First In Vivo Applicational Data of Foam-Based Intrathoracic Chemotherapy (FBiTC) in a Swine Model

BACKGROUND

For decades, both intraperitoneal and pleural chemotherapy (IPC) have been delivered as a liquid solution. Recent studies suggest that foam carriers outperform liquid carriers for locoregional chemotherapy. For the first time, this study aims to evaluate the feasibility, safety, and characteristics of foam-based intrathoracic chemotherapy (FBiTC) in an in vivo setting.

METHODS

In this study, contrast-enhanced FBiTC with doxorubicin was delivered via video-assisted thoracoscopy (VAT) in three swine under general anesthesia. Intraoperative and postoperative parameters, blood analyses, vital signs, and anesthesiologic data were collected. Additionally, an intraoperative computer tomography (CT) scan was performed, and histological tissue sections were collected and further analyzed using fluorescence microscopy.

RESULTS

FBiTC was delivered without major complications. End-tidal capnometry detected increased CO2 levels with reduced peripheral oxygen saturation and increased blood pressure and heart rate. No major intra- or postoperative complications were observed. CT scans confirmed a multidirectional distribution pattern of foam. Postoperative laboratory workup did not reveal any critical changes in hemoglobin, white blood count, or platelets. There was no evidence of critical kidney impairment or liver function. Fluorescence microscopy of tissue specimen detected doxorubicin in pleural tissues.

DISCUSSION

Our preliminary results are encouraging and indicate that FBiTC is feasible. However, to consider a possible clinical application, further studies are required to investigate the pharmacologic, pharmacodynamic, and physical properties of FBiTC and to ensure the safety of the overall procedure regarding oxygenation levels and capnography parameters.

Hyperthermic intrathoracic extracorporeal chemotherapy for secondary malignant pleural disease

OBJECTIVES

Pleural metastasis has extremely poor prognosis. Resection of pleural implants with infusion of intrathoracic hyperthermic chemotherapy may offer a survival advantage in selected patients. We evaluated the safety and efficacy of hyperthermic intrathoracic extracorporeal chemotherapy (HITEC) in patients who underwent pleurectomy/decortication (P/D) for secondary malignant pleural disease (SPD).

METHODS

A total of 101 patients were evaluated over 72 months, with 35 patients electing to proceed with P/D and 60 minutes of HITEC with cisplatin at 42°C. Inclusion criteria were adults 18-79 years with unilateral pleural dissemination. Exclusion criteria were patients without control of primary site, extrathoracic metastatic disease, significant comorbidities, and a history of adverse reaction to cisplatin.

RESULTS

Median age was 56 years (36-73); 60% were women. SPD was thymoma in 13, breast cancer in 9, lung cancer in 6, colon cancer in 2, renal cell in 2, and esophageal, anal, and thymic cancers in one each. There was no operative mortality. Postoperative complications occurred in 18 patients (51%). No patient developed renal failure. Median follow-up was 24 months (4-60). The overall survival rate was 61%; 17 patients (49%) developed recurrent disease at a median of 12 months (6-36). There were no recurrences after 36 months Eleven patients (31%) died of metastatic disease at a median of 17 months (7-25).

CONCLUSIONS

Surgical cytoreduction of SPD followed by HITEC with cisplatin was well tolerated. No patient developed cisplatin-related toxicities. Long-term follow-up is warranted to determine survival advantage and refinement of inclusion criteria.

Differentiating malignant and benign pleural effusion in patients with lung cancer: an 18F-FDG PET/CT retrospectively study

Rationale

To explore the clinical role of ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) in differentiating malignant pleural effusion (MPE) from benign pleural effusion (BPE) in patients with lung cancer.

Methods

Over a 8-year period, we retrospectively reviewed PET/CT data of lung cancer patients with pleural effusion, with 237 participants enrolled for analysis. The nature of pleural effusion was confirmed using pleural cytology or biopsy. MPE versus BPE comparison and multiple regression analysis were performed. Receiver operating characteristic (ROC) curve analysis was used for evaluating the diagnostic performance.

