Management of Malignant Pleural Effusion

The utilization of the k-means clustering for cancer cell detection and classification with serous effusion

Cytological analysis of serous effusion specimens is essential for cancer diagnosis. In this work, we analyzed three-dimensional (3D) morphologic features by clustering to discriminate between malignant and nonmalignant cells in serous effusion specimens collected from 10 patients with pleural and peritoneal effusion accumulation symptoms. After the nuclei and mitochondria were fluorescently labeled, we obtained confocal image stack data and conducted 3D reconstruction and morphological feature parameter computation. Confocal images were segmented, interpolated, and reconstructed. Quantitative comparison across cell types has been made by 27 morphological features of volume and surface linked to the cell, nucleus, and mitochondria. We used an unsupervised machine learning method ofk-meansclustering to separate the cell distribution objectively and effectively in the 3D parameter space of the cell morphology features. The statistical significance of the differences was examined on morphological features among the three cell clusters. The clustering results were also analyzed against those of cytopathological examinations performed by collaborative pathologist on specimens collected from the same patients. These results showed that 3D morphologic features allow clustering of the effusion cells in the space of these parameters and may help produce new ways to quickly profile cells for cancer diagnosis in clinical settings. By incorporating these techniques into clinical practice, healthcare professionals may be able to more effectively detect and treat cancers in patients.

An Integrated Clinical and Computerized Tomography-Based Radiomic Feature Model to Separate Benign from Malignant Pleural Effusion

INTRODUCTION

Distinguishing between malignant pleural effusion (MPE) and benign pleural effusion (BPE) poses a challenge in clinical practice. We aimed to construct and validate a combined model integrating radiomic features and clinical factors using computerized tomography (CT) images to differentiate between MPE and BPE.

METHODS

A retrospective inclusion of 315 patients with pleural effusion (PE) was conducted in this study (training cohort: n = 220; test cohort: n = 95). Radiomic features were extracted from CT images, and the dimensionality reduction and selection processes were carried out to obtain the optimal radiomic features. Logistic regression (LR), support vector machine (SVM), and random forest were employed to construct radiomic models. LR analyses were utilized to identify independent clinical risk factors to develop a clinical model. The combined model was created by integrating the optimal radiomic features with the independent clinical predictive factors. The discriminative ability of each model was assessed by receiver operating characteristic curves, calibration curves, and decision curve analysis (DCA).

RESULTS

Out of the total 1,834 radiomic features extracted, 15 optimal radiomic features explicitly related to MPE were picked to develop the radiomic model. Among the radiomic models, the SVM model demonstrated the highest predictive performance [area under the curve (AUC), training cohort: 0.876, test cohort: 0.774]. Six clinically independent predictive factors, including age, effusion laterality, procalcitonin, carcinoembryonic antigen, carbohydrate antigen 125 (CA125), and neuron-specific enolase (NSE), were selected for constructing the clinical model. The combined model (AUC: 0.932, 0.870) exhibited superior discriminative performance in the training and test cohorts compared to the clinical model (AUC: 0.850, 0.820) and the radiomic model (AUC: 0.876, 0.774). The calibration curves and DCA further confirmed the practicality of the combined model.

CONCLUSION

This study presented the development and validation of a combined model for distinguishing MPE and BPE. The combined model was a powerful tool for assisting in the clinical diagnosis of PE patients.

Lung cancer cells detection by a photoelectrochemical MoS2 biosensing chip

This research aims to explore the potential application of this approach in the production of biosensor chips. The biosensor chip is utilized for the identification and examination of early-stage lung cancer cells. The findings of the optical microscope were corroborated by the field emission scanning electron microscopy, which provided further evidence that the growth of MoS2 is uniform and that there is minimal disruption in the electrode, hence minimizing the likelihood of an open circuit creation. Furthermore, the bilayer structure of the produced MoS2 has been validated through the utilization of Raman spectroscopy. A research investigation was undertaken to measure the photoelectric current generated by three various types of clinical samples containing lung cancer cells, specifically the CL1, NCI-H460, and NCI-H520 cell lines. The findings from the empirical analysis indicate that the coefficient of determination (R-Square) for the linear regression model was approximately 98%. Furthermore, the integration of a double-layer MoS2 film resulted in a significant improvement of 38% in the photocurrent, as observed in the device's performance.

Outcomes for Malignant Pleural Effusions Because of Melanoma Treated With Indwelling Pleural Catheters

BACKGROUND

Indwelling pleural catheters (IPCs) reduce dyspnea and improve quality of life in patients with malignant pleural effusions (MPEs). Data on outcomes of MPEs secondary to metastatic melanoma managed with IPCs are scarce. We aimed to evaluate outcomes of patients receiving IPCs for MPEs secondary to melanoma compared with other malignancies.

METHODS

We identified patients from our prospectively collected database of all patients who had an IPC insertion for MPEs at our tertiary care center for melanoma between May 2006 and November 2018 and for nonmelanoma between May 2006 and June 2013. Chart reviews were conducted to obtain patient demographics, catheter complications, time of IPC removal or death, x-ray imaging, and pleural fluid characteristics.

RESULTS

We identified 27 MPEs because of melanoma and 1114 because of nonmelanoma malignancies treated with IPC. The most frequent complication was pleural fluid loculation requiring fibrinolytics which was significantly higher in the melanoma (14.8%) compared with the nonmelanoma group (3.8%; P =0.02). Cumulative incidence functions for catheter removal ( P =0.8) or death with catheter in situ ( P =0.3) were not significant between melanoma and nonmelanoma groups in competing risk analysis. Baseline radiographic pleural effusion scores were similar, but became significantly higher (increased pleural opacity) in the melanoma group at time points following IPC insertion ( P <0.05).

CONCLUSION

MPEs because of melanoma had a higher rate of loculations requiring fibrinolytics and less radiographic improvement after IPC insertion suggesting this patient subgroup has a more complicated pleural space which may be less responsive to drainage.

A Microfluidic System for Detecting Tumor Cells Based on Biomarker Hexaminolevulinate (HAL): Applications in Pleural Effusion

Malignant pleural effusion is a common clinical problem, which often occurs in cases of malignant tumors, especially in lung cancer. In this paper, a pleural effusion detection system based on a microfluidic chip, combined with specific tumor biomarker, hexaminolevulinate (HAL), used to concentrate and identify tumor cells in pleural effusion was reported. The lung adenocarcinoma cell line A549 and mesothelial cell line Met-5A were cultured as the tumor cells and non-tumor cells, respectively. The optimum enrichment effect was achieved in the microfluidic chip when the flow rates of cell suspension and phosphate-buffered saline achieved 2 mL/h and 4 mL/h, respectively. At the optimal flow rate, the proportion of A549 increased from 28.04% to 70.01% due to the concentration effect of the chip, indicating that tumor cells could be enriched by a factor of 2.5 times. In addition, HAL staining results revealed that HAL can be used to identify tumor cells and non-tumor cells in chip and clinical samples. Additionally, the tumor cells obtained from the patients diagnosed with lung cancer were confirmed to be captured in the microfluidic chip, proving the validity of the microfluidic detection system. This study preliminarily demonstrates the microfluidic system is a promising method with which to assist clinical detection in pleural effusion.

