Malignant pleural effusion

[Management of Malignant Pleural Effusion]

Malignant pleural effusion is a common diagnosis in metastasized cancers. It is always of palliative character. Main symptoms are dyspnoea and reduced quality of life. Diagnosis is made by ultrasound-guided puncture of the pleural effusion (cytology) and often video-assisted thoracic surgery with biopsy of the pleural surface (histology). The goal of treatment is a fast, sustainable, minimally invasive, patient-centred therapy that increases quality of life. Besides systemic therapy and best supportive care the patient can be treated with local therapy including either pleurodesis (via drainage or VATS) or an indwelling-pleural catheter (IPC). Decision for one of these procedures is made upon performance index (ECOG), expandability of the lung, prognosis and the patient's wish. For the first technique, the lung must be expandable. The latter one (IPC) can be implanted both with expandable and trapped lung. Both are similarly effective in symptom control.

Review on treatment of pleural metastasis and malignant pleural effusion with Pressurized IntraThoracic Aerosol Chemotherapy (PITAC)

Background

Malignant pleural effusion (MPE) is a common and debilitating condition seen in advanced cancer disease, and life-expectancy is short. Symptoms include pain and severe shortness of breath. Current first-line treatment options include pleural drainage using catheters as well as pleurodesis. However, these treatment modalities are often inefficient and patients need repeated procedures. Pressurized IntraThoracic Aerosol Chemotherapy (PITAC) is a minimally invasive procedure, where antineoplastic agents are nebulized under pressure into the pleural space.

Content

We present the preliminary safety, feasibility, and response assessment data for PITAC based on a comprehensive literature review.

Summary

Five retrospective studies reported data on 38 PITACs in 21 patients. Data were heterogeneous and incomplete on several important aspects such as procedure, safety, local effect and long-term outcomes. PITAC seems technically feasible with a low risk of complications and may provide some reduction in MPE in selected cases.

Outlook

PITAC seems feasible, but prospective phase I and II studies are needed to define safety, indications, and efficacy.

Induction of therapeutic immunity and cancer eradication through biofunctionalized liposome-like nanovesicles derived from irradiated-cancer cells

Immunotherapy has revolutionized the treatment of cancer. However, its efficacy remains to be optimized. There are at least two major challenges in effectively eradicating cancer cells by immunotherapy. Firstly, cancer cells evade immune cell killing by down-regulating cell surface immune sensors. Secondly, immune cell dysfunction impairs their ability to execute anti-cancer functions. Radiotherapy, one of the cornerstones of cancer treatment, has the potential to enhance the immunogenicity of cancer cells and trigger an anti-tumor immune response. Inspired by this, we fabricate biofunctionalized liposome-like nanovesicles (BLNs) by exposing irradiated-cancer cells to ethanol, of which ethanol serves as a surfactant, inducing cancer cells pyroptosis-like cell death and facilitating nanovesicles shedding from cancer cell membrane. These BLNs are meticulously designed to disrupt both of the aforementioned mechanisms. On one hand, BLNs up-regulate the expression of calreticulin, an "eat me" signal on the surface of cancer cells, thus promoting macrophage phagocytosis of cancer cells. Additionally, BLNs are able to reprogram M2-like macrophages into an anti-cancer M1-like phenotype. Using a mouse model of malignant pleural effusion (MPE), an advanced-stage and immunotherapy-resistant cancer model, we demonstrate that BLNs significantly increase T cell infiltration and exhibit an ablative effect against MPE. When combined with PD-1 inhibitor (α-PD-1), we achieve a remarkable 63.6% cure rate (7 out of 11) among mice with MPE, while also inducing immunological memory effects. This work therefore introduces a unique strategy for overcoming immunotherapy resistance.

Irradiated engineered tumor cell-derived microparticles remodel the tumor immune microenvironment and enhance antitumor immunity

Radiotherapy (RT), administered to roughly half of all cancer patients, occupies a crucial role in the landscape of cancer treatment. However, expanding the clinical indications of RT remains challenging. Inspired by the radiation-induced bystander effect (RIBE), we used the mediators of RIBE to mimic RT. Specifically, we discovered that irradiated tumor cell-released microparticles (RT-MPs) mediated the RIBE and had immune activation effects. To further boost the immune activation effect of RT-MPs to achieve cancer remission, even in advanced stages, we engineered RT-MPs with different cytokine and chemokine combinations by modifying their production method. After comparing the therapeutic effect of the engineered RT-MPs in vitro and in vivo, we demonstrated that tIL-15/tCCL19-RT-MPs effectively activated antitumor immune responses, significantly prolonged the survival of mice with malignant pleural effusion (MPE), and even achieved complete cancer remission. When tIL-15/tCCL19-RT-MPs were combined with PD-1 monoclonal antibody (mAb), a cure rate of up to 60% was achieved. This combination therapy relied on the activation of CD8+ T cells and macrophages, resulting in the inhibition of tumor growth and the establishment of immunological memory against tumor cells. Hence, our research may provide an alternative and promising strategy for cancers that are not amenable to conventional RT.

Pleural fluid carbohydrate antigen 72-4 and malignant pleural effusion: a diagnostic test accuracy study

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.

