Causes and Management of Common Benign Pleural Effusions

Incidental Metastatic Lung Cancer in a Patient Being Treated for Community-Acquired Pneumonia: The Case for Lung Cancer Screening in Rural America

Lung cancer is the leading cause of cancer deaths in the United States. Efforts to decrease the number of deaths over the last decade have included the publication of guidelines by the United States Preventive Services Task Force (USPSTF) recommending annual low-dose computed tomography (LDCT) scanning in patients meeting specific criteria in order to facilitate the detection and classification of potential cancers, allowing for earlier and possibly curative intervention. Unfortunately, not every patient who meets these criteria will receive LDCT surveillance due to low socioeconomic status, geographic barriers, and limited access to healthcare related to the growing shortage of primary care physicians. We describe a case in which a patient located in a rural southeastern region of the United States presented to the emergency room with a one-week history of fevers, cough, and shortness of breath. Chest imaging revealed findings consistent with community-acquired pneumonia (CAP). He had over a 30-pack-year history of smoking cigarettes and fit the additional criteria within the USPSTF recommendations for annual LDCT scans for lung cancer screening though no screening records were found. While being treated for CAP as an inpatient, the decision was made to perform additional imaging of the patient's left hip, as he had been having increasing pain during the hospital stay. A mass lesion was seen on computed tomography (CT) scan in the posterior acetabular roof, prompting additional imaging and biopsy, which led to findings consistent with stage IV metastatic pulmonary adenocarcinoma. While improvements in both imaging and classification of potentially malignant pulmonary nodules and masses have been observed since the USPSTF recommendations were first released in 2013 and with the 2021 update, rural populations with high-risk patients who fit the criteria for LDCT scanning remain vulnerable to non-screening. This patient may have benefitted from annual LDCT screening for lung cancer. Encouraging primary care physicians to not only screen for current tobacco use but also to have necessary resources on hand in clinics to arrange for timely and appropriate screening appointments and follow-up visits is integral to improving the detection and early management of lung cancer. System-wide implementation of actions that may be carried out on multiple levels of care might provide both practitioners and patients with additional tools needed in a rural setting to decrease the number of lung cancer deaths.

Lung Cancer: Spectral and Numerical Differentiation among Benign and Malignant Pleural Effusions Based on the Surface-Enhanced Raman Spectroscopy

We present here that the surface-enhanced Raman spectroscopy (SERS) technique in conjunction with the partial least squares analysis is as a potential tool for the differentiation of pleural effusion in the course of the cancerous disease and a tool for faster diagnosis of lung cancer. Pleural effusion occurs mainly in cancer patients due to the spread of the tumor, usually caused by lung cancer. Furthermore, it can also be initiated by non-neoplastic diseases, such as chronic inflammatory infection (the most common reason for histopathological examination of the exudate). The correlation between pleural effusion induced by tumor and non-cancerous diseases were found using surface-enhanced Raman spectroscopy combined with principal component regression (PCR) and partial least squares (PLS) multivariate analysis method. The PCR predicts 96% variance for the division of neoplastic and non-neoplastic samples in 13 principal components while PLS 95% in only 10 factors. Similarly, when analyzing the SERS data to differentiate the type of tumor (squamous cell vs. adenocarcinoma), PLS gives more satisfactory results. This is evidenced by the calculated values of the root mean square errors of calibration and prediction but also the coefficients of calibration determination and prediction (R2C = 0.9570 and R2C = 0.7968), which are more robust and rugged compared to those calculated for PCR. In addition, the relationship between cancerous and non-cancerous samples in the dependence on the gender of the studied patients is presented.

Assessment of the diagnostic value of CEA, CA125, and CRP and their cut-off point for discrimination of exudative pleural effusions

