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Vázquez A, Simó M, Persiva O, Sánchez L, Sansano I, Alemán C. Diagnosis and outcome of patients with idiopathic pleural effusions. Rev Clin Esp 2023; 223:320-324. [PMID: 36990383 DOI: 10.1016/j.rceng.2023.03.005] [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: 04/11/2023]
Abstract
INTRODUCTION Long-term follow-up course for patients with idiopathic pleural effusions has not been established. METHODS From October 2013 to June 2021 all patients with idiopathic effusion were prospectively followed up with clinical examination and imaging at 1, 3, 6 and every 6 months for a minimum of 1 year. RESULTS Twenty-nine patients were diagnosed with idiopathic effusion and followed up. Mesothelioma was detected during the follow-up in two patients at 7 and 18 months, one of whom had blood-tinged pleural fluid and the other reported a 10% weight loss. Mesothelioma was not diagnosed in any of the patients with effusion covering less than two thirds of the hemithorax, and without constitutional symptoms or a blood-tinged fluid appearance. Most of the effusions resolved or showed a clear improvement in the first six months. CONCLUSION Patients without weight loss and with small, non-hematic effusions, may benefit from conservative treatment and clinical-radiological follow-up.
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Affiliation(s)
- A Vázquez
- Departments of Internal Medicine, University Autonomous of Barcelona, Universitat Autònoma de Barcelona, University Hospital Vall d'Hebron, Passeig Vall d'Hebron 119-129, Barcelona, Spain
| | - M Simó
- Departments of Nuclear Imaging, University Autonomous of Barcelona, Universitat Autònoma de Barcelona, University Hospital Vall d'Hebron, Passeig Vall d'Hebron 119-129, Barcelona, Spain
| | - O Persiva
- Departments of Radiology, University Autonomous of Barcelona, Universitat Autònoma de Barcelona, University Hospital Vall d'Hebron, Passeig Vall d'Hebron 119-129, Barcelona, Spain
| | - L Sánchez
- Departments of Thoracic Surgery, University Autonomous of Barcelona, Universitat Autònoma de Barcelona. University Hospital Vall d'Hebron, Passeig Vall d'Hebron 119-129, Barcelona, Spain
| | - I Sansano
- Departments of Pathology, University Autonomous of Barcelona, Universitat Autònoma de Barcelona, University Hospital Vall d'Hebron, Passeig Vall d'Hebron 119-129, Barcelona, Spain
| | - C Alemán
- Departments of Internal Medicine, University Autonomous of Barcelona, Universitat Autònoma de Barcelona, University Hospital Vall d'Hebron, Passeig Vall d'Hebron 119-129, Barcelona, Spain.
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2
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El-Kalashy MM, Eid HA, Awad SM, Allam ET, Hassan RAA, El-Koa AA. Role of GSDMD and VEGF in differentiating between malignant and non-malignant pleural effusions. BENI-SUEF UNIVERSITY JOURNAL OF BASIC AND APPLIED SCIENCES 2023. [DOI: 10.1186/s43088-023-00366-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
Abstract
Background
It is crucial to differentiate between benign and malignant pleural effusions while making a diagnosis. The purpose of this research was to investigate the diagnostic significance of GSDMD and VEGF in discriminating between different kinds of pleural effusion and their correlation with both progression-free and overall survivals in the malignant type.
Methods
Ninety-one pleural fluid samples, which were classified as transudates or exudates (tuberculous, para-infectious, or malignant) by pleural fluid classifications, were tested for GSDMD using sandwich ELIZA kits, and 41 of the exudative samples were randomly selected for VEGF testing. Both markers' diagnostic accuracy was assessed.
Results
The lowest level of GSDMD was associated with the transudate group (mean and SD of 2.35 ± 0.44 ng/mL) and the highest in the malignant effusion group (mean and SD of 4.38 ± 1.67 ng/mL). The specificity and sensitivity of GSDMD in the diagnosis of exudative PE were 97% and 98%, respectively (p = 0.001) with the cutoff point = 2.89). Regarding VEGF, its level was 222.3 ± 53.4 pg/ml for all studied samples where MPE (n = 21) was 261.2 ± 48.2 pg/ ml (mean ± SD), TBPE (n = 7) was 185.4 ± 6.96 pg/ml (mean ± SD), and PIPE (n = 13) was 179.3 ± 13.9 pg/ml (mean ± SD). The diagnostic accuracy of VEGF for the detection of MPE was 90% with a sensitivity of 100% and specificity of 80% and the cutoff point was 191.5 pg/ml. There were highly significant inverse correlations between progression-free survival and both GSDMD (r =− 0.531, p = 0.009) and VEGF (r = − 0.582, p = 0.006) in MPE.
Conclusion
Pleural effusion GSDMD can be an effective marker for differentiating the different kinds of PE, and VEGF levels can be a useful adjuvant marker in screening out MPE as a possible diagnosis, leading to the proper selection of patients who may benefit from more invasive procedures.
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3
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Muacevic A, Adler JR, Fujimori T, Sano C, Ohta R. Tuberculous Pleurisy Diagnosed From Massive Pleural Effusion in an Older Patient With No History of Tuberculosis. Cureus 2022; 14:e32333. [PMID: 36632275 PMCID: PMC9828074 DOI: 10.7759/cureus.32333] [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: 12/08/2022] [Indexed: 12/14/2022] Open
Abstract
Tuberculous pleurisy is an infectious disease with a poor prognosis needing early diagnosis. The use of appropriate antituberculosis drugs can improve prognosis. However, the diagnosis of tuberculous pleurisy is often challenging in older patients. Decreased activities of daily living (ADLs) may lead to difficulty in performing invasive procedures to make a definite diagnosis of pleural effusion. We report our experience with a 90-year-old female with the chief complaint of dyspnea with massive pleural effusion. We could not perform an intensive investigation for tuberculous pleurisy. Based on the high value of adenosine deaminase (ADA), we tentatively diagnosed tuberculous pleurisy for the large pleural effusion and treated her well with the initiation of four antituberculosis drugs. ADA in pleural effusion is considered effective for diagnosis among dependent older patients. Furthermore, although it is difficult to diagnose tuberculous pleurisy in older patients, starting treatment to sustain older patients' lives in their homes is crucial.
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4
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Eze NJ, Nwagboso CI, Ogbudu SO, Chidiebere E, Bassey OO, Etiuma AU. Diagnostic role of video-assisted thoracoscopy in the management of indeterminate pleural effusion. Niger J Clin Pract 2022; 25:1978-1983. [PMID: 36537454 DOI: 10.4103/njcp.njcp_311_22] [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: 06/17/2023]
Abstract
BACKGROUND The management of pleural effusion usually involves the drainage of the effusion, identification, and treatment of the underlying cause (s). Studies have shown that the initial diagnostic techniques do not give conclusive diagnosis in some cases of pleural effusion. This group of patients described as patients with indeterminate or undiagnosed pleural effusion constitutes a significant proportion of patients with pleural effusion in clinical practice. In this study, we examined the role of video-assisted thoracoscopy (VAT) in the diagnostic work-up of these patients. AIM To determine the diagnostic outcome of VAT in the management of indeterminate pleural effusion in our center. PATIENTS AND METHODS Consecutive patients who presented with pleural effusions and who met the inclusion criteria had video-assisted thoracoscopy for diagnostic purposes. Outcome measures including the diagnostic yield, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of VAT in patients with indeterminate pleural effusion, duration of the procedure, duration of hospitalization after the procedure, and complications for all the patients were documented and analyzed. RESULTS Of the 22 patients with indeterminate pleural effusion, conclusive diagnosis was obtained in 18 (81.8%) with a sensitivity of 91.7% [95% confidence interval (CI); 61.5-99.8%], specificity of 100% (95% CI; 69.1-100%), PPV of 100% (95% CI; 0-100%), and NPV of 90.9% (95% CI; 60.5-98.5%) for malignancy and a sensitivity of 78% (95% CI; 40-97%), a specificity of 100% (95% CI; 75.3-100%), PPV of 100% (95% CI; 0-100%), and NPV of 86.7% (95% CI; 65.7-95.7%) for tuberculosis. CONCLUSION Our results show that video-assisted thoracoscopy plays a useful role in our center in obtaining diagnosis in patients with indeterminate pleural effusion.
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Affiliation(s)
- N J Eze
- Department of Surgery, University of Calabar Teaching Hospital Calabar, Calabar, Cross River State, Nigeria
| | - C I Nwagboso
- Department of Surgery, University of Calabar Teaching Hospital Calabar, Calabar, Cross River State, Nigeria
| | - S O Ogbudu
- Department of Surgery, University of Calabar Teaching Hospital Calabar, Calabar, Cross River State, Nigeria
| | - E Chidiebere
- Department of Surgery, University of Calabar Teaching Hospital Calabar, Calabar, Cross River State, Nigeria
| | - O O Bassey
- Department of Surgery, University of Calabar Teaching Hospital Calabar, Calabar, Cross River State, Nigeria
| | - A U Etiuma
- Department of Surgery, University of Calabar and University of Calabar Teaching Hospital, Calabar, Cross River State, Nigeria
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5
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Deschuyteneer EP, De Keukeleire T. Diagnostic value and safety of thoracoscopic pleural biopsies in pleural exudative effusions of unknown origin, including follow-up. BMJ Open Respir Res 2022; 9:9/1/e001161. [PMID: 35277425 PMCID: PMC8919466 DOI: 10.1136/bmjresp-2021-001161] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 02/28/2022] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Pleural exudative effusions without diagnosis after initial work up are a frequent problem in any respiratory division. Several ways to obtain pleural biopsy exist. Thoracoscopy is one of the most frequently used. Differential diagnosis mainly exists out of malignant pleuritis, tuberculosis, nonspecific pleuritis and rarely systemic or autoimmune disease. We performed a retrospective data analysis of our almost 10-year period experience, the first Belgian data to be published. METHODS We performed a retrospective data analysis of all patients with unexplained pleural exudates who underwent diagnostic medical thoracoscopy under general anaesthesia in our respiratory department during the period 2006-2015. We report on diagnoses made, sensitivity and specificity, safety of thoracoscopy and follow-up of patients after thoracoscopy. RESULTS 131 patients underwent diagnostic medical thoracoscopy during the inclusion period. 44.3% (n=58) of the patients were diagnosed with malignant pleuritis, 45.0% (n=59) with nonspecific pleuritis, 7.6% (n=10) with tuberculous pleuritis and some with other benign conditions. Complications are comparable to other data published. Six months follow-up of patients with non-specific pleuritis reveal 8.5% (n=5) of these patients to have malignant pleuritis, and another 8.5% (n=5) with infectious or other benign conditions. CONCLUSION Medical thoracoscopy under general anaesthesia for diagnostic work up of pleural exudates of unknown origin generally has a high diagnostic yield. It is generally safe, certainly compared with the information it delivers. During follow-up, minority of patients with nonspecific pleuritis will prove to be malignant in origin, benign or autoimmune disease related.
