Malignant pleural effusion: from bench to bedside

Development and validation of response markers to predict survival and pleurodesis success in patients with malignant pleural effusion (PROMISE): a multicohort analysis

BACKGROUND

The prevalence of malignant pleural effusion is increasing worldwide, but prognostic biomarkers to plan treatment and to understand the underlying mechanisms of disease progression remain unidentified. The PROMISE study was designed with the objectives to discover, validate, and prospectively assess biomarkers of survival and pleurodesis response in malignant pleural effusion and build a score that predicts survival.

METHODS

In this multicohort study, we used five separate and independent datasets from randomised controlled trials to investigate potential biomarkers of survival and pleurodesis. Mass spectrometry-based discovery was used to investigate pleural fluid samples for differential protein expression in patients from the discovery group with different survival and pleurodesis outcomes. Clinical, radiological, and biological variables were entered into least absolute shrinkage and selection operator regression to build a model that predicts 3-month mortality. We evaluated the model using internal and external validation.

FINDINGS

17 biomarker candidates of survival and seven of pleurodesis were identified in the discovery dataset. Three independent datasets (n=502) were used for biomarker validation. All pleurodesis biomarkers failed, and gelsolin, macrophage migration inhibitory factor, versican, and tissue inhibitor of metalloproteinases 1 (TIMP1) emerged as accurate predictors of survival. Eight variables (haemoglobin, C-reactive protein, white blood cell count, Eastern Cooperative Oncology Group performance status, cancer type, pleural fluid TIMP1 concentrations, and previous chemotherapy or radiotherapy) were validated and used to develop a survival score. Internal validation with bootstrap resampling and external validation with 162 patients from two independent datasets showed good discrimination (C statistic values of 0·78 [95% CI 0·72-0·83] for internal validation and 0·89 [0·84-0·93] for external validation of the clinical PROMISE score).

INTERPRETATION

To our knowledge, the PROMISE score is the first prospectively validated prognostic model for malignant pleural effusion that combines biological and clinical parameters to accurately estimate 3-month mortality. It is a robust, clinically relevant prognostic score that can be applied immediately, provide important information on patient prognosis, and guide the selection of appropriate management strategies.

FUNDING

European Respiratory Society, Medical Research Funding-University of Oxford, Slater & Gordon Research Fund, and Oxfordshire Health Services Research Committee Research Grants.

Complete response to orally administered melphalan in malignant pleural effusion from an occult female genital organ primary neoplasm with BRCA1/2 mutations: a case report

BACKGROUND

Definite diagnosis of metastasis from unknown primary depends on a comprehensive immunohistochemical investigation of tumor specimen. Accurate identification of the origin site usually helps a lot in choosing the most appropriate treatment. Molecular characterization provides more chance of a cure. Echoing modern medical development, BRCA1/2 mutations have been correlated with high efficiency of poly(adenosine diphosphate-ribose) polymerase inhibitors in ovarian cancer. While a previous case report demonstrated a surprising cure of platinum-resistant ovarian cancer with BRCA2 mutation by orally administered melphalan.

CASE PRESENTATION

A 53-year-old Taiwanese woman's malignant pleural effusion was diagnosed to be a metastasis from an occult cancer in female genital organ by diligent pathological study despite absence of image evidence. She resolutely refused intravenously administered chemotherapy. After failure of anti-estrogen tamoxifen, orally administered melphalan achieved excellent complete remission. Pathogenic homozygous BRCA1 and BRCA2 mutations were later detected in tumor cells by next-generation sequencing. The same BRCA2 mutation exists in a heterozygous status in the germline deoxyribonucleic acid.

CONCLUSIONS

This is so far the second report of long-term remission of advanced female genital organ cancer with BRCA mutations achieved by orally administered melphalan. BRCA1/2 mutations and even all "BRCAness" of malignancy, at least ovarian cancer and ovarian-related cancers, probably not only correlate with high efficacy of poly(adenosine diphosphate-ribose) polymerase inhibitors but also lead to a high-potential cure by orally administered melphalan. We recommend that clinical trials that test this assumption be carefully designed and sophisticatedly performed.