Pleural effusion is divided into exudative and transudative effusion, and the distinction between exudate and transudate requires multiple investigations of biochemical parameters and their comparison in pleural fluid and serum. This study aimed to assess the diagnostic value of CEA, CA125, and CRP and their cut-off point for discrimination of exudative pleural effusions. This epidemiological and cross-sectional study was performed on 50 patients aged between 18 to 90 years with the diagnosis of exudative pleural effusion referred to Imam Khomeini Hospital in Ahvaz in 2018 and 2019. Demographic and clinical information of patients were collected. The pleural effusion was diagnosed based on physical examination and chest radiography. Pleural effusion was confirmed by thoracentesis. A pleural fluid sample was taken from all patients, and the levels of CEA, CA125, and CRP markers were measured in the pleural fluid. Differentiation of transudate and exudate pleural effusions was performed using Light criteria. The mean CEA and CA125 level of pleural fluid were significantly higher, and the mean CRP level of pleural fluid was significantly lower in patients with malignant diagnoses (P <0.05). Cut-off value with highest sensitivity and specificity in differentiating types of exudative pleural effusions was obtained for CEA tumor marker (greater than 49.8), CA125 tumor marker (greater than 814.02), and CRP marker (less than 7.56). Also, in differentiating types of exudative pleural effusions, CEA tumor marker had sensitivity (89.03%) and specificity (78.42%); CA125 tumor marker had sensitivity (53.18%) and specificity (62.44%), and CRP marker had sensitivity (82.16%), and specificity (89.05%) were. Although the tumor markers had high specificity in the present study, the low sensitivity of some of these tumor markers reduced their diagnostic value. On the other hand, given the numerous advantages of tumor markers, such as low cost and non-invasive, combining them with another can increase the diagnostic value and accuracy.

BCNU (Bis-chloroethylnitrosourea, Carmustine) Toxicity Presented as a Large Pleural Effusion 60 Days Post Autologous Stem Cell Transplant for Non-Hodgkin Lymphoma

Non-Hodgkin lymphoma is a commonly encountered malignancy. Treatment for advanced stages commonly consists of chemotherapy followed by autologous stem cell transplant. BCNU (bis-chloroethylnitrosourea, carmustine) is frequently used as part of the conditioning regimen for autologous stem cell transplant. BCNU is well known to cause pulmonary toxicity, but it is uncommon for pulmonary toxicity to present as a pleural effusion. In our case, a patient with non-Hodgkin lymphoma, particularly mantle cell lymphoma, was given BCNU prior to autologous stem cell transplant. The BCNU resulted in the patient developing large bilateral pleural effusions 60 days post transplant. Knowledge of this potential complication following BCNU use as well as proper treatment can help patients avoid excessive medical visits and tests.

Pleural transudate: pathophysiology during superior vena cava syndrome

Pathophysiology, diagnosis and treatment of pleural transudates has widely been described in the literature [1–3]. Except for left heart failure, which requires diuretics, thoracoscopic talc pleurodesis appears to be a safe and effective therapeutic option [4–6]. We report the case of a woman who presented with a sudden pleural fluid formation from her parietal pleura during a talc pleurodesis for a recurrent transudative pleural effusion. We discuss the pathophysiology of this phenomenon.

Pleural transudative effusion arises from imbalances between the hydrostatic and/or oncotic pressures. Temperature drop following talc poudrage through a spray may accentuate the pressure changes induced by superior vena cava syndrome.http://ow.ly/EpZm30nwVZj

Malignant pleural mesothelioma presenting with remitting-relapsing pleural effusions: report of two cases

Pleural effusions are common and are associated with malignancy in one sixth of cases. Malignant pleural effusion (MPE) is typically persistent and progressive, prompting further investigations if the initial tests are not diagnostic. A spontaneously remitting effusion is commonly presumed to be benign, and further investigations may not be performed. We present two cases in which the presenting pleural effusion spontaneously resolved but recurred (in one case, multiple times), leading to further investigations that revealed an underlying malignant pleural epithelioid mesothelioma. These cases demonstrate the need for clinicians to be aware that remitting effusions can occur in the context of pleural malignancy and should be kept under observation, with a low threshold for further investigation if relapse occurs.

Diagnostic value of tumour markers in pleural effusions

Introduction

We investigated whether tumour markers carcinoembryonic antigen (CEA), neuron-specific enolase (NSE), cancer antigen 125 (CA-125), and cytokeratin 19 fragment (CYFRA 21-1) in pleural effusions and serum can be used to distinguish pleural effusion aetiology.

Materials and methods

During the first thoracentesis, we measured pleural fluid and serum tumour marker concentrations and calculated the pleural fluid/serum ratio for patients diagnosed with pleural effusion, using electrochemiluminescence immunoassays. Receiver operating characteristic (ROC) analysis was carried out and the Hanley and McNeil method was used to test the significance of the difference between the areas under ROC curves (AUCs). In order to detect which tumour marker best discriminates between malignant and non-malignant pleural effusions and to establish the predictive value of those markers, discriminant function analysis (DFA) and logistic regression analysis were utilized.

