETing the utility of CT-guided pleural biopsy facilitated by PET-CT imaging. Eur Respir J 2024; 63:2400037. [PMID: 38302182 DOI: 10.1183/13993003.00037-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 01/07/2024] [Indexed: 02/03/2024]
Affiliation(s)
- Uffe Bodtger
- Respiratory Research Unit PLUZ, Department of Respiratory Medicine, Zealand University Hospital; Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - José M Porcel
- Pleural Medicine and Clinical Ultrasound Unit, Department of Internal Medicine, Arnau de Vilanova University Hospital, IRBLleida, University of Lleida, Lleida, Spain
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Gonnelli F, Hassan W, Bonifazi M, Pinelli V, Bedawi EO, Porcel JM, Rahman NM, Mei F. Malignant pleural effusion: current understanding and therapeutic approach. Respir Res 2024; 25:47. [PMID: 38243259 PMCID: PMC10797757 DOI: 10.1186/s12931-024-02684-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 01/05/2024] [Indexed: 01/21/2024] Open
Abstract
Malignant pleural effusion (MPE) is a common complication of thoracic and extrathoracic malignancies and is associated with high mortality and elevated costs to healthcare systems. Over the last decades the understanding of pathophysiology mechanisms, diagnostic techniques and optimal treatment intervention in MPE have been greatly advanced by recent high-quality research, leading to an ever less invasive diagnostic approach and more personalized management. Despite a number of management options, including talc pleurodesis, indwelling pleural catheters and combinations of the two, treatment for MPE remains symptom directed and centered around drainage strategy. In the next future, because of a better understanding of underlying tumor biology together with more sensitive molecular diagnostic techniques, it is likely that combined diagnostic and therapeutic procedures allowing near total outpatient management of MPE will become popular. This article provides a review of the current advances, new discoveries and future directions in the pathophysiology, diagnosis and management of MPE.
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Affiliation(s)
- Francesca Gonnelli
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona Via Conca 71, Ancona, 60126, Italy
| | - Wafa Hassan
- Department of Respiratory Medicine, Sheffield Teaching Hospitals, University of Sheffield, Sheffield, UK
| | - Martina Bonifazi
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona Via Conca 71, Ancona, 60126, Italy
| | | | - Eihab O Bedawi
- Department of Respiratory Medicine, Sheffield Teaching Hospitals, University of Sheffield, Sheffield, UK
| | - José M Porcel
- Research Group of Cancer Biomarkers, Lleida Institute for Biomedical Research Dr. Pifarré Foundation (IRBLleida), Lleida, Spain
- Pleural Medicine and Clinical Ultrasound Unit, Department of Internal Medicine, Arnau de Vilanova, University Hospital, Lleida, Spain
| | - Najib M Rahman
- Oxford Pleural Unit, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, UK
- Oxford NIHR Biomedical Research Unit, Oxford, UK
- Chinese Academy of Medicine Oxford Institute, Oxford, UK
| | - Federico Mei
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona Via Conca 71, Ancona, 60126, Italy.
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Trapé J, Bérgamo S, González-Garcia L, González-Fernández C. Lung cancer tumor markers in serous effusions and other body fluids. Tumour Biol 2024; 46:S99-S110. [PMID: 36502355 DOI: 10.3233/tub-220024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
From its onset and during its progression, lung cancer may affect various extrapulmonary structures. These include the serous membranes, the pleura and pericardium, and less frequently the central nervous system, with leptomeningeal involvement. In these cases, fluid accumulates in the serous membranes which may contain substances secreted by the tumor. Measuring the concentrations of these substances can provide useful information for elucidating the origin of the fluid accumulation, either in pleural and pericardial effusions or in cerebrospinal fluid. This paper describes the histological types of lung cancer that most frequently affect the serosa and leptomeninges. It also reviews the literature on tumor markers in different fluids and makes recommendations for their interpretation.
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Affiliation(s)
- Jaume Trapé
- Department of Laboratory Medicine, Althaia Xarxa Assistencial Universitària de Manresa, Manresa, Catalonia, Spain
- Tissue Repair and Regeneration Laboratory, Centre for Health and Social Care Research, University of Vic - Central University of Catalonia, Vic, Catalonia, Spain
- Faculty of Medicine, University of Vic - Central University of Catalonia, Vic, Catalonia, Spain
| | - Silvia Bérgamo
- Department of Laboratory Medicine, Althaia Xarxa Assistencial Universitària de Manresa, Manresa, Catalonia, Spain
- Tissue Repair and Regeneration Laboratory, Centre for Health and Social Care Research, University of Vic - Central University of Catalonia, Vic, Catalonia, Spain
- Doctoral School, University of Vic - Central University of Catalonia, Vic, Catalonia, Spain
| | - Laura González-Garcia
- Department of Laboratory Medicine, Althaia Xarxa Assistencial Universitària de Manresa, Manresa, Catalonia, Spain
- Tissue Repair and Regeneration Laboratory, Centre for Health and Social Care Research, University of Vic - Central University of Catalonia, Vic, Catalonia, Spain
| | - Carolina González-Fernández
- Department of Laboratory Medicine, Althaia Xarxa Assistencial Universitària de Manresa, Manresa, Catalonia, Spain
- Gastrointestinal Oncology, Endoscopy and Surgery Research Group, Manresa, Catalonia, Spain
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Cao XS, Yan L, Jiang TW, Huang JH, Chen H, Porcel JM, Zheng WQ, Hu ZD. Pleural fluid carbohydrate antigen 72-4 and malignant pleural effusion: a diagnostic test accuracy study. Ther Adv Respir Dis 2024; 18:17534666231222333. [PMID: 38189269 PMCID: PMC10775747 DOI: 10.1177/17534666231222333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 12/05/2023] [Indexed: 01/09/2024] Open
Abstract
BACKGROUND The prognosis of malignant pleural effusion (MPE) is poor. A timely and accurate diagnosis is the prerequisite for managing MPE patients. Carbohydrate antigen 72-4 (CA72-4) is a diagnostic tool for MPE. OBJECTIVE We aimed to evaluate the diagnostic accuracy of pleural fluid CA72-4 for MPE. DESIGN A prospective, preregistered, and double-blind diagnostic test accuracy study. METHODS We prospectively enrolled participants with undiagnosed pleural effusions from two centers in China (Hohhot and Changshu). CA72-4 concentration in pleural fluid was measured by electrochemiluminescence. Its diagnostic accuracy for MPE was evaluated by a receiver operating characteristic (ROC) curve. The net benefit of CA72-4 was determined by a decision curve analysis (DCA). RESULTS In all, 153 participants were enrolled in the Hohhot cohort, and 58 were enrolled in the Changshu cohort. In both cohorts, MPE patients had significantly higher CA72-4 levels than benign pleural effusion (BPE) patients. At a cutoff value of 8 U/mL, pleural fluid CA72-4 had a sensitivity, specificity, and area under the ROC curve (AUC) of 0.46, 1.00, and 0.79, respectively, in the Hohhot cohort. In the Changshu cohort, CA72-4 had a sensitivity, specificity, and AUC of 0.27, 0.94, and 0.86, respectively. DCA revealed the relatively high net benefit of CA72-4 determination. In patients with negative cytology, the AUC of CA72-4 was 0.67. CONCLUSION Pleural fluid CA72-4 helps differentiate MPE and BPE in patients with undiagnosed pleural effusions.
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Affiliation(s)
- Xi-Shan Cao
- Department of Laboratory Medicine, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
- Key Laboratory for Biomarkers, Inner Mongolia Medical University, Hohhot, China
| | - Li Yan
- Key Laboratory for Biomarkers, Inner Mongolia Medical University, Hohhot, China
- Department of Respiratory and Critical Care Medicine, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Ting-Wang Jiang
- Department of Key Laboratory, Affiliated Changshu Hospital of Nantong University, Suzhou, China
| | - Jin-Hong Huang
- Department of Pulmonary and Critical Care Medicine, Affiliated Changshu Hospital of Nantong University, Suzhou, China
| | - Hong Chen
- Department of Pulmonary and Critical Care Medicine, Affiliated Changshu Hospital of Nantong University, Suzhou, China
| | - José M. Porcel
- Pleural Medicine and Clinical Ultrasound Unit, Department of Internal Medicine, Arnau de Vilanova University Hospital, IRBLleida, University of Lleida, Lleida, Spain
| | - Wen-Qi Zheng
- Department of Laboratory Medicine, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
- Key Laboratory for Biomarkers, Inner Mongolia Medical University, Hohhot, China
| | - Zhi-De Hu
- Department of Laboratory Medicine, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot 010010, China
- Key Laboratory for Biomarkers, Inner Mongolia Medical University, Hohhot, China
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Wei M, Zhang Y, Zhao L, Zhao Z. Development and validation of a radiomics nomogram for diagnosis of malignant pleural effusion. Discov Oncol 2023; 14:213. [PMID: 37999794 PMCID: PMC10673775 DOI: 10.1007/s12672-023-00835-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 11/21/2023] [Indexed: 11/25/2023] Open
Abstract
OBJECTIVE We aimed to develop a radiomics nomogram based on computed tomography (CT) scan features and high-throughput radiomics features for diagnosis of malignant pleural effusion (MPE). METHODS In this study, 507 eligible patients with PE (207 malignant and 300 benign) were collected retrospectively. Patients were divided into training (n = 355) and validation cohorts (n = 152). Radiomics features were extracted from initial unenhanced CT images. CT scan features of PE were also collected. We used the variance threshold algorithm and least absolute shrinkage and selection operator (LASSO) to select optimal features to build a radiomics model for predicting the nature of PE. Univariate and multivariable logistic regression analyzes were used to identify significant independent factors associated with MPE, which were then included in the radiomics nomogram. RESULTS A total of four CT features were retained as significant independent factors, including massive PE, obstructive atelectasis or pneumonia, pleural thickening > 10 mm, and pulmonary nodules and/or masses. The radiomics nomogram constructed from 13 radiomics parameters and four CT features showed good predictive efficacy in training cohort [area under the curve (AUC) = 0.926, 95% CI 0.894, 0.951] and validation cohort (AUC = 0.916, 95% CI 0.860, 0.955). The calibration curve and decision curve analysis showed that the nomogram helped differentiate MPE from benign pleural effusion (BPE) in clinical practice. CONCLUSION This study presents a nomogram model incorporating CT scan features and radiomics features to help physicians differentiate MPE from BPE.
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Affiliation(s)
- Mingzhu Wei
- Department of Radiology, Shaoxing People's Hospital, Shaoxing, Zhejiang, People's Republic of China.
- Department of Radiology, Shaoxing People's Hospital, No. 568, Zhongxing North Road, Yuecheng District, Shaoxing, 312000, Zhejiang, People's Republic of China.
| | - Yaping Zhang
- Department of Radiology, Shaoxing People's Hospital, Shaoxing, Zhejiang, People's Republic of China
| | - Li Zhao
- Department of Radiology, Shaoxing People's Hospital, Shaoxing, Zhejiang, People's Republic of China
| | - Zhenhua Zhao
- Department of Radiology, Shaoxing People's Hospital, Shaoxing, Zhejiang, People's Republic of China
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Simó M, Persiva O, Sánchez L, Montoro B, Vázquez A, Sansano I, Alemán C. A PET-CT score for discriminating malignant from benign pleural effusions. Med Clin (Barc) 2023; 161:422-428. [PMID: 37487808 DOI: 10.1016/j.medcli.2023.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/19/2023] [Accepted: 06/20/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND AND OBJECTIVES The results of previous PET-CT studies are contradictory for discriminating malignant from benign pleural effusions. We purpose to develop a PET-CT score for differentiating between benign and malignant effusions. PATIENTS AND METHODS We conducted a prospective study of consecutive patients with pleural effusions undergoing PET-CT from October 2013 to October 2019 (referral cohort). PET-CT scan features evaluated using the SUV were: linear thickening; nodular thickening; nodules; masses; circumferential thickening; mediastinal and fissural pleural involvement; intrathoracic lymph nodes; pleural loculation; inflammatory consolidation; pleural calcification; cardiomegaly; pericardial effusion; bilateral effusion; lung mass; liver metastasis and other extra-pleural malignancy. The results were validated in an independent prospective cohort from November 2019 to June 2021. RESULTS One hundred and ninety-nine patients were enrolled in the referral cohort (91 with malignant effusions and 108 benign). The most useful parameters for the development of a PET-CT score were: nodular pleural thickening, pleural nodules with SUV>7.5, lung mass or extra pleural malignancy (10 points each), mammary lymph node with SUV>4.5 (5 points) and cardiomegaly (-1 point). With a cut-off value of >9 points in the referral cohort, the score established the diagnosis of malignant pleural effusion with sensitivity 87.9%, specificity 90.7%, positive predictive value 88.9%, negative predictive value 89.9%, positive likelihood ratio 7.81 and negative likelihood ratio 0.106. These results were validated in an independent prospective cohort of 75 patients. CONCLUSIONS PET-CT score was shown to provide relevant information for the identification of malignant pleural effusion.