Single-cell profiling reveals distinct immune response landscapes in tuberculous pleural effusion and non-TPE

Background

Tuberculosis (TB) is caused by Mycobacterium tuberculosis (Mtb) and remains a major health threat worldwide. However, a detailed understanding of the immune cells and inflammatory mediators in Mtb-infected tissues is still lacking. Tuberculous pleural effusion (TPE), which is characterized by an influx of immune cells to the pleural space, is thus a suitable platform for dissecting complex tissue responses to Mtb infection.

Methods

We employed singe-cell RNA sequencing to 10 pleural fluid (PF) samples from 6 patients with TPE and 4 non-TPEs including 2 samples from patients with TSPE (transudative pleural effusion) and 2 samples with MPE (malignant pleural effusion).

Result

Compared to TSPE and MPE, TPE displayed obvious difference in the abundance of major cell types (e.g., NK, CD4+T, Macrophages), which showed notable associations with disease type. Further analyses revealed that the CD4 lymphocyte population in TPE favored a Th1 and Th17 response. Tumor necrosis factors (TNF)-, and XIAP related factor 1 (XAF1)-pathways induced T cell apoptosis in patients with TPE. Immune exhaustion in NK cells was an important feature in TPE. Myeloid cells in TPE displayed stronger functional capacity for phagocytosis, antigen presentation and IFN-γ response, than TSPE and MPE. Systemic elevation of inflammatory response genes and pro-inflammatory cytokines were mainly driven by macrophages in patients with TPE.

Conclusion

We provide a tissue immune landscape of PF immune cells, and revealed a distinct local immune response in TPE and non-TPE (TSPE and MPE). These findings will improve our understanding of local TB immunopathogenesis and provide potential targets for TB therapy.

Macrophage-derived exosome promotes regulatory T cell differentiation in malignant pleural effusion

Introduction

Tumor-associated macrophages are one of the key components of the tumor microenvironment. The immunomodulatory activity and function of macrophages in malignant pleural effusion (MPE), a special tumor metastasis microenvironment, have not been clearly defined.

Methods

MPE-based single-cell RNA sequencing data was used to characterize macrophages. Subsequently, the regulatory effect of macrophages and their secreted exosomes on T cells was verified by experiments. Next, miRNA microarray was used to analyze differentially expressed miRNAs in MPE and benign pleural effusion, and data from The Cancer Genome Atlas (TCGA) was used to evaluate the correlation between miRNAs and patient survival.

Results

Single-cell RNA sequencing data showed macrophages were mainly M2 polarized in MPE and had higher exosome secretion function compared with those in blood. We found that exosomes released from macrophages could promote the differentiation of naïve T cells into Treg cells in MPE. We detected differential expression miRNAs in macrophage-derived exosomes between MPE and benign pleural effusion by miRNA microarray and found that miR-4443 was significantly overexpressed in MPE exosomes. Gene functional enrichment analysis showed that the target genes of miR-4443 were involved in the regulation of protein kinase B signaling and lipid biosynthetic process.

Conclusions

Taken together, these results reveal that exosomes mediate the intercellular communication between macrophages and T cells, yielding an immunosuppressive environment for MPE. miR-4443 expressed by macrophages, but not total miR-4443, might serve as a prognostic marker in patients with metastatic lung cancer.

Survival analysis and prognosis of patients with breast cancer with pleural metastasis

Background

Breast cancer (BC) is the most common malignant cancer. The prognosis of patients differs according to the location of distant metastasis, with pleura being a common metastatic site in BC. Nonetheless, clinical data of patients with pleural metastasis (PM) as the only distant metastatic site at initial diagnosis of metastatic BC (MBC) are limited.

Patient cohort and methods

The medical records of patients who were hospitalized in Shandong Cancer Hospital between January 1, 2012 and December 31, 2021 were reviewed, and patients eligible for the study were selected. Survival analysis was conducted using Kaplan-Meier (KM) method. Univariate and multivariate Cox proportional-hazards models were used to identify prognostic factors. Finally, based on these selected factors, a nomogram was constructed and validated.

Results

In total, 182 patients were included; 58 (group A), 81 (group B), and 43 (group C) patients presented with only PM, only lung metastasis (LM), and PM combined with LM, respectively. The KM curves revealed no significant difference in overall survival (OS) among the three groups. However, in terms of survival after distant metastasis (M-OS), the difference was significant: patients with only PM exhibited the best prognosis, whereas those with PM combined with LM exhibited the worst prognosis (median M-OS: 65.9, 40.5, and 32.4 months, respectively; P = 0.0067). For patients with LM in groups A and C, those with malignant pleural effusion (MPE) exhibited significantly worse M-OS than those without MPE. Univariate and multivariate analyses indicated that primary cancer site, T stage, N stage, location of PM, and MPE were independent prognostic factors for patients with PM without other distant metastasis. A nomogram prediction model incorporating these variables was created. According to the C-index (0.776), the AUC values of the 3-, 5-, and 8-year M-OS (0.86, 0.86, and 0.90, respectively), and calibration curves, the predicted and actual M-OS were in good agreement.

Conclusion

BC patients with PM only at the first diagnosis of MBC exhibited a better prognosis than those with LM only or PM combined with LM. We identified five independent prognostic factors associated with M-OS in this subset of patients, and a nomogram model with good predictive efficacy was established.