Results

Of the 237 participants, 170 had MPEs and 67 had BPEs. Compared with BPEs, MPEs had higher pleural SUVmax and thicker pleura and were more common among non-small cell lung cancers, peripheral tumors, and women (p < 0.05). BPEs had larger and higher ¹⁸F-FDG uptake thoracic lymph nodes and more complications of pneumonia (p < 0.05) than MPEs. Multiple regression analysis was used to identify the pleural SUVmax (odds ratio, OR = 38.8), sex (OR = 0.033), and mediastinal lymphoid node size (OR = 0.86) as independent risk factors for MPEs. The sensitivity, specificity, and area under the ROC curve (AUC) in the combined ROC curve analysis by using the three factors were 95.3%, 95.5%, and 0.989, respectively.

Conclusion

¹⁸F-FDG PET/CT integrated imaging is an effective non-invasive method for differential diagnosis of MPE in patients with lung cancer. Pleural SUVmax combined with thoracic lymph nodes and sex has high diagnostic value.

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

Background

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

Patient cohort and methods

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

Results

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

Conclusion

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

Surgical treatment in malignant pleural effusion

Malignant pleural effusion can be described as the presence of exudate in the pleural space, accompanied by the detection of cancer cells in pleural fluid or tissue, which is the indicator of the disease in its advance stages, and survival time of these patients ranges between 3 and 12 months. Treatment options for malignant pleural effusion vary from observation in asymptomatic patients to pleurectomies or even extrapleural pneumonectomies in severe cases.

Advantage of Hybrid 18F-Fluoride Positron Emission Tomography/Computed Tomography to Diagnose Malignant Rib Invasion by Pleural Metastasis in a Background of Reactive Periostitis

Diffuse osteoblastic activity in the ribs on bone scan is seen in association with pleural thickening. Irrespective of the pleural pathology, this represents benign finding caused by pleural hyperemia or reactive periostitis, with preserved cortical integrity. However, malignant involvement of the ribs can occur by local invasion of pleural malignancy causing cortical lysis. Herein, we describe the ¹⁸F-fluoride positron emission tomography/computed tomography findings of reactive periostitis of the ribs in pleural metastasis and emphasize the advantage of hybrid imaging in detecting local malignant tumor invasion superimposed in such condition.

Early Progression in Non-Small Cell Lung Cancer (NSCLC) with High PD-L1 Treated with Pembrolizumab in First-Line Setting: A Prognostic Scoring System Based on Clinical Features

BACKGROUND

Pembrolizumab is approved in monotherapy for the first-line (1L) of advanced or metastatic NSCLC patients with high PD-L1 (≥50%). Despite a proportion of patients achieve long-term survival, about one-third of patients experience detrimental survival outcomes, including early death, hyperprogression, and fast progression. The impact of clinical factors on early progression (EP) development has not been widely explored.

METHODS

We designed a retrospective, multicenter study involving five Italian centers, in patients with metastatic NSCLC with PD-L1 ≥ 50%, treated with Pembrolizumab in a 1L setting. EP was defined as a progressive disease within three months from pembrolizumab initiation. Baseline clinical factors of patients with and without EP were collected and analyzed. Logistic regression was performed to identify clinical factors associated with EP and an EP prognostic score was developed based on the logistic model.

RESULTS

Overall, 321 out of 336 NSCLC patients treated with 1L pembrolizumab provided all the data for the analysis. EP occurred in 137 (42.7%) patients; the median PFS was 3.8 months (95% CI: 2.9-4.7), and median OS was not reached in the entire study population. Sex, Eastern Cooperative Oncology Group (ECOG) performance status (PS), steroids, metastatic sites ≥2, and the presence of liver/pleural metastasis were confirmed as independent factors for EP by multivariate analysis. By combining these factors, we developed an EP prognostic score ranging from 0-13, with three-risk group stratification: 0-2 (good prognosis), 3-6 (intermediate prognosis), and 7-13 (poor prognosis). The area under the curve (AUC) of the model was 0.76 (95% CI: 0.70-0.81).

CONCLUSIONS

We identified six clinical factors independently associated with EP. We developed a prognostic score model for EP-risk to potentially improve clinical practice and patient selection for 1L pembrolizumab in NSCLC with high PD-L1, in the real-world clinical setting.

Pleural and pulmonary metastases from nonseminomatous germ cell tumors successfully managed by extrapleural pneumonectomy

INTRODUCTION

Surgery for postchemotherapy residual nonseminomatous germ cell tumors may be difficult due to exceptional lesion size and location.