Efficacy of hyperthermia pleurodesis: A comparative experimental study on serous membrane of abdominopelvic and thoracic cavities of rats

BACKGROUND

Pleurodesis is a common technique for treating the accumulation of air or liquid in the pleural space caused by pneumothorax or pleural effusion, it is based on the bounding of pleural layers through induced inflammatory lesions. There are several pleurodesis procedures.

OBJECTIVES

To test and describe the inflammatory effect of hyperthermia on the pleural and peritoneal mesothelia of rats, with the aim of testing the effectiveness of this process for inducing pleurodesis.

METHODS

35 Sprague-Dawley (male/female) rats were randomized into four treatment groups: Group A (Talc, 10 individuals); group B (control, 5 individuals); group C (hyperthermic isotonic saline, 10 individuals); and group D (filtrate air at 50°, 10 individuals). Inflammatory effect of hyperthermia was the primary outcome parameter.

RESULTS

In the talc group, minimal adhesions between both pleural and peritoneal layers were observed in seven rats. Talc produced peritoneal mesothelium inflammation and fibrosis associated to foreign body giant cells in 80% (8/10) of the sample. Furthermore, clear evidence of a granulomatous foreign-body reaction was detected. No macroscopic and/or microscopic damage was registered in the remaining three groups (control, hyperthermic, and filtrate air).

CONCLUSIONS

Talc is an excellent method for producing pleuro-peritoneal inflammatory lesions. On the contrary, hyperthermia apparently does not induce the macroscopic and microscopic damage that is required for efficient pleurodesis. Therefore, hyperthermia should not be used for pleurodesis procedures.

Effectiveness and Safety of Real-Time Transthoracic Ultrasound-Guided Thoracentesis

Purpose: The purpose of the present study was to specifically evaluate the effectiveness and safety of real-time ultrasound-guided thoracentesis in a case series of pleural effusion. Patients and methods: An observational prospective study was conducted. From February 2018 to December 2019, a total of 361 consecutive real-time transthoracic ultrasound (TUS)-guided thoracentesis were performed in the Unit of Diagnostic and Interventional Ultrasound of the Research Hospital “Fondazione Casa Sollievo della Sofferenza” of San Giovanni Rotondo, Foggia, Italy. The primary indication for thoracentesis was therapeutic in all the cases (i.e., evacuation of persistent small/moderate pleural effusions to avoid super-infection; drainage of symptomatic moderate/massive effusions). For completeness, further diagnostic investigations (including chemical, microbiological, and cytological analysis) were conducted. All the procedures were performed by two internists with more than 30 years of experience in interventional ultrasound using a multifrequency convex probe (3–8 MHz). For pleural effusions with a depth of 2–3 cm measured at the level of the costo-phrenic sinus was employed a dedicated holed convex-array probe (5 MHz). Results: In all the cases, the attempts at thoracentesis were successful, allowing the achievement of the therapeutic purpose of the procedure (i.e., the complete drying of the pleural space or the withdrawal of fluid till a “safe” quantity [a mean of 1.5 L, max 2 L] producing relief from symptoms) regardless of the initial extent of the pleural effusion. There were only 3 cases of pneumothorax, for a prevalence rate of complications in this population of 0.83%. No statistical difference was recorded in the rate of pneumothorax according to the initial amount of pleural fluid in the effusion (p = 0.12). All the pleural effusions classified as transudates showed an anechoic TUS appearance. Only the exudative effusions showed a complex nonseptated or a hyperechoic TUS appearance. However, an anechoic TUS pattern was not unequivocally associated with transudates. Some chronic transudates have been classified as exudates by Light’s criteria, showing also a complex nonseptated TUS appearance. The cytological examination of the drained fluid allowed the detection of neoplastic cells in 15.89% cases. On the other hand, the microbiological examination of effusions yielded negative results in all the cases. Conclusions: Real-time TUS-guided thoracentesis is a therapeutically effective and safe procedure, despite the diagnostic yield of the cytological or microbiological examinations on the collected liquid being very low. Future blinded randomized studies are required to definitely clarify the actual benefit of the real-time TUS-guided procedure over percussion-guided and other ultrasound-based procedures.

Integrated Microfluidic Handheld Cell Sorter for High-Throughput Label-Free Malignant Tumor Cell Sorting

Handheld sample preparation devices are urgently required for point-of-care diagnosis in resource-limited settings. In this paper, we develop a novel handheld sorter with a multifunction integrated microfluidic chip. The integrated microfluidic handheld sorter (μHCS) is composed of three units, including cartridges, shells, and core integrated microchip. The integrated microchip contains two flow regulators for achieving the on-chip regulation of the input flows generated by a low-cost diaphragm pump to the desired flow rates and a spiral inertial microfluidic channel for size-based cell separation. After introducing the conceptual design of our μHCS system, the performances of the separate spiral channel and flow regulator are systematically characterized and optimized, respectively. Finally, the prototype of the μHCS is successfully assembled to separate the malignant tumor cells from the clinical pleural effusions. Our μHCS is simple to use, inexpensive, portable, and compact and can be used for high-throughput label-free separation of rare cells from large volume samples in resource-limited areas.

Pleural Effusion Revealing a Diagnosis of Ewing Sarcoma

Pleural effusion can rarely present as an initial manifestation of Ewing sarcoma. We illustrate a case of a young male adult who was admitted with pleural effusion that led to the diagnosis of Ewing sarcoma.

IL-26 promotes the pathogenesis of malignant pleural effusion by enhancing CD4+ IL-22+ T-cell differentiation and inhibiting CD8+ T-cell cytotoxicity

IL-26 is a newly discovered IL-10 cytokine family member mainly secreted by Th17 cells. However, the relationship between IL-26 and lung cancer remains unclear. The present study reported that IL-26 is involved in the production and promotion of malignant pleural effusion (MPE) for the first time. The concentrations of IL-26 and several Th17-related cytokines in MPE and peripheral blood (PB) from MPE patients were measured. IL-26, IL-10, and IL-6 were elevated in MPE compared to PB. The cell resource of IL-26 was primary Th17 cells measured by flow cytometry, whereas Tc17 cells and macrophages could also contribute to higher concentration of IL-26 in MPE. Abundant IL-6 and IL-23 in MPE could promote the frequency of IL-26 expressed by CD4+ T cells through phosphorylating STAT3 signaling pathway and promoting the expression of a specific Th17 lineage marker RORγt subsequently. IL-26 could selectively increase Th22 proportion through up-regulating the percentage of Ki-67 expressed by CD4+ T cells and the expression of IL-22 secreted by memory CD4+ T cells. In addition, IL-26 could decrease secretion of granzyme B. The tumor-killing activity of CD8+ T cells were inhibited as well when cocultured with malignant cells. Furthermore, the accumulation of IL-26 protein in MPE predicted poor patient survival. In summary, our results indicated that IL-26 was involved in the pathogenesis of MPE by exerting its impacts on both CD4+ T cells and CD8+ T cells.

Efficacy of hyperthermia pleurodesis: A comparative experimental study on serous membrane of abdominopelvic and thoracic cavities of rats

BACKGROUND

Pleurodesis is a common technique for treating the accumulation of air or liquid in the pleural space caused by pneumothorax or pleural effusion, it is based on the bounding of pleural layers through induced inflammatory lesions. There are several pleurodesis procedures.