Evaluation of efficacy and safety for Brucea javanica oil emulsion in the control of the malignant pleural effusions via thoracic perfusion

Background

Brucea javanica oil emulsion (BJOE) is traditional Chinese medicine with implicated anti-tumor activity, which has been used for treating lung cancer in China. The aim of this investigation was to evaluate the effects and safety of intrapleural injection of BJOE in treating malignant pleural effusion (MPE).

Methods

The randomised controlled trials (RCTs) on the effects and safety of BJOE in treating MPE were searched from electronic medical database including MEDLINE, SCI, EMBASE, Cochrance Library and CNKI. A total of 14 RCTs with 1085 patients were involved in this meta-analysis.

Results

The overall response rate (ORR) of traditional chemotherapy drugs plus BJOE was higher than that of traditional chemotherapy drugs alone (p = 0.001; odds ratio = 1.39). Meanwhile, the combination of BJOE and traditional chemotherapy drugs improved the quality of life (QOL) of patients with MPE (p < 0.001; odds ratio = 1.56) compared with traditional chemotherapy drugs alone. Moreover, the participation of BJOE reduced the myelotoxicity and digestive reactions caused by traditional chemotherapy drugs (p < 0.05).

Conclusions

The efficacy and safety of traditional chemotherapy drugs plus BJOE was superior to traditional chemotherapy drugs alone via intrapleural injection in controlling MPE, which suggested that BJOE can be used to treat MPE.

Diagnostic value of tumour markers in pleural effusions

Introduction

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

Materials and methods

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

Results

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

Conclusions

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

Efficacy and safety profile of autologous blood versus talc pleurodesis for malignant pleural effusion: a randomized controlled trial

BACKGROUND

Autologous blood is a novel, high-efficacy sclerosant for treatment of malignant pleural effusion (MPE), similar to tetracycline. There has been no comparative data between autologous blood and a worldwide sclerosant like talc. We aimed to compare the effectiveness of autologous blood versus talc pleurodesis.

METHODS

A prospective study was conducted at Songklanagarind Hospital, Songkhla, Thailand. A total of 123 symptomatic MPE cases were randomized to receive autologous blood pleurodesis (ABP) versus pleurodesis with talc slurry. In the ABP group, 100 ml of autologous venous blood was instilled through a chest drain, followed by 50 ml of sterile normal saline (NSS). In the talc group, 20 ml of 1% lidocaine diluted in 30 ml NSS was instilled, followed by 4 g of sterile talc (Steritalc®, a non-small particle size talc) suspended in 100 ml of NSS. A 30-day pleurodesis efficacy (according to Paladine's criteria), along with the adverse events, was evaluated.

RESULTS

Fifty-six cases in the ABP, and 54 cases in the talc group completed the study. There was no difference between the two groups in the demographic data. The overall pleurodesis success rate at 30 days was 82.0% in the ABP group, comparable to the talc pleurodesis group (87.0%, p = 0.12). The percentage of fever (9.0% versus 28.0%, p = 0.04), amount of acetaminophen required by each participant (2.2 ± 0.7 versus 4.6 ± 0.9 tablets, p = 0.03), pain score and percentage of cases who needed opioids (9.0% versus 26.0%, p = 0.02) and hospital stay (10.2 ± 2.7 versus 12.8 ± 3.4, p = 0.04) were significantly lower in the ABP group; no infectious or serious events occurred.

CONCLUSIONS

ABP had an equivalent efficacy compared to talc pleurodesis for MPE treatment. ABP offered less fever and pain and could shorten hospital stays, and neither produced means ABP did not produce clotted drainage, pulmonary or systemic adverse events.

