Medical thoracoscopy

The Role of Medical Thoracoscopy with Talc Poudrage in Spontaneous, Iatrogenic, and Traumatic Pneumothorax: A Prolonged Experience of a Tertiary Care Center

INTRODUCTION

Medical thoracoscopy is a minimally invasive and safe procedure mostly performed for unexplained exudative pleural effusions but may be considered for pneumothorax (PNX).

METHODS

This retrospective study included participants affected by PNX who underwent medical thoracoscopy with talc poudrage at a single academic hospital from 2008 to 2021. The primary endpoint was the observation of complete radiographical lung re-expansion and absence of air supply from the chest drain within 7 days of medical thoracoscopy. The secondary endpoint was achieving no recurrence of ipsilateral PNX at 24 months post-discharge.

RESULTS

A total of 95 patients affected by primary spontaneous PNX (PSP), secondary spontaneous PNX (SSP), iatrogenic, and traumatic PNX were enrolled. An additional procedure was required by 17.89% of patients, and only one patient with SSP required subsequent surgery. Recurrence of PNX occurred on the same side within 24 months after discharge in 9.47% of patients, with a median time to recurrence of 13.5 months. The PSP group was significantly more likely to achieve the primary endpoint. Pleural morphology was significantly associated with reaching the primary endpoint, while receiving a cumulative dose of talc greater than or equal to 4 g during hospitalization was associated with a lower risk of meeting it. Receiving a cumulative dose of talc greater than or equal to 4 g led in all cases to the achievement of the secondary endpoint. Patients with iatrogenic and traumatic PNX had an excellent prognosis in both the short- and long-term evaluation.

CONCLUSION

Medical thoracoscopy is an effective procedure for treating PNX in the acute setting in selected cases while preventing long-term relapses. Large prospective clinical studies are needed to support and better define the role of medical thoracoscopy in current clinical practice.

NCCP-ICS joint consensus-based clinical practice guidelines on medical thoracoscopy

Medical Thoracoscopy (MT) is commonly performed by respiratory physicians for diagnostic as well as therapeutic purposes. The aim of the study was to provide evidence-based information regarding all aspects of MT, both as a diagnostic tool and therapeutic aid for pulmonologists across India. The consensus-based guidelines were formulated based on a multistep process using a set of 31 questions. A systematic search of published randomized controlled clinical trials, open labelled studies, case reports and guidelines from electronic databases, like PubMed, EmBase and Cochrane, was performed. The modified grade system was used (1, 2, 3 or usual practice point) to classify the quality of available evidence. Then, a multitude of factors were taken into account, such as volume of evidence, applicability and practicality for implementation to the target population and then strength of recommendation was finalized. MT helps to improve diagnosis and patient management, with reduced risk of post procedure complications. Trainees should perform at least 20 medical thoracoscopy procedures. The diagnostic yield of both rigid and semirigid techniques is comparable. Sterile-graded talc is the ideal agent for chemical pleurodesis. The consensus statement will help pulmonologists to adopt best evidence-based practices during MT for diagnostic and therapeutic purposes.

Pleural clinic: where thoracic ultrasound meets respiratory medicine

Thoracic ultrasound (TUS) has become an essential procedure in respiratory medicine. Due to its intrinsic safety and versatility, it has been applied in patients affected by several respiratory diseases both in intensive care and outpatient settings. TUS can complement and often exceed stethoscope and radiological findings, especially in managing pleural diseases. We hereby aimed to describe the establishment, development, and optimization in a large, tertiary care hospital of a pleural clinic, which is dedicated to the evaluation and monitoring of patients with pleural diseases, including, among others, pleural effusion and/or thickening, pneumothorax and subpleural consolidation. The clinic was initially meant to follow outpatients undergoing medical thoracoscopy. In this scenario, TUS allowed rapid and regular assessment of these patients, promptly diagnosing recurrence of pleural effusion and other complications that could be appropriately managed. Over time, our clinic has rapidly expanded its initial indications thus becoming the place to handle more complex respiratory patients in collaboration with, among others, thoracic surgeons and oncologists. In this article, we critically describe the strengths and pitfalls of our "pleural clinic" and propose an organizational model that results from a synergy between respiratory physicians and other professionals. This model can inspire other healthcare professionals to develop a similar organization based on their local setting.

Massive pulmonary embolism led to cardiac arrest two days after thoracoscopy in a young male with pleural tuberculosis

TB itself is considered an independent risk factor for VTE; however, developing pulmonary embolism after medical thoracoscopy is extremely rare. Herein, we describe a 30-year-old previously healthy male with pleural tuberculosis developed a massive pulmonary embolism with subsequent cardiac arrest after a diagnostic medical thoracoscopy. Computed tomography pulmonary angiogram (CTPA) showed major right pulmonary embolism (PE). Unfortunately, the patient passed away despite resuscitation and extensive organ support in the intensive care unit (ICU). This case highlights the thrombotic risk in this population group in order to avoid such devastating complications.