OBJECTIVES

To test and describe the inflammatory effect of hyperthermia on the pleural and peritoneal mesothelia of rats, with the aim of testing the effectiveness of this process for inducing pleurodesis.

METHODS

35 Sprague-Dawley (male/female) rats were randomized into four treatment groups: Group A (Talc, 10 individuals); group B (control, 5 individuals); group C (hyperthermic isotonic saline, 10 individuals); and group D (filtrate air at 50°, 10 individuals). Inflammatory effect of hyperthermia was the primary outcome parameter.

RESULTS

In the talc group, minimal adhesions between both pleural and peritoneal layers were observed in seven rats. Talc produced peritoneal mesothelium inflammation and fibrosis associated to foreign body giant cells in 80% (8/10) of the sample. Furthermore, clear evidence of a granulomatous foreign-body reaction was detected. No macroscopic and/or microscopic damage was registered in the remaining three groups (control, hyperthermic, and filtrate air).

CONCLUSIONS

Talc is an excellent method for producing pleuro-peritoneal inflammatory lesions. On the contrary, hyperthermia apparently does not induce the macroscopic and microscopic damage that is required for efficient pleurodesis. Therefore, hyperthermia should not be used for pleurodesis procedures.

The Focused Assessment with Sonography in Cancer (FASC) Examination

Malignant effusions occur frequently in patients with cancer and are important to diagnose and treat. In this report, we describe a novel point-of-care ultrasound (POCUS) protocol to rapidly identify pleural effusion, pericardial effusion, and ascites: The Focused Assessment with Sonography in Cancer (FASC). This protocol utilizes six standard sonographic positions to identify the presence of fluid in common anatomic spaces. The FASC examination is intended for widespread use by oncologists and other clinicians who treat patients with cancer.

Pro-cathepsin D as a diagnostic marker in differentiating malignant from benign pleural effusion: a retrospective cohort study

BACKGROUND

Malignant pleural effusion (MPE) causes substantial symptomatic burden in advanced malignancy. Although pleural fluid cytology is a commonly accepted gold standard of diagnosis, its low diagnostic yield is a challenge for clinicians. The aim of this study was to determine whether pro-cathepsin D can serve as a novel biomarker to discriminate between MPE and benign pleural effusion (BPE).

METHODS

This study included 81 consecutive patients with exudative pleural effusions who had underwent thoracentesis or pleural biopsy. Pleural fluid and serum were collected as a standard procedure for all individuals at the same time. The level of pro-cathepsin D was measured by the sandwich enzyme-linked immunosorbent assay method.

RESULTS

Though there were no significant differences in plasma pro-cathepsin D between the two groups, the level of pleural fluid pro-cathepsin D was significantly higher in the MPE group than the BPE group (0.651 versus 0.590 pg/mL, P = 0.034). The discriminative power of pleural fluid pro-cathepsin D for diagnosing MPE was moderate, with 81% sensitivity and 53% specificity at a pro-cathepsin D cut-off ≥0.596 pg/mL (area under the curve: 0.656). Positive and negative predictive values for MPE were 38 and 89%, respectively, with pro-cathepsin D cut-off value (> 0.596 pg/mL).

CONCLUSIONS

The level of pleural fluid pro-cathepsin D was found to be significantly higher in MPE than in BPE. Although results of this study could not support the sole use of pleural fluid pro-cathepsin D to diagnose MPE, pleural fluid pro-cathepsin D can be added to pre-existing diagnostic methods for ruling-in or ruling-out MPE.

Thoracic perfusion of recombinant mutant human tumor necrosis factor (rmhTNF) can be considered as a good adjunct in the treatment of malignant pleural effusion caused by lung cancer

BACKGROUND

Tumor necrosis factor (TNF) has been investigated to be correlated with the occurrence and progression of lung cancer. This investigation was to assess the efficacy and safety of recombinant mutant human tumor necrosis factor (rmhTNF) for controlling malignant pleural effusion (MPE) through thoracic perfusion.

METHODS

Through searching from MEDLINE, Web of Science, EMBASE, Cochrance Library, OVID and China National Knowledge Infrastructure (CNKI), a total of 12 studies with 694 patients were included in this study. A series of meta-analysis methods were used to analyze the extracted data.

RESULTS

Thoracic perfusion of rmhTNF combined with cisplatin promoted the objective response rate (ORR) (P < 0.001; odds ratio = 4.49) and the quality of life (QOL) of patients with MPE (P < 0.001; odds ratio = 10.33), as compared with cisplatin alone. Although the participation of rmhTNF increased the incidence of fever (P < 0.001), it seemed to relieve the adverse reactions in the digestive tract (P = 0.017).

CONCLUSIONS

Thoracic perfusion of rmhTNF contributes to the treatment of MPE and improves the QOL of MPE patients.

Clinical course of non-small cell lung cancer patients with dry pleural dissemination: Retrospective observational study

We investigated the prognosis of patients with dry pleural dissemination (DPD) of non-small cell lung cancer (NSCLC) and the risk factors of developing to malignant pleural effusion (MPE).We retrospectively reviewed 104 patients with NSCLC and DPD, confirmed surgically from 1996 to 2016. Incidence rate and risk factors of MPE were analyzed statistically. The prognosis of NSCLC patients with MPE was evaluated using the Kaplan-Meier method.The most common histologic type was adenocarcinoma in 95 (91.3%) patients. The median follow-up duration was 65.5 months and the median survival time was 37.7 months. MPE developed in 51 (49%) patients, and the median effusion-free interval was 41.9 months. The median survival time of the patients with and without MPE was not different (41.3 vs 31.7 months, P = .16). No predictive factors for the development of MPE were identified. Fifteen (14.4%) patients underwent invasive procedures for the management of MPE.Almost half of all patients with NSCLC and DPD experienced MPE, and 14.4% patients developed symptomatic MPE requiring invasive procedures. MPE in DPD did not affect the survival in NSCLC patients.

Treatment of Pleural Effusions with Nonintubated Video-Assisted Thoracoscopic Surgery

Video-assisted thoracic surgery has considerably improved the care of the thoracic surgical patient. Patients are able to leave the hospital sooner and experience less pain with equal oncologic outcomes when compared with open surgery. Nonintubated thoracic surgery has more recently been applied in the management of both benign and malignant pleural effusions. This article provides the general thoracic surgeon a detailed description on how to manage pleural effusions using video-assisted thoracoscopic surgery in a nonintubated patient. Surgical techniques and pearls are also presented.

Referral Characteristics of Palliative Care Service in Patients With Advanced Non-Small Cell Lung Cancer in a Tertiary Cancer Center

BACKGROUND

The American Society of Clinical Oncology recently recommends patients with metastatic non-small cell lung cancer (NSCLC) should be offered palliative care services earlier. We sought to investigate the timing of palliative care referral of Chinese patients with NSCLC in our center.

METHOD

Retrospective medical data including demographic characteristics and referral information were collected for analysis. Overall survival (OS) was calculated as the time since cancer diagnosis till patient's death. The time interval from palliative care (PC) referral to a patient's death (PC-D) was calculated. The PC-D/OS ratio was calculated to illustrate the comparison of the duration of PC in the overall length of disease.