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Affiliation(s)
- Evan Patrick Deschuyteneer
- Respiratory Division, AZ Sint-Elisabeth Ziekenhuis Zottegem vzw, Zottegem, Belgium .,Intensive Care Unit, AZ Sint-Elisabeth Ziekenhuis Zottegem vzw, Zottegem, Belgium
| | - Tom De Keukeleire
- Respiratory Division, AZ Sint-Elisabeth Ziekenhuis Zottegem vzw, Zottegem, Belgium.,Respiratory Division, UZ Brussel, Brussel, Belgium
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6
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Chen KC, Tsai SW, Zhang X, Zeng C, Yang HY. The investigation of the volatile metabolites of lung cancer from the microenvironment of malignant pleural effusion. Sci Rep 2021; 11:13585. [PMID: 34193905 PMCID: PMC8245642 DOI: 10.1038/s41598-021-93032-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 06/16/2021] [Indexed: 12/29/2022] Open
Abstract
For malignant pleural effusions, pleural fluid cytology is a diagnostic method, but sensitivity is low. The pleural fluid contains metabolites directly released from cancer cells. The objective of this study was to diagnose lung cancer with malignant pleural effusion using the volatilomic profiling method. We recruited lung cancer patients with malignant pleural effusion and patients with nonmalignant diseases with pleural effusion as controls. We analyzed the headspace air of the pleural effusion by gas chromatography-mass spectrometry. We used partial least squares discriminant analysis (PLS-DA) to identify metabolites and the support vector machine (SVM) to establish the prediction model. We split data into a training set (80%) and a testing set (20%) to validate the accuracy. A total of 68 subjects were included in the final analysis. The PLS-DA showed high discrimination with an R2 of 0.95 and Q2 of 0.58. The accuracy of the SVM in the test set was 0.93 (95% CI 0.66, 0.998), the sensitivity was 83%, the specificity was 100%, and kappa was 0.85, and the area under the receiver operating characteristic curve was 0.96 (95% CI 0.86, 1.00). Volatile metabolites of pleural effusion might be used in patients with cytology-negative pleural effusion to rule out malignancy.
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Affiliation(s)
- Ke-Cheng Chen
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan.,National Taiwan University College of Medicine, Taipei, Taiwan
| | - Shih-Wei Tsai
- Institute of Environmental and Occupational Health Sciences, National Taiwan University College of Public Health, No. 17 Xuzhou Road, Taipei, 10055, Taiwan
| | - Xiang Zhang
- Department of Chemistry, University of Louisville, Louisville, KY, USA
| | - Chian Zeng
- Institute of Environmental and Occupational Health Sciences, National Taiwan University College of Public Health, No. 17 Xuzhou Road, Taipei, 10055, Taiwan
| | - Hsiao-Yu Yang
- Institute of Environmental and Occupational Health Sciences, National Taiwan University College of Public Health, No. 17 Xuzhou Road, Taipei, 10055, Taiwan. .,Department of Public Health, National Taiwan University College of Public Health, Taipei, Taiwan. .,Department of Environmental and Occupational Medicine, National Taiwan University Hospital, Taipei, Taiwan.
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7
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Abstract
Advanced malignancy is a prevalent cause of exudative pleural effusion. The management of malignant pleural effusion (MPE) has been the subject of several recent randomized controlled trials and excellent reviews. Less attention has been focused on another controversial and challenging aspect of MPE: establishing the diagnosis. Before selecting the optimal management strategy, the presence of an MPE must first be correctly identified with an emphasis on minimizing invasiveness and discomfort in a patient with late-stage cancer. The aim of the present review is to summarize the current knowledge about MPE diagnostics and to propose an algorithm for the diagnosis of MPE in established or suspected malignancy.
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8
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Shaikh F, Lentz RJ, Feller-Kopman D, Maldonado F. Medical thoracoscopy in the diagnosis of pleural disease: a guide for the clinician. Expert Rev Respir Med 2020; 14:987-1000. [PMID: 32588676 DOI: 10.1080/17476348.2020.1788940] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Developing a feasible and accurate means of evaluating pleural pathology has been an ongoing effort for over 150 years. Pleural fluid cellular and biomarker analyses are simple ways of characterizing and uncovering pathologic entities of pleural disease. However, obtaining samples of pleural tissue has become increasingly important. In cases of suspected malignancy and certain infections histopathology, culture, and molecular testing are necessary to profile diseases more effectively. The pleura is sampled via several techniques including blind transthoracic biopsy, image-guided biopsy, and surgical thoracotomy. Given the heterogeneity of pleural disease, low diagnostic yields, or invasiveness no procedural gold standard has been established in pleural diagnostics. AREAS COVERED Herein, we provide a review of the literature on medical thoracoscopy (MT), its development, technical approach, indications, risks, current and future role in the evaluation of thoracic disease. Pubmed was searched for articles published on MT, awake thoracoscopy, and pleuroscopy with a focus on reviewing literature published in the past 5 years. EXPERT OPINION As the proficiency and number of interventional pulmonologists continues to grow, MT is ideally positioned to become a front-line diagnostic tool in pleural disease and play an increasingly prominent role in the treatment algorithm of various pleural pathologies.
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Affiliation(s)
- Faisal Shaikh
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine, University of Los Angeles , Los Angeles, CA, USA
| | - Robert J Lentz
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Interventional Pulmonology , Nashville, TN, USA
| | - David Feller-Kopman
- Division of Pulmonary, Critical Care, and Sleep Medicine, Johns Hopkins Hospital , Baltimore, MD, USA
| | - Fabien Maldonado
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Interventional Pulmonology , Nashville, TN, USA
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9
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Jordano Q, Aiello TF, Rami R, Jaen A, Sierra ADL. Video-thoracoscopy for the evaluation of undiagnosed pleural effusion: Is it possible to optimize its indication? Eur J Intern Med 2020; 73:105-107. [PMID: 31932191 DOI: 10.1016/j.ejim.2019.12.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 12/20/2019] [Accepted: 12/28/2019] [Indexed: 11/23/2022]
Affiliation(s)
- Queralt Jordano
- Internal Medicine Department, University Hospital Mutua Terrassa, Universitat de Barcelona, Plaza Dr.Robert, 5, 08221 Terrassa, Barcelona, Spain.
| | - Tommaso Francesco Aiello
- Internal Medicine Department, University Hospital Mutua Terrassa, Universitat de Barcelona, Plaza Dr.Robert, 5, 08221 Terrassa, Barcelona, Spain.
| | - Ramon Rami
- Thoracic Surgery Department, University Hospital Mutua Terrassa, Universitat de Barcelona, Plaza Dr.Robert, 5, 08221 Terrassa, Barcelona, Spain.
| | - Angels Jaen
- Research Foundation, University Hospital Mutua Terrassa, Universitat de Barcelona, Plaza Dr.Robert, 5, 08221 Terrassa Barcelona, Spain.
| | - Alejandro de la Sierra
- Internal Medicine Department, University Hospital Mutua Terrassa, Universitat de Barcelona, Plaza Dr.Robert, 5, 08221 Terrassa, Barcelona, Spain.
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10
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Epelbaum O, Rahman NM. Contemporary approach to the patient with malignant pleural effusion complicating lung cancer. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:352. [PMID: 31516898 DOI: 10.21037/atm.2019.03.61] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Malignant pleural effusion (MPE) occurring in the patient with lung cancer can have profound prognostic and management implications. If clinically relevant, such an effusion first needs to be confirmed as malignant and then, in the majority of lung cancer patients, it will require a pleural intervention to relieve symptoms related to fluid accumulation. The field of pleural diseases in general, and pleural malignancy in particular, has undergone dynamic changes in recent years as the evidence base informing practice has grown by leaps and bounds. Both the diagnosis and management of MPE are dynamically changing disciplines in thoracic medicine. As commonly happens, emerging data have generated just as many questions as they have answered. The aim of the present review is to summarize the current knowledge about MPE resulting from lung cancer in a manner that is accessible to clinicians across medical specialties.