Results

Serum tumour markers CYFRA 21-1 and NSE as well as pleural NSE were good predictors of pleural effusion malignancy and their combined model was found statistically significant (Chi-square = 28.415, P < 0.001). Respective ROC analysis showed significant discrimination value of the combination of these three markers (AUC = 0.79).

Conclusions

Serum markers showed superiority to pleural fluid markers in determining pleural fluid aetiology. Serum CYFRA 21-1 and NSE concentrations as well as pleural fluid NSE values had the highest clinical value in differentiating between malignant and non-malignant pleural effusions. The combination of these three markers produced a significant model to resolve pleural effusion aetiology.

Vascular endothelial growth factor and protein level in pleural effusion for differentiating malignant from benign pleural effusion

Pleural effusion is associated with multiple benign and malignant conditions. Currently no biomarkers differentiate malignant pleural effusion (MPE) and benign pleural effusion (BPE) sensitively and specifically. The present study identified a novel combination of biomarkers in pleural effusion for differentiating MPE from BPE by enrolling 75 patients, 34 with BPE and 41 with MPE. The levels of lactate dehydrogenase, glucose, protein, and total cell, neutrophil, monocyte and lymphocyte counts in the pleural effusion were measured. The concentrations of interleukin (IL)-1β, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12, tumor necrosis factor-α, interferon γ, transforming growth factor-β1, colony stimulating factor 2, monocyte chemoattractant protein-1 and vascular endothelial growth factor (VEGF) were detected using cytometric bead arrays. Protein and VEGF levels differed significantly between patients with BPE and those with MPE. The optimal cutoff value of VEGF and protein was 214 pg/ml and 3.35 g/dl respectively, according to the receiver operating characteristic curve. A combination of VEGF >214 pg/ml and protein >3.35 g/dl in pleural effusion presented a sensitivity of 92.6% and an accuracy of 78.6% for MPE, but was not associated with a decreased survival rate. These results suggested that this novel combination strategy may provide useful biomarkers for predicting MPE and facilitating early diagnosis.

Accuracy of complement activation product levels to detect infected pleural effusion in rats

BACKGROUND

Pleural empyema is a well-known complication of pneumonia. If treatment is delayed, empyema may increase morbidity and mortality in affected patients. Therefore, the identification of empyema biomarkers in parapneumonic pleural effusion is desirable. Previous research has suggested complement activation products as candidate empyema markers.

OBJECTIVE

To compare the levels of complement activation products C3a, C5a, and C5b9 in pleural effusion induced by Staphylococcus aureus (SA), Streptococcus pneumoniae (SP), or turpentine (control).

METHODS

Thirty-nine male Wistar rats (mean weight 414 g; 290-546 g) were allocated as follows: 17 animals in the SA group, 12 in the SP group, and 10 in the control group. Bacteria or turpentine were injected into the pleural space. After 12 hr, intrapleural fluid was collected using ultrasound-guided thoracentesis. Levels of complement activation products were determined using ELISA kits.

RESULTS

Two SA and one SP animals died before 12 hr. Mean levels were as follows: C3a: 1066.82 µg/ml (937.29-1196.35 µg/ml) in SA, 1188.28 µg/ml (1095.65-1280.92 µg/ml) in SP, and 679.13 µg/ml (601.29-756.98 µg/ml) in controls (P < 0.001); C5a: 55.727 ng/ml (41.22-70.23 ng/ml) in SA, 520.107 ng/ml (278.92-761.3 ng/ml) in SP, and 5.268 ng/ml (1.68-8.85 ng/ml) in controls (P < 0.001); C5b9: 15.02 ng/ml (13.1-16.94 ng/ml) in SA, 16.63 ng/ml (14.37-18.9 ng/ml) in SP, and 14.05 ng/ml (9.8-18.29 ng/ml) in controls (P = 0.692). ROC analysis revealed an area under the curve of 0.987 (95% CI: 0.953-1) for C3a; 1 (1-1) for C5a; and 0.757 for C5b9 (0.523-0.990).

CONCLUSIONS

In the present rat model, complement activation fragments C3a and C5a accurately detected infected pleural effusion. Pediatr Pulmonol. 2017;52:757-762. © 2017 Wiley Periodicals, Inc.