Comparison of proteomic landscape of extracellular vesicles in pleural effusions isolated by three strategies

Extracellular vesicles (EVs) derived from pleural effusion (PE) is emerging as disease biomarkers. However, the methods for isolation of EVs from PE (pEVs) were rarely studied. In our study, three methods for isolating pEVs of lung cancer patients were compared, including ultracentrifugation (UC), a combination of UC and size exclusion chromatography (UC-SEC) and a combination of UC and density gradient ultracentrifugation (UC-DGU). The subpopulation of pEVs was identified by nanoparticle tracking analysis (NTA), transmission electron microscopy (TEM), Western blotting (WB) and nano-flow cytometry (nFCM). Additionally, the proteomic landscape of pEVs was analyzed by Label-free proteomics. The results showed that, compared with UC and UC-DGU, the UC-SEC method separated pEVs with the highest purity. In the proteomic analysis, on average, 1595 proteins were identified in the pEVs isolated by UC-SEC, much more than pEVs isolated by UC (1222) or UC-DGU (807). Furthermore, approximately 90% of identified proteins in each method were found in the EVs public database ExoCarta. Consistent with this, GO annotation indicated that the core proteins identified in each method were mainly enriched in "extracellular exosome." Many of the top 100 proteins with high expression in each method were suggested as protein markers to validate the presence of EVs in the MISEV2018 guidelines. In addition, combined with lung tissue-specific proteins and vesicular membrane proteins, we screened out and validated several novel protein markers (CD11C, HLA DPA1 and HLA DRB1), which were enriched in pEVs rather than in plasma EVs. In conclusion, our study shows that the method of UC-SEC could significantly improve the purity of EVs and the performance of mass spectrometry-based proteomic profiling in analyzing pEVs. The exosomal proteins CD11C, HLA DPA1 and HLA DRB1 may act as potential markers of pEVs. The proteomic analysis of pEVs provides important information and new ideas for studying diseases complicated with PE.

Scheule A, Markowiak T, Ried M. The Treatment of Malignant Pleural Effusion With Permanent Indwelling Pleural Catheters

BACKGROUND

40 000 to 60 000 people develop malignant pleural effusion (MPE) in Germany each year. The most common causes are lung cancer and breast cancer. Patients with pleural carcinomatosis have a median survival time of four months.

METHODS

We investigated the current health services situation regarding treatment with indwelling pleural catheters (IPC) versus talc pleurodesis (TP) in Germany based on registry data from the Federal Statistical Office, the Pleural Tumor Registry of the German Society for Thoracic Surgery, and the IPC registry of the ewimed GmbH company. In addition, we conducted a selective literature review on IPC and TP.

RESULTS

The symptoms of dyspnea and thoracic pressure determine the need for therapy in MPE. Both TP and IPC are effective treatment options for MPE. Both therapeutic procedures are considered equally effective with respect to the relief of dyspnea, post-interventional quality of life, and complication rates. TP yields a higher rate of successful pleurodesis than IPC (relative risk: 1.56; 95% confidence interval: [1.26; 1.92]; p < 0.0001), while patients who receive an IPC stay in the hospital for a shorter time than those who undergo TP (a difference of slightly more than two days). The survival of patients with MPE is not affected by which of the two local therapeutic procedures is chosen.

CONCLUSION

The indication for either IPC or TP needs to be determined individually for each patient on the basis of his or her general condition, symptoms, clinical situation ("trapped lung"), and prognosis.

A Case of Pneumonia Masking Pleural Malignancy

The invasion of the pleural membrane by a malignant pleural tumor can lead to the production of malignant pleural effusion (MPE), resulting in the symptoms of dyspnea, and some patients have cough, sputum and other symptoms, which are easily confused with pneumonia. In this case, the initial diagnosis of the patient is pneumonia, and the final diagnosis is pneumonia combined with pleural malignancy. Therefore, if the patient has unexplained symptoms of bloody pleural effusion, it is necessary to examine for malignant tumors and should actively perform thoracentesis and drainage, look for malignant cells in the pleural effusion cell precipitation, evaluate the nature of pleural effusion, conduct pleural biopsy tissue examination, and determine the type and source of lung malignancy by the combined application of cell block technology and immunohistochemistry. Take the cytological examination results in pleural effusion seriously, and finally, surgical or immunotherapy can be performed.

High-throughput concentration of rare malignant tumor cells from large-volume effusions by multistage inertial microfluidics

On-chip concentration of rare malignant tumor cells (MTCs) in malignant pleural effusions (MPEs) with a large volume is challenging. Previous microfluidic concentrators suffer from a low concentration factor (CF) and a limited processing throughput. This study describes a low-cost multiplexed microfluidic concentrator that can enable high-throughput (up to 16 mL min^-1) and high CF (over 40-fold for single run) concentration of rare cells from large-volume biofluids (up to hundreds of milliliters). The multiplexed device was fabricated using inexpensive polymer-film materials using a quick non-clean-room process within 30 min. The multiplexing and flow distribution approaches applied in the device achieved high-throughput processing. By adopting serial cascading, an ultrahigh CF of approximately 1400 was achieved. Moreover, the microfluidic concentrator was successfully applied for the concentration and purification of rare MTCs within MPEs collected from patients with advanced metastatic lung and breast cancers. The provision of concentrated samples with low background cells could improve the sensitivity of cytology and thus reduce the time required for cytological examination. This novel concentrator offers the distinct advantages of a remarkable CF, high throughput, low device cost, and label-free processing and can therefore be readily integrated with other on-chip cell sorters to enhance the identification of MPEs.