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Affiliation(s)
- Oleg Epelbaum
- Division of Pulmonary, Critical Care and Sleep Medicine, Westchester Medical Center, Valhalla, NY, USA
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Respiratory Trials Unit, Oxford University, Oxford, UK
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11
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Reuter S, Lindgaard D, Laursen C, Fischer BM, Clementsen PF, Bodtger U. Computed tomography of the chest in unilateral pleural effusions: outcome of the British Thoracic Society guideline. J Thorac Dis 2019; 11:1336-1346. [PMID: 31179075 DOI: 10.21037/jtd.2019.03.75] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background The guidelines from the British Thoracic Society (BTS) regarding the investigation of unilateral pleural effusions recommend computed tomography (CT) in exudates. We decided to investigate if clinicians follow BTS guidelines' recommendations with respect to CT in patients with unilateral pleural effusions. Secondly, to investigate the diagnostic consequences of following and not following this recommendation. Methods The study was a retrospective, non-randomized study including consecutive patients referred to our tertiary centers in 2013-2016 because of unilateral pleural effusion. Patients undergoing chest CT for unilateral pleural effusion of unknown cause after thoracentesis and chest X-ray were included. Patients were categorized as having pleural exudates or transudates, according to Light's criteria, if applicable. We registered use of CT, and calculated diagnostic values. Results In total, 323 of the 465 included patients underwent CT (69%). CT was performed in the majority of patients not having an exudate (transudates: n=40; 54%; Light's criteria not assessed: n=111; 67%). 18F-FDG positron emission tomography (PET)/CT without prior CT was performed in 32 patients with an exudate (58%). The sensitivity of a non-guideline supported CT (70%) was significantly higher compared to a guideline supported CT (47%), P value <0.045. The post-test probability of a positive guideline-supported CT [likelihood ratio (LR) positive 3.26] for a later diagnosis of thoracic malignancy increased the probability from 25% to 52%. A negative CT (LR negative 0.62) decreased the probability to 17%. For a non-guideline-supported CT the numbers were (LR positive 3.42) 53% and (LR negative 0.38) 11%, respectively. Conclusions Clinicians appear not to follow BTS guidelines when deciding to perform chest CT. The relevance of this deviation is supported by the superior sensitivity of CT non-guideline supported CT. Overall, CT is associated with suboptimal sensitivity and negative predictive values for the diagnosis of thoracic malignancy.
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Affiliation(s)
- Simon Reuter
- Department of Respiratory Medicine, Naestved Hospital, Naestved, Denmark.,Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Dennis Lindgaard
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
| | - Christian Laursen
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
| | - Barbara Malene Fischer
- Department of Clinical Physiology, Nuclear Medicine and PET, University of Copenhagen, Copenhagen, Denmark
| | - Paul Frost Clementsen
- Department of Respiratory Medicine, Zealand University Hospital, Roskilde, Denmark.,Copenhagen Academy for Medical Education and Simulation (CAMES), University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Uffe Bodtger
- Department of Respiratory Medicine, Naestved Hospital, Naestved, Denmark.,Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark.,Department of Respiratory Medicine, Zealand University Hospital, Roskilde, Denmark
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12
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Simó M, Pallisa E, Jaúregui A, Montoro B, Vázquez A, Bello I, Persiva O, Alemán C. Thoracic CT Scan vs PET-TC Imaging in the Diagnosis of Patients Suffering Exudative Pleural Effusions with Suspicion of Malignancy. Arch Bronconeumol 2019; 55:544-546. [PMID: 31014556 DOI: 10.1016/j.arbres.2019.02.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 02/18/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Marc Simó
- Department of Nuclear Medicine, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Esther Pallisa
- Department of Radiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Alberto Jaúregui
- Department of Thoracic Surgery, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Bruno Montoro
- Department of Pharmacy, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Ana Vázquez
- Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Irene Bello
- Department of Thoracic Surgery, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Oscar Persiva
- Department of Radiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Carmen Alemán
- Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
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13
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Reuter S, Naur TMH, Clementsen PF, Bodtger U. The value of computed tomography in discriminating malignant from non-malignant causes of unresolved unilateral pleural effusions: a systematic review. Eur Clin Respir J 2019; 6:1565803. [PMID: 33868602 PMCID: PMC8026111 DOI: 10.1080/20018525.2019.1565803] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022] Open
Abstract
The scientific background in expert-opinion papers for recommending Computed Tomography (CT) in unilateral pleural exudates is based on studies including patients with other findings than unilateral pleural effusions or selected patients undergoing thoracoscopy. Therefore, we performed a systematic review investigating the sensitivity of CT for predicting malignancy in patients with unilateral, non-transudative, pleural effusions. A search strategy was developed with the assistance of a medical information specialist at our university library. We searched PubMed/MEDLINE, EMBASE and Cochrane Library, ClinicalTrials.gov and articles citing the included studies. No date restrictions were applied (the first included paper was published in 2001 (1)), and only literature in English was included. We used the Quality Assessment of Diagnostic Accuracy Studies 2 for bias assessment. We registered the protocol at PROSPERO (CRD42018094830). Five studies were included, two prospective and three retrospective, all performed in Western Europe. No study reported diagnostic values for patients with unilateral, non-transudative pleural effusions only; one study did for unilateral pleural effusions. In the remaining studies, most patients had unilateral effusions and non-transudative effusions. Patients were primarily males and >70 years. All but one study found a high incidence of malignancy, dominated by malignant pleural mesothelioma. All studies were limited by risk of bias and applicability, predominantly regarding study population, pretests and index test. The current evidence supporting the sensitivity of CT for predicting malignancy in unilateral pleural effusions (both non-transudative and all types of effusion) is very low and did not allow meta-analysis. Standardization of patient population and CT protocol may facilitate conclusions of futures studies.
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Affiliation(s)
- Simon Reuter
- Department of Respiratory Medicine, Naestved Hospital, Naestved, Denmark.,Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Therese Maria Henriette Naur
- Copenhagen Academy for Medical Education and Simulation (CAMES), Rigshospitalet, University of Copenhagen and the Capital Region of Denmark, Copenhagen, Denmark
| | - Paul Frost Clementsen
- Copenhagen Academy for Medical Education and Simulation (CAMES), Rigshospitalet, University of Copenhagen and the Capital Region of Denmark, Copenhagen, Denmark.,Department of Respiratory Medicine, Zealand University Hospital, Roskilde, Denmark.,Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Uffe Bodtger
- Department of Respiratory Medicine, Naestved Hospital, Naestved, Denmark.,Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark.,Department of Respiratory Medicine, Zealand University Hospital, Roskilde, Denmark
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14
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Liu C, Huang L, Zhang X, Yang J. Combination of DNA ploidy analysis and miR-21 or miR-24 in screening malignant pleural effusion. Interact Cardiovasc Thorac Surg 2019; 26:376-381. [PMID: 29069463 DOI: 10.1093/icvts/ivx327] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Accepted: 09/06/2017] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The study aimed to assess the combination of DNA ploidy analysis (DPA) and the expression of microRNA-21 (miR-21) or microRNA-24 (miR-24) in the detection of malignant pleural effusion (MPE). METHODS In this prospective research, a total of 40 samples (20 benign and 20 malignant effusions), flexural effusion exfoliated cells and cell-free miR-21 and miR-24 were collected. DPA and exfoliative cytology examinations were conducted to diagnose flexural effusion exfoliated cells. Quantitative reverse transcriptase polymerase chain reaction was carried out to measure the expressions of miR-21 and miR-24. Receiver operating characteristic curve and the area under the curve were applied to evaluate the accuracy rate of different diagnostic approaches on MPE. RESULTS In the MPE group, DPA demonstrated a higher rate of accuracy in MPE diagnosis than exfoliative cytology. The expressions of miR-21 and miR-24 were significantly higher in MPE than in benign pleural effusion (P < 0.05). Furthermore, area under the curve, sensitivity and specificity were 0.942, 95% and 90% for the combination of miR-21 and DPA and 0.973, 100% and 80% for the union of miR-24 and DPA, respectively, representing a significant improvement in both accuracy and sensitivity. Therefore, the combination of DPA and miR-21 or miR-24 appears to be a better biomarker for discriminating MPE from benign pleural effusion. CONCLUSIONS The combination of DPA and miR-21 or miR-24 may function as a promising diagnostic tool of MPE. Registration number ChiCTR-TRC-14004719.
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Affiliation(s)
- Chongmei Liu
- Department of Pathology, Yueyang Second People's Hospital, Yueyang, Hunan, China
| | - Liuyan Huang
- Graduate School of The University of South China, Hengyang, Hunan, China
| | - Xuechun Zhang
- Graduate School of The University of South China, Hengyang, Hunan, China
| | - Juan Yang
- Graduate School of The University of South China, Hengyang, Hunan, China
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Pan Y, Bai W, Chen J, Mao Y, Qian X, Xu K, Tang S, Zhang J, Chen C, Chen J, Hu X. Diagnosing malignant pleural effusion using clinical and analytical parameters. J Clin Lab Anal 2018; 33:e22689. [PMID: 30390322 DOI: 10.1002/jcla.22689] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 09/14/2018] [Accepted: 09/16/2018] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Malignant pleural effusion (MPE) is common and diagnosis is often problematic. A cancer ratio (serum lactate dehydrogenases: pleural adenosine deaminase ratio) has been proposed for diagnosing MPE. However, the usefulness of this "cancer ratio" and the clinical-radiological criteria for diagnosing MPE has not been clearly determined to date. The aim of this study was to assess the performance of those parameters in the diagnosis of MPE. METHODS We analyzed 240 patients including 120 with MPE and 120 with non-MPE (93 tuberculous and 27 parapneumonic). Patients were divided into two groups: MPE and non-MPE (eg, tuberculous and parapneumonic). We constructed two predictive models to assess the probability of MPE: (a) clinical-radiological data only and (b) a combination of clinical-radiological data, the cancer ratio, and the carcinoembryonic antigen (CEA). The performances of the predictive models were assessed using receiver operating characteristic (ROC) curves and by examining the calibration. RESULTS The area under the ROC curves for model 1 and model 2 were excellent, 0.936 and 0.998, respectively. The overall diagnostic accuracies for model 1 and model 2 were 87.5% and 98.8%, respectively. CONCLUSION The results confirm that both models achieved a high diagnostic accuracy for MPE; however, model 2 was superior with the addition of its simplicity of use in daily practice. This model should be applied to determine which patients with a pleural effusion of unknown origin would not benefit from further invasive procedures.