RESULTS

The mean age of 155 patients with advanced NSCLC was 62.83 years. Before referral to PC, 128 patients received anticancer treatment including surgeon (46.5%). Sixty-three (40.6%) patients died in palliative care unit. The median OS of 144 patients with end cutoff was 19 months (mean = 31.49, 95% confidence interval [CI] = 25.86-37.12). The median PC-D was 41 days (mean = 73.84, 95% CI = 60.37-87.40). The mean interval of PC-D/OS of 144 patients with definitely death time was 0.22 (SD: 0.27, 95% CI: 0.17-0.26). The median interval was 0.089. More than half of patients (n = 75, 51.8%) underwent PC less than 1% time (PC-D/OS < 0.1) of their whole disease course. Patients who were indigenous to Shanghai (P = .013) and who had brain metastasis (P = .072) had the potential longer PC-D/OS ratio. A high proportion of patients reported loss of appetite (92.8%) and fatigue (91.4%) at the initial of referral to PC.

CONCLUSION

This retrospective study, in a population of patients with advanced NSCLC, gave detailed information about PC services in a tertiary cancer center.

A Study Investigating Markers in PLeural Effusion (SIMPLE): a prospective and double-blind diagnostic study

INTRODUCTION

Serum and fluid laboratory markers are valuable for exploring the aetiologies of pleural effusion (PE) because of their relative non-invasiveness, low cost, objective result and short turnaround time. The diagnostic accuracy of these potential markers needs to be rigorously evaluated before their widespread application in clinical practice. Here, we plan to perform a Study Investigating Markers in PLeural Effusion (SIMPLE).

METHODS AND ANALYSIS

This is a prospective and double-blind clinical trial which is being performed at the Affiliated Hospital of Inner Mongolia Medical University, China. Adult patients admitted for the evaluation of aetiology of PE from September 2018 to July 2021 will be enrolled after informed consent. Pleural fluid and serum specimens will be collected and stored at -80°C for the laboratory analysis. The final diagnosis will be concurred with further imaging, microbiology, cytology and biopsy if needed. The results of investigated laboratory markers will be unknown to the clinicians who will make diagnosis and the clinical diagnoses will be unknown to the laboratory technicians who will determine markers. The diagnostic accuracy of investigated markers will be assessed using receiver operating characteristics (ROC) curve analysis, multivariable logistic regression model, decision curve analysis (DCA), net reclassification index (NRI) and integrated discriminatory index (IDI).

ETHICS AND DISSEMINATION

The study is approved by the Ethic Committee of the Affiliated Hospital of Inner Mongolia Medical University (NO: 2018011). The results of SIMPLE will be submitted to international scientific peer-reviewed journals or conferences in laboratory medicine or respiratory medicine, thoracic diseases.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registry (ChiCTR1800017449); Pre-results.

Pleural fluid due to papillary thyroid cancer

We report herein a rare case of massive pleural effusion caused by papillary thyroid cancer, which was accompanied by multiple pulmonary metastasis. A 91-year-old male patient presented with shortness of breath due to massive right pleural fluid. Cytological specimens, which were obtained from pleural fluid by thoracentesis, and was consistent with that observed in surgically resected thyroid cancer 6-year previously. Immunocytochemical staining of the cells was positive for cytokeratin (CK)-7, CK-19, and positive for thyroglobulin. Massive pleural fluid due to a metastatic from papillary thyroid cancer is very rare but may develop in long-term survivors with this disease as observed in this case.

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

Background

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

Methods

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

Results

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

Conclusions

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

Macrophage-derived CCL22 promotes an immunosuppressive tumor microenvironment via IL-8 in malignant pleural effusion

Immune dysfunction often occurs in malignant pleural effusion (MPE). In our previous study, TGF-β derived predominantly from macrophages plays an important role in impairing T cell cytotoxicity in MPE. Therefore, we aimed to investigate whether other immunoregulatory cells and factors mediated TGF-β secretion from macrophages, involved in the immunosuppressive microenvironment of MPE, and to provide clues for potential immune therapy for MPE as well. We found that CCL22 level in MPE was significantly higher than that in non-malignant pleural effusion. The high level of CCL22 was closely associated with poor survival in MPE patients with lung cancer. CCL22 was dominantly produced by tumor-associated macrophages (TAMs) in MPE. Meanwhile, TAM-derived TGF-β mediated CCL22 expression in TAMs via c-Fos. CCL22 promoted the recruitment of regulatory T cells (Tregs) in MPE. Lastly, Treg-secreted high level of IL-8 further induced TGF-β production from TAMs, and promoted the immunosuppressive tumor microenvironment in MPE. Our results indicate that macrophage-derived CCL22 plays an important role in the immunosuppressive tumor microenvironment via IL-8 in MPE.

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

BACKGROUND

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

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.

Is neuron-specific enolase useful for diagnosing malignant pleural effusions? evidence from a validation study and meta-analysis

Background

Neuron-Specific enolase (NSE) has been used as a typical tumor marker and shows a potential to diagnose malignant pleural effusion (MPE). The ability of NSE in diagnosing MPE has been investigated in many studies, but with inconsistent conclusions. This study sought to investigate the diagnostic accuracy of NSE for MPE through a clinical study and together with a meta-analysis.

Methods

Pleural effusion samples from 136 patients with MPE and 102 patients with benign pleural effusion (BPE) were collected, and NSE levels were measured by electrochemiluminescence immunoassay. Receiver operating characteristic (ROC) curve analysis was performed to assess the ability of NSE to differentiate MPE from BPE. Literature search was conducted to identify suitable publications, data were extracted and diagnostic indexes including sensitivity, specificity, positive/negative likelihood ratio (PLR/NLR), and diagnostic odds ratio (DOR) were pooled. Summary ROC curve was generated to determine the overall diagnostic accuracy of NSE for MPE.

Results

Levels of NSE were significantly increased in pleural effusion from patients with MPE than that from BPE (18.53 ± 27.30 vs. 6.41 ± 6.95 ng/ml, p < 0.001). With a cut-off value of 8.92 ng/ml, pleural NSE had a sensitivity of 59.56% and a specificity of 83.33% in diagnosing MPE. A total of 14 studies with 1896 subjects were included for meta-analysis. The diagnostic parameters of NSE were listed as follows: sensitivity, 0.53 (95% CI: 0.38–0.67); specificity, 0.85 (95% CI: 0.75–0.91); PLR, 3.54 (95% CI: 2.33–5.39); NLR, 0.56 (95% CI: 0.42–0.73); and DOR, 6.39 (95% CI: 3.72–10.96). The area under the summary ROC curve was 0.78.

Conclusions

The role of pleural NSE measurement in diagnosing MPE is limited and with a low sensitivity. The clinical utility of NSE assay should be combined with the results of other tumor markers examination and the detail clinical information of patient. Further studies are needed to confirm the role of NSE in diagnosing MPE.

Electronic supplementary material

The online version of this article (10.1186/s12885-017-3572-2) contains supplementary material, which is available to authorized users.