Comparison of Efficiency of Pleurodesis Between Video Assisted Thoracoscopic Surgery (VATS) and Standard Thoracostomy

Background

Chemical pleurodesis is generally accepted palliative dyspnea therapy and preventive of re-accumulation of pleural fluid in patients with malignant pleural effusions.

Aim

Comparative analyses of efficiency of chemical pleurodesis between Video Assisted Thoracoscopic Surgery (VATS) and standard thoracostomy.

Methods

From 01.01.2016-01.01.2017 at the Clinic for Thoracic Surgery of University Clinical Center (UCC) Sarajevo retrospective analysis was performed. Studied patients underwent VATS pleurodesis (G1) and standard thoracostomy pleurodesis (G2), with 60 in each group, respecting defined inclusion and exclusion criteria. Pleurodesis success was examined radiologically over the next three months.

Results

Average age of all patients was 63.97±8.75 years. Gender related, 45% were men and 55% were women (F/M=1.47:1). Average hospitalization was 7.22±1.37 (G1: 6.68±1.16; G2: 7.44±1.40; Mann-Whitney U-test: p=0.0016) days. Average thoracic drainage duration was 5.45±1.69, (G1: 4.28±1.15,G2: 6.05±1.58; Mann-Whitney U-test p<0.0001) days. Pleurodesis success after first month was 98.30% in G1, 91.60% in G2 (G1 vs. G2; p=0.2089); after second month was 98.30% in G1, 78.30% in G2 (G1 vs. G2; p=0.0011) and after three months was 91.60% in G1, 63.30% in G2(G1 vs. G2; p=0.0006). Average dyspnea degree (0-5) after the pleurodesis was 0.050±0.22 in G1 and 0.62±0.76 in G2 (Mann-Whitney U-test; p=0.0001). Complication were noticed in 9.2% patients, in G1 3.3%, 15.0% in G2.

Conclusion

Difference in pleurodesis efficiency between the G1 and G2 was established after second month and was even more evident after third month in favor of G1. Results show the significant statistical improvement of the degree of dyspnea in G1 as opposite to the G2.

Palliative Care and Interventional Pulmonology

Since pulmonary pathologies, such as lung cancer and chronic obstructive pulmonary disease (COPD), are some of the leading causes of morbidity and mortality around the world, pulmonologists are likely to encounter patients with unmet palliative care needs. This article focuses on the symptoms and complications encountered by patients with terminal pulmonary conditions, briefly describes the non-interventional palliative strategies, and then discusses more advanced therapies available in the realm of interventional pulmonology. Most of the literature discussed here is derived from patients with lung cancer and COPD.

Integrated semi-targeted metabolomics analysis reveals distinct metabolic dysregulation in pleural effusion caused by tuberculosis and malignancy

BACKGROUND

Tuberculous pleural effusion (TPE) and malignant pleural effusion (MPE) are the 2 most frequent causes of exudative pleural effusions (PEs). However, the clinical differentiation is challenging.

METHODS

Metabolic signatures in pleural effusion from 156 patients were profiled. An integrated semi-targeted metabolomics platform was incorporated for high throughput metabolite identification and quantitation. In this platform, orbitrap based mass spectrometry with data dependent MS/MS acquisition was applied in the analysis. In-house database containing ~1000MS/MS spectra were established and "MetaInt" was developed for metabolite alignment.

RESULTS

Using this strategy, lower levels of amino acids, citric acid cycle intermediates and free fatty acids accompanied with elevated acyl-carnitines and bile acids were observed, demonstrating increased energy expenditure caused by TPE. Kynurenine pathway from tryptophan was significantly enhanced in TPE. The ratio of tryptophan/kynurenine exhibited decent performance in differentiating TPE from MPE with sensitivity of 92.7% and specificity of 86.1%. After two further independent validations, it turns out that the ratio of tryptophan/kynurenine can be applied confidently as a potential biomarker together with adenosine deaminase (ADA) for clinical diagnosis of TPE.