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Affiliation(s)
- Yong Pan
- Department of Clinical Laboratory Medicine, Wenzhou Central Hospital, Wenzhou, China
| | - Wenjing Bai
- Department of Clinical Laboratory Medicine, Wenzhou Central Hospital, Wenzhou, China
| | - Jiangnan Chen
- Department of Clinical Laboratory Medicine, ShaoXing Municipal Hospital, Shao Xing, China
| | - Yijian Mao
- Department of Clinical Laboratory Medicine, Wenzhou Central Hospital, Wenzhou, China
| | - Xiaohong Qian
- Department of Clinical Laboratory Medicine, Wenzhou Central Hospital, Wenzhou, China
| | - Ke Xu
- Department of Clinical Laboratory Medicine, Wenzhou Central Hospital, Wenzhou, China
| | - Shaohua Tang
- Department of Clinical Laboratory Medicine, Wenzhou Central Hospital, Wenzhou, China
| | - Junwu Zhang
- Department of Clinical Laboratory Medicine, Wenzhou Traditional Chinese Medicine Hospital, Wenzhou, China
| | - Chong Chen
- Department of Clinical Laboratory Medicine, Wenzhou Central Hospital, Wenzhou, China
| | - Jingyi Chen
- Department of Clinical Laboratory Medicine, Wenzhou Central Hospital, Wenzhou, China
| | - Xingzhong Hu
- Department of Clinical Laboratory Medicine, Wenzhou Central Hospital, Wenzhou, China
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Bielsa S, García-Zamalloa A, Monteagudo P, González-Sans D, Ascanio D, Esquerda A, Taboada-Gómez J, Porcel JM. Detection of Pleural Fluid Biochemistry Changes in Two Consecutive Thoracenteses for Differentiating Malignant from Benign Effusions. Arch Bronconeumol 2018; 54:320-326. [PMID: 29496288 DOI: 10.1016/j.arbres.2018.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 01/03/2018] [Accepted: 01/19/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess whether changes in pleural fluid (PF) biochemistries between two consecutive thoracenteses enable clinicians to predict malignant or benign pleural effusions (PE). METHODS Retrospective study of patients with lymphocytic exudates and negative PF cytology, who underwent a second thoracentesis in our center in the last 15 years in whom a final diagnosis was reached (derivation sample). Absolute (Δa) and percentage differences (Δp) in PF biochemistries which predicted a malignant or benign PE in the derivation sample were evaluated in an independent population (validation sample). RESULTS The derivation sample included 214 PE patients (70 malignant and 144 benign PE). Δp lactate dehydrogenase (LDH) >0%, Δp neutrophils >-10% (any increase or less than 10% decrease) and Δa protein <0.1g/dL (any increase or less than 0.1g/dL decrease) between the second and the first thoracentesis had an odds ratio of 6.4, 3.9 and 2.1, respectively, to discriminate malignant from benign PE. The presence of the three conditions together had a positive likelihood ratio of 5.6, whereas the absence of any of the 3 parameters had a likelihood ratio of 0.04 for predicting malignancy. These results were reproduced in the validation sample. CONCLUSION An increase in LDH and neutrophils along with a decrease in protein in a second thoracentesis increase the probability of malignant PE, while the opposite reduces it significantly.
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Affiliation(s)
- Silvia Bielsa
- Unidad de Medicina Pleural, Hospital Universitario Arnau de Vilanova, IRBLLEIDA, Lleida, España
| | | | - Paula Monteagudo
- Unidad de Medicina Pleural, Hospital Universitario Arnau de Vilanova, IRBLLEIDA, Lleida, España
| | - Didac González-Sans
- Servicio de Medicina Interna, Hospital Universitario Vall d'Hebrón, Barcelona, España
| | - David Ascanio
- Facultad de Medicina, Universitat de Lleida, Lleida, España
| | - Aureli Esquerda
- Servicio de Análisis Clínicos, Hospital Universitario Arnau de Vilanova, IRBLLEIDA, Lleida, España
| | - Jorge Taboada-Gómez
- Servicio de Medicina Preventiva y Salud Pública, Hospital de Urdúliz-Alfredo Espinosa, Urduliz, Vizcaya, España
| | - José M Porcel
- Unidad de Medicina Pleural, Hospital Universitario Arnau de Vilanova, IRBLLEIDA, Lleida, España.
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Clinical Relevance of Human Mammaglobin mRNA in Pleural Effusion from Patients Undergoing Thoracoscopy: A Pilot Study. Int J Biol Markers 2018; 27:e99-104. [DOI: 10.5301/jbm.2012.9305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2012] [Indexed: 11/20/2022]
Abstract
Background human mammaglobin (hMAM) expression has been reported in pleural effusions (PE). The aim of this study was to assess the clinical relevance of hMAM mRNA in PE from patients who underwent thoracoscopy. Material and methods A total of 288 patients with PE were studied, 155 of which were diagnosed with malignant and 133 with non-malignant diseases by thoracoscopy. Cells from PE were analyzed by nested hMAM RT-PCR. Statistical analyses were performed to evaluate the diagnostic performance parameters (DPP), the association between hMAM expression and benign or malignant status and the relative risk of cancer for patients with negative thoracoscopy showing hMAM positivity. Results hMAM mRNA was found in 68/288 (23.6%) PE samples of which 51 were from the 155 patients diagnosed with malignant diseases and 17 were from the 133 patients diagnosed with non-malignant diseases. A significant correlation between hMAM expression and malignancy was found (OR=3.04) and the DPP were as follows: sensitivity=32.9%, specificity=87.2%, accuracy=58.0%, positive predictive value=75.0% and negative predictive value=52.7%. Among the patients with negative thoracoscopy (n=133), 5/17 (29.4%) hMAM-positive patients had or developed a tumor during the 18-month follow up period, as compared to 10/116 (8.6%) hMAM-negative patients (relative risk of 4.6 for developing a malignancy). Conclusion These findings suggest a possible application of hMAM RT-PCR detection in PE as to identify a false-negative thoracoscopy in non-specific pleuritis.
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Abstract
Objectives: It is not always possible to move critically ill patients to the operating or endoscopy room for a pleuroscopy. Bedside pleuroscopy is indicated for these patients. The aim of this study was to investigate the safety and complications of bedside pleuroscopy in an Intensive Care Unit (ICU). Materials and Methods: The patients who had undergone routine examinations for pleural effusion, with no established diagnosis at the previous admission were included in this analysis. Patients received local analgesia with bedside pleuroscopy performed by a chest physician in the ICU with continuous monitoring. Results: Twenty-five patients (17 males and 8 females) with a mean age of 74 ± 3 years were enrolled. Their mean APACHE II score was 23 ± 1. The duration of drainage from the pigtail catheter was a mean 3.9 ± 0.2 days, and mean ventilator usage was 6 ± 0.7 days. The length of stay in the ICU was 11 ± 1 days. Most pleural effusions occurred on the right side (17/25, 68%). Fifteen patients (60%) had malignant effusions, four (16%) had parapneumonic effusions, three (12%) had empyema, and two (8%) had tuberculosis. Complications occurred in 11 (44%) patients. There were no major complications such as bleeding or procedure-related death. The most common complication was transient chest pain (n = 6, 24%). Conclusions: Pleuroscopy performed at the bedside in the ICU is a simple and safe procedure. It has the potential for use in critical patients as serious complications are rare.
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Affiliation(s)
- Hean Ooi
- Department of Preventive Medicine, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan.,Department of Pulmonology and Critical Care, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
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Wang W, Zhou Q, Zhai K, Wang Y, Liu JY, Wang XJ, Wang Z, Zhang JC, Tong ZH, Shi HZ. Diagnostic accuracy of interleukin 27 for tuberculous pleural effusion: two prospective studies and one meta-analysis. Thorax 2017; 73:240-247. [PMID: 28844060 DOI: 10.1136/thoraxjnl-2016-209718] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 07/12/2017] [Accepted: 07/31/2017] [Indexed: 11/04/2022]
Abstract
BACKGROUND Accurate differentiating diagnosis is essential for choosing treatment for exudative pleural effusions. OBJECTIVE To establish the diagnostic accuracy of interleukin 27 for tuberculous pleural effusion (TPE). METHODS First, the concentrations of pleural interleukin 27, interferon-gamma and adenosine deaminase were compared between 51 patients with TPE and 103 with non-TPEs (Beijing cohort), and their diagnostic values were evaluated. These were further verified in another independent population (Wuhan cohort, n=120). In the second part of the study, we performed a meta-analysis. RESULTS With a cut-off value of 591.4 ng/L in the Beijing cohort, the area under the curve, sensitivity, specificity, positive predictive value and negative predictive value of interleukin 27 to diagnose TPE were 0.983 (95% CI 0.947 to 0.997), 96.1% (86.5% to 99.5%), 99.0% (94.7% to 100%), 98.0 (89.4 to 99.9) and 98.1 (93.3 to 99.8), respectively. Excellent diagnostic accuracy of interleukin 27 was also found in the Wuhan cohort and was further confirmed in the meta-analysis. The diagnostic performance of interleukin 27 was comparable to that of interferon-gamma and was more accurate than that of adenosine deaminase. Since the post-test probability of a negative result was always <0.1%, a negative test was considered to exclude TPE in all tuberculosis prevalence settings. CONCLUSIONS Interleukin 27 can be used to diagnose TPE in a high prevalence setting, and a negative result can also be reliably used to rule out TPE in all prevalence settings.