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Affiliation(s)
- Marc Simó
- Department of Nuclear Imaging, Universitat Autònoma de Barcelona, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
| | - Oscar Persiva
- Department of Radiology, Universitat Autònoma de Barcelona, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Leire Sánchez
- Department of Thoracic Surgery, Universitat Autònoma de Barcelona, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Bruno Montoro
- Department of Pharmacy, Universitat Autònoma de Barcelona, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Ana Vázquez
- Department of Internal Medicine, Universitat Autònoma de Barcelona, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Irene Sansano
- Department of Pathology, Universitat Autònoma de Barcelona, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Carmen Alemán
- Department of Internal Medicine, Universitat Autònoma de Barcelona, Hospital Universitari Vall d'Hebron, Barcelona, Spain
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11
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Souza CA, Gomes MM, Gupta A. Pleural Malignancy-Challenges in Diagnosis and Multidisciplinary Approach. Semin Roentgenol 2023; 58:420-430. [PMID: 37973271 DOI: 10.1053/j.ro.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 06/16/2023] [Accepted: 07/02/2023] [Indexed: 11/19/2023]
Affiliation(s)
- Carolina A Souza
- Division of Cardiothoracic Radiology, Department of Medical Imaging, The Ottawa Hospital Research Institute, University of Ottawa, 501 Smyth Road, Ottawa, Ontario, Canada.
| | - Marcio M Gomes
- Department of Pathology & Laboratory Medicine, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada, 501 Smyth Road. Ottawa, Ontario, Canada
| | - Ashish Gupta
- Division of Cardiothoracic Radiology, Department of Medical Imaging, The Ottawa Hospital Research Institute, University of Ottawa, 501 Smyth Road, Ottawa, Ontario, Canada
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12
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Maturu VN, Prasad VP, Biradar M, Narahari NK. Pleural Pustule-a Novel Thoracoscopic Appearance of Pleural Tuberculosis. J Bronchology Interv Pulmonol 2023; 30:354-362. [PMID: 35968962 DOI: 10.1097/lbr.0000000000000887] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 06/28/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Thoracoscopic pleural biopsy is the gold standard for diagnosing tubercular pleural effusion (TPE). Various thoracoscopic appearances like sago grain nodules, caseous necrosis, and adhesions have been described in TPE. However, none of these have high specificity for diagnosing TPE. In this study we evaluate a novel finding on thoracoscopy, the " Pleural Pustule." METHODS This is a retrospective analysis of patients who underwent thoracoscopy for undiagnosed pleural effusion. Visual inspection of the pleura was performed to identify abnormalities. Biopsies were obtained from those areas and sent for histopathology, acid fast bacillus (AFB) smear, culture, and Xpert MTB/Rif assay. Pleural pustule was defined as a pus filled nodule on the pleural surface. RESULTS Of the 259 patients included, 92 were diagnosed with TPE. Pleural pustule(s) were identified in 16 patients with TPE. Presence of pleural pustule had a sensitivity, specificity, positive predictive value, and negative predictive value of 17.4%, 100%, 100% and 68.7%, respectively, for diagnosing TPE. Histopathology of pleural pustule demonstrated necrotizing granulomas in all. In patients with pleural pustule, a microbiological diagnosis of tuberculosis was achieved in 93.7% patients (AFB smear, Xpert MTB/Rif assay, and MTB culture positive in 31.3%, 93.7%, and 43.7% cases, respectively). There is a strong association between pleural pustule and positive Xpert MTB/Rif assay ( P =0.002) and microbiologic confirmation of diagnosis ( P =0.017). CONCLUSION The presence of pleural pustule on thoracoscopy has a high positive predictive value for TPE. In tuberculosis-endemic countries, this can be considered suggestive for TPE. When identified, a biopsy from the pleural pustule should be performed as it will likely yield a positive microbiologic diagnosis.
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Affiliation(s)
| | | | - Mahendra Biradar
- Department of Pulmonary Medicine, Yashoda Superspeciality Hospitals, Somajiguda
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13
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Liu Y, Huang W, Yang J, Yuan S, Li C, Wang W, Liang Z, Wu A. Construction of a multi-classified decision tree model for identifying malignant pleural effusion and tuberculous pleural effusion. Clin Biochem 2023; 120:110655. [PMID: 37769933 DOI: 10.1016/j.clinbiochem.2023.110655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 09/19/2023] [Accepted: 09/25/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVE Pleural effusion (PE) is a common clinical complication associated with various disorders. We aimed to utilize laboratory variables and their corresponding ratios in serum and PE for the differential diagnosis of multiple types of PE based on a decision tree (DT) algorithm. METHODS A total of 1435 untreated patients with PE admitted to The First Affiliated Hospital of Ningbo University were enrolled. The demographic and laboratory variables were collected and compared. The receiver operating characteristic curve was used to select important variables for diagnosing malignant pleural effusion (MPE) or tuberculous pleural effusion (TPE) and included in the DT model. The data were divided into the training set and the test set at a ratio of 7:3. The training data was used to develop the DT model, and the test data was for evaluating the model. Independent data was collected as external validation. RESULTS Three PE indicators (carcinoembryonic antigen, adenosine deaminase [ADA], and total protein), two serum indicators (neuron-specific enolase and cytokeratin 19 fragments), and two ratios [high-sensitivity C-reactive protein (hsCRP)/ PE lymphocyte and hsCRP/PE ADA] were used to construct the DT model. The area under the curve (AUC), sensitivity, and specificity for diagnosing MPE were 0.963, 84.0%, 91.6% in the training set, 0.976, 84.1%, 88.6% in the test set, and 0.955,83.3%, 86.7% in the external validation set. The AUC, sensitivity, and specificity of diagnosing TPE were 0.898, 86.8%, 92.3% in the training set, 0.888, 88.8%, 92.7% in the test set, and 0.778, 84.8%, 94.3% in the external validation set. CONCLUSION The DT model showed good diagnostic efficacy and could be applied for the differential diagnosis of MPE and TPE in clinical settings.
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Affiliation(s)
- Yanqing Liu
- Department of Laboratory Medicine, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Weina Huang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Jing Yang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Songbo Yuan
- Department of Laboratory Medicine, the Affiliated People's Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Congcong Li
- Hangzhou DIAN Medical Diagnostics Laboratory, Hangzhou, Zhejiang, China
| | - Weiwei Wang
- School of Laboratory Medicine and Life Sciences, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Zhigang Liang
- Department of Thoracic Surgery, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China.
| | - Aihua Wu
- Department of Laboratory Medicine, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China.
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14
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Marqués M, Pont M, Hidalgo I, Sorolla MA, Parisi E, Salud A, Sorolla A, Porcel JM. MicroRNAs Present in Malignant Pleural Fluid Increase the Migration of Normal Mesothelial Cells In Vitro and May Help Discriminate between Benign and Malignant Effusions. Int J Mol Sci 2023; 24:14022. [PMID: 37762343 PMCID: PMC10531386 DOI: 10.3390/ijms241814022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/06/2023] [Accepted: 09/08/2023] [Indexed: 09/29/2023] Open
Abstract
The sensitivity of pleural fluid (PF) analyses for the diagnosis of malignant pleural effusions (MPEs) is low to moderate. Knowledge about the pathobiology and molecular characteristics of this condition is limited. In this study, the crosstalk between stromal cells and tumor cells was investigated in vitro in order to reveal factors that are present in PF which can mediate MPE formation and aid in discriminating between benign and malignant etiologies. Eighteen PF samples, in different proportions, were exposed in vitro to mesothelial MeT-5A cells to determine the biological effects on these cells. Treatment of normal mesothelial MeT-5A cells with malignant PF increased cell viability, proliferation, and migration, and activated different survival-related signaling pathways. We identified differentially expressed miRNAs in PF samples that could be responsible for these changes. Consistently, bioinformatics analysis revealed an enrichment of the discovered miRNAs in migration-related processes. Notably, the abundance of three miRNAs (miR-141-3p, miR-203a-3, and miR-200c-3p) correctly classified MPEs with false-negative cytological examination results, indicating the potential of these molecules for improving diagnosis. Malignant PF produces phenotypic and functional changes in normal mesothelial cells. These changes are partly mediated by certain miRNAs, which, in turn, could serve to differentiate malignant from benign effusions.
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Affiliation(s)
- Marta Marqués
- Research Group of Cancer Biomarkers, Lleida Institute for Biomedical Research Dr. Pifarré Foundation (IRBLleida), Avda Alcalde Rovira Roure 80, 25198 Lleida, Spain; (M.M.); (M.P.); (I.H.); (M.A.S.); (E.P.); (A.S.); (A.S.)
| | - Mariona Pont
- Research Group of Cancer Biomarkers, Lleida Institute for Biomedical Research Dr. Pifarré Foundation (IRBLleida), Avda Alcalde Rovira Roure 80, 25198 Lleida, Spain; (M.M.); (M.P.); (I.H.); (M.A.S.); (E.P.); (A.S.); (A.S.)
| | - Iván Hidalgo
- Research Group of Cancer Biomarkers, Lleida Institute for Biomedical Research Dr. Pifarré Foundation (IRBLleida), Avda Alcalde Rovira Roure 80, 25198 Lleida, Spain; (M.M.); (M.P.); (I.H.); (M.A.S.); (E.P.); (A.S.); (A.S.)
| | - Maria Alba Sorolla
- Research Group of Cancer Biomarkers, Lleida Institute for Biomedical Research Dr. Pifarré Foundation (IRBLleida), Avda Alcalde Rovira Roure 80, 25198 Lleida, Spain; (M.M.); (M.P.); (I.H.); (M.A.S.); (E.P.); (A.S.); (A.S.)
| | - Eva Parisi
- Research Group of Cancer Biomarkers, Lleida Institute for Biomedical Research Dr. Pifarré Foundation (IRBLleida), Avda Alcalde Rovira Roure 80, 25198 Lleida, Spain; (M.M.); (M.P.); (I.H.); (M.A.S.); (E.P.); (A.S.); (A.S.)
| | - Antonieta Salud
- Research Group of Cancer Biomarkers, Lleida Institute for Biomedical Research Dr. Pifarré Foundation (IRBLleida), Avda Alcalde Rovira Roure 80, 25198 Lleida, Spain; (M.M.); (M.P.); (I.H.); (M.A.S.); (E.P.); (A.S.); (A.S.)
- Department of Medical Oncology, Arnau de Vilanova University Hospital, Avda Alcalde Rovira Roure 80, 25198 Lleida, Spain
| | - Anabel Sorolla
- Research Group of Cancer Biomarkers, Lleida Institute for Biomedical Research Dr. Pifarré Foundation (IRBLleida), Avda Alcalde Rovira Roure 80, 25198 Lleida, Spain; (M.M.); (M.P.); (I.H.); (M.A.S.); (E.P.); (A.S.); (A.S.)
| | - José M. Porcel
- Research Group of Cancer Biomarkers, Lleida Institute for Biomedical Research Dr. Pifarré Foundation (IRBLleida), Avda Alcalde Rovira Roure 80, 25198 Lleida, Spain; (M.M.); (M.P.); (I.H.); (M.A.S.); (E.P.); (A.S.); (A.S.)
- Pleural Medicine and Clinical Ultrasound Unit, Department of Internal Medicine, Arnau de Vilanova University Hospital, Avda Alcalde Rovira Roure 80, 25198 Lleida, Spain
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15
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Fox AH, Nishino M, Osarogiagbon RU, Rivera MP, Rosenthal LS, Smith RA, Farjah F, Sholl LM, Silvestri GA, Johnson BE. Acquiring tissue for advanced lung cancer diagnosis and comprehensive biomarker testing: A National Lung Cancer Roundtable best-practice guide. CA Cancer J Clin 2023; 73:358-375. [PMID: 36859638 DOI: 10.3322/caac.21774] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 01/13/2023] [Accepted: 01/24/2023] [Indexed: 03/03/2023] Open
Abstract
Advances in biomarker-driven therapies for patients with nonsmall cell lung cancer (NSCLC) both provide opportunities to improve the treatment (and thus outcomes) for patients and pose new challenges for equitable care delivery. Over the last decade, the continuing development of new biomarker-driven therapies and evolving indications for their use have intensified the importance of interdisciplinary communication and coordination for patients with or suspected to have lung cancer. Multidisciplinary teams are challenged with completing comprehensive and timely biomarker testing and navigating the constantly evolving evidence base for a complex and time-sensitive disease. This guide provides context for the current state of comprehensive biomarker testing for NSCLC, reviews how biomarker testing integrates within the diagnostic continuum for patients, and illustrates best practices and common pitfalls that influence the success and timeliness of biomarker testing using a series of case scenarios.
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Affiliation(s)
- Adam H Fox
- Division of Pulmonary Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Mizuki Nishino
- Department of Imaging, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Raymond U Osarogiagbon
- Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee, USA
| | - M Patricia Rivera
- Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Lauren S Rosenthal
- Prevention and Early Detection Department, American Cancer Society, Atlanta, Georgia, USA
| | - Robert A Smith
- Prevention and Early Detection Department, American Cancer Society, Atlanta, Georgia, USA
| | - Farhood Farjah
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Lynette M Sholl
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Gerard A Silvestri
- Division of Pulmonary Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Bruce E Johnson
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
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16
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Li Q, Hu C, Su S, Ma Z, Geng Y, Hu Y, Jin H, Li H, Lu B. Impact of thoracic tumor radiotherapy on survival in non-small-cell lung cancer with malignant pleural effusion treated with targeted therapy: Propensity score matching study. Cancer Med 2023; 12:14949-14959. [PMID: 37288833 PMCID: PMC10417183 DOI: 10.1002/cam4.6130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/11/2023] [Accepted: 05/14/2023] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND EGFR-mutant (EGFR-M) and ALK-positive (ALK-P)are common in malignant pleural effusion (MPE) with metastatic non-small-cell lung cancer (NSCLC) (MPE-NSCLC). The impact of thoracic tumor radiotherapy on survival in such patients remains unclear. We aimed to investigate whether thoracic tumor radiotherapy could improve overall survival (OS) in such patients. METHODS According to whether or not patients accepted thoracic tumor radiotherapy, 148 patients with EGFR-M or ALK-P MPE-NSCLC treated with targeted therapy were classified into two groups: DT group without thoracic tumor radiotherapy and DRT group with thoracic tumor radiotherapy. Propensity score matching (PSM) was performed to balance clinical baseline characteristics. Overall survival was analyzed by Kaplan-Meier, compared by log-rank test, and evaluated using Cox proportional hazards model. RESULTS Median survival time (MST) was 25 months versus 17 months in the DRT group and DT group. The OS rates at 1, 2, 3, 5 years in the DRT group and DT group were 75.0%, 52.8%, 26.8%, 11.1% and 64.5%, 28.4%, 9.2%, 1.8%, respectively (χ2 = 12.028, p = 0.001). Compared with DT group, the DRT group still had better survival after PSM (p = 0.007). Before and after PSM, factors associated with better OS through multivariable analysis were that thoracic tumor radiotherapy, radiotherapy, N0-2 , and ALK-TKIs. Grades 4-5 radiation toxicities were not observed in patients; 8 (11.6%) and 7 (10.1%) out of the DRT group suffered from Grade 3 radiation esophagitis and radiation pneumonitis, respectively. CONCLUSION Our results for EGFR-M or ALK-P MPE-NSCLC showed that thoracic tumor radiotherapy may be crucial factor in improving OS with acceptable toxicities. Potential biases should not be neglected: Further randomized controlled trials are necessary to confirm this result.