Diagnostic accuracy of the cancer ratio for the prediction of malignant pleural effusion: evidence from a validation study and meta-analysis

OBJECTIVE

This study aimed to assess the diagnostic accuracy of serum LDH to pleural ADA ratio (cancer ratio, CR)for malignant pleural effusion (MPE) through an original study and meta-analysis.

METHODS

We retrospectively collected data from 145 patients with MPE and 117 cases of benign pleural effusions (BPE). The diagnostic performance of CR and a typical biomarker of MPE, carcinoembryonic antigen (CEA), were analysed using the receiver operating characteristic (ROC) curves and the area under the curve (AUC) as a measure of accuracy. The overall diagnostic accuracy of CR was summarised by a standard diagnostic meta-analysis.

RESULTS

Significantly higher CR and pleural CEA values were observed in the MPE patients than in the BPE patients. At a cut-off value of 14.97, CR showed high sensitivity (0.91), low specificity (0.67), and high AUC (0.85). The combination of CEA and CR increased the AUC to 0.98. The meta-analysis included seven studies involving 2,078 patients. The pooled values for sensitivity, specificity, positive/negative likelihood ratio, and diagnostic odds ratio of CR were 0.96, 0.88, 7.70, 0.05, and 169, respectively. The AUC of the summary ROC of CR was 0.98.

CONCLUSION

CR has a high diagnostic accuracy for predicting MPE, especially when used in combination with pleural CEA.

Acellular fraction from malignant effusions has cytotoxicity in breast cancer cells

Malignant ascites (MA) and malignant pleural effusion (MPE) are frequently developed in patients with metastatic cancer; however, the biological properties of these fluids have not been clarified. The present study explored the biological role of a low molecular fraction derived from malignant effusions on the activation of peripheral blood mononuclear cells and on the proliferation of breast cancer cells and fibroblast 55x cells. A <10-kDa fraction from effusions of 41 oncological patients and 34 individuals without cancer was purified, and its potential role in inhibiting nitric oxide (NO) production on lipopolysaccharide (LPS)-stimulated peripheral blood mononuclear cells was explored, as well as its cytotoxicity on MCF-7 breast cancer cells and fibroblast 55x cells. A significant decrease in NO production was observed in the <10-kDa fraction from malignant effusions. In addition, the acellular fraction from MA decreased the viability of breast cancer cells without affecting human fibroblasts. These data support the presence of low molecular weight molecules in malignant samples with a specific role in inhibiting the defense mechanisms of peripheral blood mononuclear cells and decreasing the viability of breast cancer cells in vitro.

Chinese medicine Xiaoshui decoction inhibits malignant pleural effusion in mice and mediates tumor-associated macrophage polarization by activating autophagy

ETHNOPHARMACOLOGICAL RELEVANCE

Xiaoshui decoction (XSD) is a traditional Chinese medicine compound prescription that has been shown to reinforce the spleen and remove the fluid retention, while being widely used in the treatment of malignant pleural effusion (MPE). We previously reported that XSD alleviates symptoms and improves the quality of life in patients with MPE; however, the mechanism employed by XSD on MPE has not yet been elucidated.

AIM OF THE STUDY

To investigate the role and mechanism of XSD in inhibiting the development of MPE, and in regulating macrophage polarization in vitro and in vivo.

MATERIALS AND METHODS

A murine MPE model was used to study the effect of XSD on MPE. Mice with MPE were randomly allocated to a control group and XSD-low-dose (1.144 g/mL), XSD-middle-dose (2.288 g/mL), XSD-high-dose (4.576 g/mL), or cisplatin groups. RAW264.7 cells were induced to form tumor-associated macrophages (TAMs) as well as M1 and M2 macrophages using different conditioned media in vitro.

RESULTS

XSD effectively inhibited MPE formation, reduced pleural permeability and angiogenesis, and prolonged mice survival. Particularly, XSD treatment induced the polarization of TAMs to the M1 phenotype in MPE. Moreover, in-vitro XSD remarkably promoted the expansion of M1 macrophages and reduced M2 macrophages by enhancing autophagy.

CONCLUSIONS

XSD inhibits MPE development and regulates macrophage polarization by activating autophagy, indicating that XSD may serve as a novel option for integrative MPE therapies.

The diagnostic value of pleural fluid homocysteine in malignant pleural effusion

Background

Pleural fluid homocysteine (HCY) can be useful for diagnosis of malignant pleural effusion (MPE). There are no published studies comparing the diagnostic accuracy of HCY with other tumour markers in pleural fluid for diagnosis of MPE. The aim was to compare the accuracy of HCY with that of carcinoembryonic antigen (CEA), cancer antigen (CA) 15.3, CA19.9 and CA125 in pleural fluid and to develop a probabilistic model using these biomarkers to differentiate benign (BPE) from MPE.

Methods

Patients with pleural effusion were randomly included. HCY, CEA, CA15.3, CEA19.9 and CA125 were quantified in pleural fluid. Patients were classified into two groups: MPE or BPE. By applying logistic regression analysis, a multivariate probabilistic model was developed using pleural fluid biomarkers. The diagnostic accuracy was determined by receiver operating characteristic (ROC) curves and calculating the area under the curve (AUC).