Immune Regulation of Toll-Like Receptor 2 Engagement on CD4+ T Cells in Murine Models of Malignant Pleural Effusion

Toll-like receptor (TLR) 2 has a well-known role in sensing multiple ligands that include microbial products, endotoxin, and some extracellular matrix molecules; however, its role in the development of malignant pleural effusion (MPE) remains unknown. We performed the present study to explore the impact of TLR2 signaling on the development of MPE and to define the underlying mechanisms by which TLR2 works. Development of MPE was compared between TLR2^-/- and wild-type (WT) mice. The effect of TLR2 on differentiation of T helper type 17 (Th17), Th9, and Th2 cells in MPE was explored. The mechanisms of TLR2 on survival of mice bearing MPE were also investigated. MPE volume in TLR2^-/- mice was lower than that in WT mice, and the survival of TLR2^-/- mice bearing MPE was longer than that of WT mice. TLR2 deficiency increased, and TLR2 activation decreased, Th17 cells in MPE, whereas TLR2 signaling showed the contrary effects on Th2 cells. Th9 cells were increased in MPE of TLR2^-/- mice but were not influenced by TLR2 signaling. Intraperitoneal injection of anti-IL-17 monoclonal antibody (mAb), anti-IL-9 mAb, or recombinant mouse IL-4 accelerated the death of TLR2^-/- mice bearing MPE, and intraperitoneal injection anti-IL-17 mAb in TLR2^-/- mice was associated with a significantly shorter survival time than in WT mice. We have demonstrated, for the first time, that TLR2 signaling promotes the development of MPE and accelerates the death of mice bearing MPE by directly suppressing Th17 cell differentiation and directly promoting Th2 cell differentiation, and also by indirectly suppressing Th9 cell differentiation via an IL-17-dependent mechanism.

Indwelling Pleural Catheters: A Clinical Option in Trapped Lung

Malignant pleural effusion (MPE) symptoms have a real impact on quality of life. Surgical approach through video-assisted thoracic surgery provides a first step in palliation. In patients unfit for general anesthesia, awake pleuroscopy represents an alternative. Sclerosing agents can be administered at the bedside through a chest tube. Ideal treatment of MPE should include adequate long-term symptom relief, minimize hospitalization, and reduce adverse effects. Indwelling pleural catheter (IPC) allows outpatient management of MPE through periodic ambulatory fluid drainage. IPC offers advantages over pleurodesis in patients with poor functional status who cannot tolerate pleurodesis or in patients with trapped lungs.

Survival Difference in Patients with Malignant Pleural Effusions Treated with Pleural Catheter or Talc Pleurodesis

Malignant pleural effusions (MPE) are commonly managed with either pleural catheter (PC) or talc pleurodesis (TP). The aim of this study was to compare survival in MPE patients treated with either PC or TP. A retrospective review of our cancer center database was performed. Patients with metastatic cancer and MPE were analyzed. Demographic and clinical data were tabulated and compared. A total of 238 patients with MPE treated by either PC or TP were included. Of these, 79 patients comprised the PC group and 159 the TP group. PC had a higher incidence of advanced disease (stage III or IV) at initial diagnosis compared with TP (70.9% vs 57.2%, P = 0.05). TP had a longer postprocedure length of stay compared with PC (7.1 vs 5.0 days, P = 0.02); however, overall length of stay was similar (9.7 vs 11.1 days, P = 0.34). Read-missions were significantly lower in TP (11.9% vs 22.8%, P = 0.04). Mean survival was higher in TP compared with PC (18.7 vs 4.1 months, P < 0.001). Patients with metastatic cancer and MPE treated with TP had significantly higher survival compared with PC. This is likely related to a greater disease burden in PC, as 70 per cent of patients in this group had stage III or IV disease on initial presentation.

Increased soluble and membrane-bound PD-L1 contributes to immune regulation and disease progression in patients with tuberculous pleural effusion

Soluble and membrane-bound programmed death ligand-1 (sPD-L1 and mPD-L1, respectively) have been demonstrated to participate in the immune suppression of non-small cell lung cancer. However, the contribution of sPD-L1 and mPD-L1 to immune regulation and disease progression in patients with pleural effusions remains unknown. The present study evaluated the levels of sPD-L1 and membrane-bound PD-1/PD-L1 in the peripheral blood and pleural effusions of patients with tuberculous pleural effusion (TPE), malignant pleural effusion (MPE) and non-tuberculous non-malignant pleural effusion (n-TB n-M). Furthermore, selected T lymphocytes and cluster of differentiation (CD)14⁺ monocytes were co-cultured to investigate the potential effect of the PD-1/PD-L1 pathway in TPE. Levels of sPD-L1 and PD-L1 on CD14⁺ monocytes were increased in the TPE group, as compared with the MPE and n-TB n-M groups. Furthermore, sPD-L1 levels and the expression levels of PD-L1 on CD14⁺ monocytes were demonstrated to be positively correlated with interferon (IFN)-γ concentration in pleural effusions. Therefore, IFN-γ may increase the expression of PD-L1 on CD14⁺ monocytes in vitro. Cell counting kit-8 analysis demonstrated that anti-PD-L1 antibody was able to partially reverse the proliferation of T lymphocytes in the co-culture system. The results of the present study indicated that sPD-L1 or mPD-L1 are associated with the immune regulation and disease progression of TPE, and may serve as possible biomarkers of TPE. Furthermore, sPD-L1 and the PD-1/PD-L1 pathway of TPE may be associated with the Th1 immune response; therefore, an anti-PD-1/PD-L1 pathway suggests a potential immune therapy strategy for the treatment of TPE.

Interleukin-17 inhibits development of malignant pleural effusion via interleukin-9-dependent mechanism

Th17 and Th9 cells have been demonstrated to possess immune regulatory functions in malignant pleural effusion (MPE). However, whether IL-17 can affect differentiation and function of Th9 cells in MPE remains unknown. The objective of the present study was to explore the impact of IL-17 on the in vivo differentiation of Th9 cells in relation to Th2 cells in a murine model of MPE, and to explore whether IL-17 inhibits MPE formation via IL-9‒dependent mechanism. It was found that Th9 and Th2 cells were decreased in MPE from IL-17 ^-/- mice as compared with wild type mice. IL-17 deficiency inhibited Th9 and Th2 cell differentiation via suppressing transcription factors IRF4 and GATA-3, respectively. IL-17 deficiency enhanced MPE formation by promoting angiogenesis and proliferation of pleural tumors, and thus accelerated the death of mice bearing MPE. The in vivo administration of anti-IL-9 neutralizing mAb accelerated the death of WT mice; whereas administration of exogenous IL-9 improved the survival of IL-17 ^-/- mice. Our data provide the first definitive evidence that IL-17 promotes the differentiation of Th9 and Th2 cells in MPE. Our findings also demonstrate that IL-17 inhibits the formation of MPE and improves the survival of mice bearing MPE via an IL-9-dependent mechanism.