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Affiliation(s)
- Qingsong Li
- Department of Thoracic OncologyAffiliated Hospital of Guizhou Medical UniversityGuiyangChina
- Department of Thoracic OncologyAffiliated Cancer Hospital of Guizhou Medical UniversityGuiyangChina
- Teaching and Research Department of OncologyClinical Medical College of Guizhou Medical UniversityGuiyangChina
| | - Cheng Hu
- Department of Thoracic OncologyAffiliated Hospital of Guizhou Medical UniversityGuiyangChina
- Department of Thoracic OncologyAffiliated Cancer Hospital of Guizhou Medical UniversityGuiyangChina
- Teaching and Research Department of OncologyClinical Medical College of Guizhou Medical UniversityGuiyangChina
| | - Shengfa Su
- Department of Thoracic OncologyAffiliated Hospital of Guizhou Medical UniversityGuiyangChina
- Department of Thoracic OncologyAffiliated Cancer Hospital of Guizhou Medical UniversityGuiyangChina
- Teaching and Research Department of OncologyClinical Medical College of Guizhou Medical UniversityGuiyangChina
| | - Zhu Ma
- Department of Thoracic OncologyAffiliated Hospital of Guizhou Medical UniversityGuiyangChina
- Department of Thoracic OncologyAffiliated Cancer Hospital of Guizhou Medical UniversityGuiyangChina
| | - Yichao Geng
- Department of Thoracic OncologyAffiliated Hospital of Guizhou Medical UniversityGuiyangChina
- Department of Thoracic OncologyAffiliated Cancer Hospital of Guizhou Medical UniversityGuiyangChina
- Teaching and Research Department of OncologyClinical Medical College of Guizhou Medical UniversityGuiyangChina
| | - Yinxiang Hu
- Department of Thoracic OncologyAffiliated Hospital of Guizhou Medical UniversityGuiyangChina
- Department of Thoracic OncologyAffiliated Cancer Hospital of Guizhou Medical UniversityGuiyangChina
- Teaching and Research Department of OncologyClinical Medical College of Guizhou Medical UniversityGuiyangChina
| | - Haijie Jin
- Department of Thoracic OncologyAffiliated Hospital of Guizhou Medical UniversityGuiyangChina
- Department of Thoracic OncologyAffiliated Cancer Hospital of Guizhou Medical UniversityGuiyangChina
- Teaching and Research Department of OncologyClinical Medical College of Guizhou Medical UniversityGuiyangChina
| | - Huiqin Li
- Department of Thoracic OncologyAffiliated Hospital of Guizhou Medical UniversityGuiyangChina
- Department of Thoracic OncologyAffiliated Cancer Hospital of Guizhou Medical UniversityGuiyangChina
| | - Bing Lu
- Department of Thoracic OncologyAffiliated Hospital of Guizhou Medical UniversityGuiyangChina
- Department of Thoracic OncologyAffiliated Cancer Hospital of Guizhou Medical UniversityGuiyangChina
- Teaching and Research Department of OncologyClinical Medical College of Guizhou Medical UniversityGuiyangChina
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17
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Huang JH, Chen H, Zhang ZC, Gu J, Yan L, Jiang MP, Zheng WQ, Hu ZD, Jiang TW. Age affects the diagnostic accuracy of the cancer ratio for malignant pleural effusion. BMC Pulm Med 2023; 23:198. [PMID: 37286973 DOI: 10.1186/s12890-023-02475-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 05/10/2023] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Cancer ratio (CR), which is defined as serum lactate dehydrogenase (LDH) to pleural fluid adenosine deaminase (ADA) ratio, has been reported to be a useful diagnostic marker for malignant pleural effusion (MPE). Whether its diagnostic accuracy is affected by age remains unknown. This study aimed to investigate the effects of age on the diagnostic accuracy of CR. METHODS The participants in this study were from a prospective cohort (SIMPLE cohort, n = 199) and a retrospective cohort (BUFF cohort, n = 158). All participants were patients with undiagnosed pleural effusion (PE). We used receiver operating characteristic (ROC) curves to evaluate the diagnostic accuracy of CR. The effect of age on the diagnostic accuracy of CR was investigated by adjusting the upper limit of age for participant enrolment. RESULTS Eighty-eight MPE patients were verified in the SIMPLE cohort, and thirty-five MPE patients were verified in the BUFF cohort. The AUCs of CR in the SIMPLE and BUFF cohorts were 0.60 (95% CI: 0.52-0.68) and 0.63 (95% CI: 0.54-0.71), respectively. In both cohorts, the AUCs of CR decreased with the advancement of age. CONCLUSION Age can affect the diagnostic accuracy of CR for MPE. CR has limited diagnostic value in older patients. KEY MESSAGE Cancer ratio is a promising diagnostic marker for malignant pleural effusion. This study revealed that its diagnostic accuracy decreased in older patients. Its diagnostic accuracy is overestimated by previous studies using tuberculosis and pneumonia patients as controls.
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Affiliation(s)
- Jin-Hong Huang
- Department of Pulmonary and Critical Care Medicine, the Affiliated Changshu Hospital of Nantong University, 215500, Changshu, China
| | - Hong Chen
- Department of Pulmonary and Critical Care Medicine, the Affiliated Changshu Hospital of Nantong University, 215500, Changshu, China
| | - Zhi-Cheng Zhang
- Department of Key Laboratory, the Affiliated Changshu Hospital of Nantong University, 215500, Changshu, China
| | - Jie Gu
- Department of Key Laboratory, the Affiliated Changshu Hospital of Nantong University, 215500, Changshu, China
| | - Li Yan
- Department of Respiratory and Critical Care Medicine, the Affiliated Hospital of Inner Mongolia Medical Universit, 010050, Hohhot, China
| | - Meng-Ping Jiang
- The Affiliated Hospital of Inner Mongolia Medical University, 010050, Hohhot, China
| | - Wen-Qi Zheng
- Department of Laboratory Medicine, the Affiliated Hospital of Inner Mongolia Medical University, 010050, Hohhot, China
| | - Zhi-De Hu
- Department of Laboratory Medicine, the Affiliated Hospital of Inner Mongolia Medical University, 010050, Hohhot, China.
| | - Ting-Wang Jiang
- Department of Key Laboratory, the Affiliated Changshu Hospital of Nantong University, 215500, Changshu, China.
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18
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Porcel JM. Expert Review on Contemporary Management of Common Benign Pleural Effusions. Semin Respir Crit Care Med 2023. [PMID: 37263288 DOI: 10.1055/s-0043-1769096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Heart failure (HF) and cirrhosis are frequently associated with pleural effusions (PEs). Despite their apparently benign nature, both HF-related effusions and hepatic hydrothorax (HH) have poor prognosis because they represent an advanced stage of the disease. Optimization of medical therapy in these two entities involve not only the use of diuretics, but also other pharmacological therapies. For instance, all HF patients with reduced or mildly reduced left ventricular ejection fraction can benefit from angiotensin receptor-neprilysin inhibitors, beta blockers, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter 2 inhibitors. Conversely, it is better for HH patients to avoid nonselective beta blockers. Refractory cardiac- and cirrhosis-related PEs are commonly managed by iterative therapeutic thoracentesis. When repeated aspirations are needed, thereby diminishing quality of life, the insertion of an indwelling pleural catheter (IPC) may be warranted. However, in selected HH patients who are diuretic-resistant or diuretic-intractable, placement of transjugular intrahepatic portosystemic shunts should be considered as a bridge to liver transplantation, whereas in transplant candidates the role of IPC is debatable. Another benign condition, pleural tuberculosis (TB) is a serious health problem in developing countries. Diagnostic certainty is still a concern due to the paucibacillary nature of the infection, although the use of more sensitive nucleic acid amplification tests is becoming more widespread. Its treatment is the same as that of pulmonary TB, but the potential drug interactions between antiretroviral and anti-TB drugs in HIV-coinfected patients as well as the current recommended guidelines for the different types of anti-TB drugs resistance should be followed.
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Affiliation(s)
- José M Porcel
- Pleural Medicine Unit, Department of Internal Medicine, Arnau de Vilanova University Hospital, IRBLleida, University of Lleida, Lleida, Spain
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19
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Ozcelik N, Ozcelik AE, Guner Zirih NM, Selimoglu I, Gumus A. Deep learning for diagnosis of malign pleural effusion on computed tomography images. Clinics (Sao Paulo) 2023; 78:100210. [PMID: 37149920 DOI: 10.1016/j.clinsp.2023.100210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 04/01/2023] [Accepted: 04/18/2023] [Indexed: 05/09/2023] Open
Abstract
BACKGROUND The pleura is a serous membrane that surrounds the lungs. The visceral surface secretes fluid into the serous cavity and the parietal surface ensures a regular absorption of this fluid. If this balance is disturbed, fluid accumulation occurs in the pleural space called "Pleural Effusion". Today, accurate diagnosis of pleural diseases is becoming more critical, as advances in treatment protocols have contributed positively to prognosis. Our aim is to perform computer-aided numerical analysis of Computed Tomography (CT) images from patients showing pleural effusion images on CT and to examine the prediction of malignant/benign distinction using deep learning by comparing with the cytology results. METHODS The authors classified 408 CT images from 64 patients whose etiology of pleural effusion was investigated using the deep learning method. 378 of the images were used for the training of the system; 15 malignant and 15 benign CT images, which were not included in the training group, were used as the test. RESULTS Among the 30 test images evaluated in the system; 14 of 15 malignant patients and 13 of 15 benign patients were estimated with correct diagnosis (PPD: 93.3%, NPD: 86.67%, Sensitivity: 87.5%, Specificity: 92.86%). CONCLUSION Advances in computer-aided diagnostic analysis of CT images and obtaining a pre-diagnosis of pleural fluid may reduce the need for interventional procedures by guiding physicians about which patients may have malignancies. Thus, it is cost and time-saving in patient management, allowing earlier diagnosis and treatment.
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Affiliation(s)
- Neslihan Ozcelik
- Recep Tayyip Erdogan University, Faculty of Medicine, Training and Research Hospital, Chest Disease, Rize, Turkey.
| | - Ali Erdem Ozcelik
- Recep Tayyip Erdogan University, Engineering and Architecture Faculty, Department of Landscape Architecture (Geomatics Engineer), Rize, Turkey
| | - Nese Merve Guner Zirih
- Recep Tayyip Erdogan University, Faculty of Medicine, Training and Research Hospital, Chest Disease, Rize, Turkey
| | - Inci Selimoglu
- Recep Tayyip Erdogan University, Faculty of Medicine, Training and Research Hospital, Chest Disease, Rize, Turkey
| | - Aziz Gumus
- Recep Tayyip Erdogan University, Faculty of Medicine, Training and Research Hospital, Chest Disease, Rize, Turkey
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20
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Baban F, Koepplin JW, Ahmad M, Clarke-Brodber AL, Bois MC, Hartley CP, Sturgis CD. TRPS1 outperforms GATA3 in pleural effusions with metastatic breast carcinoma versus mesothelioma. Diagn Cytopathol 2023. [PMID: 37096814 DOI: 10.1002/dc.25148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 03/28/2023] [Accepted: 04/17/2023] [Indexed: 04/26/2023]
Abstract
INTRODUCTION In evaluating malignant pleural fluid cytology, metastatic adenocarcinomas and mesotheliomas are often differential diagnoses. GATA binding protein 3 (GATA3) has historically been used to confirm metastatic breast carcinomas; however, GATA3 has low specificity if mesothelioma is included in differential diagnoses. Trichorhinophalangeal syndrome type 1 (TRPS1) protein is expressed in all types of breast carcinomas, with reported high specificity and sensitivity. We investigated the performance of TRPS1 immunohistochemistry (IHC) and compared it to GATA3 in pleural fluids diagnosed with metastatic breast carcinoma and mesothelioma. METHODS Thirty-six consecutive ThinPrep pleural fluids and 4 pleural fine needle aspirations (FNAs) with diagnoses of metastatic breast carcinoma (21) and mesothelioma (19) were retrieved, and IHC with TRPS1 and GATA3 was performed on all. Immunoreactivity scores for TRPS1 were calculated by multiplying percentage of immunoreactive cells by staining intensity. Immunoreactivity scores were negative if 0 or 1, low positive if 2, intermediate positive if 3 or 4, or high positive if 6 or 9. Nuclear immunoreactivity of ≥10% with at least moderate intensity was judged GATA3 positive. RESULTS GATA3 showed immunoreactivity in all metastatic breast carcinomas and 84% of mesotheliomas. TRPS1 was immunoreactive in all breast carcinoma cases (18 with a score of 9 and 3 with a score of 6). TRPS1 showed low positivity in 5% of mesothelioma cases with all other cases being negative. CONCLUSION When cytomorphologic differential diagnoses of mesothelioma exist, TRPS1 is a more specific marker than GATA3 for confirmation of metastatic breast carcinoma in pleural fluid cytology.