Results

Population of study comprised 133 patients (72 males and 61 females) aged between 1 and 96 years (median = 70 years), 81 BPE and 52 MPE. The logistic regression analysis included HCY (p<0.0001) and CEA (p = 0.0022) in the probabilistic model and excluded the other tumour markers. The probabilistic model was: HCY+CEA = Probability(%) = 100×(1+e^-z)^-1, where Z = 0.5471×[HCY]+0.3846×[CEA]–8.2671. The AUCs were 0.606, 0.703, 0.778, 0.800, 0.846 and 0.948 for CA125, CA19.9, CEA, CA15.3, HCY and HCY+CEA, respectively.

Conclusions

Pleural fluid HCY has higher accuracy for diagnosis of MPE than CEA, CA15.3, CA19.9 and CA125. The combination of HCY and CEA concentrations in pleural fluid significantly improves the diagnostic accuracy of the test.

Diagnostic value of CD206+CD14+ macrophages in diagnosis of lung cancer originated malignant pleural effusion

Background

Pleural effusions are common complications of various diseases. Patients with malignant pleural effusion (MPE) usually face poor prognosis and short life expectancy. Discriminating between MPE and benign pleural effusion remains to be difficult. The aim of our current study was to evaluate whether CD206⁺CD14⁺ macrophages could be a diagnostic biomarker for MPE.

Methods

The percentages of CD14⁺, CD86⁺CD14⁺ and CD206⁺CD14⁺ macrophages in pleural effusions were determined by flow cytometry in 34 patients with MPE and 26 with benign pleural effusion, and their diagnostic performances were evaluated by receiver operating characteristic (ROC) curves.

Results

The percentages of CD14⁺, CD86⁺CD14⁺ and CD206⁺CD14⁺ macrophages were remarkably higher in MPE than in benign pleural effusion (all P<0.05). With a cutoff value of 39.8%, a high sensitivity of 88.2% and high specificity of 100.0% were found in CD206⁺CD14⁺ macrophages to diagnose MPE. The area under the curve, positive predictive value and negative predictive value of CD206⁺CD14⁺ macrophages were 0.980 (95% CI, 0.905 to 0.999), 100.0 (88.4 to 100.0) and 86.7 (69.3 to 96.2), respectively. The diagnostic performance of CD206⁺CD14⁺ macrophages was more accurate than those of CD14⁺ and CD86⁺CD14⁺ macrophages.

Conclusions

CD206⁺CD14⁺ macrophages could be used to discriminate MPE from benign pleural effusion.

Diagnostic yield of pleural fluid cytology in malignant effusions: an Australian tertiary centre experience

BACKGROUND

Timely diagnosis of malignant pleural effusions is critical to guide prognosis and management decisions. Cytological analysis of pleural fluid has been the first-line diagnostic test for many decades, with highly variable reported sensitivities of 40-90%. Its diagnostic accuracy in modern practice in Australia needs to be understood.

AIMS

To determine the diagnostic yield of pleural fluid cytology for the detection of malignant pleural effusions and to determine the aetiologies of pleural effusions at our centre.

METHODS

The study involved the retrospective chart review of all pleural fluid samples submitted for cytological analysis at a tertiary referral centre in Melbourne, Australia, over a 12-month period. Aetiology of all effusions was determined, and sensitivity, specificity, negative predictive value and diagnostic accuracy for the detection of malignant pleural effusions were calculated. We also examined diagnostic yield based on tumour cell type.

RESULTS

Of the 153 cases analysed, 61 (39.9%) were malignant. Lung cancers accounted for 44.3% of malignant effusions, followed by mesothelioma (18%), ovarian carcinoma (11.5%) and lymphoma (8.2%). The commonest single causes of a benign effusion were cardiac (16.3%) and parapneumonic (13%). Sensitivity for diagnosis of malignant effusions was 67.2% overall, but 87.9% for adenocarcinomas and only 45.5% for mesothelioma.

CONCLUSION

Tumour type is an important determinant of pleural fluid cytology diagnostic yield. Cytology has good sensitivity and specificity for the diagnosis of adenocarcinoma, but if another tumour type is suspected, particularly mesothelioma, clinicians should be aware of the limitations.

Sarcopenia in patients with malignant pleural effusion: impact on symptoms, health status, and response to hospitalization

BACKGROUND

Malignant pleural effusion (MPE) refers to the presence of neoplastic cells in the pleural fluid and was previously associated with lung cancer, breast cancer, and lymphoma. Patients with MPE effusion have significant symptoms, diminishing their overall quality of life but little is known about the influence sarcopenia may have on their clinical presentation.

PURPOSE

To examine the prevalence of sarcopenia in patients with MPE and its relationship with symptoms, health status, and the response to hospitalization.

METHODS

Seventy-four patients with MPE underwent measurements of symptoms, health-related quality of life, and functional status upon admission, discharge, and 3 months after hospital discharge.

RESULTS

Patients with MPE and sarcopenia were symptomatic during hospitalization and at discharge. Additionally, health-related quality of life and functional status were worse in patients with MPE and sarcopenia. All measures of patients with MPE and sarcopenia were significantly poorer 3 months after hospital discharge.

CONCLUSIONS

Sarcopenia is a clinical characteristic with substantial negative effects in patients with MPE. Specific interventions may need to be provided, designed, and offered in the clinical setting.