A Randomized Controlled Study to Observe the Efficacy of External Treatment With a Traditional Chinese Medicine Herbal Ointment on Malignant Plural Effusion: Outcome Report and Design Review

Background. Malignant pleural effusion (MPE) is a common complication in most malignancies. Despite its frequent occurrence, current knowledge of MPE remains limited and the effect of the management is still unsatisfying. Traditional Chinese medicine (TCM) external treatment has unique advantages, such as quicker efficacy and fewer side effects. Objective. To observe the effects and safety of Kang’ai Xiaoshui ointment (TCM herbal ointment) in MPE. Design. This was a placebo-controlled double-blinded randomized study. A total of 80 patients were enrolled, of which 72 were randomized to receive Kang’ai Xiaoshui ointment or placebo at an allocation ratio of 1:1. Kang’ai Xiaoshui ointment or placebo was applied on the thorax wall for 8 hours daily. The intervention lasted 2 weeks. Kang’ai Xiaoshui ointment consisted of Astragalus membranaces （黄芪）, Semen pharbitidis （牵牛子）, Cassia twig （桂枝）, Pericarpium arecae （大腹皮）, Curcuma zedoary （莪术）, Borneol （冰片), and other substances. In both groups, diuresis and drainages were used as needed. Outcomes covered the quantity of pleural effusion evaluation, TCM Symptom Scale, Karnofsky Performance Scale, and safety indicators such as routine blood test, blood biochemistry test, and response table of skin irritation. Results. Of 72 patients randomized to receive Kang’ai Xiaoshui ointment or placebo along with symptomatic treatment, the response rate was documented as 42.4% for the treatment group and 25.0% for the placebo group (P = .138). As for the TCM symptom scale, the treatment group showed improvement in chest distress (P = .003), fullness and distention (P = .042), shortness of breath (P < .001), no statistical significance in palpitation (P = .237), and pain (P = .063), whereas the placebo group did not show statistical significance in any of the 5 symptoms. Major adverse events related to the treatment, mainly skin irritation, were distributed equally. Conclusions. Kang’ai Xiaoshui ointment showed a potential of reducing MPE, and it could alleviate symptoms of dyspnea. Thus, it may be appropriate as a supplementary intervention for MPE. There were some flaws in the study design. A larger scale and better designed trial is advocated.

Chemical Pleurodesis Using Mistletoe Extraction (ABNOVAviscum(®) Injection) for Malignant Pleural Effusion

PURPOSE

Malignant pleural effusion (MPE) is common in patients with advanced cancer. Chemical pleurodesis can be considered for MPE that do not respond to chemotherapy, radiotherapy, or therapeutic thoracentesis. However, it is not yet clear which agent is more effective and safer in chemical pleurodesis.

METHODS

This study was designed as a single arm, multicenter, and open-label phase III clinical trial to evaluate efficacy and safety of chemical pleurodesis using mistletoe extraction (ABNOVAviscum(®) Injection). References of other agents in chemical pleurodesis were investigated to compare efficacy and safety. Efficacy was evaluated by followed up chest X-ray and changes of clinical symptoms and Karnofsky performance scale. Safety was evaluated by serious adverse event (SAE) and changes of laboratory findings. A follow-up period was 4 weeks after last pleurodesis.

RESULTS

Of 62 patients, 49 (79.0%) had complete response, 11 (17.7%) had partial response, and two had no response. Mean response rate was significantly different in this study comparing with reference response rate which was 64% (p <0.0001). There were two SAEs, but all were recovered without sequelas.

CONCLUSION

The results of this study suggest that mistletoe extraction (ABNOVAviscum(®) Injection) could be an effective and safe agent of chemical pleurodesis in patients with MPE.

Simple intrapleural hyperthermia at thoracoscopic exploration to treat malignant pleural effusion

Background

Malignant pleural effusion (MPE) occurs at a terminal stage of cancer, and related symptoms may considerably reduce a patient’s respiratory function and quality of life. We assessed the benefit of simple intrapleural hyperthermia (SIH) during thoracoscopic exploration for MPE.

Methods

We conducted a retrospective review of 34 patients underwent thoracoscopic exploration and SIH procedures for MPE between April, 2009 and July, 2014 at our institution. One month after removal of the tube, therapeutic efficacy was evaluated, calculating response rates and recurrence rate.

Results

In this cohort (male, 11; female, 23; average age, 54.2 ± 12.7 years), the most frequent primary cancers were breast (n = 11, 32.4 %), lung (n = 10, 29.4 %), and ovarian (n = 6, 17.6 %). Therapeutic response (ie, presence of pleural effusion) was assessed 1 month after chest tube removal, with 19 (55.9 %) showing complete response (CR), 9 (26.5 %) showing partial response (PR), and non-response (NR) seen in 6 (17.6 %). The combined (CR + PR) response rate was 82.4 %. During follow-up, there were seven instances of recurrence, requiring repeat drainage. Three- and 7-month recurrence-free rates were 86.9 and 73.9 %, respectively. No postoperative respiratory complications or fever developed. Early death within 3 months from progression of primary cancer was identified as a risk factor in patients of NR status (HR = 18.36, p = 0.043).

Conclusions

If thoracoscopic exploration is indicated for MPE, SIH is a safe and effective management alternative in patients whose primary malignancy is not rapidly progressing.

Review: Cell Dynamics in Malignant Pleural Effusions

Malignant pleural effusions (MPEs) are a common manifestation found in patients with lung cancer. After cytological and histological confirmation of malignancy, talc pleurodesis still remains the treatment of choice in patients with MPEs resistant to chemotherapy. Despite this, primary challenges include reduced quality of life and life expectancy in general. Therefore, a better understanding of the cell biology of MPEs, along with improvements in treatment is greatly needed. It has recently been demonstrated that MPEs may represent an excellent source for identification of molecular mechanisms within the tumor and its environment. The present review summarizes the current understanding of MPEs cells and tumor microenvironment, and particularly focuses on dissecting the cross-talk between MPEs and epithelial to mesenchymal transition (EMT), inflammation and cancer stem cells.

Efficacy and safety of recombinant human tumor necrosis factor application for the treatment of malignant pleural effusion caused by lung cancer

Malignant pleural effusion (MPE) signifies a poor prognosis for patients with lung cancer. For treating physicians, the primary goals are to achieve sufficient control of MPE and minimize invasive intervention. Recombinant human mutant tumor necrosis factor‐alpha (rhu‐TNF) has been used in the treatment of MPE. The aim of our research was to evaluate the efficacy and safety of rhu‐TNF application via ultrasound‐guided chest tube for the treatment of MPE. rhu‐TNF was administered as a single dose to 102 patients with MPE caused by lung cancer, and dexamethasone (Dxm, 5 mg) was administered 30 minutes before rhu‐TNF in 35 randomly selected patients in order test its ability to prevent side effects. The primary endpoint was the efficacy of the rhu‐TNF treatment (disease response rate) and side effects (pain, fever, and flu‐like symptoms), evaluated four weeks after instillation. The disease response rate of rhu‐TNF treatment was 81.37%. Side effects included 13 (12.75%) patients complaining of flu‐like symptoms, 15 (14.71%) with fever/chill, and 14 (13.73%) with chest pain. A significantly higher efficacy was observed for treatment with 3 MU versus 2 MU of rhu‐TNF (P = 0.036), while the adverse effects were similar. There was no significant association between the dose of rhu‐TNF and progression‐free survival (P = 0.752). In conclusion, our study shows that intra‐pleural instillation of rhu‐TNF achieves sufficient control of MPE and minimizes invasive intervention.