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Affiliation(s)
- Farah Baban
- Department of Laboratory Medicine and Pathology, Division of Anatomic Pathology-Mayo Clinic, Rochester, Minnesota, USA
| | - Justin W Koepplin
- Department of Laboratory Medicine and Pathology, Division of Anatomic Pathology-Mayo Clinic, Rochester, Minnesota, USA
| | - Muhammad Ahmad
- Department of Laboratory Medicine and Pathology, Division of Anatomic Pathology-Mayo Clinic, Rochester, Minnesota, USA
| | - Anna-Lee Clarke-Brodber
- Department of Laboratory Medicine and Pathology, Division of Anatomic Pathology-Mayo Clinic, Rochester, Minnesota, USA
| | - Melanie C Bois
- Department of Laboratory Medicine and Pathology, Division of Anatomic Pathology-Mayo Clinic, Rochester, Minnesota, USA
| | - Christopher P Hartley
- Department of Laboratory Medicine and Pathology, Division of Anatomic Pathology-Mayo Clinic, Rochester, Minnesota, USA
| | - Charles D Sturgis
- Department of Laboratory Medicine and Pathology, Division of Anatomic Pathology-Mayo Clinic, Rochester, Minnesota, USA
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Hsu SC, Chang SY, Hwang YT, Terng HJ, Tsai CL, Shen CH, Huang SK, Chian CF. mRNA markers associated with malignant pleural effusion. Sci Rep 2023; 13:6677. [PMID: 37095178 PMCID: PMC10126123 DOI: 10.1038/s41598-023-32872-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 04/04/2023] [Indexed: 04/26/2023] Open
Abstract
Malignant pleural effusions (MPE) commonly result from malignant tumors and represent advanced-stage cancers. Thus, in clinical practice, early recognition of MPE is valuable. However, the current diagnosis of MPE is based on pleural fluid cytology or histologic analysis of pleural biopsies with a low diagnostic rate. This research aimed to assess the diagnostic ability of eight previously identified Non-Small Cell Lung Cancer (NSCLC)-associated genes for MPE. In the study, eighty-two individuals with pleural effusion were recruited. There were thirty-three patients with MPE and forty-nine patients with benign transudate. mRNA was isolated from the pleural effusion and amplified by Quantitative real-time PCR. The logistic models were further applied to evaluate the diagnostic performance of those genes. Four significant MPE-associated genes were discovered in our study, including Dual-specificity phosphatase 6 (DUSP6), MDM2 proto-oncogene (MDM2), Ring finger protein 4 (RNF4), and WEE1 G2 Checkpoint Kinase (WEE1). Pleural effusion with higher expression levels of MDM2 and WEE1 and lower expression levels of RNF4 and DUSP6 had a higher possibility of being MPE. The four-gene model had an excellent performance distinguishing MPE and benign pleural effusion, especially for pathologically negative effusions. Therefore, the gene combination is a suitable candidate for MPE screening in patients with pleural effusion. We also identified three survival-associated genes, WEE1, Neurofibromin 1 (NF1), and DNA polymerase delta interacting protein 2 (POLDIP2), which could predict the overall survival of patients with MPE.
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Affiliation(s)
- Shih-Chang Hsu
- Department of Emergency, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, ROC
- Emergency Department, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan, ROC
| | - Shan-Yueh Chang
- Division of Pulmonary and Critical Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Yi-Ting Hwang
- Department of Statistics, National Taipei University, Taipei, Taiwan, ROC
| | | | - Chen-Liang Tsai
- Division of Pulmonary and Critical Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Chih-Hao Shen
- Division of Pulmonary and Critical Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Shau Ku Huang
- National Institute of Environmental Health Sciences, National Health Research Institutes, Zhunan, Taiwan, ROC
- Johns Hopkins Asthma and Allergy Center, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Chih-Feng Chian
- Division of Pulmonary and Critical Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC.
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Zhang M, Jiang MP, Yan L, Wen JX, Zheng WQ, Hu ZD. Age affects the diagnostic accuracy of serum N-terminal pro-B-type natriuretic peptide for heart failure in patients with pleural effusion. Clin Biochem 2023; 114:52-58. [PMID: 36669639 DOI: 10.1016/j.clinbiochem.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/20/2022] [Accepted: 01/12/2023] [Indexed: 01/19/2023]
Abstract
BACKGROUND Serum N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a well-recognized diagnostic marker for heart failure (HF) in patients with dyspnea or pleural effusion (PE). The effects of age on the diagnostic accuracy of NT-proBNP in dyspneic patients are widely known; however, whether its diagnostic accuracy is affected by age in patients with PE remains unknown. This study aimed to investigate the influence of age on the diagnostic accuracy of serum NT-proBNP for HF in patients with PE. METHODS Patients with PE were recruited from the BUFF (Biomarkers for patients with Undiagnosed pleural eFFusion) cohort and the SIMPLE (a Study Investigating Markers in PLeural Effusion) cohort. Serum NT-proBNP on admission and final diagnosis were extracted from the participant's medical records. The diagnostic accuracy of serum NT-proBNP was evaluated by a operating characteristic (ROC) curve analysis. The influence of age on the diagnostic accuracy of NT-proBNP was investigated through subgroup analyses. RESULTS One hundred and four participants were enrolled from the BUFF cohorts (HF, 32; non-HF, 72). One hundred and sixteen participants were enrolled from the SIMPLE cohort (HF, 21; non-HF, 95). The area under the ROC curve (AUCs) of NT-proBNP in the pooled cohort was 0.78 (95 %CI: 0.71 - 0.85). The AUC of NT-proBNP decreased in older patients. CONCLUSION Serum NT-proBNP has moderate diagnostic accuracy for HF in old patients with PE. The diagnostic accuracy of serum NT-proBNP in these patients decreases with the advancement of age.
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Affiliation(s)
- Man Zhang
- Department of Thoracic Surgery, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot 010010, China
| | - Meng-Ping Jiang
- The Affiliated Hospital of Inner Mongolia Medical University, Hohhot 010010, China
| | - Li Yan
- Department of Respiratory and Critical Care Medicine, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot 010010, China
| | - Jian-Xun Wen
- Department of Medical Experiment Center, The Basic Medical Sciences College of Inner Mongolia Medical University, Hohhot 010010, China
| | - Wen-Qi Zheng
- Department of Laboratory Medicine, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot 010010, China
| | - Zhi-De Hu
- Department of Laboratory Medicine, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot 010010, China.
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23
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Fazli Khalaf F, Asadi Gharabaghi M, Balibegloo M, Davari H, Afshar S, Jahanbin B. Pleural CEA, CA-15-3, CYFRA 21-1, CA-19-9, CA-125 discriminating malignant from benign pleural effusions: Diagnostic cancer biomarkers. Int J Biol Markers 2023:3936155231158661. [PMID: 36942429 DOI: 10.1177/03936155231158661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
INTRODUCTION There is a need for a rapid, accurate, less-invasive approach to distinguishing malignant from benign pleural effusions. We investigated the diagnostic value of five pleural tumor markers in exudative pleural effusions. METHODS By immunochemiluminescence assay, we measured pleural concentrations of tumor markers. We used the receiver operating characteristic curve analysis to assess their diagnostic values. RESULTS A total of 281 patients were enrolled. All tumor markers were significantly higher in malignant pleural effusions than benign ones. The area under the curve of carcinoembryonic antigen (CEA), carbohydrate antigen (CA) 15-3, cytokeratin fragment 19 (CYFRA) 21-1, CA-19-9, and CA-125 were 0.81, 0.78, 0.75, 0.65, and 0.65, respectively. Combined markers of CEA + CA-15-3 and CEA + CA-15-3 + CYFRA 21-1 had a sensitivity of 87% and 94%, and specificity of 75% and 58%, respectively. We designed a diagnostic algorithm by combining pleural cytology with pleural tumor marker assay. CEA + CYFRA 21-1 + CA-19-9 + CA-15-3 was the best tumor markers panel detecting 96% of cytologically negative malignant pleural effusions, with a negative predictive value of 98%. CONCLUSIONS Although cytology is specific enough, it has less sensitivity in identifying malignant pleural fluids. As a result, the main gap is detecting malignant pleural effusions with negative cytology. CEA was the best single marker, followed by CA-15-3 and CYFRA 21-1. Through both cytology and suggested panels of tumor markers, malignant and benign pleural effusions could be truly diagnosed with an accuracy of about 98% without the need for more invasive procedures, except for the cohort with negative cytology and a positive tumor markers panel, which require more investigations.
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Affiliation(s)
- Farzaneh Fazli Khalaf
- Pathology Department, Cancer Institute, Tehran University of Medical Science, Tehran, Iran
| | - Mehrnaz Asadi Gharabaghi
- Department of Pulmonary Medicine, Thoracic Research Center, Tehran University of Medical Science, Tehran, Iran
| | - Maryam Balibegloo
- Cancer Immunology Project (CIP), Universal Scientific Education and Research Network, Chicago, IL, USA
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamidreza Davari
- General Thoracic Surgery Ward, Tehran University of Medical Sciences, Tehran, Iran
| | - Samaneh Afshar
- Cancer Institute, Tehran University of Medical Science, Tehran, Iran
| | - Behnaz Jahanbin
- Pathology Department, Cancer Institute, Tehran University of Medical Science, Tehran, Iran
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24
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Cao XS, Zheng WQ, Hu ZD. Diagnostic value of soluble biomarkers for parapneumonic pleural effusion. Crit Rev Clin Lab Sci 2023; 60:233-247. [PMID: 36593742 DOI: 10.1080/10408363.2022.2158779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Parapneumonic pleural effusion (PPE) is a common complication in patients with pneumonia. Timely and accurate diagnosis of PPE is of great value for its management. Measurement of biomarkers in circulating and pleural fluid have the advantages of easy accessibility, short turn-around time, objectiveness and low cost and thus have utility for PPE diagnosis and stratification. To date, many biomarkers have been reported to be of value for the management of PPE. Here, we review the values of pleural fluid and circulating biomarkers for the diagnosis and stratification PPE. The biomarkers discussed are C-reactive protein, procalcitonin, presepsin, soluble triggering receptor expressed on myeloid cells 1, lipopolysaccharide-binding protein, inflammatory markers, serum amyloid A, soluble urokinase plasminogen activator receptor, matrix metalloproteinases, pentraxin-3 and cell-free DNA. We found that none of the available biomarkers has adequate performance for diagnosing and stratifying PPE. Therefore, further work is needed to identify and validate novel biomarkers, and their combinations, for the management of PPE.
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Affiliation(s)
- Xi-Shan Cao
- Department of Laboratory Medicine, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Wen-Qi Zheng
- Department of Laboratory Medicine, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Zhi-De Hu
- Department of Laboratory Medicine, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
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25
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Yang Q, Niu Y, Wen JX, Yang DN, Han YL, Wen XH, Yan L, Huang JH, Chen H, Zheng WQ, Jiang TW, Hu ZD. Value of human epididymis secretory protein 4 in differentiating malignant from benign pleural effusion: an analysis of two cohorts. Ther Adv Respir Dis 2023; 17:17534666231216566. [PMID: 38084849 PMCID: PMC10722922 DOI: 10.1177/17534666231216566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 11/08/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Lung cancer is the most common cause of malignant pleural effusion (MPE). Serum human epididymis secretory protein 4 (HE4) is a useful diagnostic marker for lung cancer. OBJECTIVE This study aimed to evaluate the diagnostic accuracy of pleural fluid HE4 for MPE. DESIGN A prospective, double-blind diagnostic test accuracy study. METHODS Patients with undiagnosed pleural effusion were enrolled in two cohorts (Hohhot and Changshu). Electrochemiluminescence immunoassay was used to detect pleural fluid HE4. The diagnostic accuracy of HE4 was evaluated by a receiver operating characteristic (ROC) curve, and the net benefit of HE4 was assessed by a decision curve analysis (DCA). RESULTS A total of 66 MPEs and 86 benign pleural effusions (BPEs) were enrolled in the Hohhot cohort. In the Changshu cohort, 26 MPEs and 32 BPEs were enrolled. In both cohorts, MPEs had significantly higher pleural fluid HE4 than BPEs. The area under the ROC curve (AUC) of HE4 was 0.73 (95% CI: 0.64-0.81) in the Hohhot cohort and 0.79 (95% CI: 0.67-0.91) in the Changshu cohort. At a threshold of 1300 pmol/L, HE4 had sensitivities of 0.44 (95% CI: 0.33-0.56) in the Hohhot cohort and 0.54 (95% CI: 0.35-0.73) in the Changshu cohort. The corresponding specificities were 0.90 (95% CI: 0.83-0.95) in the Hohhot cohort and 0.94 (95% CI: 0.84-1.00) in the Changshu cohort. In subgroup analyses, HE4 had an AUC (95% CI) of 0.78 (0.71-0.85) in exudates and an AUC of 0.69 (0.57-0.81) in patients with negative effusion cytology. The DCA revealed that HE4 determination had a net benefit in both cohorts. CONCLUSION Pleural fluid HE4 has moderate diagnostic accuracy for MPE and has net benefit in pleural effusion patients with unknown etiology.
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Affiliation(s)
- Qian Yang
- Department of Laboratory Medicine, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Yan Niu
- Department of Medical Experiment Center, The Basic Medical Sciences College of Inner Mongolia Medical University, Hohhot, China
| | - Jian-Xun Wen
- Department of Medical Experiment Center, The Basic Medical Sciences College of Inner Mongolia Medical University, Hohhot, China
| | - Dan-Ni Yang
- Department of Laboratory Medicine, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Yu-Ling Han
- Department of Laboratory Medicine, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
- Department of Parasitology, The Basic Medical Sciences College of Inner Mongolia Medical University, Hohhot, China
| | - Xu-Hui Wen
- Department of Laboratory Medicine, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
- Department of Parasitology, The Basic Medical Sciences College of Inner Mongolia Medical University, Hohhot, China
| | - Li Yan
- Department of Respiratory and Critical Care Medicine, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Jin-Hong Huang
- Department of Pulmonary and Critical Care Medicine, Affiliated Changshu Hospital of Nantong University, Changshu, China
| | - Hong Chen
- Department of Pulmonary and Critical Care Medicine, Affiliated Changshu Hospital of Nantong University, Changshu, China
| | - Wen-Qi Zheng
- Department of Laboratory Medicine, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, ChinaDepartment of Parasitology, The Basic Medical Sciences College of Inner Mongolia Medical University, Hohhot, China
| | - Ting-Wang Jiang
- Department of Key Laboratory, Affiliated Changshu Hospital of Nantong University, Changshu 215500, China
| | - Zhi-De Hu
- Department of Laboratory Medicine, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot 010050, China
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26
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Kassirian S, Hinton SN, Cuninghame S, Chaudhary R, Iansavitchene A, Amjadi K, Dhaliwal I, Zeman-Pocrnich C, Mitchell MA. Diagnostic sensitivity of pleural fluid cytology in malignant pleural effusions: systematic review and meta-analysis. Thorax 2023; 78:32-40. [PMID: 35110369 DOI: 10.1136/thoraxjnl-2021-217959] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 12/30/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pleural fluid cytology is an important diagnostic test used for the investigation of pleural effusions. There is considerable variability in the reported sensitivity for the diagnosis of malignant pleural effusions (MPE) in the literature. OBJECTIVE The purpose of this review is to determine the diagnostic sensitivity of pleural fluid cytology for MPE, both overall and by tumour type, to better inform the decision-making process when investigating pleural effusions. DATA SOURCES A literature search of EMBASE and MEDLINE was performed by four reviewers. Articles satisfying inclusion criteria were evaluated for bias using the QUADAS-2 tool. DATA EXTRACTION For quantitative analysis, we performed a metaanalysis using a binary random-effects model to determine pooled sensitivity. Subgroup analysis was performed based on primary cancer site and meta-regression by year of publication. SYNTHESIS Thirty-six studies with 6057 patients with MPE were included in the meta-analysis. The overall diagnostic sensitivity of pleural fluid cytology for MPE was 58.2% (95% CI 52.5% to 63.9%; range 20.5%-86.0%). There was substantial heterogeneity present among studies (I2 95.5%). For primary thoracic malignancies, sensitivity was highest in lung adenocarcinoma (83.6%; 95% CI 77.7% to 89.6%) and lowest in lung squamous cell carcinoma (24.2%; 95% CI 17.0% to 31.5%) and mesothelioma (28.9%; 95% CI 16.2% to 41.5%). For malignancies with extrathoracic origin, sensitivity was high for ovarian cancer (85.2%; 95% CI 74.2% to 96.1%) and modest for breast cancer (65.3%; 95% CI 49.8% to 80.8%). CONCLUSIONS Pleural fluid cytology has an overall sensitivity of 58.2% for the diagnosis of MPE. Clinicians should be aware of the high variability in diagnostic sensitivity by primary tumour type as well as the potential reasons for false-negative cytology results.PROSPERO registration numberCRD42021231473.