CASE PRESENTATION

A 47-year-old man presented with swelling and pain in the left scrotum. Computed tomography revealed a solid occupied lesion in the left scrotum with huge metastases in the left lung and pleura. Results of a left high inguinal orchiectomy indicated a pathological diagnosis of germ cell tumors of several histological types. The patient declined postoperative chemotherapy but returned to our department 10 months later with dyspnea. Serum tumor marker levels were restored to normal range by adjuvant chemotherapy. Thereafter, an extrapleural pneumonectomy was performed for the remaining tumors. He has since been asymptomatic without recurrence or dyspnea for over 5 years.

CONCLUSION

Extrapleural pneumonectomy is a valid treatment option for the management of huge pleural and pulmonary metastases of nonseminomatous germ cell tumors.

Technique of pressurized intrathoracic aerosol chemotherapy (PITAC) for malignant pleural effusion

Objectives

Malignant pleural effusion (MPE) is a devastating evolution of several malignancies. Pressurized intrathoracic aerosol chemotherapy (PITAC) might be a novel therapy option in MPE.

Methods

PITAC is considered for patients with MPE with a performance status <2 and without other metastatic sites. General anesthesia is administered and a double-lumen bronchial tube is inserted. The patient is placed in a lateral decubitus position, and the operation is performed after ipsilateral lung exclusion. Two 12-mm balloon trocars are inserted—one in the seventh intercostal space in the mid-axillary line and one in the fifth intercostal space in the anterior axillary line. Extent of pleural disease and volume of MPE are documented. MPE is removed and parietal pleural biopsy are performed. An intrathoracic pressure of 12 mmHg CO₂ is established, and a combination of Cisplatin (10.5 mg/m² in a total volume of 150 cc NaCl 0.9%) and Doxorubicin (2.1 mg/m² in a total volume of 50 cc NaCl 0.9%) are aerosolized via nebulizer in the pleural cavity. Vital signs and nebulization are remote-controlled. After 30 min, the remaining toxic aerosol is exhausted using a closed surgical smoke evacuation system. A 24Fr chest tube is inserted in postero-apical position with continuous negative pressure of 20 cm H₂O. When needed, PITAC may be repeated every six weeks in alternate with systemic chemotherapy.

Results

In our hands, the technique above has shown to be feasible and safe.

Conclusions

Further studies are needed to assess the potential symptomatic and oncological benefits of PITAC in MPE.

Pulmonary and pleural metastasis mimicking COVID-19 infection in stage IV ovarian cancer: a case report

BACKGROUND

The differential diagnosis of lung and pleural metastases and coronavirus disease 2019 (COVID-19) can be challenging.

CASE

We report a case of a 41-year-old woman with FIGO (International Federation of Gynecology and Obstetrics) stage IV ovarian cancer with pleural and pulmonary spread. After primary cytoreduction was performed, she developed a high fever and worsening dyspnea with desaturation (92% in ambient air). Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was suspected, but three swabs gave negative results. Computed tomographic scan showed radiologic imaging strongly suspect for COVID-19 and the patient was transferred to a COVID-19 ward. The final diagnosis was paraneoplastic fever.

CONCLUSION

Lung and pleural metastases can mimic SARS-CoV-2 infection.

Endoscopic ultrasound-guided pleural biopsy in the hands of the pulmonologist

The use of the endobronchial ultrasound (EBUS) endoscope in the oesophagus, the so-called EUS-B procedure, for the diagnosis and staging of thoracic malignancy is quickly gaining ground. Pleural lesions located close to the oesophagus can be inaccessible to transthoracic biopsy and endoscopic procedures can be the only option. We here present two cases demonstrating that EUS-B-guided fine needle aspiration (EUS-B-FNA) of pleural lesions is possible. The first case demonstrates a EUS-B-FNA with malignant mesothelioma of a pleural lesion in a 70-year-old patient. In the second case, EUS-B-FNA diagnosed a pleural metastasis from adenoid cystic adenocarcinoma in a 75-year-old-patient. In conclusion, we hereby demonstrate that EUS-B-FNA from pleural lesions is feasible and appears to be safe.