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Affiliation(s)
- Wen Wang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Qiong Zhou
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Kan Zhai
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Yao Wang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Jing-Yuan Liu
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiao-Juan Wang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Zhen Wang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Jian-Chu Zhang
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhao-Hui Tong
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Huan-Zhong Shi
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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20
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Predicting Malignant and Paramalignant Pleural Effusions by Combining Clinical, Radiological and Pleural Fluid Analytical Parameters. Lung 2017; 195:653-660. [PMID: 28656381 DOI: 10.1007/s00408-017-0032-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 06/19/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND The usefulness of clinical, radiological and pleural fluid analytical parameters for diagnosing malignant and paramalignant pleural effusion is not clearly stated. Hence this study aimed to identify possible predictor variables of diagnosing malignancy in pleural effusion of unknown aetiology. METHODS Clinical, radiological and pleural fluid analytical parameters were obtained from consecutive patients who had suffered pleural effusion of unknown aetiology. They were classified into three groups according to their final diagnosis: malignant, paramalignant and benign pleural effusion. The CHAID (Chi-square automatic interaction detector) methodology was used to estimate the implication of the clinical, radiological and analytical variables in daily practice through decision trees. RESULTS Of 71 patients, malignant (n = 31), paramalignant (n = 15) and benign (n = 25), smoking habit, dyspnoea, weight loss, radiological characteristics (mass, node, adenopathies and pleural thickening) and pleural fluid analytical parameters (pH and glucose) distinguished malignant and paramalignant pleural effusions (all with a p < 0.05). Decision tree 1 classified 77.8% of malignant and paramalignant pleural effusions in step 2. Decision tree 2 classified 83.3% of malignant pleural effusions in step 2, 73.3% of paramalignant pleural effusions and 91.7% of benign ones. CONCLUSIONS The data herein suggest that the identified predictor values applied to tree diagrams, which required no extraordinary measures, have a higher rate of correct identification of malignant, paramalignant and benign effusions when compared to techniques available today and proved most useful for usual clinical practice. Future studies are still needed to further improve the classification of patients.
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Hatata EA, Daabis RG, El Sabaa BM, Baess AI, Abd El-Rahman IA. Doxycycline poudrage: An old agent for a new technique. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2017. [DOI: 10.1016/j.ejcdt.2016.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Abstract
Although it is curable, tuberculosis remains one of the most frequent causes of pleural effusions on a global scale, especially in developing countries. Tuberculous pleural effusion (TPE) is one of the most common forms of extrapulmonary tuberculosis. TPE usually presents as an acute illness with fever, cough and pleuritic chest pain. The pleural fluid is an exudate that usually has predominantly lymphocytes. The gold standard for the diagnosis of TPE remains the detection of Mycobacterium tuberculosis in pleural fluid, or pleural biopsy specimens, either by microscopy and/or culture, or the histological demonstration of caseating granulomas in the pleura along with acid fast bacilli, Although adenosine deaminase and interferon-γ in pleural fluid have been documented to be useful tests for the diagnosis of TPE. It can be accepted that in areas with high tuberculosis prevalence, the easiest way to establish the diagnosis of TPE in a patient with a lymphocytic pleural effusion is to generally demonstrate a adenosine deaminase level above 40 U/L. The recommended treatment for TPE is a regimen with isoniazid, rifampin, and pyrazinamide for two months followed by four months of two drugs, isoniazid and rifampin.
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Affiliation(s)
- Kan Zhai
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Yong Lu
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Huan-Zhong Shi
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
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Wang XJ, Yang Y, Wang Z, Xu LL, Wu YB, Zhang J, Tong ZH, Shi HZ. Efficacy and safety of diagnostic thoracoscopy in undiagnosed pleural effusions. Respiration 2015; 90:251-5. [PMID: 26279455 DOI: 10.1159/000435962] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 06/08/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The differential diagnosis of pleural effusions can present a considerable challenge, and the etiology of pleural effusions varies depending on the population studied. OBJECTIVE This study aimed to assess the efficacy and safety of medical thoracoscopy in the diagnosis of patients with undiagnosed pleural effusions in a Chinese population. METHODS Between July 2005 and June 2014, medical thoracoscopy (MT) using the semirigid instrument was performed in 833 patients with pleural effusions of unknown etiology in our Institute, where diagnostic thoracocentesis or/and blind pleural biopsy had failed to yield an answer. Demographic, radiographic, procedural, and histological data were recorded and analyzed. RESULTS During this 9-year study, satisfactory pleural biopsy samples were obtained in 833 patients, and MT revealed malignant pleural effusion in 342 (41.1%) patients, benign pleural effusion in 429 (51.5%) patients, and 62 (7.4%) patients could not get definite diagnoses. The overall diagnostic efficiency of MT was 92.6% (771/833). After MT, the only severe complication was empyema, seen in 3 patients (0.4%). The most common minor complication was transient chest pain (44.1%) from the indwelling chest tube. CONCLUSIONS MT is an effective and safe procedure for diagnosing pleural effusions of undetermined causes. In areas with high tuberculosis prevalence, MT should be particularly helpful in the differential diagnosis of tuberculous pleural effusion.
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Affiliation(s)
- Xiao-Juan Wang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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Perplexing pneumonia: Early anticipation and outcome. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2015. [DOI: 10.1016/j.ejcdt.2014.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Sun W, Li J, Jiang HG, Ge LP, Wang Y. Diagnostic value of MUC1 and EpCAM mRNA as tumor markers in differentiating benign from malignant pleural effusion. QJM 2014; 107:1001-7. [PMID: 24939190 DOI: 10.1093/qjmed/hcu130] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The sensitivity of conventional cytology for the detection of tumor cells in pleural effusion (PE) is inadequate. Mucine 1 (MUC1) and epithelial cell adhesion molecule (EpCAM) are two frequently and intensely expressed tumor-associated antigens in malignancies of epithelial origin. OBJECTIVE To evaluate the diagnostic value of pleural fluid MUC1 and EpCAM mRNA in differentiating benign and malignant PE. METHOD Fifty-eight patients with malignant PE and 40 patients with benign PE were included in this study. Pleural fluid MUC1 and EpCAM mRNA levels were measured by quantitative real-time PCR. Carcinoembryonic antigen (CEA) and cytokeratin 19 fragment (Cyfra21-1) were also detected simultaneously. The receiver operating characteristic (ROC) curves were constructed to assess diagnostic performance of the four tumor markers in PE. RESULTS For the diagnosis of malignant PE, MUC1 and EpCAM mRNA had larger area under ROC curves (0.916 and 0.922) and higher sensitivity (67.2 and 70.7%) with the same specificity, when compared with CEA and Cyfra21-1 (0.821 and 0.780; 48.3 and 44.8%, respectively). By combining cytology with MUC and EpCAM, a positive result indicating the presence of malignancy was achieved in 87.9%, with a good specificity of 95%. CONCLUSIONS Compared with CEA and Cyfra21-1, the performance of MUC1 and EpCAM mRNA in malignant PE diagnosis was better. MUC1 and EpCAM mRNA in combination with cytology is a highly sensitive and specific diagnostic tool for detecting malignancy in PE.
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Affiliation(s)
- W Sun
- From the Department of Pulmonary Medicine and Center of Experimental Medicine, Affiliated Hospital of Jiangsu University, 438 North Jiefang Street, Zhenjiang 212001, China
| | - J Li
- From the Department of Pulmonary Medicine and Center of Experimental Medicine, Affiliated Hospital of Jiangsu University, 438 North Jiefang Street, Zhenjiang 212001, China
| | - H-G Jiang
- From the Department of Pulmonary Medicine and Center of Experimental Medicine, Affiliated Hospital of Jiangsu University, 438 North Jiefang Street, Zhenjiang 212001, China
| | - L-P Ge
- From the Department of Pulmonary Medicine and Center of Experimental Medicine, Affiliated Hospital of Jiangsu University, 438 North Jiefang Street, Zhenjiang 212001, China
| | - Y Wang
- From the Department of Pulmonary Medicine and Center of Experimental Medicine, Affiliated Hospital of Jiangsu University, 438 North Jiefang Street, Zhenjiang 212001, China
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Na MJ. Diagnostic tools of pleural effusion. Tuberc Respir Dis (Seoul) 2014; 76:199-210. [PMID: 24920946 PMCID: PMC4050067 DOI: 10.4046/trd.2014.76.5.199] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Revised: 04/04/2014] [Accepted: 04/11/2014] [Indexed: 01/31/2023] Open
Abstract
Pleural effusion is not a rare disease in Korea. The diagnosis of pleural effusion is very difficult, even though the patients often complain of typical symptoms indicating of pleural diseases. Pleural effusion is characterized by the pleural cavity filled with transudative or exudative pleural fluids, and it is developed by various etiologies. The presence of pleural effusion can be confirmed by radiological studies including simple chest radiography, ultrasonography, or computed tomography. Identifying the causes of pleural effusions by pleural fluid analysis is essential for proper treatments. This review article provides information on the diagnostic approaches of pleural effusions and further suggested ways to confirm their various etiologies, by using the most recent journals for references.
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Affiliation(s)
- Moon Jun Na
- Respiratory Division, Department of Internal Medicine, Konyang University College of Medicine, Daejeon, Korea
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Botana Rial M, Briones Gómez A, Ferrando Gabarda JR, Cifuentes Ruiz JF, Guarín Corredor MJ, Manchego Frach N, Cases Viedma E. Tru-cut needle pleural biopsy and cytology as the initial procedure in the evaluation of pleural effusion. Arch Bronconeumol 2014; 50:313-7. [PMID: 24576447 DOI: 10.1016/j.arbres.2013.12.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Revised: 12/13/2013] [Accepted: 12/18/2013] [Indexed: 10/25/2022]
Abstract
INTRODUCTION AND OBJECTIVES The evaluation of pleural effusion (PE) includes various techniques, including pleural biopsy (PB). Our aim was to study the diagnostic yield of Tru-Cut needle PB (TCPB) and to define clinical/radiological situations in which TCPB might be indicated as an initial procedure. METHODOLOGY Retrospective study of TCPB in a hospital centre (2010-2012). Cases of pleural lesions without effusion were excluded. Clinical and radiological variables, diagnostic yield, TCPB complications and factors associated with the diagnostic yield of the combination of TCPB and thoracocentesis as initial procedure were analysed. RESULTS One hundred and twenty-seven (127) TCPB were reviewed: 29.1% were cases of malignant PE and in 18.9% the cause of the PE could not be determined. The diagnostic yield of TCPB for tuberculosis was 76.5% (13/17) and 54% (20/37) for malignant PE. Complications occurred in 4.7% of the cases. In 72 patients with a final definitive diagnosis, TCPB was performed at the same time as the initial thoracocentesis. Diagnostic yield for the combination of TCPB/cytology as an initial technique was 43% (31/72) compared to 12.5% (9/72) for cytology only (p=0.01). The only predictive variable for the indication of TCBP as an initial technique was a PE volume>2/3 (P=.04). CONCLUSIONS TCPB is safe and provides an acceptable diagnostic yield, particularly when combined with simultaneous cytology in the evaluation of PE of various aetiologies. Radiological criteria may help guide the selection of patients who could benefit from this technique as an initial procedure combined with thoracocentesis.