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Affiliation(s)
- Shayan Kassirian
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Stephanie N Hinton
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Sean Cuninghame
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Rushil Chaudhary
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Alla Iansavitchene
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Kayvan Amjadi
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Inderdeep Dhaliwal
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Cady Zeman-Pocrnich
- Department of Pathology and Laboratory Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Michael A Mitchell
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
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Botana Rial M, Pérez Pallarés J, Cases Viedma E, López González FJ, Porcel JM, Rodríguez M, Romero Romero B, Valdés Cuadrado L, Villena Garrido V, Cordovilla Pérez R. Diagnosis and Treatment of Pleural Effusion. Recommendations of the Spanish Society of Pulmonology and Thoracic Surgery. Update 2022. Arch Bronconeumol 2023; 59:27-35. [PMID: 36273933 DOI: 10.1016/j.arbres.2022.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 09/06/2022] [Accepted: 09/07/2022] [Indexed: 12/27/2022]
Abstract
Pleural effusion (PE) is a common yet complex disease that requires specialized, multidisciplinary management. Recent advances, novel diagnostic techniques, and innovative patient-centered therapeutic proposals have prompted an update of the current guidelines. This document provides recommendations and protocols based on a critical review of the literature on the epidemiology, etiology, diagnosis, prognosis, and new therapeutic options in PE, and addresses some cost-effectiveness issues related to the main types of PE.
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Affiliation(s)
- Maribel Botana Rial
- Unidad de Técnicas Broncopleurales, Servicio de Neumología, Hospital Álvaro Cunqueiro (Vigo), Instituto de Investigación Sanitaria Galicia Sur, Spain.
| | - Javier Pérez Pallarés
- Servicio de Neumología, Hospital General Universitario Santa Lucía, Cartagena, Murcia, Spain
| | - Enrique Cases Viedma
- Servicio de Neumología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | | | - José Manuel Porcel
- Unidad de Medicina Pleural, Servicio de Medicina Interna, Hospital Universitario Arnau de Vilanova, IRB Lleida, Universidad de Lleida, Lleida, Spain
| | - María Rodríguez
- Departamento de Cirugía Torácica, Clínica Universidad de Navarra. Madrid, Spain
| | - Beatriz Romero Romero
- Unidad de Endoscopia Respiratoria, Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Virgen del Rocío, Sevilla, Spain
| | - Luis Valdés Cuadrado
- Servicio de Neumología, Complejo Hospitalario Universitario de Santiago, Instituto de Investigación Sanitaria de Santiago de Compostela, Departamento de Medicina, Universidad de Santiago de Compostela, Spain
| | - Victoria Villena Garrido
- Servicio de Neumología, Hospital Universitario 12 de Octubre, Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Spain
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Poon IK, Chan RCK, Choi JSH, Ng JKM, Tang KT, Wong YYH, Chan KP, Yip WH, Tse GM, Li JJX. A comparative study of diagnostic accuracy in 3026 pleural biopsies and matched pleural effusion cytology with clinical correlation. Cancer Med 2023; 12:1471-1481. [PMID: 35848750 PMCID: PMC9883572 DOI: 10.1002/cam4.5038] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 07/01/2022] [Accepted: 07/07/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Pleural effusion can be caused by a wide range of benign and malignant conditions. Pleural biopsy and effusion cytology represent two key methods of pathological diagnosis. To compare the performance these two methods, a large cohort of matched pleural biopsy and effusion cytology with clinical follow-up was reviewed. METHODS Pleural biopsies and effusion cytology specimens over a period of 18 years were retrieved. Cytology specimens collected within 7 days of pleural biopsy were matched. Reports were reviewed, and the cause for pleural effusion was determined by hospital disease coding and clinical data. RESULTS Totally, 3026 cases were included. The leading cause of benign effusion was tuberculosis (n = 650). Malignant pleural effusion (MPE) was more common in older females (p < 0.001) and mostly due to lung cancer (n = 959), breast cancer (n = 64), and mesothelioma (n = 48). The inadequate/insufficient (B1/C1) rate of biopsy was higher than cytology (15.6% vs. 0.3%) but the rates for other diagnostic categories were similar. Biopsy and cytology showed a correlation coefficient of 0.315, improving to 0.449 when inadequate/insufficient (B1/C1) cases were excluded. The ROM for benign cytology (C2) was lower than biopsy (B2) (p < 0.001). Compared with biopsy, the diagnostic accuracy was higher in cytology overall and for metastatic carcinomas (p < 0.001) but lower for hematolymphoid malignancies (p = 0.014) and mesotheliomas (p = 0.002). CONCLUSIONS These results suggest that effusion cytology may be better for confirming benignity and diagnosing carcinomatous MPE. In these cases, pleural biopsy may be withheld to reduce procedural risks. However, for suspected hematolymphoid malignancies and mesothelioma, biopsy should be considered.
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Affiliation(s)
- Ivan K Poon
- Department of Anatomical and Cellular Pathology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Ronald C K Chan
- Department of Anatomical and Cellular Pathology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Joseph S H Choi
- Department of Anatomical and Cellular Pathology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Joanna K M Ng
- Department of Anatomical and Cellular Pathology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Katsie T Tang
- Department of Anatomical and Cellular Pathology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Yolanda Y H Wong
- Department of Anatomical and Cellular Pathology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Ka Pang Chan
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Wing Ho Yip
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Gary M Tse
- Department of Anatomical and Cellular Pathology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Joshua J X Li
- Department of Anatomical and Cellular Pathology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
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29
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Ak G, Metintas S, Taskın AN, Uzel Sener M, Soyler Y, Yilmaz M, Turna A, Akin Kabalak P, Bilaceroglu S, Koksal D, Yilmaz Demirci N, Sogukpinar O, Boga S, Ercelik M, Karadeniz G, Polat G, Guldaval F, Aka Akturk U, Yilmaz S, Ogan N, Yilmaz S, Esendagli D, Caglayan B, Zeybek A, Durmus Kocak N, Mutlu P, Atinkaya Baytemir C, Sarbay I, Yilmaz U, Metintas M. Evaluation of Exudative Pleural Effusions: A Multicenter, Prospective, Observational Study. Lung 2022; 200:807-815. [PMID: 36173482 DOI: 10.1007/s00408-022-00573-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 09/21/2022] [Indexed: 12/30/2022]
Abstract
PURPOSE The aim of this study is to determine the diagnostic performances of pleural procedures in undiagnosed exudative pleural effusions and to evaluate factors suggestive of benign or malignant pleural effusions in tertiary care centers. METHODS This was a multicenter prospective observational study conducted between January 1 and December 31, 2018. A total of 777 patients with undiagnosed exudative pleural effusion after the initial work-up were evaluated. The results of diagnostic procedures and the patients' diagnoses were prospectively recorded. Sensitivity, specificity, and accuracy estimates with 95% confidence intervals were used to examine the performance of pleural procedures to detect malignancy. RESULTS The mean age ± SD of the 777 patients was 62.0 ± 16.0 years, and 68.3% of them were male. The most common cause was malignancy (38.3%). Lung cancer was the leading cause of malignant pleural effusions (20.2%). The diagnostic sensitivity and accuracy of cytology were 59.5% and 84.3%, respectively. The diagnostic sensitivity of image-guided pleural biopsy was 86.4%. The addition of image-guided pleural biopsy to cytology increased diagnostic sensitivity to more than 90%. Thoracoscopic biopsy provided the highest diagnostic sensitivity (94.3%). The highest diagnostic sensitivity of cytology was determined in metastatic pleural effusion from breast cancer (86.7%). CONCLUSION The diagnostic performance increases considerably when cytology is combined with image-guided pleural biopsy in malignant pleural effusions. However, to avoid unnecessary interventions and complications, the development of criteria to distinguish patients with benign pleural effusions is as important as the identification of patients with malignant pleural effusions.
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Affiliation(s)
- Guntulu Ak
- Medical Faculty, Department of Chest Diseases, Eskisehir Osmangazi University, Eskisehir, Turkey.
| | - Selma Metintas
- Medical Faculty, Department of Public Health, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Ayse Naz Taskın
- Department of Chest Diseases, University of Health Sciences Turkey, Ankara Atatürk Sanatory Education and Research Hospital, Ankara, Turkey
| | - Melahat Uzel Sener
- Department of Chest Diseases, University of Health Sciences Turkey, Ankara Atatürk Sanatory Education and Research Hospital, Ankara, Turkey
| | - Yasemin Soyler
- Department of Chest Diseases, University of Health Sciences Turkey, Ankara Atatürk Sanatory Education and Research Hospital, Ankara, Turkey
| | - Meltem Yilmaz
- Medical Faculty, Department of Chest Diseases, Namik Kemal University, Tekirdaǧ, Turkey
| | - Akif Turna
- Department of Thoracic Surgery, Cerrahpasa Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Pınar Akin Kabalak
- Department of Chest Diseases, University of Health Sciences Turkey, Ankara Atatürk Sanatory Education and Research Hospital, Ankara, Turkey
| | - Semra Bilaceroglu
- Department of Pulmonary Medicine, University of Health Sciences Turkey, Izmir Dr Suat Seren Pulmonary Diseases and Thoracic Surgery Training and Research Hospital, Izmir, Turkey
| | - Deniz Koksal
- Medical Faculty, Department of Chest Diseases, Hacettepe University, Ankara, Turkey
| | | | - Ozlem Sogukpinar
- Department of Chest Diseases, University of Health Sciences Turkey, Sureyyapasa Pulmonary Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Sibel Boga
- Department of Chest Diseases, University of Health Sciences Turkey, Sureyyapasa Pulmonary Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Merve Ercelik
- Medical Faculty, Department of Chest Diseases, Duzce University, Duzce, Turkey
| | - Gulistan Karadeniz
- Department of Pulmonary Medicine, University of Health Sciences Turkey, Izmir Dr Suat Seren Pulmonary Diseases and Thoracic Surgery Training and Research Hospital, Izmir, Turkey
| | - Gulru Polat
- Department of Pulmonary Medicine, University of Health Sciences Turkey, Izmir Dr Suat Seren Pulmonary Diseases and Thoracic Surgery Training and Research Hospital, Izmir, Turkey
| | - Filiz Guldaval
- Department of Pulmonary Medicine, University of Health Sciences Turkey, Izmir Dr Suat Seren Pulmonary Diseases and Thoracic Surgery Training and Research Hospital, Izmir, Turkey
| | - Ulku Aka Akturk
- Department of Chest Diseases, University of Health Sciences Turkey, Sureyyapasa Pulmonary Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Senay Yilmaz
- Medical Faculty, Department of Chest Diseases, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Nalan Ogan
- Medical Faculty, Department of Chest Diseases, Ufuk University, Ankara, Turkey
| | - Saliha Yilmaz
- Department of Chest Diseases, University of Health Sciences Turkey, Ankara Atatürk Sanatory Education and Research Hospital, Ankara, Turkey
| | - Dorina Esendagli
- Medical Faculty, Department of Chest Diseases, Baskent University, Ankara, Turkey
| | - Benan Caglayan
- Medical Faculty, Department of Chest Diseases, Koc University, Istanbul, Turkey
| | - Arife Zeybek
- Medical Faculty, Department of Thoracic Surgery, Mugla Sitki Kocman University, Mugla, Turkey
| | - Nagihan Durmus Kocak
- Department of Chest Diseases, University of Health Sciences Turkey, Sureyyapasa Pulmonary Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Pinar Mutlu
- Medical Faculty, Department of Chest Diseases, Canakkale Onsekiz Mart University, Canakkale, Turkey
| | - Cansel Atinkaya Baytemir
- Hamidiye Faculty of Medicine, Department of Thoracic Surgery, University of Health Sciences Turkey, Istanbul, Turkey
| | - Ismail Sarbay
- Department of Thoracic Surgery, Cerrahpasa Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Ulku Yilmaz
- Department of Chest Diseases, University of Health Sciences Turkey, Ankara Atatürk Sanatory Education and Research Hospital, Ankara, Turkey
| | - Muzaffer Metintas
- Medical Faculty, Department of Chest Diseases, Eskisehir Osmangazi University, Eskisehir, Turkey
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Yan Z, Wen JX, Wang H, Jiang TW, Huang JH, Chen H, Yan L, Hu ZD, Zheng WQ. Diagnostic accuracy of pleural fluid lactate dehydrogenase to adenosine deaminase ratio for tuberculous pleural effusion: an analysis of two cohorts. BMC Pulm Med 2022; 22:428. [PMCID: PMC9675061 DOI: 10.1186/s12890-022-02247-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 11/16/2022] [Indexed: 11/21/2022] Open
Abstract
Background This study aimed to evaluate the diagnostic accuracy of pleural fluid (PF) lactate dehydrogenase (LDH) to adenosine deaminase (ADA) (LDH/ADA) ratio for tuberculous pleural effusion (TPE). Especially to explore whether the LDH/ADA ratio provides added diagnostic value to ADA. Methods The diagnostic accuracy of PF LDH/ADA ratio and ADA for TPE was evaluated in two cohorts, named the BUFF (Biomarkers for patients with Undiagnosed pleural eFFusion) cohort (62 with TPE and 194 with non-TPE) and the SIMPLE (a Study Investigating Markers in PLeural Effusion) cohort (33 with TPE and 177 with non-TPE). Receiver operating characteristic (ROC) curve and decision curve were used to measure the diagnostic accuracy of the PF LDH/ADA ratio. The added diagnostic value of the LDH/ADA ratio to ADA was evaluated with net reclassification improvement (NRI) and integrated discrimination improvement (IDI). Results The area under the ROC curves (AUCs) of PF ADA and LDH/ADA ratio in the BUFF cohort were 0.76 and 0.74, respectively. In the SIMPLE cohort, the AUCs of PF ADA and LDH/ADA ratio were 0.80 and 0.85, respectively. The decision curves of PF LDH/ADA and ADA were close in both the BUFF and SIMPLE cohorts. The NRI and IDI analyses did not reveal any added diagnostic value of LDH/ADA to ADA. Conclusions PF LDH/ADA ratio has moderate diagnostic accuracy for TPE. It does not provide added diagnostic value beyond ADA. The current evidence does not support LDH/ADA ratio for diagnosing TPE.