Elevated Hsp90-beta contributes to differential diagnosis of pleural effusion caused by lung cancer and correlates with malignant biological behavior of lung cancer

Background

Hsp90-beta has been investigated to be correlated with the occurrence and development of tumor. The intention of this research was to test the level of Hsp90-beta in malignant pleural effusion (MPE) of patients with lung cancer and disclose the clinical significance of Hsp90-beta as a potential tumor marker for differential diagnosis of pleural effusion caused by lung cancer.

Methods

The level of Hsp90-beta was determined using enzyme-linked immunosorbent assay. Calculations of the Hsp90-beta threshold, the sensitivity and specificity for distinguishing MPE from benign pleural effusion were performed using receiver operator characteristic curve.

Results

The level of Hsp90-beta in MPE of lung cancer patients was higher than that in control individuals (P < 0.05) and increased MPE Hsp90-beta was correlated with the pathological differentiation, tumor size and lymphatic metastasis (P < 0.05). The cutoff value of Hsp90-beta produced by receiver operator characteristic curve for distinguishing lung cancer from control individuals were 1.659 ng/mL and the sensitivity and specificity were 93.46 and 79%.

Conclusions

Increased Hsp90-beta in MPE was correlated with malignant biological behavior of lung cancer patients, indicating that the level of Hsp90-beta could be a tool of referential value for differential diagnosis of pleural effusion caused by lung cancer.

Malignant Pleural Effusion from Metastatic Prostate Cancer: A Case Report with Unusual Cytologic Findings

We present a case of 55-year-old man who complained of dyspnea and sputum for a month. He was an ex-smoker with a history of prostate cancer and pulmonary tuberculosis. Chest radiographs revealed bilateral pleural effusions of a small to moderate amount. Pigtail catheters were inserted for drainage. The pleural fluid consisted of large clusters and tightly cohesive groups of malignant cells, which however could not be ascribed to prostate cancer with certainty. We performed immunocytochemical panel studies to determine the origin of cancer metastasis. The immunostaining results were positive for prostate-specific antigen, alpha-methylacyl-coenzyme A racemase, and Nkx 3.1, consistent with prostate cancer. Pleural effusion associated with prostate cancer is rare. To our knowledge, this is the first case report in Korea to describe cytologic features of malignant pleural effusion associated with prostate cancer.

Identification of 10 Candidate Biomarkers Distinguishing Tuberculous and Malignant Pleural Fluid by Proteomic Methods

PURPOSE

Pleural effusion, an accumulation of fluid in the pleural space, usually occurs in patients when the rate of fluid formation exceeds the rate of fluid removal. The differential diagnosis of tuberculous pleurisy and malignant pleural effusion is a difficult task in high tuberculous prevalence areas. The aim of the present study was to identify novel biomarkers for the diagnosis of pleural fluid using proteomics technology.

MATERIALS AND METHODS

We used samples from five patients with transudative pleural effusions for internal standard, five patients with tuberculous pleurisy, and the same numbers of patients having malignant effusions were enrolled in the study. We analyzed the proteins in pleural fluid from patients using a technique that combined two-dimensional liquid-phase electrophoresis and matrix assisted laser desorption/ionization-time of flight-mass spectrometry.

RESULTS

We identified a total of 10 proteins with statistical significance. Among 10 proteins, trasthyretin, haptoglobin, metastasis-associated protein 1, t-complex protein 1, and fibroblast growth factor-binding protein 1 were related with malignant pleural effusions and human ceruloplasmin, lysozyme precursor, gelsolin, clusterin C complement lysis inhibitor, and peroxirexdoxin 3 were expressed several times or more in tuberculous pleural effusions.

CONCLUSION

Highly expressed proteins in malignant pleural effusion were associated with carcinogenesis and cell growth, and proteins associated with tuberculous pleural effusion played a role in the response to inflammation and fibrosis. These findings will aid in the development of novel diagnostic tools for tuberculous pleurisy and malignant pleural effusion of lung cancer.

Pulmonary Manifestations of Solid Non-Pulmonary Malignancies

The lungs are a common site of metastatic disease. Pulmonary metastases develop due to local blood flow and cellular or biochemical properties of tumor cells. Metastases develop from any type of malignancy and may occur via hematogenous, lymphatic, aerogenous, and/or direct spread. Metastatic disease may present with symptoms indistinguishable from primary lung cancer, including dyspnea, hemoptysis, and chest pain. Radiographically, these may present as parenchymal lung disease, mediastinal lymphadenopathy, airway obstruction, or pleural and vascular disease. No part of the thorax is spared from metastatic potential. This review highlights complications of non-pulmonary solid malignancies based on sites of anatomic metastases.

[Survival of malignant and paramalignant pleural effusions in Ouagadougou]

This study aimed to present the survival of patients with malignant and paramalignant pleural effusion (MPE) in a context of resource-limited countries. We retrospectively studied patients received for malignant and paramalignant pleural effusion in three health facilities in Ouagadougou from 1st August 2009 to 30 July 2015. Survival was analyzed according to various characteristics related to patients and disease. Eighty patients with a mean age of 54 years were selected. The sex-ratio was 0.9. Sixteen patients had comorbidities. Pleural effusion was revealing, synchronous and metachronous in respectively 55 %, 26.3 % and 17.5 % of cases. Lung cancer was the most common cause of MPE (27.5 %), followed by breast cancer (18.7 %). The median overall survival was 3 months; it varied between primary cancers: 5 months for primary cancer unknown, 4 months for lung cancers and 2 months for breast cancers. Sex and the presence of comorbidities were independent factors influencing survival of patients. In this study, patient survival length is strongly compromised by inadequacies of medical technical equipment.