CONCLUSIONS

Conclusively, the integrated in-house platform for high throughput semi-targeted metabolomics analysis reliably identified great potential of tryptophan/kynurenine ratio as a novel diagnostic biomarker to distinguish pleural effusion caused by tuberculosis and malignancy.

Abundant expression of TIM-3, LAG-3, PD-1 and PD-L1 as immunotherapy checkpoint targets in effusions of mesothelioma patients

Malignant pleural mesothelioma (MPM) is an aggressive cancer with an increasing incidence, poor prognosis and limited effective treatment options. Hence, new treatment strategies are warranted which include immune checkpoint blockade approaches with encouraging preliminary data. Research on the immunological aspects of the easily accessible mesothelioma microenvironment could identify prognostic and/or predictive biomarkers and provide useful insights for developing effective immunotherapy. In this context, we investigated the immune cell composition of effusions (pleural and ascites fluids) from 11 different chemotherapy-treated MPM patients. We used multicolor flow cytometry to describe different subsets of immune cells and their expression of immune checkpoint molecules TIM-3, LAG-3, PD-1 and PD-L1. We demonstrate a patient-dependent inter- and intraspecific variation comparing pleural and ascites fluids in immune cell composition and immune checkpoint expression. We found CD4⁺ and CD8⁺ T cells, B cells, macrophages, natural killer cells, dendritic cells and tumor cells in the fluids. To the best of our knowledge, we are the first to report TIM-3 and LAG-3 expression and we confirm PD-1 and PD-L1 expression on different MPM effusion-resident immune cells. Moreover, we identified two MPM effusion-related factors with clinical value: CD4+ T cells were significantly correlated with better response to chemotherapy, while the percentage of PD-L1⁺ podoplanin (PDPN)⁺ tumor cells is a significant prognostic factor for worse outcome. Our data provide a basis for more elaborate research on MPM effusion material in the context of treatment follow-up and prognostic biomarkers and the development of immune checkpoint-targeted immunotherapy.

Suspension state increases reattachment of breast cancer cells by up-regulating lamin A/C

Extravasation is a rate-limiting step of tumor metastasis, for which adhesion to endothelium of circulating tumor cells (CTCs) is the prerequisite. The suspension state of CTCs undergoing detachment from primary tumor is a persistent biomechanical cue, which potentially regulates the biophysical characteristics and cellular behaviors of tumor cells. In this study, breast tumor cells MDA-MB-231 in suspension culture condition were used to investigate the effect of suspension state on reattachment of CTCs. Our study demonstrated that suspension state significantly increased the adhesion ability of breast tumor cells. In addition, suspension state markedly promoted the formation of stress fibers and focal adhesions and reduced the motility in reattached breast cancer cells. Moreover, lamin A/C was reversibly accumulated at posttranscriptional level under suspension state, improving the cell stiffness of reattached breast cancer cells. Disruption of actin cytoskeleton by cytochalasin D caused lamin A/C accumulation. Conversely, decreasing actomyosin contraction by ROCK inhibitor Y27632 reduced lamin A/C level. Knocking down lamin A/C weakened the suspension-induced increase of adhesion, and also abolished the suspension-induced decrease of motility and increase of stress fibers and focal adhesion in reattaching tumor cells, suggesting a crucial role of lamin A/C. In conclusion, it was demonstrated that suspension state promoted the reattachment of breast tumor cells by up-regulating lamin A/C via cytoskeleton disruption. These findings highlight the important role of suspension state for tumor cells in tumor metastasis.

Management of malignant pleural effusion: challenges and solutions

Malignant pleural effusion (MPE) is a sign of advanced cancer and is associated with significant symptom burden and mortality. To date, management has been palliative in nature with a focus on draining the pleural space, with therapies aimed at preventing recurrence or providing intermittent drainage through indwelling catheters. Given that patients with MPEs are heterogeneous with respect to their cancer type and response to systemic therapy, functional status, and pleural milieu, response to MPE therapy is also heterogeneous and difficult to predict. Furthermore, the impact of therapies on important patient outcomes has only recently been evaluated consistently in clinical trials and cohort studies. In this review, we examine patient outcomes that have been studied to date, address the question of which are most important for managing patients, and review the literature related to the expected value for money (cost-effectiveness) of indwelling pleural catheters relative to traditionally recommended approaches.