Role of MCP-1 in pleural effusion development in a carrageenan-induced murine model of pleurisy

BACKGROUND AND OBJECTIVE

Exudative pleural effusions affect over 1500 patients per million population each year. The pathobiology of pleural exudate formation remains unclear. Our recent study revealed monocyte chemotactic protein-1 (MCP-1) as a key driver of fibrinolytic-induced exudate effusion while another study found a role for MCP-1 in malignant effusion formation. In the present study, we further evaluated the role of MCP-1 in the development of pleural effusion in a mouse model of acute pleural inflammation.

METHODS

λ-Carrageenan (CAR) was injected into the pleural cavity of CD1 mice and pleural effusion volume measured up to 16 h post-injection. Pleural effusion and serum protein and MCP-1 concentrations were measured and differential cell counts performed in fluids. Mice were also treated with either intraperitoneal (i) anti-MCP-1 antibody or isotype control or (ii) an MCP-1 receptor (CCR2) antagonist or vehicle control 12 h prior to and at the time of CAR injection.

RESULTS

Intrapleural CAR induced significant pleural fluid accumulation (300.0 ± 49.9 μL) in mice after 4 h. Pleural fluid MCP-1 concentrations were significantly higher than corresponding serum MCP-1 (144 603 ± 23 204 pg/mL vs 3703 ± 801 pg/mL, P < 0.0001). A significant decrease in pleural fluid formation was seen both with anti-MCP-1 antibody (median (interquartile range, IQR): 36 (0-168) μL vs controls 290 (70-436) μL; P = 0.02) or CCR2 antagonist (153 (30-222) μL vs controls 240 (151-331) μL, P = 0.0049).

CONCLUSIONS

Blockade of MCP-1 activity significantly reduced inflammatory pleural effusion formation in a CAR model. Together with recent successes in MCP-1 blockade in other effusion formation models, our data strongly support clinical evaluation of MCP-1 antagonists as a novel approach to pleural fluid management.

Experience with indwelling pleural catheters in the treatment of recurrent pleural effusions

Recurrent pleural effusions are frequently encountered in clinical practice. Whether malignant or nonmalignant, they often pose a challenge to the practicing clinician. When they recur, despite optimum medical therapy of the underlying condition and repeated thoracenteses, more invasive definitive approaches are usually required. Since its introduction in 1997, the PleurX catheter became the preferred method to treat recurrent malignant pleural effusions. Since then, a number of publications have documented its utility in managing recurrent nonmalignant pleural effusions. The purpose of this paper is to review the use of the PleurX catheter in recurrent pleural effusions.

A 22-year-old man with pleural tuberculosis associated hydropneumothorax: Case report and literature review

A 22-year-old Asian male presented with fever, non-productive cough, right-sided pleuritic chest pain and was found to have a large right hydropneumothorax. A chest tube was placed. Pleural fluid analysis revealed a lymphocytic predominant exudate and he was subsequently started on four-drug daily anti-tuberculosis therapy (isoniazid, ethambutol, rifampin, pyrazinamide). Pleural biopsy revealed acid-fast bacilli. Given his persistent pleural effusion, he was given four doses of intrapleural tissue plasminogen activator (tPA) and dornase alpha (DNase) via his chest tube over a period of 6 days resulting in clinical and radiologic improvement. Pleural biopsy and pleural fluid culture specimens later revealed Mycobacterium tuberculosis. Intrapleural tPA-DNase therapy has demonstrated improved resolution of infections and shortened hospitalizations for parapneumonic infectious effusions. However, there is little literature on the use of intrapleural fibrinolytics specifically for pleural tuberculosis associated effusions. Furthermore, the American Thoracic Society does not comment on therapeutic thoracentesis or intrapleural fibrinolytic therapy in their recommendations for treatment of pleural tuberculosis. In our case of pleural TB-associated hydropneumothorax, the use of intrapleural tPA-DNase therapy facilitated pleural fluid drainage and resulted in near-complete resolution of the effusion.

Comparison of mesothelin and fibulin-3 in pleural fluid and serum as markers in malignant mesothelioma

PURPOSE OF REVIEW

Malignant mesothelioma is an asbestos-induced, aggressive tumour, which frequently presents with pleural effusion. There are over 60 reported causes that can result in the development of a pleural effusion. Currently, there are no tumour biomarkers in widespread clinical use for the differential diagnosis of mesothelioma from other diseases. With the incidence of mesothelioma expected to continue to increase, it is timely to review the current status of effusion-based biomarkers for mesothelioma diagnosis.