Utility of GATA-3 in the work-Up of breast adenocarcinoma and its differential diagnosis in serous effusions:: A Cell-Block Microarray Study

BACKGROUND

GATA-3 is a transcription factor involved in human tissue growth and differentiation. It is a potential marker for breast carcinoma origin in metastasis and predictive of good prognosis. We aim to evaluate the role of GATA3 in determining the breast origin of metastatic adenocarcinoma in malignant effusions using immunohistochemistry on cell-block microarray in comparison with ER and PR results.

METHODS

Cell blocks from 100 cases of malignant and reactive serous effusions with confirmed diagnosis were selected; 28 mammary carcinomas, 64 extra-mammary adenocarcinomas (gastrointestinal, pulmonary, gynecologic), and 8 reactive mesothelium proliferation as control. Immunohistochemistry on cell-block microarray was used. Microarray slides were stained for GATA-3, ER and PR. Nuclear staining of >1% was considered positive.

RESULTS

GATA3, ER and PR were positive in 25 (89%), 20 (71%) and 16 (57%) of breast carcinoma cases, respectively. All non-breast cancer cases were negative for GATA-3 with the exception of one Müllerian adenocarcinoma (1.6%). The calculated sensitivity, specificity and positive predictive value (PPV) of GATA3 reactivity in determining the breast origin of metastatic adenocarcinoma was 89.3% (95% CI: 71.7-97.7%), 98.6% (95% CI: 91.6-99.9%) and 96.2% (95% CI: 80.4-99.9%), respectively. GATA3 positivity was associated with ER or PR positivity in 84% of cases.

CONCLUSIONS

GATA3 is a useful marker in determining the breast origin of metastatic adenocarcinoma in malignant serous effusions. Reactivity to GATA3 may indicate good prognosis. Diagn. Cytopathol. 2016;44:731-736. © 2016 Wiley Periodicals, Inc.

Utility of TTF-1 and Napsin-A in the work-up of malignant effusions

BACKGROUND

Similar to TTF-1, Napsin-A is recently used increasingly to differentiate between pulmonary adenocarcinoma (P-ADC) and extra-pulmonary adenocarcinoma (EP-ADC). The aim of this study was to compare the performance of TTF-1 and Napsin-A in determining the primary origin of adenocarcinoma in malignant serous effusion.

METHODS

Following IRB approval, cellblocks from 139 cases of malignant serous effusions of histologically or clinically determined origin including: 26 P-ADC, 108 EP-ADC, 2 pulmonary squamous cell carcinoma (P-SQC), and 3 pulmonary small cell carcinoma (P-SCC) were retrieved. Each case was stained with Napsin-A and TTF-1 and evaluated for positivity and intensity of staining.

RESULTS

Napsin-A and TTF-1 stained positive in 17/26 (65%) and 14/26 (54%) of P-ADC and in 2/108 (1.8%) and 0/108 (0%) of EP-ADC with a PPV of 89 and 100%, respectively. In combination, they positively stained 18/26 (70%) of P-ADC with a PPV of 90%. Out of 9 poorly differentiated P-ADC, 7 (78%) stained positive for Napsin-A, while 4 (45%) were reactive for TTF-1. Both Napsin-A and TTF-1 were negative in P-SQC, while P-SCC reacted positively for TTF-1 in 2/3 (66%) of cases and none for Napsin-A.

CONCLUSION

Napsin-A and TTF-1 are both useful markers in distinguishing P-ADC from EP-ADC. However, Napsin-A performed better in poorly differentiated P-ADC and its mimickers. The nuclear staining of TTF-1 is crispier and much easier to interpret than Napsin-A cytoplasmic stain. An antibody panel including TTF-1 and Napsin-A or a dual stain will be very helpful in determining the origin of metastatic adenocarcinoma in serous effusion.

Closing faucets: the role of anti-angiogenic therapies in malignant pleural diseases

Malignant pleural effusion (MPE) represents 15-35 % of pleural effusions and markedly worsens the prognosis and quality of life of patients with cancer. Malignant mesothelioma (MM) and lung adenocarcinoma are the most frequent primary and secondary causes, respectively, of MPE. Effective treatments for cancer-related MPE are warranted in order to improve symptoms, reduce the number of invasive pleural procedures, and prolong patient life. Since angiogenesis plays a key role in MPE development, the potential role of bevacizumab and other anti-angiogenic therapies have been explored in this review. No relevant phase III trials have specifically analysed the benefit from adding bevacizumab to platinum-based chemotherapy in lung cancer-related MPE. However, small retrospective series reported 71.4-93.3 % MPE control rate, a reduction in invasive procedures, and a safe profile with this combination. Being approved for the first-line treatment of non-squamous advanced NSCLC, the addition of bevacizumab should be considered for patients presenting with MPE. In addition, further studies in this are recommended. In MM, the addition of bevacizumab to platinum-based chemotherapy did not meet primary endpoints in two phase II trials. However, the beneficial results on OS reported in comparison with historical cohorts and the statistically significant benefit on PFS and OS observed in the phase III MAPS trial foretell an eventual role for the combination of platinum/pemetrexed/bevacizumab as front-line systemic therapy for pleural MM. To date, no other anti-angiogenic drug has showed significant benefit in the treatment of patients with either MPE or MM. However, new promising drugs such as ramucirumab or recombinant human endostar warrant further investigation.