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Affiliation(s)
- Maribel Botana Rial
- Unidad de Técnicas Broncopleurales, Complexo Hospitalario Universitario de Vigo, Vigo, Pontevedra, España
| | - Andrés Briones Gómez
- Unidad de Técnicas Broncopleurales, Hospital Universitario y Politécnico La Fe, Valencia, España
| | | | | | | | - Nuria Manchego Frach
- Servicio de Anatomía Patológica, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Enrique Cases Viedma
- Unidad de Técnicas Broncopleurales, Hospital Universitario y Politécnico La Fe, Valencia, España.
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Valdés L, San-José E, Ferreiro L, González-Barcala FJ, Golpe A, Álvarez-Dobaño JM, Toubes ME, Rodríguez-Núñez N, Rábade C, Lama A, Gude F. Combining clinical and analytical parameters improves prediction of malignant pleural effusion. Lung 2013; 191:633-43. [PMID: 24085319 DOI: 10.1007/s00408-013-9512-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Accepted: 09/10/2013] [Indexed: 11/26/2022]
Abstract
PURPOSE The usefulness of a panel of tumour markers and clinical-radiological criteria for diagnosing malignant pleural effusion (MPE) is not clearly stated. Our purpose was to assess the performance of those parameters in the diagnosis of MPE. METHODS Consecutive patients with exudative PE were enrolled and divided into two groups: MPE and non-MPE. Logistic regression analysis was used to estimate the probability of MPE. Four prognostic models were considered: (1) clinical-radiological variables; (2) analytical variables; (3) combination of clinical and analytical variables; and (4) simpler model removing some analytical variables. Calibration and discrimination (receiver operating characteristics curves and AUC) were performed. RESULTS A total of 491 pleural exudates were included: tuberculous (n = 72), malignant (n = 211), parapneumonic (n = 115), empyemas (n = 32), or miscellaneous (n = 61). The AUC obtained with Model 1 (absence of chest pain and fever and radiological images compatible with malignancy), Model 2 (CEA, NSE, CYFRA 21-1, and TPS), Model 3 (sum of the variables of models 1 and 2), and Model 4 (the variables of model 1 plus CEA) were 0.918, 0.832, 0.952 (all with a P < 0.05), and 0.939 (P < 0.01 compared to models 1 and 2), respectively. The correct classification rate for Models 1, 2, 3, and 4, was 87.2, 79.5, 88.4, and 87.6 %, respectively. CONCLUSIONS All models analysed had a good diagnostic yield for MPE, being greater in those that combined radiological and analytical criteria. Although Model 3 obtained a higher yield, the simplest model (Model 4) is very attractive due to its simplicity of use in daily practice.
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Affiliation(s)
- Luis Valdés
- Servicio de Neumología, Complejo Hospitalario Clínico-Universitario de Santiago, Travesia da Choupana s/n, 15706, Santiago de Compostela, Spain,
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Rivera MP, Mehta AC, Wahidi MM. Establishing the diagnosis of lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013; 143:e142S-e165S. [PMID: 23649436 DOI: 10.1378/chest.12-2353] [Citation(s) in RCA: 640] [Impact Index Per Article: 58.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Lung cancer is usually suspected in individuals who have an abnormal chest radiograph or have symptoms caused by either local or systemic effects of the tumor. The method of diagnosis of lung cancer depends on the type of lung cancer (small cell lung cancer or non-small cell lung cancer [NSCLC]), the size and location of the primary tumor, the presence of metastasis, and the overall clinical status of the patient. The objective of this study was to determine the test performance characteristics of various modalities for the diagnosis of suspected lung cancer. METHODS To update previous recommendations on techniques available for the initial diagnosis of lung cancer, a systematic search of the MEDLINE, Healthstar, and Cochrane Library databases covering material to July 2011 and print bibliographies was performed to identify studies comparing the results of sputum cytology, conventional bronchoscopy, flexible bronchoscopy (FB), electromagnetic navigation (EMN) bronchoscopy, radial endobronchial ultrasound (R-EBUS)-guided lung biopsy, transthoracic needle aspiration (TTNA) or biopsy, pleural fluid cytology, and pleural biopsy with histologic reference standard diagnoses among at least 50 patients with suspected lung cancer. Recommendations were developed by the writing committee, graded by a standardized method (see the article "Methodology for Development of Guidelines for Lung Cancer" in this guideline), and reviewed by all members of the Lung Cancer Guideline Panel prior to approval by the Thoracic Oncology NetWork, the Guidelines Oversight Committee, and the Board of Regents of the American College of Chest Physicians. RESULTS Sputum cytology is an acceptable method of establishing the diagnosis of lung cancer, with a pooled sensitivity rate of 66% and a specificity rate of 99%. However, the sensitivity of sputum cytology varies according to the location of the lung cancer. For central, endobronchial lesions, the overall sensitivity of FB for diagnosing lung cancer is 88%. The diagnostic yield of bronchoscopy decreases for peripheral lesions. Peripheral lesions < 2 or > 2 cm in diameter showed a sensitivity of 34% and 63%, respectively. R-EBUS and EMN are emerging technologies for the diagnosis of peripheral lung cancer, with diagnostic yields of 73% and 71%, respectively. The pooled sensitivity of TTNA for the diagnosis of lung cancer was 90%. A trend toward lower sensitivity was noted for lesions < 2 cm in diameter. TTNA is associated with a higher rate of pneumothorax compared with bronchoscopic procedures. In a patient with a malignant pleural effusion, pleural fluid cytology is reported to have a mean sensitivity of about 72%. A definitive diagnosis of metastatic disease to the pleural space can be estalished with a pleural biopsy. The diagnostic yield for closed pleural biopsy ranges from 38% to 47% and from 75% to 88% for image-guided closed biopsy. Thoracoscopic biopsy of the pleura carries the highest diagnostic yield, 95% to 97%. The accuracy in differentiating between small cell and non-small cell cytology for the various diagnostic modalities was 98%, with individual studies ranging from 94% to 100%. The average false-positive and false-negative rates were 9% and 2%, respectively. Although the distinction between small cell and NSCLC by cytology appears to be accurate, NSCLCs are clinically, pathologically, and molecularly heterogeneous tumors. In the past decade, clinical trials have shown us that NSCLCs respond to different therapeutic agents based on histologic phenotypes and molecular characteristics. The physician performing diagnostic procedures on a patient suspected of having lung cancer must ensure that adequate tissue is acquired to perform accurate histologic and molecular characterization of NSCLCs. CONCLUSIONS The sensitivity of bronchoscopy is high for endobronchial disease and poor for peripheral lesions < 2 cm in diameter. The sensitivity of TTNA is excellent for malignant disease, but TTNA has a higher rate of pneumothorax than do bronchoscopic modalities. R-EBUS and EMN bronchoscopy show potential for increasing the diagnostic yield of FB for peripheral lung cancers. Thoracoscopic biopsy of the pleura has the highest diagnostic yield for diagnosis of metastatic pleural effusion in a patient with lung cancer. Adequate tissue acquisition for histologic and molecular characterization of NSCLCs is paramount.
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Affiliation(s)
- M Patricia Rivera
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Atul C Mehta
- Respiratory Institute Cleveland Clinic, Cleveland, OH
| | - Momen M Wahidi
- Department of Medicine, Duke University Medical Center, Durham, NC
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Sahn SA, Huggins JT, San Jose E, Alvarez-Dobano JM, Valdes L. The Art of Pleural Fluid Analysis. ACTA ACUST UNITED AC 2013. [DOI: 10.1097/cpm.0b013e318285ba37] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Elhafez SAMA, Shehata MEA, Rashed MAE, Ali RE, Mosallam AMA. Echopulmonography versus computed tomographic chest predictors for differentiation between benign and malignant peripheral pulmonary and pleural lesions. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2013. [DOI: 10.1016/j.ejcdt.2013.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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The Long-term Prognosis of Patients With the Diagnosis of Nonmalignant Pleural Effusions After Pleuroscopy. J Bronchology Interv Pulmonol 2012; 16:25-7. [PMID: 23168464 DOI: 10.1097/lbr.0b013e318195d7a0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Several studies have demonstrated the diagnostic yield of medical thoracoscopy (pleuroscopy) in making the diagnosis of malignant pleural effusion (MPE). No previous studies, however, have reported long-term outcomes for patients undergoing diagnostic pleuroscopy in whom no malignancy was demonstrated either with cytologic examination of pleural fluid or pathologic examination of thoracoscope-guided pleural biopsies. We report the results of long-term follow-up (at least 3 y) of patients with the diagnosis of nonmalignant pleural effusions (NMPEs) after pleuroscopy. METHODS One hundred and nineteen patients underwent the procedure between 1994 and 2003 at Lahey Clinic. We report a retrospective review of 25 of those patients diagnosed with NMPE after diagnostic pleuroscopy. All 25 patients underwent thoracoscopic pleural biopsy and cytologic examination of the effusion. Outcomes were assessed using review of the medical records, appointment scheduler, social security death index, and/or telephone conversation with primary care providers. RESULTS Mean age±SD was 68 years (range, 34 to 87 y). Median survival time was estimated at 114 months. Concomitant illness was also evaluated: 40% (n=10) diabetes, 64% (n=16) coronary artery disease, 40% (n=10) congestive heart failure, 20% (n=5) liver disease, 20% (n=5) renal disease, and 36% (n=9) pulmonary disease. Final diagnoses after pleuroscopy most commonly included chronic pleuritis (n=7) and pleural plaques (n=5). Survival was found at 1 year to be 88% (22/25), 3 years 80% (20/25), and 5 years 74.7% (19/25). None of the 25 patients developed subsequent MPE. CONCLUSIONS Patients with NMPE after pleuroscopy have a favorable prognosis and are unlikely to be subsequently diagnosed with an MPE.