Intrathoracic aerosol chemotherapy via spray-catheter

Pressurized intrathoracic aerosol chemotherapy (PITAC) has been introduced to the clinical setting as a novel treatment option for pleural metastasis (PM). For decades the therapeutic application of aerosols was limited to intrabronchial delivery. However, present studies suggest performing PITAC on patients with PM and malignant pleural effusion. Using an established ex vivo swine model, the present study aimed to introduce a facilitated intrathoracic chemoaerosol application via spray-catheter. Using an ex-vivo model of 3 postmortem swine, the feasibility of intrathoracic aerosol chemotherapy (ITC) with doxorubicin using a spray-catheter was evaluated in a normal pressure environment. Following thoracotomy, the spray-catheter was inserted via trocar. Tissue samples were retrieved and further analyzed by fluorescence microscopy to detect doxorubicin contact. Our data demonstrated that the application of ITC was technically feasible and did not exhibit any significant obstacles. By making a minimally invasive thoracotomy incision it was possible to create an adequate pneumothorax without the need of a double-lumen tube or intubation. ITC did not require the creation of a pressurized environment. Tissue samples revealed doxorubicin contact within the pleura. In conclusion, ITC is a fast and feasible procedure that could possibly be administered via bedside application, therefore eliminating the need of an operating room and surgical staff. However, further studies are required to evaluate the safety of patients and physicians regarding this novel applicational modality. Nevertheless, the present study demonstrated that ITC may potentially be applied at bedside, an option that is particularly important for patients who do not qualify for PITAC procedures.

Pleural or pericardial metastasis: A significant factor affecting efficacy and adverse events in lung cancer patients treated with PD-1/PD-L1 inhibitors

Background

Immunotherapy is a new paradigm for the treatment of non‐small‐cell lung cancer (NSCLC), and targeting the PD‐1 or PD‐L1 pathway is a promising therapeutic option. Although PD‐1/PD‐L1 inhibitors are more effective than standard chemotherapy in lung cancer, clinicians are afraid to actively use them because of hyperprogression and pseudoprogression. The aim of this study was to investigate the factors associated with tumor response and serious outcomes.

Methods

We retrospectively collected the medical records of 51 patients with advanced NSCLC who received PD‐1/PD‐L1 inhibitors between January 2016 and February 2018.

Results

The mean patient age was 63.9 years, and 72.5% (37/51) were male. Most (92.2%, 47/51) had received previous systemic treatment. The overall response rate was 21.6% (11/51). The response rate was significantly lower in patients with pleural or pericardial metastasis than in patients without pleural or pericardial metastasis (4.3% vs. 35.7%; P = 0.007). Patients with pleural or pericardial metastasis had a significantly higher rate of adverse events of any grade (91.3% vs. 50.0%; P = 0.002) and grade 3–5 adverse events (52.2% vs. 25.0%; P = 0.046).

Conclusion

Pleural or pericardial metastasis is a significant factor affecting the efficacy and rate of adverse events in advanced NSCLC patients treated with PD‐1/PD‐L1 inhibitors. Clinicians should pay attention to the use of immune checkpoint inhibitors in lung cancer patients with pleural or pericardial metastasis.

Extracranial glioblastoma diagnosed by examination of pleural effusion using the cell block technique: case report

Metastatic glioblastoma is a rare condition, and several studies have reported the involvement of multiple organs including the lymph nodes, liver, and lung. The lung and pleura are reportedly the most frequent sites of metastasis, and diagnosis using less invasive tools such as cytological analysis with fine needle aspiration biopsy is challenging. Cytological analysis of fluid specimens tends to be negative because of the small number of cells obtained, whereas the cell block technique reportedly has higher sensitivity because of a decrease in cellular dispersion. Herein, the authors describe a patient with a history of diffuse astrocytoma who developed intractable, progressive accumulation of pleural fluid. Initial cytological analysis of the pleural effusion obtained by thoracocentesis was negative, but reanalysis using the cell block technique revealed the presence of glioblastoma cells. This is the first report to suggest the effectiveness of the cell block technique in the diagnosis of extracranial glioblastoma using pleural effusion. In patients with a history of glioma, the presence of extremely intractable pleural effusion warrants cytological analysis of the fluid using this technique in order to initiate appropriate chemotherapy.