Diagnostic accuracy of calretinin for malignant mesothelioma in serous effusions: a meta-analysis

Numerous studies have investigated the utility of calretinin in differentiating malignant mesothelioma (MM) from metastatic carcinoma (MC) in serous effusions. However, the results remain controversial. The aim of this study is to determine the overall accuracy of calretinin in serous effusions for MM through a meta-analysis of published studies. Publications addressing the accuracy of calretinin in the diagnosis of MM were selected from the Medline (Ovid), PubMed, the Cochrane Library Database and the Web of Science. Data from selected studies were pooled to yield summary sensitivity, specificity, positive and negative likelihood ratio (LR), diagnostic odds ratio (DOR), and receiver operating characteristic (SROC) curve. Statistical analysis was performed by Meta-Disc 1.4 and STATA 12.0 softwares. 18 studies met the inclusion criteria and the summary estimating for calretinin in the diagnosis of MM were: sensitivity 0.91 (95%CI: 0.87–0.94), specificity 0.96 (95%CI: 0.95–0.96), positive likelihood ratio (PLR) 14.42 (95%CI: 7.92–26.26), negative likelihood ratio (NLR) 0.1 (95%CI: 0.05–0.2) and diagnostic odds ratio 163.03 (95%CI: 54.62–486.63). The SROC curve indicated that the maximum joint sensitivity and specificity (Q-value) was 0.92; the area under the curve was 0.97. Our findings suggest that calretinin may be a useful diagnostic tool for confirming MM in serous effusions.

Efficacy and safety profile of autologous blood versus tetracycline pleurodesis for malignant pleural effusion

OBJECTIVES

Autologous blood pleurodesis (ABP) is used for the treatment of pneumothorax with a good efficacy. The aim of this study is to determine the efficacy and safety of ABP in the treatment of malignant pleural effusion (MPE).

METHODS

A prospective study was conducted at Songklanagarind Hospital, Thailand. Symptomatic MPE patients were randomized to receive pleurodesis with either autologous blood or tetracycline. In the ABP group, 100 ml of autologous venous blood was instilled via chest tube followed by 50 ml of sterile normal saline (NSS). In the tetracycline group, 20 ml of 1% lidocaine diluted in 30 ml NSS was instilled followed by 1 g of tetracycline diluted in 100 ml of NSS. The chest tube was clamped for 2 hours, then reconnected to suction and removed. Pleurodesis effectiveness was evaluated according to Paladine's criteria and adverse events were recorded.

RESULTS

A total of 48 symptomatic MPE patients were recruited. Of these, 24 cases were randomized to receive ABP and 24 cases received tetracycline. There was no difference between the two groups in baseline characteristics. The overall success rate of pleurodesis was the same in both the autologous blood group and the tetracycline group (83.4% versus 87.5%, p = 0.36). In the ABP group, the pain score and fever were significantly lower (8.3% versus 29.1%, p = 0.003) and there was a small percentage of cases that needed analgesia (4.2% versus 75%, p < 0.001); no serious events occurred.

CONCLUSIONS

ABP was as effective as tetracycline in the treatment of MPE. ABP produced less pain and fever, and could shorten the hospital stay.

Clinical presentation and cytopathologic features of malignant pericardial cytology: a single institution analysis spanning a 29-year period

INTRODUCTION

Pericardial effusion can be a consequence of various diseased states, including infection, autoimmune disease, renal failure, myocardial disease, and neoplasms. Although multiple case reports of malignancy-associated pericardial effusion have been published, few database analyses are available in these published reports. In this study, we retrospectively reviewed 1022 cytology cases and assessed malignancy-associated pericardial effusion.

MATERIALS AND METHODS

We reviewed our cytology reports for pericardial effusion cases from January 1, 1983 to July 31, 2013. These cases were classified as benign, atypical, malignant, and nondiagnostic. The malignant cases were further characterized based on either immunohistochemical staining results or patients' history.

RESULTS

We identified 1022 cases and grouped them as follows: 824 benign (80.6%), 38 atypical (3.7%), 158 malignant (15.4%), and 2 unsatisfactory (0.1%). Malignant cases included 131 adenocarcinoma (82.9%), 12 lymphoma (7.9%), 6 poorly differentiated carcinoma (3.8%), 4 mesothelioma (2.5%), 2 squamous cell carcinoma (1.3%), 1 melanoma (0.6%), 1 sarcoma (0.6%), and 1 small cell carcinoma (0.6%). Of these 131 adenocarcinomas, 83 cases had clinical history and/or immunohistochemical study available for further classification, which included 44 lung, 18 breast, 7 esophagogastric adenocarcinomas, 6 adenocarcinomas of unknown primary sites, 5 ovarian, and 2 rectal adenocarcinomas. The clinical presentation, prognosis, and cytopathologic features for malignant pericardial effusions are summarized.

CONCLUSIONS

In this study, 15.4% of pericardial effusion cases were caused by metastatic malignancy, with lung adenocarcinoma being the most common primary site, followed by breast and lymphoma. Relatively young patients are affected, with average age being 56 years. Prognosis is poor for patients with malignant pericardial effusion. However, targeted therapy showed improved survival.

Diagnostic accuracy of Ber-EP4 for metastatic adenocarcinoma in serous effusions: a meta-analysis

Numerous studies have investigated the utility of Ber-EP4 in differentiating metastatic adenocarcinoma (MAC) from malignant epithelial mesothelioma (MM) and/or reactive mesothelial cells (RM) in serous effusions. However, the results remain controversial. The aim of this study is to determine the overall accuracy of Ber-EP4 in serous effusions for MAC through a meta-analysis of published studies. Publications addressing the accuracy of Ber-EP4 in the diagnosis of MAC were selected from the Pubmed, Embase and Cochrane Library. Data from selected studies were pooled to yield summary sensitivity, specificity, positive and negative likelihood ratio (LR), diagnostic odds ratio (DOR), and receiver operating characteristic (SROC) curve. Statistical analysis was performed by Meta-Disc 1.4 and STATA 12.0 softwares. 29 studies, based on 2646 patients, met the inclusion criteria and the summary estimating for Ber-EP4 in the diagnosis of MAC were: sensitivity 0.8 (95% CI: 0.78-0.82), specificity 0.94 (95% CI: 0.93-0.96), positive likelihood ratio (PLR) 12.72 (95% CI: 8.66-18.7), negative likelihood ratio (NLR) 0.18 (95% CI: 0.12-0.26) and diagnostic odds ratio 95.05 (95% CI: 57.26-157.77). The SROC curve indicated that the maximum joint sensitivity and specificity (Q-value) was 0.91; the area under the curve was 0.96. Our findings suggest that BER-EP4 may be a useful diagnostic adjunctive tool for confirming MAC in serous effusions.

Pleural Metastasis as Initial Presentation of Occult Gastric Cardia Cancer: A Possible Role of PET-CT in Diagnosis

We report on a case of malignant pleural effusion as initial metastatic presentation of occult gastric cardia cancer in a young woman. To the best of our knowledge, this is the first report of gastric adenocarcinoma metastasized to pleura as an initial presentation. Location of cardia and signet ring cell histology may contribute to the manifestation. Utilization of positron emission tomography-computed tomography was helpful for proper diagnosis. For patients with such distinct clinical presentations, it would be appropriate to consider gastric cancer as one of the possible primary sites.