RECENT FINDINGS

The majority of recent studies have evaluated soluble mesothelin in effusions in a diagnostic setting for mesothelioma. However, at high specificity, the sensitivity of the assay is limited to approximately 60% at the time of diagnosis. There is considerable research effort directed toward the identification of new markers for mesothelioma through a variety of genomic, proteomic and immunomic based platforms. One of the few new biomarkers to be identified through a biomarker discovery pipeline and evaluated in pleural effusions is fibulin-3. Preliminary results on the diagnostic accuracy of fibulin-3 have been inconsistent.

SUMMARY

To date, soluble mesothelin remains the best available biomarker for mesothelioma and a positive result is clinically useful in patients with pleural effusions in whom the diagnosis is uncertain.

Diagnostic value and safety of medical thoracoscopy in tuberculous pleural effusion

BACKGROUND

Differentiating tuberculous pleural effusion from other lymphocytic pleural effusions is often challenging. This retrospective study aimed to assess the efficacy and safety of medical thoracoscopy in patients with suspected tuberculous pleural effusion.

METHODS

Between July 2005 and June 2014, patients with pleural effusions of unknown etiologies underwent medical thoracoscopy in our institute after less invasive means of diagnosis had failed. Demographic, radiographic, procedural, and histological data of patients with tuberculous pleural effusion were analyzed.

RESULTS

During this 9-year study, 333 of 833 patients with pleural effusion were confirmed to have tuberculous pleurisy. Under thoracoscopy, we observed pleural nodules in 69.4%, pleural adhesion in 66.7%, hyperemia in 60.7%, plaque-like lesions in 6.0%, ulceration in 1.5% of patients with tuberculous pleurisy. Pleural biopsy revealed the presence of Mycobacterium tuberculosis in the pleural tissue or/and demonstration of caseating granulomas in 330 (99.1%) patients. No serious adverse events were recorded, and the most common minor complication was transient chest pain (43.2%) from the indwelling chest tube.

CONCLUSIONS

Our data showed that medical thoracoscopy is a simple procedure with high diagnostic yield and excellent safety for the diagnosis of tuberculous pleural effusion.

Pleural Disorders

This chapter provides an overview of both benign and malignant pleural disorders, starting with the relevant anatomy and physiology. The focus is on the management of pneumothoraces and pleural effusions—conditions that are commonly encountered on a general thoracic surgery service. The pleural cavity is lined by parietal and visceral pleura, which are smooth membranes that are continuous with one another at the hilum and pulmonary ligaments. Parietal Pleura: innermost chest wall layer, divided into cervical, costal, mediastinal and diaphragmatic pleura.

Prognostic role of incidental pleural effusion diagnosed during echocardiographic evaluation

BACKGROUND

The purpose of this study was to determine the long-term prognostic implications of incidental pleural effusion (PE) detected during echocardiographic examination and its relationship with concomitant diseases.

HYPOTHESIS

The study hypothesis is to test whether incidental pleural PE detected during echocardiographic examination be used as a prognostic marker.

METHODS

The study was performed by evaluating patient records (N = 251) in whom PE was incidentally detected during echocardiographic examination in a tertiary hospital between 1999 and 2012. The patients were classified into 4 major groups according to the concomitant primary disease: malignancy, and cardiovascular, renal, and pulmonary diseases. The total survival time was obtained from hospital records for patients who died during the hospital stay and social security institution records for patients with out-of-hospital death.

RESULTS

One-year and 5-year life expectancies of PE cases concomitant with different disorders were as follows; heart failure (n = 151), 81% and 70%; malignancies (n = 45), 53% and 44%; pulmonary diseases (n = 37), 89% and 78%; renal diseases (n = 18), 100% and 83%; respectively. PE associated with heart failure, renal disease, and pulmonary disease had similar (P > 0.05 for all) and favorable outcomes compared to PE associated with malignancies (P < 0.001).

CONCLUSIONS

The prognosis of incidental PE was the worst in patients with concomitant malignancies; however, PE associated with nonmalignant diseases including heart failure, pulmonary disease, and renal disease have similar and favorable outcomes.