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Affiliation(s)
- Zhi Yan
- grid.413375.70000 0004 1757 7666Department of Laboratory Medicine, The Affiliated Hospital of Inner Mongolia Medical University, Tongdao North Street 1, Hohhot, 010050 China ,grid.410612.00000 0004 0604 6392Department of Parasitology, The Basic Medical Sciences College of Inner Mongolia Medical University, Hohhot, 010050 China
| | - Jian-Xun Wen
- grid.410612.00000 0004 0604 6392Department of Medical Experiment Center, The Basic Medical Sciences College of Inner Mongolia Medical University, Hohhot, 010050 China
| | - Hua Wang
- grid.413375.70000 0004 1757 7666Department of Laboratory Medicine, The Affiliated Hospital of Inner Mongolia Medical University, Tongdao North Street 1, Hohhot, 010050 China ,grid.410612.00000 0004 0604 6392Department of Parasitology, The Basic Medical Sciences College of Inner Mongolia Medical University, Hohhot, 010050 China
| | - Ting-Wang Jiang
- grid.417303.20000 0000 9927 0537Department of Key Laboratory, The Affiliated Changshu Hospital of Xuzhou Medical University, Suzhou, 215500 China
| | - Jin-Hong Huang
- grid.417303.20000 0000 9927 0537Department of Pulmonary and Critical Care Medicine, The Affiliated Changshu Hospital of Xuzhou Medical University, Suzhou, 215500 China
| | - Hong Chen
- grid.417303.20000 0000 9927 0537Department of Pulmonary and Critical Care Medicine, The Affiliated Changshu Hospital of Xuzhou Medical University, Suzhou, 215500 China
| | - Li Yan
- grid.413375.70000 0004 1757 7666Department of Respiratory and Critical Care Medicine, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, 010050 China
| | - Zhi-De Hu
- grid.413375.70000 0004 1757 7666Department of Laboratory Medicine, The Affiliated Hospital of Inner Mongolia Medical University, Tongdao North Street 1, Hohhot, 010050 China
| | - Wen-Qi Zheng
- grid.413375.70000 0004 1757 7666Department of Laboratory Medicine, The Affiliated Hospital of Inner Mongolia Medical University, Tongdao North Street 1, Hohhot, 010050 China ,grid.410612.00000 0004 0604 6392Department of Parasitology, The Basic Medical Sciences College of Inner Mongolia Medical University, Hohhot, 010050 China
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Recuero Díaz JL, Figueroa Almánzar S, Gálvez Muñoz C, Lázaro Sierra J, López Porras M, Márquez Medina D, Nabal Vicuña M, Sánchez Moreno L, González Cantalejo M, Porcel JM. Recommendations of the Spanish Society of Thoracic Surgery for the management of malignant pleural effusion. Cir Esp 2022; 100:673-683. [PMID: 35667609 DOI: 10.1016/j.cireng.2022.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 05/04/2022] [Indexed: 06/15/2023]
Abstract
This article summarizes the clinical guidelines for the diagnosis and treatment of malignant pleural effusion (MPE) sponsored by the Spanish Society of Thoracic Surgery (SECT). Ten clinical controversies were elaborated under the methodology of PICO (Patient, Intervention, Comparison, Outcome) questions and the quality of the evidence and grading of the strength of the recommendations was based on the GRADE system. Immunocytochemical and molecular analyses of pleural fluid may avoid further invasive diagnostic procedures. Currently, the definitive control of MPE can be achieved either by pleurodesis (talc poudrage or slurry) or the insertion of a indwelling pleural catheter (IPC). It is likely that the combination of both techniques (i.e., thoracoscopy with talc poudrage and insertion of a IPC, or instillation of talc slurry through a IPC) will have a predominant role in the future therapeutic management.
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Affiliation(s)
- José Luis Recuero Díaz
- Servicio de Cirugía Torácica, Hospital Universitario Miguel Servet, Zaragoza, Spain; Instituto de Investigación Sanitaria (IIS) de Aragón, Zaragoza, Spain.
| | | | - Carlos Gálvez Muñoz
- Servicio de Cirugía Torácica, Hospital Universitario de Alicante, Alicante, Spain
| | - Javier Lázaro Sierra
- Instituto de Investigación Sanitaria (IIS) de Aragón, Zaragoza, Spain; Servicio de Neumología, Hospital Royo Villanova, Zaragoza, Spain
| | - Marta López Porras
- Servicio de Cirugía Torácica, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Diego Márquez Medina
- Instituto de Investigación Sanitaria (IIS) de Aragón, Zaragoza, Spain; Servicio de Oncología Médica, Hospital Universitario Miguel Servet, Zaragoza, Spain; Universidad de Zaragoza, Zaragoza, Spain
| | - María Nabal Vicuña
- Cuidados Paliativos, Hospital Universitario Arnau de Vilanova, Lleida, Spain
| | - Laura Sánchez Moreno
- Servicio de Cirugía Torácica, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Mar González Cantalejo
- Servicio de Información Biomédica y Biblioteca, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - José M Porcel
- Unidad de Medicina Pleural, Servicio de Medicina Interna, Hospital Universitario Arnau de Vilanova, Lleida, Spain; Institut de Recerca Biomèdica de Lleida Fundació Dr. Pifarré (IRBLleida), Lleida, Spain; Universitat de Lleida, Lleida. Spain
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Baranda García F, Hernández Pérez I, Pijoan Zubizarreta JI, Pérez Fernández S, Gómez Bonilla A, Gómez Crespo B, Solórzano Santobeña J, González Muñoz I, Rezola Carasusan A, Iriberri Pascual M. Factores de riesgo y mortalidad de los derrames pleurales que precisan de una toracocentesis diagnóstica. OPEN RESPIRATORY ARCHIVES 2022. [PMID: 37496966 PMCID: PMC10369594 DOI: 10.1016/j.opresp.2022.100201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Introduction Occurrence of malignant pleural effusion (PE) is known to be associated with a poor prognosis, but the mortality of patients with non-malignant effusions has not been sufficiently studied. Our objective was to describe the clinical course and explore risk factors associated with all-cause mortality at 1, 5 and 10 years in patients who develop a PE. Methods Retrospective observational study of patients undergoing diagnostic thoracentesis during the decade 2008-2017 in a pulmonology service. Demographic, biochemical, pathological and evolutionary variables were evaluated. The etiology of the effusions was determined using standardized criteria. Results Pleural fluid samples from 358 patients with a mean age of 68.9 years (SD 15.1 years), 69.2% males, were analyzed. Malignant (29.4%), parapneumonic (19.8%) and secondary to heart failure (18.9%) effusions predominated. Patients with malignant and heart failure related PE had 1-year mortality rates of 60.0% and 30.8%, respectively, and 85% and 64.7% at 5 years. Male gender (hazard ratio [HR] 1.46; 95% CI: 1.03-2.07), positive cytology for malignancy (HR 1.66; 95% CI: 1.03-2.68) and effusion recurrence (HR 1.61; 95% CI: 1.17-2.21) were associated with a worse prognosis and 5-year mortality. Conclusions Patients undergoing thoracentesis for effusion have a high short and long-term mortality. In our series of hospitalized patients with PE, the factors associated with higher mortality at 1 and 5 years were age, male sex, recurrence of PE, and coexistence of malignancy.
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Porcel JM. Nonmalignant Pleural Effusions. Semin Respir Crit Care Med 2022; 43:570-582. [PMID: 36104027 DOI: 10.1055/s-0042-1748186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Although the potential causes of nonmalignant pleural effusions are many, the management of a few, including complicated pleural infections and refractory heart failure and hepatic hydrothoraces, can be challenging and requires the assistance of interventional pulmonologists. A pragmatic approach to complicated parapneumonic effusions or empyemas is the insertion of a small-bore chest tube (e.g., 14-16 Fr) through which fibrinolytics (e.g., urokinase and alteplase) and DNase are administered in combination. Therapeutic thoracenteses are usually reserved for small to moderate effusions that are expected to be completely aspirated at a single time, whereas video-assisted thoracic surgery should be considered after failure of intrapleural enzyme therapy. Refractory cardiac and liver-induced pleural effusions portend a poor prognosis. In cases of heart failure-related effusions, therapeutic thoracentesis is the first-line palliative therapy. However, if it is frequently needed, an indwelling pleural catheter (IPC) is recommended. In patients with hepatic hydrothorax, repeated therapeutic thoracenteses are commonly performed while a multidisciplinary decision on the most appropriate definitive management is taken. The percutaneous creation of a portosystemic shunt may be used as a bridge to liver transplantation or as a potential definitive therapy in nontransplant candidates. In general, an IPC should be avoided because of the high risk of complications, particularly infections, that may jeopardize candidacy for liver transplantation. Even so, in noncandidates for liver transplant or surgical correction of diaphragmatic defects, IPC is a therapeutic option as valid as serial thoracenteses.
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Affiliation(s)
- José M Porcel
- Pleural Medicine Unit, Department of Internal Medicine, Arnau de Vilanova University Hospital, IRBLleida, University of Lleida, Lleida, Spain
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Cao X, Zhao W, Wen X, Han Y, Yan L, Jiang T, Huang J, Chen H, Zheng W, Hu Z. Pleural homocysteine for malignant pleural effusion: A prospective and double-blind diagnostic test accuracy study. Thorac Cancer 2022; 13:2355-2361. [PMID: 35817406 PMCID: PMC9376178 DOI: 10.1111/1759-7714.14570] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/16/2022] [Accepted: 06/18/2022] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE To assess the accuracy of pleural fluid homocysteine for discriminating malignant pleural effusion (MPE) and benign pleural effusion (BPE). METHODS A total of 194 patients from two cohorts (Hohhot and Changshu) with undiagnosed pleural effusion were prospectively enrolled. Their pleural homocysteine was measured, and its diagnostic accuracy and net benefit for MPE were analyzed by receiver operating characteristic (ROC) curve analysis and decision curve analysis, respectively. RESULTS In the Hohhot cohort (n = 136) and the Changshu cohort (n = 58), MPE patients had significantly higher homocysteine levels than BPE patients. The areas under the ROC curves of homocysteine for the diagnosis of MPE were 0.61 (p = 0.027) and 0.59 (p = 0.247), respectively. The decision curves of homocysteine were close to the reference line in both the Hohhot cohort and the Changshu cohort. CONCLUSION The diagnostic accuracy of pleural fluid homocysteine for MPE was low.
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Affiliation(s)
- Xi‐Shan Cao
- Department of Laboratory MedicineThe Affiliated Hospital of Inner Mongolia Medical UniversityHohhotChina
| | - Wen Zhao
- Department of Laboratory MedicineThe Affiliated Hospital of Inner Mongolia Medical UniversityHohhotChina
| | - Xu‐Hui Wen
- Department of Laboratory MedicineThe Affiliated Hospital of Inner Mongolia Medical UniversityHohhotChina
| | - Yu‐Ling Han
- Department of Laboratory MedicineThe Affiliated Hospital of Inner Mongolia Medical UniversityHohhotChina
| | - Li Yan
- Department of Respiratory and Critical Care MedicineThe Affiliated Hospital of Inner Mongolia Medical UniversityHohhotChina
| | - Ting‐Wang Jiang
- Department of Key LaboratoryThe Affiliated Changshu Hospital of Xuzhou Medical UniversitySuzhouChina
| | - Jin‐Hong Huang
- Department of Pulmonary and Critical Care MedicineThe Affiliated Changshu Hospital of Xuzhou Medical UniversitySuzhouChina
| | - Hong Chen
- Department of Pulmonary and Critical Care MedicineThe Affiliated Changshu Hospital of Xuzhou Medical UniversitySuzhouChina
| | - Wen‐Qi Zheng
- Department of Laboratory MedicineThe Affiliated Hospital of Inner Mongolia Medical UniversityHohhotChina
| | - Zhi‐De Hu
- Department of Laboratory MedicineThe Affiliated Hospital of Inner Mongolia Medical UniversityHohhotChina
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Chang CH, Ost DE. Malignant pleural disease: a pragmatic guide to diagnosis. Curr Opin Pulm Med 2022; 28:282-287. [PMID: 35749791 DOI: 10.1097/mcp.0000000000000877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW The diagnosis of malignant pleural disease is important in the care of patients with cancer. However, a one-size-fits-all approach to diagnosis may lead to delays in care as the sensitivity of each biopsy modality varies and can be dependent on the tumor type. We review current literature on pleural biopsy techniques and propose a diagnostic algorithm for suspected malignant pleural disease. RECENT FINDINGS Recent literature has shown that the sensitivity of pleural fluid cytology varies based on tumor type resulting in a limited value of repeated thoracenteses in many cases. Furthermore, the ability to test for molecular biomarkers on pleural fluid samples has contributed to the recommendations to send large volumes of pleural fluid for analysis. Studies have also supported the consideration of medical thoracoscopy earlier in the diagnostic work-up of malignant pleural disease. SUMMARY The decision to repeat a diagnostic thoracentesis when suspecting malignant pleural effusions should take into account the primary tumor type. Open pleural biopsy with medical thoracoscopy has been shown to be a relatively safe diagnostic modality with high sensitivity and should be considered in patients with a nondiagnostic thoracentesis.