Assessing the function of homologous recombination DNA repair in malignant pleural effusion (MPE) samples

Background:

Patients with malignant pleural effusions (MPEs) generally have advanced disease with poor survival and few therapeutic options. Cells within MPEs may be used to stratify patients for targeted therapy. Targeted therapy with poly(ADP ribose) polymerase inhibitors (PARPi) depends on identifying homologous recombination DNA repair (HRR)-defective cancer cells. We aimed to determine the feasibility of assaying HRR status in MPE cells.

Methods:

A total of 15 MPE samples were collected from consenting patients with non-small-cell lung cancer (NSCLC), mesothelioma and ovarian and breast cancer. Primary cultures were confirmed as epithelial by pancytokeratin, and HRR status was determined by the detection of γH2AX and RAD51 foci following a 24-h exposure to rucaparib, by immunofluorescence microscopy. Massively parallel next-generation sequencing of DNA repair genes was performed on cultured MPE cells.

Results:

From 15 MPE samples, 13 cultures were successfully established, with HRR function successfully determined in 12 cultures. Four samples – three NSCLC and one mesothelioma – were HRR defective and eight samples – one NSCLC, one mesothelioma, one sarcomatoid, one breast and four ovarian cancers – were HRR functional. No mutations in DNA repair genes were associated with HRR status, but there was probable loss of heterozygosity of FANCG, RPA1 and PARP1.

Conclusions:

HRR function can be successfully detected in MPE cells demonstrating the potential to stratify patients for targeted therapy with PARPi.

Effectiveness and safety of diagnostic flexi-rigid thoracoscopy in differentiating exudative pleural effusion of unknown etiology: a retrospective study of 215 patients

BACKGROUND

The aim of this study was to evaluate the effectiveness and safety of diagnostic flexi-rigid thoracoscopy in differentiating exudative pleural effusion of unknown etiology.

METHODS

A total of 215 patients with undiagnosed exudative pleural effusion were consecutively recruited between January 2011 and February 2013. Thoracoscopy was carried out under local anesthesia, and multisite pleural biopsies were performed using a flexi-rigid thoracoscope. The tolerance of the patients, surgical complications and postoperative pathological diagnosis rate were used to evaluate the effectiveness and safety of the thoracoscopy procedures.

RESULTS

All patients, Karnofsky performance status (KPS) >70, could tolerate both the thoracoscopic surgery and pleural biopsy; there were no severe complications. Thoracoscopic findings included pleural hyperaemia, fibrinous adhesion, nodular bulge and fester. The pathological biopsy confirmed diagnoses of malignant tumor (97 cases), tuberculous pleuritis (91 cases), tuberculous empyema (one case), pulmonary schistosomiasis (one case) and unknown etiology (25 cases). The total diagnosis rate was 88.4%. Subcutaneous emphysema occurred in ten cases and fever in six cases, all of which recovered completely with conservative treatment.

CONCLUSIONS

Flexi-rigid thoracoscopy had a high diagnosis rate, differentiating exudative pleural effusion of unknown etiology with satisfactory effectiveness and safety. There was high degree of relationship between thoracoscopic appearance and primary disease or tumor classification.

Malignant pleural effusion

Malignant pleural effusion (MPE) refers to the presence of neoplastic cells in the pleural fluid. Approximately 40 000 people per year in the UK are affected by MPE and it is associated with significant morbidity and an overall poor prognosis. Management should be prompt and care plans should be individualized and involve a multidisciplinary team of healthcare professionals. This article reviews the pathophysiology of MPE along with available investigations and management strategies for these patients.

Efficacy and safety of talc pleurodesis for malignant pleural effusion: a meta-analysis

Background

Talc pleurodesis has been widely used to control malignant pleural effusion; however, it is still not clear whether talc pleurodesis is more effective than other local therapies. We performed a meta-analysis to evaluate the efficacy and safety of talc pleurodesis in the management of malignant pleural effusion.

Methods

PubMed, Embase, and Web of Science were searched for English-language studies of clinical controlled trials comparing talc pleurodesis with control therapies until August 8, 2013. Success rate and incidence of adverse events were evaluated. Relative risks were estimated using random- or fixed- effects model and statistical heterogeneity was assessed using I² test.

Results

Twenty trials involving 1,525 patients with malignant pleural effusion were included. The success rate of talc pleurodesis was significantly higher than that of control therapies (relative risk, 1.21; 95% confidence interval, 1.01–1.45; p = 0.035) with similar adverse events. In addition, thoracoscopic talc poudrage was more effective than bedside talc slurry (relative risk, 1.12; 95% confidence interval, 1.01–1.23; p = 0.026).

Conclusions

The current evidences suggested the benefit for talc pleurodesis in the treatment of malignant pleural effusion. Talc pleurodesis, especially thoracoscopic talc poudrage pleurodesis, should be performed in patients with malignant pleural effusion, especially those with life-expectancy longer than one month.

Prognostic role of incidental pleural effusion diagnosed during echocardiographic evaluation

BACKGROUND

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

HYPOTHESIS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Superiority and clinical significance of Lunx mRNA in the diagnosis of malignant pleural effusion caused by pulmonary carcinoma

Background

Pulmonary carcinoma is the main cause of malignant pleural effusions (MPEs). However, there is no satisfactory marker for diagnosing MPEs caused by pulmonary carcinoma. The purpose of this study is to assess the clinical significance of Lunx mRNA detection in diagnosing MPEs caused by pulmonary carcinoma.

Methods

A total of 209 patients with pleural effusions were recruited. The patients were diagnosed by cast-off cells, bronchoscopy, and pleural biopsy. The levels of Lunx mRNA in the pleural effusions were determined by real-time PCR. The levels of PH, LDH, glucose, albumin, and CEA were also determined. Patients who accepted chemotherapy underwent Lunx mRNA detection before and after the first chemotherapy session. The patients were divided into four groups according the effect of chemotherapy: complete remission (CR), partial remission (PR), no change (NC), and progressive disease (PD). The patients were also divided into two groups according the change in direction of Lunx mRNA expression after chemotherapy: increased group and decreased group. The patients were followed up to determine survival.

Results

Lunx mRNA was positive in 89 of 106 patients with pleural effusions caused by pulmonary carcinoma. The specificity and sensitivity were 95.9% and 84.9%. The area under the ROC curve was 0.922. Lunx mRNA detection was better than detection using cast-off cells and CEA. All of the Lunx-positive patients with MPEs were diagnosed with pulmonary carcinoma, and all extrapulmonary carcinoma patients were Lunx-negative. The positive predictive value of Lunx mRNA for the source of tumor cells was 100%. Lunx mRNA expression decreased after the first session of chemotherapy in the CR and PR groups, increased in the PD group, there was no change in the NC group. Further analysis indicated the change in direction of Lunx mRNA expression was associated with the overall survival of patients. The patients in the increased group had longer overall survival times than those in the decreased group.

Conclusion

Lunx mRNA is a specific tumor gene that is highly expressed in MPEs caused by pulmonary carcinoma. The changes in Lunx mRNA levels after chemotherapy can predict the prognosis of patients with MPEs caused by pulmonary carcinoma.