A Woman in Her 30s With a History of Cervical Cancer Presents With Shortness of Breath and Pleuritic Chest Pain

A woman in her 30s presented to the ED with a 3-month history of shortness of breath on exertion, dry cough, and pleuritic chest pain. A month ago, the patient was seen at an internal medicine clinic and was found to have a right pleural effusion. A thoracentesis revealed straw-colored fluid, a total nucleated cell count of 1,260 × 10⁶/L, and a differential with neutrophils of 0.15, lymphocytes of 0.55, macrophages/monocytes of 0.19, and eosinophils of 0.10. Fluid cytology and culture were negative. The patient was presumed to have a parapneumonic effusion and treated empirically with antibiotics. However, she continued to have progressive symptoms, prompting her current visit to the ED. The patient was diagnosed with stage IIIB invasive cervical squamous cell carcinoma (SCC) approximately 7 months ago. MRI of the pelvis demonstrated a cervical mass with invasion of the right parametrial fat, but there was no evidence of uterine, vaginal, or lymph node involvement. A CT scan of the chest, abdomen, and pelvis was negative for distant metastases. The patient completed treatment with external beam radiation therapy and cisplatin chemotherapy 6 months ago. Three weeks prior to presentation to the ED, a repeat MRI pelvis showed no evidence of tumor progression and features consistent with posttreatment fibrotic changes.

Comparing approaches to the management of malignant pleural effusions

INTRODUCTION

Management of symptomatic malignant pleural effusions is becoming more complex due to the range of treatment options, which include therapeutic thoracenteses, thoracoscopic talc pleurodesis, bedside pleurodesis with talc or other sclerosing agents via small-bore chest catheters, indwelling pleural catheters, surgery, or a combination of some of these procedures. Areas covered: Recent advances for the expanding range of treatment options in malignant pleural effusions are summarized, according to the best available evidence. Expert commentary: Selection of a treatment approach in malignant pleural effusions should take into account patient preferences and performance status, tumor type, predicted prognosis, presence of a non-expandable lung, and local experience or availability. The role of pleurodesis has decreased with the advent of indwelling pleural catheters, which provide a high degree of symptomatic relief on an outpatient basis and, therefore, are being positioned as a first choice therapy in many centers. Talc poudrage pleurodesis should probably be reserved for those situations in which pleural tumor invasion is discovered during diagnostic thoracoscopy. Ongoing randomized controlled trials will offer solid evidence on which of the available palliative approaches should be selected for each particular patient.

Diagnostic value of soluble B7-H4 and carcinoembryonic antigen in distinguishing malignant from benign pleural effusion

OBJECTIVE

To explore the diagnostic value of joint detection of soluble B7-H4 (sB7-H4) and carcinoembryonic antigen (CEA) in identifying malignant pleural effusion (MPE) from benign pleural effusion (BPE).

METHODS

A total of 97 patients with pleural effusion specimens were enrolled from The First Affiliated Hospital of Zhengzhou University between June 2014 and December 2015. All cases were categorized into malignant pleural effusion group (n = 55) and benign pleural effusion group (n = 42) according to etiologies. Enzyme-linked immunosorbent assay was applied to examine the levels of sB7-H4 in pleural effusion and meanwhile CEA concentrations were detected by electro-chemiluminescence immunoassays. Receiver operating characteristic (ROC) curve was established to assess the diagnostic value of sB7-H4 and CEA in pleural effusion. The correlation between sB7-H4 and CEA levels was analyzed by Pearson's product-moment.