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Affiliation(s)
- Christopher H Chang
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Recuero Díaz JL, Figueroa Almánzar S, Gálvez Muñoz C, Lázaro Sierra J, López Porras M, Márquez Medina D, Nabal Vicuña M, Sánchez Moreno L, González Cantalejo M, M. Porcel J. Recomendaciones de la Sociedad Española de Cirugía Torácica para el manejo del derrame pleural maligno. Cir Esp 2022. [DOI: 10.1016/j.ciresp.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Guinde J, Dutau H, Astoul P. Management of Malignant Pleural Effusion: Where Are We Now? Semin Respir Crit Care Med 2022; 43:559-569. [PMID: 35613947 DOI: 10.1055/s-0042-1748185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Pleural malignancies are among the most common causes of pleural disease and form the basis of our daily pleural practice. There has been significant research and increase in both diagnostic and therapeutic management of malignant pleural diseases in the last decade. Good-quality data have led to a paradigm shift in the management options of pleural malignancies, and indwelling pleural catheter is now recommended and widely used as first-line intervention. Several trials compared different treatment modalities for pleural malignancies and continue to emphasize the need to reduce hospital length of stay and unnecessary pleural intervention, and the importance of patient choice in clinical decision making. This practical review aims to summarize the current knowledge for the management of pleural malignancies, and the understanding of the steps that we still have to climb to optimize management and reduce morbidity.
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Affiliation(s)
- Julien Guinde
- Department of Thoracic Oncology, Pleural Diseases, and Interventional Pulmonology, North University Hospital, Marseille, France
| | - Hervé Dutau
- Department of Thoracic Oncology, Pleural Diseases, and Interventional Pulmonology, North University Hospital, Marseille, France
| | - Philippe Astoul
- Department of Thoracic Oncology, Pleural Diseases, and Interventional Pulmonology, North University Hospital, Marseille, France.,Aix-Marseille University, Marseille, France
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Fan X, Liu Y, Liang Z, Wang S, Yang J, Wu A. Diagnostic Value of Six Tumor Markers for Malignant Pleural Effusion in 1,230 Patients: A Single-Center Retrospective Study. Pathol Oncol Res 2022; 28:1610280. [PMID: 35515016 PMCID: PMC9065255 DOI: 10.3389/pore.2022.1610280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 03/15/2022] [Indexed: 11/13/2022]
Abstract
Background: The diagnostic value of tumor markers in pleural effusion (PE) and serum for malignant pleural effusion (MPE) is still in debate. This study aimed to evaluate the diagnostic value of six tumor markers in PE, serum, and the corresponding PE/serum (PE/S) ratio in distinguishing MPE from benign pleural effusion (BPE). Methods: A total of 1,230 patients with PE (452 MPEs and 778 BPEs) were retrospectively included in the study. PE and serum levels of carcinoembryonic antigen (CEA), carbohydrate antigen 15-3 (CA15-3), carbohydrate antigen 125 (CA125), carbohydrate antigen 19-9 (CA19-9), cytokeratin 19 fragment (CYFRA 21-1), and neuron-specific enolase (NSE) were measured. The area under the curve (AUC) was used to assess the single and combined diagnostic values of the six tumor markers for MPE. Results: The levels of the six tumor markers in PE, serum, and PE/S were significantly higher in MPE than that in BPE, except for serum CA125. PE CEA showed the highest AUC [0.890 (0.871–0.907)] at a cut-off value of 3.7 ng/ml compared to any single tumor marker using receiver operating characteristic (ROC) analysis. The specificity, sensitivity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (PLR), and negative likelihood ratio (NLR) of PE CEA were 74.1%, 95.5%, 90.5%, 86.4%, 16.47, and 0.27, respectively. The combination of PE CEA and serum CYFRA21-1 showed the best diagnostic performance with an AUC of 0.934 (sensitivity, 79.9%; specificity, 95.7%, PPV, 90.5; PLR, 17.35) among all two or three combinations. Besides, serum CYFRA21-1 was the best diagnostic tumor marker in distinguishing cytology-negative MPE from BPE at a cut-off value of 3.0 ng/ml. Conclusion: PE CEA was the best diagnostic tumor marker in distinguishing MPE from BPE. Serum CYFRA21-1 was the best diagnostic tumor marker in distinguishing cytology-negative MPE from BPE. The combination of PE CEA and serum CYFRA21-1 could increase the diagnostic performance in distinguishing MPE from BPE and cytology-negative MPE from BPE.
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Affiliation(s)
- Xin Fan
- Department of Dermatology, Ningbo First Hospital, Ningbo, China
| | - Yanqing Liu
- Department of Laboratory Medicine, Ningbo First Hospital, Ningbo, China
| | - Zhigang Liang
- Department of Thoracic Surgery, Ningbo First Hospital, Ningbo, China
| | - Shanshan Wang
- Department of Laboratory Medicine, Ningbo First Hospital, Ningbo, China
| | - Jing Yang
- Department of Respiratory and Critical Care, Ningbo First Hospital, Ningbo, China
| | - Aihua Wu
- Department of Laboratory Medicine, Ningbo First Hospital, Ningbo, China
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Ahmed R, Aujayeb A. Pleural Effusions and Pericarditis: A Retrospective Cohort Study of Patients Undergoing Cardiac Magnetic Resonance Imaging. Cureus 2022; 14:e23599. [PMID: 35494953 PMCID: PMC9048031 DOI: 10.7759/cureus.23599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2022] [Indexed: 11/05/2022] Open
Abstract
Background Pleural effusions can occur due to acute pericarditis and can necessitate intervention. We sought to add to the evidence base by performing a retrospective review of patients presenting to the advanced cardiac imaging unit with pericarditis and pleural effusion to determine laterality, trends in pleural fluid analyses, and the need for pleural intervention. Local ethical (Caldicott) approval was obtained for this study. Methodology Descriptive statistical methodology was applied with continuous data presented as mean (standard deviation, SD; range) and categorical variables as frequencies or percentages. Results In 60 patients with pericarditis, 24 (39%) had pleural effusions on contemporaneous imaging. The mean age of the study population was 63.3 years (range: 20-83), and 17 patients were males. Diagnoses were viral (five), rheumatological (one), amyloidosis (one), listeria (one), and the rest idiopathic (17). Four effusions were only left-sided, one right-sided, and 20 bilateral. Ten pleural taps were performed, one for a unilateral effusion and nine for one side being bigger than the other. The mean pH was 7.46 (7.33-7.6), mean lactate dehydrogenase was 210 (74-393 U/L), mean fluid protein was 36.1 (19-56 g/L) (four effusions exudative/three transudative), mean glucose was 5.8 (4.8-6.8 mmol/L), and all cytologies were negative. Five patients underwent large volume aspirations for symptom control. Three indwelling pleural catheters (IPC) were placed for treatment refractory effusions. There was one pleural space infection in six months related to an IPC. There were three deaths at 12 months, with none related to pericarditis. Conclusions Pleural effusions associated with pericarditis are usually small, bilateral, and exudative. Treatment refractory cases require pleural intervention, with aspirations, drains, and IPCs being viable options. Further prospective studies are warranted.
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Lu P, Sun Y, Liang B, Yu L. Derivation and validation of a 18F-FDG PET/CT scoring model to predict malignant pleural effusion. Nucl Med Commun 2022; 43:177-185. [PMID: 34864810 DOI: 10.1097/mnm.0000000000001505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To develop an 18F-fluorodeoxyglucose PET/computed tomography (CT) scoring model based on metabolic and radiologic findings of the pleura and fluid to identify malignant pleural effusion. METHODS The PET and CT findings from patients with pleural effusion in the derivation dataset were used to develop a scoring model. Then, the diagnostic accuracy of the predictive score was verified by the validation dataset. RESULTS Eight parameters independently predicting malignancy were retained in the scoring model, including pleural nodules or masses (4 points), focal pleural thickening (2 points), absence of pleural loculation (2 points), thickness of mediastinal pleura involvement ≥0.5 cm (2 points), maximum standardized uptake value (SUVmax) of mediastinal pleura involvement ≥2.3 (2 points), thickness of nonmediastinal pleura involvement ≥0.5 cm (1 point), SUVmax of nonmediastinal pleura involvement ≥3.0 (1 point) and fluid SUVmax ≥1.6 (1 point). The operating characteristics of the PET/CT score were 0.958 area under the curve (AUC), 88.6% sensitivity, 91.2% specificity, 10.09 positive likelihood ratio and 0.13 negative likelihood ratio, with 6 points as the threshold. These values in the validation dataset were 0.947, 91.7%, 88.4%, 7.91 and 0.094, respectively. No difference was found in AUCs between the derivation and validation datasets (z = 0.517, P = 0.697). The negative predictive value was 99.4% in the score from 0 to 2, and the positive predictive value was 98.3% for patients with score between 9 and 15. CONCLUSIONS The PET/CT scoring model is a valuable strategy to help physicians to distinguish malignant-benign pleural effusion and stratify patients who will benefit from invasive procedures.
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Affiliation(s)
| | - Yajuan Sun
- Department of Radiologic Diagnosis, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang
| | | | - Lijuan Yu
- Department of Nuclear Medicine
- Department of Nuclear Medicine, Affiliated Cancer Hospital of Hainan Medical College, Haikou, Hainan, China
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Tousheed SZ, Dutt TS, Annapandian VM. Evolution of semi-rigid thoracoscopy. Indian J Tuberc 2022; 69:12-19. [PMID: 35074144 DOI: 10.1016/j.ijtb.2021.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/04/2021] [Indexed: 06/14/2023]
Abstract
Pleural effusions despite being so common, there is no much literature available regarding definite diagnosis for pleural effusions. Application of Light's criteria changed the approach to pleural effusion and till date remains a very useful step in the diagnosis of pleural effusions. Pleural fluid biochemistry and adenosine deaminase (ADA) enzyme levels play a significant role in the diagnosis of tubercular effusion. Studies have shown that levels of ADA are more often higher in tubercular effusion than in any other cause for it. But ADA levels can also be elevated in other types of parapneumonic effusions (PPEs), especially complicated PPEs. Hence it is difficult to distinguish a tubercular pleural effusion (TPE) from other PPEs based on pleural fluid ADA levels alone. LDH/ADA ratio as an indicator for ruling out tuberculosis was analyzed in few studies with high sensitivity and specificity. The pleural fluid cytology has a varying sensitivity, with a maximum of only 60% and it may increase with subsequent tapping. Closed pleural biopsy using a Cope or Abrams needle has a sensitivity up to 80% in cases of tuberculous effusion and 40%-73% in cases of Malignancies. Semi-rigid thoracoscopy not only allows for visualization of the pleura but also helps in procuring the biopsies under direct visualization from the abnormal looking areas. In cases of primary pleural malignancies like mesothelioma, pleurodesis can also be done in the same setting after taking the biopsy, hence reducing the number of procedures. Limitation of the semi-rigid thoracoscopy is smaller sample size and more superficial sampling of the pleura. Cryobiopsy and Electrocautery guided pleural biopsy using the IT knife are the modifications in the semi-rigid thoracoscopy to overcome the drawback of smaller sample size. While navigation band image guided pleuroscopy helps in better visualization of the vasculature of pleura during the biopsy. Management of pleural effusions has evolved over a period of time. Starting with a single criterion based on pleural fluid proteins to semi-rigid thoracoscopy. The inexhaustible research in this field suggests the desperate need for a gold standard procedure with cost effectiveness in the management of undiagnosed pleural effusions. Semi-rigid thoracoscopy has revolutionized the management of undiagnosed pleural effusions, but it has its own limitations. Various modifications have been proposed and tried to overcome the limitations to make it a cost-effective procedure.
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Affiliation(s)
- Syed Zulkharnain Tousheed
- Department of Pulmonology and Internal Medicine, Mazumdar Shaw Medical Center, Narayana Health City, Bengaluru, India.
| | - Tiyas Sen Dutt
- Department of Respiratory Medicine, Peterborough City Hospital, NHS, UK
| | - Vellaichamy M Annapandian
- Department of Pharmacology, Narayana Institute of Medical Sciences, Narayana Hrudayalaya Foundations, Bengaluru, India
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Wu A, Liang Z, Yuan S, Wang S, Peng W, Mo Y, Yang J, Liu Y. Development and Validation of a Scoring System for Early Diagnosis of Malignant Pleural Effusion Based on a Nomogram. Front Oncol 2021; 11:775079. [PMID: 34950585 PMCID: PMC8688822 DOI: 10.3389/fonc.2021.775079] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 11/17/2021] [Indexed: 01/19/2023] Open
Abstract
Background The diagnostic value of clinical and laboratory features to differentiate between malignant pleural effusion (MPE) and benign pleural effusion (BPE) has not yet been established. Objectives The present study aimed to develop and validate the diagnostic accuracy of a scoring system based on a nomogram to distinguish MPE from BPE. Methods A total of 1,239 eligible patients with PE were recruited in this study and randomly divided into a training set and an internal validation set at a ratio of 7:3. Logistic regression analysis was performed in the training set, and a nomogram was developed using selected predictors. The diagnostic accuracy of an innovative scoring system based on the nomogram was established and validated in the training, internal validation, and external validation sets (n = 217). The discriminatory power and the calibration and clinical values of the prediction model were evaluated. Results Seven variables [effusion carcinoembryonic antigen (CEA), effusion adenosine deaminase (ADA), erythrocyte sedimentation rate (ESR), PE/serum CEA ratio (CEA ratio), effusion carbohydrate antigen 19-9 (CA19-9), effusion cytokeratin 19 fragment (CYFRA 21-1), and serum lactate dehydrogenase (LDH)/effusion ADA ratio (cancer ratio, CR)] were validated and used to develop a nomogram. The prediction model showed both good discrimination and calibration capabilities for all sets. A scoring system was established based on the nomogram scores to distinguish MPE from BPE. The scoring system showed favorable diagnostic performance in the training set [area under the curve (AUC) = 0.955, 95% confidence interval (CI) = 0.942-0.968], the internal validation set (AUC = 0.952, 95% CI = 0.932-0.973), and the external validation set (AUC = 0.973, 95% CI = 0.956-0.990). In addition, the scoring system achieved satisfactory discriminative abilities at separating lung cancer-associated MPE from tuberculous pleurisy effusion (TPE) in the combined training and validation sets. Conclusions The present study developed and validated a scoring system based on seven parameters. The scoring system exhibited a reliable diagnostic performance in distinguishing MPE from BPE and might guide clinical decision-making.