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Trapé J, Molina R, Sant F, Montesinos J, Arnau A, Franquesa J, Blavia R, Martín E, Marquilles E, Perich D, Pérez C, Roca JM, Doménech M, López J, Badal JM. Diagnostic accuracy of tumour markers in serous effusions: a validation study. Tumour Biol 2012; 33:1661-8. [PMID: 22678976 DOI: 10.1007/s13277-012-0422-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Accepted: 05/16/2012] [Indexed: 10/28/2022] Open
Abstract
The utility of tumour markers (TM) in the differential diagnosis of cancer in serous effusion (fluid effusion (FE)) has been the subject of controversy. The aim of this study was to prospectively validate our previous study and to assess whether the addition of adenosine deaminase (ADA), C-reactive protein (CRP) or percentage of polymorphonuclear cells (%PN) allows the identification of false positives. In this study, carcinoembryonic antigen, cancer antigen 15-3, cancer antigen 19-9, ADA, CRP and %PN in FE were determined in 347 patients with 391 effusions. Effusions were considered as malignant effusion when at least one TM in serum exceeded the cutoff and the ratio FE/S was higher than 1.2. Also, cases with values of ADA, CRP and %PN above the established cutoffs in serous effusion were considered as potential false positives. The combined sensitivity and specificity of the three TM was 76.2 % (95 % confidence intervals (CI) 67.8-83.3 %) and 97.0 % (95 % CI 94.1-98.7), respectively. Subanalysis of the 318 cases with previous criteria and negative ADA, CRP and %PN obtained sensitivities of 78.4 % (95 % CI 69.4-85.6) and a specificity of 100 % (95 % CI 98.2-100). The results obtained validate our previous study and are improved with the addition of ADA, CRP and %PN. TM in serous effusions and serum could be useful for the diagnostic assessment of patients with serous effusions.
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Affiliation(s)
- Jaume Trapé
- Service of Laboratory Medicine, Althaia, Xarxa Assistencial Universitària de Manresa, Dr. Joan Soler 1-3, 08243, Manresa, Catatonia, Spain.
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Metintas M, Ak G, Cadirci O, Yildirim H, Dundar E, Metintas S. Outcome of patients diagnosed with fibrinous pleuritis after medical thoracoscopy. Respir Med 2012; 106:1177-83. [PMID: 22608353 DOI: 10.1016/j.rmed.2012.04.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2011] [Revised: 03/31/2012] [Accepted: 04/24/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND In patients with post- medical thoracoscopy histopathological diagnoses of fibrinous pleuritis, confusion can occur concerning subsequent procedures. This issue is particularly important in regions where mesothelioma is prevalent. We aimed to identify false negatives among patients where mesothelioma was common due to asbestos exposure whose histopathological diagnosis following thoracoscopy was fibrinous pleuritis. We also determined risk factors associated with patients that required additional advanced invasive procedures for diagnosis. METHODS Overall, 287 patients who underwent thoracoscopy were included in the study. Patients diagnosed with fibrinous pleuritis as a result of thoracoscopy were followed for 2 years regarding this condition. More invasive procedures were performed on patients who showed no recuperation or developed pleural disease again during the follow-up period. RESULTS Fibrinous pleuritis was observed in 101 (35.2%) patients. Follow-up of these patients revealed that the false negative rate was 18% for malignant pleural diseases. The thoracoscopist's opinion regarding the pleural space, computed tomography scan findings indicating malignancy, pain and female gender were determined to be risk factors for malignant pleural diseases. CONCLUSIONS In regions where mesothelioma is prevalent and one of the above-stated risk factors is present, patients whose post-thoracoscopy histopathological diagnosis is fibrinous pleuritis should be treated with a more advanced invasive diagnosis procedure.
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Affiliation(s)
- Muzaffer Metintas
- Eskisehir Osmangazi University, Medical Faculty, Department of Chest Diseases, Eskisehir, Turkey.
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Practical approaches to diagnose and treat for T0 malignant pleural mesothelioma: a proposal for diagnostic total parietal pleurectomy. Int J Clin Oncol 2012; 17:33-9. [DOI: 10.1007/s10147-011-0368-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Indexed: 11/26/2022]
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Abstract
There are many diseases that cause pleural effusions. When a patient with a pleural effusion is first evaluated, one should determine if the patient has a transudate or an exudate. A diagnostic approach to the patient with an undiagnosed pleural effusion is outlined. The most common pleural effusions including those caused by congestive heart failure, cirrhosis, pneumonia, malignancy, tuberculosis, lupus erythematosus, rheumatoid disease, and chylothorax are discussed.
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Affiliation(s)
- Richard W Light
- Division of Allergy/Pulmonary/Critical Care, Vanderbilty University Medical Center, Nashville, TN 37232, USA.
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Kaifi JT, Toth JW, Gusani NJ, Kimchi ET, Staveley-O'Carroll KF, Belani CP, Reed MF. Multidisciplinary management of malignant pleural effusion. J Surg Oncol 2011; 105:731-8. [PMID: 21960207 DOI: 10.1002/jso.22100] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Accepted: 09/01/2011] [Indexed: 01/15/2023]
Affiliation(s)
- Jussuf T Kaifi
- Section of Surgical Oncology, Department of Surgery, Penn State Hershey Cancer Institute, Penn State College of Medicine, Hershey, Pennsylvania, USA.
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Oba Y, Abu-Salah T. The prevalence and diagnostic significance of eosinophilic pleural effusions: a meta-analysis and systematic review. ACTA ACUST UNITED AC 2011; 83:198-208. [PMID: 21576924 DOI: 10.1159/000327200] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Accepted: 03/01/2011] [Indexed: 01/31/2023]
Abstract
BACKGROUND Eosinophilic pleural effusion (EPE) is defined by an eosinophil count of ≥10% in the pleural fluid and often caused by air or blood in the pleural space. The diagnostic significance of EPEs is still a matter of debate. OBJECTIVE The objective of this study was to systematically review the medical literature to evaluate the diagnostic significance of EPEs. METHODS Electronic databases were searched from 1950 to April 2010 to perform a meta-analysis. Data were extracted using standardized forms, and pooled odds ratios with 95% confidence intervals were calculated. A logistic regression analysis was also performed to evaluate the association between the pleural eosinophil counts and the likelihood of underlying causes of EPEs. RESULTS We identified a total of 687 cases of EPE. The most common cause of EPEs was malignancy (26%) followed by idiopathic (25%) and parapneumonic (13%) effusions. The likelihood of malignancy or tuberculosis was somehow lower in EPEs than in non-EPEs, but the differences were not statistically significant. The prevalence of malignancy was significantly lower in the group of patients that required a pathologic confirmation (21 vs. 30%; p = 0.01). The likelihood of malignancy was inversely correlated with the pleural fluid eosinophil counts. The likelihood of idiopathic effusion was significantly higher in EPEs than in non-EPEs. CONCLUSIONS Malignancy was the most common cause of EPEs. EPEs appeared to be a negative predictor of malignancy when a pleural fluid eosinophil count was extremely high. EPEs were more likely to be idiopathic as compared with non-EPEs.
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Affiliation(s)
- Yuji Oba
- University of Missouri, Columbia, Mo. 65212, USA.
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Mishra EK, Davies RJO. Advances in the investigation and treatment of pleural effusions. Expert Rev Respir Med 2010; 4:123-33. [PMID: 20387298 DOI: 10.1586/ers.09.67] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Pleural effusions present a challenge for both diagnosis and treatment. They are a commonly presenting problem of a wide range of local and systemic potentially life threatening diseases and cause significant breathlessness. Significant advances have been made in the last 5 years in the diagnostic pathway and management options. This article reviews recent developments in the investigation of pleural effusions, particularly in pleural fluid analysis, biomarkers, imaging and pleural biopsy, and in the treatment of pleural infection and both malignant and benign effusions, including the use of indwelling pleural catheters. Although significant recent advances have been made in the management of pleural effusions, there the need still remains for further research if we are to reduce the morbidity and mortality caused by pleural effusions.
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Affiliation(s)
- Eleanor K Mishra
- Oxford Respiratory Trials Unit, Nuffield Department of Medicine, University of Oxford, Churchill Hospital, Old Road, Headington, Oxford, OX3 7LJ, UK.
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Uzbeck MH, Almeida FA, Sarkiss MG, Morice RC, Jimenez CA, Eapen GA, Kennedy MP. Management of malignant pleural effusions. Adv Ther 2010; 27:334-47. [PMID: 20544327 DOI: 10.1007/s12325-010-0031-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2010] [Indexed: 10/19/2022]
Abstract
Malignant pleural effusions are a common clinical problem in patients with primary thoracic malignancy and metastatic malignancy to the thorax. Symptoms can be debilitating and can impair tolerance of anticancer therapy. This article presents a comprehensive review of pharmaceutical and nonpharmaceutical approaches to the management of malignant pleural effusion, and a novel algorithm for management based on patients' performance status.