RESULTS

The concentrations of sB7-H4 and CEA in MPE exhibited obviously higher than those of BPE ([60.08 ± 35.04] vs. [27.26 ± 9.55] ng/ml, P = .000; [41.49 ± 37.16] vs. [2.41 ± 0.94] ng/ml, P = .000). The AUC area under ROC curve of sB7-H4 and CEA was 0.884 and 0.954, respectively. Two cutoff values by ROC curve analysis of sB7-H4 36.5 ng/ml and CEA 4.18 ng/ml were obtained, with a corresponding sensitivity (81.82%, 87.28%), specificity (90.48%, 95.24%), accuracy (85.57%, 90.72%), positive predictive value (PPV) (91.84%, 96.0%), negative predictive value (NPV) (79.17%, 85.11%), positive likelihood ratio (PLR) (8.614, 18.327), and negative likelihood ratio (NLR) (0.201, 0.134). When sB7-H4 and CEA were combined to detect pleural effusion, it obtained a higher sensitivity 90.91% and specificity 97.62%. Furthermore, correlation analysis result showed that the level of sB7-H4 was correlated with CEA level (r = .770, P = .000).

CONCLUSIONS

sB7-H4 was a potentially valuable tumor marker in the differentiation between BPE and MPE. The combined detection of sB7-H4 and CEA could improve the diagnostic sensitivity and specificity for MPE.

Prognostic Factors of 30-day Survival of Patients with Malignant Pleural Effusion

Background:

Treatment of malignant pleural effusion (MPE) depends on the 1 month prognosis of patients. Until now, there is no study evaluate factors affecting 1 month survival.

Aims:

This study aims to determine the predictors of survival within 1 month.

Methods:

Prospective study of 102 patients with MPE. Biochemistry data of pleural fluid, characteristics of tumor, and massiveness of the effusion were analyzed to determine their effect on 30-day survival of the patients. Univariate analysis was performed using Chi-square. All prognostic factors that had P < 0.25 were included in multivariate analysis using Cox regression.

Results:

Median age of patients was 51 years, most of them were female (56%). Common primary sites of tumor were lung (31%), breast (19%), and lymphatic tissue (11%). In univariate analysis, factors that have P < 0.25 were low glucose concentration in pleural fluid (P = 0.01), high lactate dehydrogenase concentration in pleural fluid (P = 0.25), and high risk tumor (P = 0.24). In multivariate analysis, only low glucose concentration was significantly related to poor survival within 1 month (hazard ratio 2.85 [1.10–7.61], P = 0.03).

Conclusions:

Low level of glucose in pleural fluid is an important factor related to 30-day survival in patients with MPE. It can be used to determine prognosis-based treatment objectively.

[Pulmonary causes of chest pain]

Chest pain represents one of the most frequent symptoms of pulmonary diseases, in addition to dyspnea and cough. The broad differential diagnostics include the intensely painful but prognostically benign acute pleurisy as well as potentially life-threatening events, such as acute pulmonary embolism or malignant chest diseases. Primary spontaneous pneumothorax is characterized by acute chest pain. Pain associated with a respiratory infection, such as pneumonia rarely poses a difficult diagnostic problem. Painful diseases of the lungs can be differentiated in an initial approach by asking the patient if the pain is related to breathing, which is characteristic of pleuritic chest diseases. Pulmonary hypertension, lung cancer and mesothelioma show more constant pain unrelated to respiratory movements. It is most important to differentiate pain associated with acute exacerbation of chronic obstructive pulmonary disease (COPD), whereby a possible cardiac comorbidity, such as acute coronary syndrome (ACS) should always be considered.

Current best practice in the evaluation and management of malignant pleural effusions

Malignant pleural effusions (MPEs) are an important cause of cancer-related mortality and morbidity. It is a heterogeneous group of conditions, which leads to debilitating symptoms and confers a poor prognosis. Recent well-designed randomized trials have provided a broader evidence base for an expanding range of treatment options. Together, with new prognostic scoring systems and a greater understanding of how different patient phenotypes respond to treatment, this allows greater personalization of management. This article will discuss the current evidence on evaluation and management of MPEs.