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Affiliation(s)
- Aihua Wu
- Department of Laboratory Medicine, Ningbo First Hospital, Ningbo, China
| | - Zhigang Liang
- Department of Thoracic Surgery, Ningbo First Hospital, Ningbo, China
| | - Songbo Yuan
- Department of Clinical Laboratory, The Affiliated People Hospital of Ningbo University, Ningbo, China
| | - Shanshan Wang
- Department of Laboratory Medicine, Ningbo First Hospital, Ningbo, China
| | - Weidong Peng
- Department of Respiratory and Critical Care Medicine, The Affiliated People Hospital of Ningbo University, Ningbo, China
| | - Yijun Mo
- Department of Laboratory Medicine, Ningbo First Hospital, Ningbo, China
| | - Jing Yang
- Department of Respiratory and Critical Care Medicine, Ningbo First Hospital, Ningbo, China
| | - Yanqing Liu
- Department of Laboratory Medicine, Ningbo First Hospital, Ningbo, China
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Biancosino C, van der Linde LIS, Sauter G, Stellmacher F, Krüger M, Welker L. Cytological Diagnostic Procedures in Malignant Mesothelioma. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1374:41-49. [PMID: 34787829 DOI: 10.1007/5584_2021_680] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Malignant mesotheliomas (MM) are rare tumors with high mortality rates, whose incidence varies regionally and nationally, and the diagnosis is difficult. Histology-based diagnosis is considered the gold standard despite its low sensitivity of 57-84%. However, recent advances in cytological analysis offer promise for diagnostic advancements. In this study, we reappraised the current cytological guidelines for the MM diagnosis and concluded on their practicability and reliability. The study included 5731 consecutive specimens of pleural effusions from 4552 patients (3026 males of the average age of 67.5 years and 1526 females of the average age of 65.4 years) between December 2017 and January 2000. Out of these patients, 444 (9.8%) were diagnosed with MM. The effusions were examined by immunocytochemistry using routine Giemsa staining. Additionally, hyaluronic acid (HA) was assessed. Cytological findings confirmed 223 out of the 444 MM. The additional 88 cases with negative cytology were corroborated by supplemental assessments of HA above 30 mg/L. Cytological evaluation accomplished the sensitivity of 0.50, specificity of 0.99, and a positive predictive value (PPV) of 0.97 for MM diagnosis. The use of HA determination raised the sensitivity to 0.70 without affecting the specificity or PPV. We conclude that cytological evaluation of effusions aided by the assessment of HA demonstrates the diagnostic sensitivity and specificity for MM no less than the hitherto standard histological evaluation. The cytology-based MM diagnosis may thus be routinely considered when MM is suspected and may offer confirmatory advantages in difficult or doubtful diagnostic cases.
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Affiliation(s)
- Christian Biancosino
- Department of Thoracic Surgery, HELIOS University Hospital Wuppertal, Wuppertal, Germany.
| | | | - Guido Sauter
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Marcus Krüger
- Department of Thoracic Surgery, Martha - Maria Hospital Halle, Halle, Germany
| | - Lutz Welker
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Abstract
Fifty years from their initial description, Light's criteria are still unhesitatingly accepted as the default reference test for separating pleural transudates and exudates. Efforts should be focused not so much on trying to find an even more reliable technique for categorizing PEs but on improving the misclassification rate of transudates that characterize Light's criteria. Despite their shortcomings, Light's criteria may well continue their reign for another 50 years. Long live the Light's criteria!
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Nicotinamide phosphoribosyltransferase as a biomarker for the diagnosis of infectious pleural effusions. Sci Rep 2021; 11:21121. [PMID: 34702907 PMCID: PMC8548599 DOI: 10.1038/s41598-021-00653-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 10/15/2021] [Indexed: 11/08/2022] Open
Abstract
Nicotinamide phosphoribosyltransferase (NAMPT) has been reported to be involved in infectious diseases, but it is unknown whether it plays a role in infectious pleural effusions (IPEs). We observed the levels of NAMPT in pleural effusions of different etiologies and investigated the clinical value of NAMPT in the differential diagnosis of infectious pleural effusions. A total of 111 patients with pleural effusion were enrolled in the study, including 25 parapneumonic effusions (PPEs) (17 uncomplicated PPEs, 3 complicated PPEs, and 5 empyemas), 30 tuberculous pleural effusions (TPEs), 36 malignant pleural effusions (MPEs), and 20 transudative effusions. Pleural fluid NAMPT levels were highest in the patients with empyemas [575.4 (457.7, 649.3) ng/ml], followed by those with complicated PPEs [113.5 (103.5, 155.29) ng/ml], uncomplicated PPEs [24.9 (20.2, 46.7) ng/ml] and TPEs [88 (19.4, 182.6) ng/ml], and lower in patients with MPEs [11.5 (6.5, 18.4) ng/ml] and transudative effusions [4.3 (2.6, 5.1) ng/ml]. Pleural fluid NAMPT levels were significantly higher in PPEs (P < 0.001) or TPEs (P < 0.001) than in MPEs. Moreover, Pleural fluid NAMPT levels were positively correlated with the neutrophil percentage and lactate dehydrogenase (LDH) levels and inversely correlated with glucose levels in both PPEs and TPEs, indicating that NAMPT was implicated in the neutrophil-associated inflammatory response in infectious pleural effusion. Further, multivariate logistic regression analysis showed pleural fluid NAMPT was a significant predictor distinguishing PPEs from MPEs [odds ratio (OR) 1.180, 95% confidence interval (CI) 1.052-1.324, P = 0.005]. Receiver-operating characteristic (ROC) analysis demonstrated that NAMPT was a promising diagnostic factor for the diagnosis of infectious effusions, with the areas under the curve for pleural fluid NAMPT distinguishing PPEs from MPEs, TPEs from MPEs, and IPEs (PPEs and TPEs) from NIPEs were 0.92, 0.85, and 0.88, respectively. In conclusion, pleural fluid NAMPT could be used as a biomarker for the diagnosis of infectious pleural effusions.
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46
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Cell block examination of pleural fluid, an underused and overlooked method for evaluation of malignant pleural effusion. Am J Med Sci 2021; 363:556-557. [PMID: 34666061 DOI: 10.1016/j.amjms.2021.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 06/25/2021] [Accepted: 10/14/2021] [Indexed: 11/20/2022]
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Shojaee S, Roy-Chowdhuri S, Safi J, Grosu HB. Cytologic Investigations for the Diagnosis of Malignant Pleural Effusion in Non-small Cell Lung Cancer: State-of-the-art Review for Pulmonologists. J Bronchology Interv Pulmonol 2021; 28:310-321. [PMID: 34238837 DOI: 10.1097/lbr.0000000000000789] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 05/26/2021] [Indexed: 12/24/2022]
Abstract
Lung cancer is the current leading cause of cancer-related deaths worldwide, and malignant pleural effusion, an indicator of the advanced stage of this disease, portends a poor prognosis. Thus, making an accurate diagnosis of malignant pleural effusion is of paramount importance. During the past decade, the prognosis of patients with advanced non-small cell lung cancer has improved substantially, especially in those treated with targeted therapy and immunotherapy. The use of pleural fluid cytology should not only provide diagnoses but also aid in the selection of targeted therapies, especially when obtaining a histologic specimen is too difficult. In this evidence-based review, we address the importance of pleural fluid cytology in non-small cell lung cancer patients, from making the diagnosis to making treatment-related decisions when only pleural fluid is available.
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Affiliation(s)
- Samira Shojaee
- Department of Pulmonary Medicine, Virginia Commonwealth University, Richmond, VA
| | - Sinchita Roy-Chowdhuri
- Departments of Pathology
- Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Javeryah Safi
- Department of Pulmonary Medicine, Virginia Commonwealth University, Richmond, VA
| | - Horiana B Grosu
- Departments of Pathology
- Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
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Clinical and Epidemiological Features of Tuberculous Pleural Effusion in Alicante, Spain. J Clin Med 2021; 10:jcm10194392. [PMID: 34640410 PMCID: PMC8509524 DOI: 10.3390/jcm10194392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 09/23/2021] [Accepted: 09/24/2021] [Indexed: 11/17/2022] Open
Abstract
We aimed to (1) evaluate the incidence of tuberculous pleural effusion (TPE) over 25 years in our centre; (2) measure the yield of different diagnostic techniques; (3) compare TPE features between immigrant and native patients. Retrospective study of patients who underwent diagnostic thoracentesis and pleural biopsy in our hospital between 1995 and 2020. TPE was diagnosed in 71 patients (65% natives, 35% immigrants). Onset was acute in 35%, subacute in 26% and prolonged in 39%. Radiological features were atypical in 42%. Thoracentesis specimens were lymphocyte-predominant in 84.5% of patients, with elevated adenosine deaminase in 75% of patients. Diagnostic yield of pleural biopsy was 78%. Compared with native patients, more immigrants had previous contact with TB (54% vs. 17%, p = 0.001), prior TB (21% vs. 4%, p < 0.02) and atypical radiological features (58% vs. 34%, p < 0.03). TPE incidence was six times higher in the immigrant population (6.7 vs. 1.1 per 100,000 person-years, p < 0.001). TPE has an acute onset and sometimes atypical radiological features. Pleural biopsy has the highest diagnostic yield. Reactivation, prior contact with TB, atypical radiological features, complications, and positive microbiology results are more common in immigrant patients.
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49
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Diagnosis of tuberculous pleural effusions: A review. Respir Med 2021; 188:106607. [PMID: 34536698 DOI: 10.1016/j.rmed.2021.106607] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/19/2021] [Accepted: 09/03/2021] [Indexed: 01/24/2023]
Abstract
Tuberculous pleural effusion (TPE) is the second most common presentation of extrapulmonary tuberculosis. The paucibacillary nature of the effusion poses diagnostic challenges. Biomarkers like adenosine deaminase and interferon-γ have some utility for diagnosing TPEs, as do cartridge-based polymerase chain reaction (PCR) methods. When these fluid studies remain indeterminate, pleural biopsies must be performed to confirm the diagnosis. This review article elaborates on the scientific evidence available for various diagnostic tests and presents a practical approach to the diagnosis of TPEs.
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50
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Garrison GW, Cho JL, Deng JC, Camac E, Oh S, Sundar K, Baptiste JV, Cheng GS, De Cardenas J, Fitzgerald C, Garfield J, Ha NT, Holden VK, O’Corragain O, Patel S, Wayne MT, McSparron JI, Wang T, Çoruh B, Hayes MM, Guzman E, Channick CL. ATS Core Curriculum 2021. Adult Pulmonary Medicine: Thoracic Oncology. ATS Sch 2021; 2:468-483. [PMID: 34667994 PMCID: PMC8518653 DOI: 10.34197/ats-scholar.2021-0032re] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 05/25/2021] [Indexed: 11/18/2022] Open
Abstract
The American Thoracic Society Core Curriculum updates clinicians annually in adult and pediatric pulmonary disease, medical critical care, and sleep medicine at the annual international conference. The 2021 Pulmonary Core Curriculum focuses on lung cancer and include risks and prevention, screening, nodules, therapeutics and associated pulmonary toxicities, and malignant pleural effusions. Although tobacco smoking remains the primary risk factor for developing lung cancer, exposure to other environmental and occupational substances, including asbestos, radon, and burned biomass, contribute to the global burden of disease. Randomized studies have demonstrated that routine screening of high-risk smokers with low-dose chest computed tomography results in detection at an earlier stage and reduction in lung cancer mortality. On the basis of these trials and other lung cancer risk tools, screening recommendations have been developed. When evaluating lung nodules, clinical and radiographic features are used to estimate the probability of cancer. Management guidelines take into account the nodule size and cancer risk estimates to provide recommendations at evaluation. Newer lung cancer therapies, including immune checkpoint inhibitors and molecular therapies, cause pulmonary toxicity more frequently than conventional chemotherapy. Treatment-related toxicity should be suspected in patients receiving these medications who present with respiratory symptoms. Evaluation is aimed at excluding other etiologies, and treatment is based on the severity of symptoms. Malignant pleural effusions can be debilitating. The diagnosis is made by using simple pleural drainage and/or pleural biopsies. Management depends on the clinical scenario and the patient's preferences and includes the use of serial thoracentesis, a tunneled pleural catheter, or pleurodesis.
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Affiliation(s)
- Garth W. Garrison
- Divison of Pulmonary Disease and Critical Care Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont
| | - Josalyn L. Cho
- Division of Pulmonary, Critical Care and Occupational Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Jane C. Deng
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | - Erin Camac
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Scott Oh
- Division of Pulmonary, Critical Care Medicine, Clinical Immunology, and Allergy, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Krishna Sundar
- Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah, Salt Lake City, Utah
| | - Janelle V. Baptiste
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center–Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Guang-Shing Cheng
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Jose De Cardenas
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
- Section of Thoracic Surgery, Department of Surgery, School of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Codi Fitzgerald
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Jamie Garfield
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Ngoc-Tram Ha
- Division of Pulmonary and Critical Care Medicine, School of Medicine, University of Maryland, Baltimore, Maryland; and
| | - Van K. Holden
- Division of Pulmonary and Critical Care Medicine, School of Medicine, University of Maryland, Baltimore, Maryland; and
| | - Oisin O’Corragain
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Sahil Patel
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center–Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Max T. Wayne
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | - Jakob I. McSparron
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | - Tisha Wang
- Division of Pulmonary, Critical Care Medicine, Clinical Immunology, and Allergy, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Başak Çoruh
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Margaret M. Hayes
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center–Harvard Medical School, Harvard University, Boston, Massachusetts
| | | | - Colleen L. Channick
- Division of Pulmonary, Critical Care Medicine, Clinical Immunology, and Allergy, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
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