HER2/HER3-positive metastatic salivary duct carcinoma in the pleural effusion: A case report

Salivary duct carcinoma (SDC) is an aggressive form of salivary gland tumor, and SDC patients tend to be older men, more commonly in advanced stage with a poorer prognosis. Although the cytological characteristics of SDC on fine-needle aspiration cytology have been well-described at the primary site, they have not been explored in metastasis. Here we reported a case of HER2/HER3-positive metastatic SDC in the lung and pleural effusion. The patient was a man in his 50s who had undergone extended total parotidectomy in 2008. He was originally diagnosed as having HER2-positive left parotid SDC. Six years later a mass was discovered in the left lung by chest computed tomography (CT) and was diagnosed as metastatic SDC by both bronchial biopsy and cytology. Subsequently he had a recurrent SDC in the left pleural effusion and died of respiratory failure. Cytological findings from bronchial brushing smear showed small sheet clusters in a slightly necrotic background. In the pleural effusion cytology, tumor cells appeared as ball-like clusters of epithelioid cells with apocrine-like findings. In immunocytochemistry, HER3 of SDC cells in pleural effusion was significantly overexpressed relative to the matched primary tumor, even though HER2 amplification did not change. Cytological findings and HER family receptors differed between the primary and metastatic SDC. Therefore, molecular tests, such as protein expression and gene amplification using cytological specimens, may become important in future when determining therapy strategies in patients with distant metastasis.

Lung adenocarcinoma with intraoperatively diagnosed pleural seeding: Is main tumor resection beneficial for prognosis?

OBJECTIVE

To evaluate whether main tumor resection improves survival compared with pleural biopsy alone in patients with lung adenocarcinoma with intraoperatively diagnosed pleural seeding.

METHODS

Forty-three patients with lung adenocarcinoma with pleural seeding diagnosed unexpectedly during surgery performed between January 2006 and December 2014 were included in this retrospective study using a prospectively collected lung cancer database. Each surgeon decided whether to perform main tumor resection or pleural biopsy alone.

RESULTS

Main tumor and visible pleural nodule resection was performed in 30 patients (tumor resection group). The remaining 13 patients underwent pleural nodule biopsy alone (open-close group). The clinical T stage was higher in the open-close group than in the tumor resection group (P = .02). The tumor resection group had longer operative times compared with the open-close group (mean, 141.8 vs 80.3 minutes). There were no other statistically significant differences in perioperative parameters. The surgical method was the sole statistically significant prognostic factor. Patients in the tumor resection group had better progression-free survival (3-year survival: 44.5% vs 0%; P = .009) and overall survival (3-year survival: 82.9% vs 38.5%; P = .013) than did the open-close group. There was no significant survival difference between sublobar resection and lobectomy for the main tumor resection.

CONCLUSIONS

Our study demonstrated improved progression-free and overall survival after main tumor and visible pleural nodule resection in patients with lung adenocarcinoma with intraoperatively diagnosed pleural seeding. Further randomized trials are needed to define the role of main tumor resection in these patients.

Multimodality imaging characteristics of tension pyopneumothorax secondary to pulmonary carcinoma in a cat

A 3-year-old Himalayan cat was presented with respiratory distress. Radiography showed multiple gas opacity foci, with the locations dependent on patient positioning, and severe pleural effusion with a contralateral mediastinal shift. A large volume of fluid and air was aspirated, and the fluid components were consistent with a nonseptic exudate. A pulmonary mass, pleural nodules, and an air-fluid interface with air bubbles trapped in fibrous septations were identified using thoracic ultrasonography and CT. The cat died 2 days after imaging studies. Necropsy revealed tension pyopneumothorax caused by pulmonary carcinoma and multiple pleural metastases.

Correlations between EGFR gene polymorphisms and pleural metastasis of lung adenocarcinoma