Pleural involvement in lung cancer

The pleural space, a sterile secluded environment in the thoracic cavity, represents an attractive metastatic site for various cancers of lung, breast and gastrointestinal origins. Whereas lung and breast adenocarcinomas could invade the pleural space because of their anatomic proximity, "distant" cancers like ovarian or gastrointestinal tract adenocarcinomas may employ more active mechanisms to the same end. A pleural metastasis is often accompanied by a malignant pleural effusion (MPE), an unfavorable complication that severely restricts the quality of life and expectancy of the cancer patient. MPE is the net "product" of three different processes, namely inflammation, enhanced angiogenesis and vascular leakage. Current efforts are focusing on the identification of cancer cell autocrine (specific mutation spectra and biochemical pathways) and paracrine (cytokine and chemokine signals) characteristics as well as host features (immunological or other) that underlie the MPE phenotype. Herein we examine the pleural histology, cytology and molecular characteristics that make the pleural cavity an attractive metastasis destination for lung adenocarcinoma. Mesothelial and tumor features that may account for the tumor's ability to invade the pleural space are highlighted. Finally, possible therapeutic interventions specifically targeting MPE are discussed.

Diagnostic accuracy of endostatin for malignant pleural effusion: A clinical study and meta-analysis

BACKGROUND

The diagnosis of malignant pleural effusion (MPE) remains a clinical challenge. Many studies suggest that endostatin is a potential marker for MPE. This study aimed to determine the diagnostic value of endostatin with respect to MPE and to summarize the overall diagnostic performance of endostatin via a meta-analysis.

METHODS

Pleural effusion samples from patients with both malignant and nonmalignant disease were collected, and the pleural levels of endostatin and carcino-embryonic antigen (CEA) were subsequently measured. The diagnostic performances of endostatin and CEA were analyzed via standard receiver operator characteristic curve analysis methods, using the AUC as a measure of accuracy. The overall diagnostic accuracy of endostatin for MPE was summarized through a bivariate meta-analysis with standard method recommended.

RESULTS

Fifty-two patients with MPEs and 64 patients with benign pleural effusions (BPEs) were included this study. Pleural endostatin levels were significantly increased in the setting of MPE compared with BPE (104.78 ± 64.58 vs. 56.81 ± 28.84 ng/ml; p < 0.001). Using a cutoff value of 79.7 ng/ml, the sensitivity and specificity of endostatin in diagnosing MPE were shown to be 51.92% and 85.94%, respectively, and the AUC was 0.747. The combination of endostatin and CEA enhanced diagnostic performance with respect to MPE. In addition to this study, another eight studies were included in this meta-analysis. The pooled diagnostic estimates were 0.69 for sensitivity and 0.78 for specificity. The positive likelihood ratio and negative likelihood ratio for endostatin were 3.16 and 0.40, respectively. The diagnostic odds ratio was 7.89, and the AUC of the summary receiver operator characteristic curve was 0.79.

CONCLUSION

Pleural levels of endostatin are increased in the setting of MPE. However, endostatin exhibits a limited efficacy for the diagnosis of MPE and shows a relatively low sensitivity. The assessment of endostatin in combination with CEA may enhance diagnostic accuracy with respect to MPE.

Homocysteine: new tumor marker in pleural fluid

There are no published studies examining the utility of total homocysteine (HCY) in pleural fluid. The aim was to measure the accuracy of pleural fluid HCY concentration for diagnosis of malignant pleural effusion (MPE). We studied pleural fluids obtained by thoracocentesis in patients with pleural effusion. Pleural fluid HCY concentration was measured by immunonephelometry using N Latex HCY reagent with monoclonal antibody in automated analyzers BNII (Siemens Diagnostics®). Patients were classified into two groups according to the etiology of pleural effusion: benign pleural effusions (BPE) and MPE. Pleural effusion was categorized as MPE if malignant cells were demonstrated in pleural fluid or pleural biopsy. The accuracy of pleural fluid HCY concentration for diagnosis of MPE was determined using receiver operating characteristic (ROC) techniques by analyzing the area under the ROC curve (AUC). We studied 89 patients with ages between 1 and 96 years old (median = 66). Forty-eight patients were BPE and 41 were MPE. Pleural fluid HCY concentration was significantly higher in patients with MPE (median = 13.70 μmol/L) than in those with BPE (median = 8.05 μmol/L). The AUC value was 0.833 (95 % confidence interval (CI) 0.739-0.903). The optimal cutoff value was 13.1 μmol/L exhibiting 56.1 % (95 % CI 39.8-71.5) sensitivity and 85.4 % (95 % CI 72.2-93.9) specificity. Pleural fluid HCY concentration showed high diagnostic accuracy to predict whether a pleural effusion is benign or malignant. Pleural fluid HCY concentration may be measured easily and quickly in automated analyzers and could be a tumor marker commonly used for diagnosis of MPE.