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Abstract
PURPOSE OF REVIEW The technique and clinical applications of medical thoracoscopy have substantially evolved in the last few decades. The recent development of a semirigid thoracoscope, which is handled similarly to a bronchoscope, has made this procedure more attractive to pulmonologists. We will review the latest data on clinical applications, recently developed techniques, and safety of medical thoracoscopy, focusing mainly on its role in thoracic malignancies. RECENT FINDINGS Recent data confirm the high diagnostic yield of medical thoracoscopy - both with rigid and semirigid instruments - in detecting pleural metastases and determining the origin of pleural effusions. The degree of pleural adhesions found during thoracoscopy has been proposed by some authors as a prognostic factor for survival in patients with malignant pleural effusion. A large prospective multicenter study has established the safety of talc poudrage with large-particle talc, showing no cases of acute respiratory distress syndrome. SUMMARY Medical thoracoscopy is an excellent tool to establish diagnosis in patients with exudative pleural effusion of unclear origin. It is highly valuable in clarifying the origin of pleural effusions in patients with lung cancer, as the presence of a malignant pleural effusion is associated with poor survival and precludes the possibility of treatment with curative intention. Pleurodesis with talc poudrage is efficacious and well tolerated, especially with the use of large-particle talc.
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Ryerson CJ, Churg A, Wilcox PG. A 48-year-old woman with remote hodgkin disease and bilateral pleural effusions. Chest 2009; 136:934-937. [PMID: 19736198 DOI: 10.1378/chest.09-0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
| | - Andrew Churg
- Departments of Pathology, University of British Columbia, Vancouver, BC, Canada
| | - Pearce G Wilcox
- Medicine, University of British Columbia, Vancouver, BC, Canada
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Diagnosis and Staging of Lung and Pleural Malignancy — an Overview of Tissue Sampling Techniques and the Implications for Pathological Assessment. Clin Oncol (R Coll Radiol) 2009; 21:451-63. [DOI: 10.1016/j.clon.2009.03.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2008] [Revised: 11/03/2008] [Accepted: 03/24/2009] [Indexed: 11/19/2022]
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Kim KW, Choi HJ, Kang S, Park SY, Jung DC, Cho JY, Cho KS, Kim SH. The utility of multi-detector computed tomography in the diagnosis of malignant pleural effusion in the patients with ovarian cancer. Eur J Radiol 2009; 75:230-5. [PMID: 19481402 DOI: 10.1016/j.ejrad.2009.04.061] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2008] [Accepted: 04/23/2009] [Indexed: 11/30/2022]
Abstract
PURPOSE The purpose of this study was to retrospectively assess possible clinical predictors of malignant pleural effusion in patients with ovarian cancer. MATERIALS AND METHODS This review was performed on 38 ovarian cancer patients that showed pleural effusion in a CT scan and who underwent thoracocentesis before treatment. CT scans were obtained using a 4-channel multi-detector CT scanner. Fisher's exact test was used to determine the probability of malignant pleural effusion as a function of; amount of ascites, lymph node enlargement, amount of pleural effusion, pleural nodules, and pleural thickening. RESULTS Sixteen (42.1%) of the 38 patients had malignant pleural effusion and malignant pleural effusion amounts were greater than those with nonmalignant effusion. Pleural nodules were more frequently found in the malignant pleural effusion group (eight [50%] patients) than in the nonmalignant group (zero [0%] patient) (p<0.001). Supradiaphragmatic lymph node enlargement (with short axis diameter 1cm or more) was more frequent in malignant group (12 [75%] patients) than in the nonmalignant group (two [9.1%] patients) (p<0.001). CONCLUSION The probability of malignant pleural effusion in patients with ovarian cancer was found to be correlated with the amount of pleural effusion, the presence of pleural nodules, and supradiaphragmatic lymph node enlargement.
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Affiliation(s)
- Kyung Won Kim
- Department of Radiology and Institute of Radiation Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
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Semi-rigid thoracoscopy for undiagnosed exudative pleural effusions: a comparative study. Chin Med J (Engl) 2008. [DOI: 10.1097/00029330-200808010-00010] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Abstract
Malignant pleural effusions (MPEs) complicate the clinical course of patients with a broad array of malignancies, which are most often due to lymphomas or carcinomas of the breast, lung, gastrointestinal tract or ovaries. Patients may present with a MPE as the initial manifestation of a cancer or develop an effusion during the advanced phases of a known malignancy. In either circumstance, the median survival after presentation with a MPE is 4 months. Effusions may result from direct pleural invasion (MPE) or indirect effects (paraneoplastic effusions), such as impairment of fluid efflux from the pleural space by lymphatic obstruction or pleural effects of cancer radiation or drug therapy. Because only 50% of patients with cancer who develop a pleural effusion during their clinical course have a MPE, careful evaluation of the effusion to establish its aetiology is required to direct therapy. Management is palliative with interventions directed towards decreasing the volume of intrapleural fluid and the severity of associated symptoms.
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Yoneda KY, Mathur PN, Gasparini S. The evolving role of interventional pulmonary in the interdisciplinary approach to the staging and management of lung cancer. Part III: diagnosis and management of malignant pleural effusions. Clin Lung Cancer 2008; 8:535-47. [PMID: 18186958 DOI: 10.3816/clc.2007.n.040] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The diagnosis and management of a malignant pleural effusion can be one of the most vexing problems faced by physicians and their patients. Lung cancer is the most common primary tumor of origin with a prognosis that is limited, but variable and correlated with performance status (PS). Therefore, with a poor PS and known advanced lung cancer, establishing whether or not an effusion is malignant might not be necessary. Conversely, identifiable subsets of patients will have a much better survival, and establishing a definitive diagnosis could be of critical importance. In the great majority of cases, a diagnosis can be determined by serial thoracenteses with or without closed pleural biopsy. However, thoracoscopy is increasingly being utilized and can expedite the workup by obviating the need for repeated thoracenteses and/or closed pleural biopsy, while in the same setting providing definitive palliative treatment. Although studies comparing diagnostic and treatment strategies are limited, we will present the available data with the intention of providing the practicing oncologist with a practical strategy for the diagnosis and management of malignant pleural effusions due to lung cancer. The interventional pulmonologist can play an important role from diagnosis to palliation, greatly facilitating the care of patients with malignant pleural effusions.
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Affiliation(s)
- Ken Y Yoneda
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of California, Davis Medical Center, Sacramento, CA 95817, USA.
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Abstract
Malignant pleural effusions (MPEs) are an important complication for patients with intrathoracic and extrathoracic malignancies. Median survival after diagnosis of an MPE is 4 months. Patients can present with an MPE as a complication of far-advanced cancer or as the initial manifestation of an underlying malignancy. Common cancer types causing MPEs include lymphomas, mesotheliomas, and carcinomas of the breast, lung, gastrointestinal tract, and ovaries. However, almost all tumor types have been reported to cause MPEs. New imaging modalities assist the evaluation of patients with a suspected MPE; however, positive cytologic or tissue confirmation of malignant cells is necessary to establish a diagnosis. Even in the presence of known malignancy, up to 50% of pleural effusions are benign, underscoring the importance of a firm diagnosis to guide therapy. Rapidly evolving interventional and histopathologic techniques have improved the diagnostic yield of standard cytology and biopsy. Management of an MPE remains palliative; it is critical that the appropriate management approach is chosen on the basis of available expertise and the patient's clinical status. This review summarizes the pathogenesis, diagnosis, and management of MPE. Studies in the English language were identified by searching the MEDLINE database (1980-2007) using the search terms pleura, pleural, malignant, pleurodesis, and thoracoscopy.
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Affiliation(s)
- John E Heffner
- Department of Medicine, Providence Portland Medical Center, Oregon Health and Science University, 5040 NE Hoyt St, Ste 540, Portland, OR 97213, USA.
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Lee P, Hsu A, Lo C, Colt HG. Prospective evaluation of flex-rigid pleuroscopy for indeterminate pleural effusion: accuracy, safety and outcome. Respirology 2008; 12:881-6. [PMID: 17986118 DOI: 10.1111/j.1440-1843.2007.01144.x] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aimed to assess prospectively the accuracy, safety and outcome of flex-rigid pleuroscopy in the diagnosis of patients with indeterminate pleural effusions. METHODS Included in the study were all patients with unilateral exudative pleural effusions of unknown aetiology who underwent diagnostic flex-rigid pleuroscopy from July 2003 to June 2005, and were followed until December 2005. The procedure was conducted in the endoscopy suite under local anaesthesia and, where indicated, talc poudrage was carried out at the same time. Clinical data, length of hospitalization, chest tube drainage, outcome, diagnostic accuracy of pleuroscopy and procedure-related adverse events were recorded prospectively. RESULTS Fifty-one patients were recruited (20 male and 31 female). Median age was 53 years (range 45-67). Flex-rigid pleuroscopy was 96% accurate and yielded a diagnosis in 49 out of 51 patients. It was safely carried out without need for surgical intervention, blood transfusion or endotracheal intubation. Culture-negative fever was observed in eight patients (16%), and five patients (10%) required additional analgesia for postoperative pain. Duration of chest tube drainage and length of stay for patients who underwent diagnostic pleuroscopy were 1 and 2 days, respectively, while they were both 3 days when talc poudrage was carried out. Success rates with pleuroscopic talc pleurodesis for malignant pleural effusions were 94%, 92% and 89.5% at 3, 6 and 12 months, respectively, and the 30-day mortality was 0%. CONCLUSION Flex-rigid pleuroscopy is a safe procedure with a high diagnostic accuracy and should be considered for the evaluation of indeterminate pleural effusion.
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Affiliation(s)
- Pyng Lee
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore.
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Affiliation(s)
- N M Rahman
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford OX3 7LJ
| | - R J O Davies
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford OX3 7LJ
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