Proliferation, growth, and differentiation of cells are strictly controlled by the signal system of epidermal growth factor receptor (EGFR). If any link of the EGFR signals system is interfered with or damaged, the proliferation, growth, and differentiation of cells would become uncontrolled. EGFR is overexpressed in a variety of malignant tumors, such as non-small-cell lung cancer, colorectal cancer and breast cancer. Results of the study have proved that EGFR overexpression is closely associated with mutations and variants of the EGFR genes, whose mutations and variants are associated with occurrence, metastasis, and prognosis of different types of tumors, including lung cancer. This study is aimed at investigating whether the polymorphisms of CA simple sequence repeat in intron 1 (CA-SSR1), -216G/T, and R497K in the EGFR are able to induce EGFR activation and whether overexpression is associated with pleural metastasis of lung adenocarcinoma. A total of 432 lung adenocarcinoma patients with pleural metastasis (metastasis group) and 424 patients with lung adenocarcinoma but without pleural metastasis (nonmetastasis group) were enrolled in this study. For all patients, the CA-SSR1 genotypes were determined by capillary electrophoresis, polymerase chain reaction amplification, and direct DNA sequencing, and the R497K and -216G/T genotypes were determined by polymerase chain reaction amplification and direct DNA sequencing. EGFR expression was evaluated by immunohistochemical staining in primary tumor tissues with different -216G/T, R497K, and CA-SSR1 genotypes. Our results showed significant differences between pleural metastasis and nonmetastasis groups in the genotype and allele distribution of -216G/T, R497K, and CA-SSR1 polymorphisms of the EGFR gene. The -216T allele, Arg allele, and shorter CA-SSR1 (<17) had significantly increased risks of pleural metastasis compared with the -216G allele, Lys allele, and longer CA-SSR1 (≥17), respectively. The expression of EGFR was higher in patients with genotypes of -216T/T or -216G/T, Arg/Arg or Arg/Lys, and shorter CA-SSR1 (<17) than that in patients with genotypes of -216G/G, Lys/Lys, and longer CA-SSR1 (≥17), respectively. These results indicate that -216G/T, R497K, and CA-SSR1 polymorphisms are associated with the risk of pleural metastasis of lung adenocarcinoma, which may be related to the overexpression of EGFR protein induced by -216G/T, R497K, and CA-SSR1 polymorphisms.

Photodynamic Therapy in Non-Gastrointestinal Thoracic Malignancies

Photodynamic therapy has a role in the management of early and late thoracic malignancies. It can be used to facilitate minimally-invasive treatment of early endobronchial tumours and also to palliate obstructive and bleeding effects of advanced endobronchial tumours. Photodynamic therapy has been used as a means of downsizing tumours to allow for resection, as well as reducing the extent of resection necessary. It has also been used successfully for minimally-invasive management of local recurrences, which is especially valuable for patients who are not eligible for radiation therapy. Photodynamic therapy has also shown promising results in mesothelioma and pleural-based metastatic disease. As new generation photosensitizers are being developed and tested and methodological issues continue to be addressed, the role of photodynamic therapy in thoracic malignancies continues to evolve.

Recurrent papillary thyroid carcinoma with pleural metastasis diagnosed by effusion cytology: a report of cases with clinicopathologic correlation

Papillary thyroid carcinoma (PTC) is typically an indolent disease characterized by slow growth and a favorable prognosis. In rare instances, this disease may metastasize to the pleura and manifest as a malignant pleural effusion. We report 3 female patients of Japanese/Okinawan ancestry with a history of PTC who presented with hydrothorax. Cytologic examination in conjunction with immunohistochemical staining enabled a definitive diagnosis of metastatic PTC. Molecular analysis of the mitogen activated protein kinase (MAPK) and phosphatidylinositol 3-kinase (PI3K) pathways demonstrated the presence of the v-raf murine sarcoma viral oncogene homolog B (BRAF)(V600E) mutation in 2 of our 3 patients, with the absence of any other clinically significant mutations in all cases. Further investigation is necessary to elucidate the molecular and environmental mechanisms involved in this aggressive manifestation of PTC.

Chest CT findings of pleural tuberculosis: differential diagnosis of pleural tuberculosis and malignant pleural dissemination

BACKGROUND

The imaging features of pleural tuberculosis (PTB) can be similar to those of malignant pleural dissemination (MPD) with several case reports of CT findings in atypical presentations of PTB.

PURPOSE

To describe the computed tomography (CT) features of PTB by comparing these imaging findings with those of MPD and to use the results to differentiate between the two diseases.

MATERIAL AND METHODS

The study included 135 patients with PTB and 69 with MPD. The CT images were assessed in terms of the presence, extent, and contour of pleural thickening. Pleural nodules were analyzed in terms of number, size, and location. The CT findings of PTB and MPD were compared.

RESULTS

The CT findings of PTB included circumferential pleural thickening (32.6%), mediastinal pleural involvement (31.9%), nodular thickening (8.9%), and pleural thickening >1 cm (2.2%). The CT features of MPD included nodular pleural thickening (56.5%), mediastinal pleural involvement (40.6%), circumferential thickening (23.2%), and pleural thickening >1 cm (7.2%). Comparing PTB and MPD, nodular pleural thickening was observed more frequently with MPD than PTB (P <0.001).

CONCLUSION

Nodular pleural thickening is observed in 8.9% of the patients with PTB on chest CT. Comparing PTB and MPD, nodular pleural thickening was the only finding significantly associated with MPD, particularly with nodules >10 mm.

Definitive surgery and intraoperative photodynamic therapy: a prospective study of local control and survival for patients with pleural dissemination of non-small cell lung cancer

Patients with non-small cell lung cancer (NSCLC) with pleural dissemination have very limited survivals often of just 6-9 months. Prior reports of aggressive surgical resection of pleural metastases have shown no consistent improvements in overall survival and very high rates of local recurrences. Based on this and the generally very diffuse pleural dissemination seen in patients, chemotherapy and palliative interventions are standard of care. By attempting to sterile microscopic residual disease after surgical resection, intraoperative photodynamic therapy (PDT) could improve local pleural control and overall survival compared with surgery alone for patients with NSCLC with pleural metastasis. Prior attempts to demonstrate an improvement in clinical outcomes with PDT as an intraoperative adjuvant combined with definitive surgery to treat pleural malignancies have not been successful, perhaps due, in part, to limited ability to perform real-time dosimetry and ensure adequate and even light distribution throughout the chest cavity. A stratified phase II trial assessed the efficacy of definitive surgery and intraoperative PDT with real-time dosimetry in patients with NSCLC with pleural dissemination demonstrated prolonged local control and a higher than expected 21.7-month median survival from the time of surgery and PDT among 22 enrolled patients. This is the first ever report describing optimal methods, techniques, and dosimetry that could be used to safely and reproducibly deliver intraoperative PDT to the chest cavity as part of multimodality therapy for NSCLC with pleural metastasis.

Solitary pulmonary nodule-a case of peripheral adenocarcinoma with rapid metastasis

Currently, lung cancer has rapidly become the malignancy with the highest morbility and motality in China, with an overall 5-year survival rate of only 10-15%. Early diagnosis and surgical excision is critically important to increase the survival rate of patients with lung cancer and improve their prognosis. However, patients with early lung cancer often have no specific symptom or sign, manifest radiologically only as solitary pulmonary nodules (SPNs). Here we describe a patient presenting with SPN, which was confirmed to be lung adenocarcinoma with pleural metastasis 23 days later.

Case of pleural metastasis of prostate cancer

The most frequent sites of prostate cancer metastases are the bone and lung. Pleural metastasis of prostate cancer is clinically rare. We report a case with solitary pleural thickening arising from the metastasis of prostate cancer. A 71-year-old man was referred to our hospital for further examination of pleural thickening detected during a chest computed tomography (CT) examination. A video-assisted pleural biopsy was performed. The pathological findings showed that the tumor cells had spread from the parietal pleura to adipose tissue around the costal muscles. The tumor cells were positive for prostate-specific antigen (PSA) and negative for calretinin, cytokeratin (Ck5/6) and D2-40. These findings suggested that the pleural lesion was a metastasis of the prostate cancer.

-216G/T (rs712829), a functional variant of the EGFR promoter, is associated with the pleural metastasis of lung adenocarcinoma

Numerous mutations and variants in the epidermal growth factor receptor (EGFR) gene have been demonstrated to be associated with the occurrence, metastasis and prognosis of various types of tumors, including lung cancer. Thus, the present study aimed to investigate whether -216G/T (rs712829), a functional polymorphism of the EGFR promoter that is able to induce EGFR activation and overexpression, is associated with the pleural metastasis of lung adenocarcinoma. The study subjects were comprised of 326 patients with primary lung adenocarcinoma and 312 matched cases with pleural metastasis. The -216G/T genotypes were determined in all subjects by PCR amplification and direct DNA sequencing, and EGFR expression was also evaluated by immunohistochemical staining in the primary tumor tissues with various -216G/T genotype backgrounds. The results showed that the frequencies of allele T and genotypes G/T and T/T in the pleural metastasis group were significantly higher compared with those in the non-metastasis group, with adjusted ORs of 1.46 (95% CI, 1.015–1.963) for G/T and 1.97 (95% CI, 1.051–3.152) for T/T. Furthermore, the expression of the EGFR protein was higher in the primary lung adenocarcinoma tissues with -216T/T and -216G/T compared with those with -216G/G (P<0.05). These results collectively indicate that the -216G/T polymorphism in the EGFR promoter is associated with the risk of the pleural metastasis of lung adenocarcinoma and that this effect may be associated with -216G/T-induced overexpression of the EGFR protein.