Assessment of a panel of miRNAs in serum and pleural fluid for the differential diagnosis of malignant and benign pleural effusion

BACKGROUND

Differential diagnosis between malignant pleural effusion (MPE) and benign pleural effusion (BPE) remains a clinical challenge.

OBJECTIVE

The aim of the study is to assess the efficacy of the serum and pleural fluid (PF) miRNA panels in distinguishing MPE from BPE.

METHODS

Fourteen candidate miRNAs which were shown aberrant expression in lung cancer based on previous studies were tested by quantitative real-time PCR (qRT-PCR) in 20 MPE patients and 20 BPE patients. Significantly aberrantly expressed miRNAs were further assessed by qRT-PCR in all patients enrolled in this study. A receiver operating characteristic (ROC) curve was constructed, and the area under the ROC curve (AUC) was calculated to evaluated the diagnostic performance of the miRNAs.

RESULTS

miR-21, miR-29c and miR-182 were found to be significantly aberrantly expressed in the serum and PF of MPE patients. The AUCs for the combination of miR-21, miR-29c and miR-182 in serum and PF were 0.832 and 0.89 respectively in distinguishing MPE from infection-associated PE including tuberculous pleurisy and parapneumonia PE, and 0.866 and 0.919 respectively for differentiating MPE from heart failure-associated PE, which were superior to AUC of each individual miRNAs.

CONCLUSIONS

miR-21, miR-29c and miR-182 in serum and PF could be useful biomarkers for MPE of diagnosis.

Clinical utility of thoracoscopy in elderly tuberculous pleurisy patients under local anesthesia

INTRODUCTION

Diagnosing tuberculous pleurisy is important in Japan because it currently has a moderate tuberculosis prevalence. However, physicians often have difficulty making a diagnosis. It was reported that thoracoscopy under local anesthesia is useful for the diagnosis of tuberculous pleurisy, but there are no reports focusing on elderly patients.

METHODS

In this study, the usefulness of thoracoscopy under local anesthesia was evaluated in elderly patients. Among 170 patients who underwent thoracoscopy under local anesthesia at our hospital during 11 years from January 2008 to December 2018, those aged 75 years or older (n = 75) were investigated retrospectively.

RESULTS

A total of 55 patients underwent thoracoscopy under local anesthesia for detailed examination of pleural effusion of unknown cause. Of these, 18 were diagnosed as tuberculous pleurisy. The median age was 82 years (range: 75-92 years). The diagnosis of tuberculous pleurisy was made in 11 patients in whom Mycobacterium tuberculosis was detected and in four patients whose pathological findings indicated epithelioid granuloma accompanied by caseous necrosis. Clinical diagnosis was made in the remaining three patients based on thoracoscopic findings of the pleural cavity and a high level of adenosine deaminase in pleural fluid. No serious complications attributable to the examination were observed in any patient.

CONCLUSIONS

Thoracoscopy under local anesthesia was useful for the diagnosis of tuberculous pleurisy in elderly patients, with useful information being also obtained for the treatment of tuberculosis.

Medical thoracoscopy in the diagnosis of pleural disease: a guide for the clinician

INTRODUCTION

Developing a feasible and accurate means of evaluating pleural pathology has been an ongoing effort for over 150 years. Pleural fluid cellular and biomarker analyses are simple ways of characterizing and uncovering pathologic entities of pleural disease. However, obtaining samples of pleural tissue has become increasingly important. In cases of suspected malignancy and certain infections histopathology, culture, and molecular testing are necessary to profile diseases more effectively. The pleura is sampled via several techniques including blind transthoracic biopsy, image-guided biopsy, and surgical thoracotomy. Given the heterogeneity of pleural disease, low diagnostic yields, or invasiveness no procedural gold standard has been established in pleural diagnostics.

AREAS COVERED

Herein, we provide a review of the literature on medical thoracoscopy (MT), its development, technical approach, indications, risks, current and future role in the evaluation of thoracic disease. Pubmed was searched for articles published on MT, awake thoracoscopy, and pleuroscopy with a focus on reviewing literature published in the past 5 years.

EXPERT OPINION

As the proficiency and number of interventional pulmonologists continues to grow, MT is ideally positioned to become a front-line diagnostic tool in pleural disease and play an increasingly prominent role in the treatment algorithm of various pleural pathologies.

The Utility of Intraoperative Microbiological, Cytological, and Histopathological Sampling in the Setting of an Empyema Necessitating Lung Decortication Surgery

INTRODUCTION AND AIMS

 Empyema thoracis is a pleural space pathology that indicates accumulation of purulent material in the pleural space. It is often associated with an underlying infectious process, such as pneumonia, but can also be a ramification of a more sinister etiology, such as lung carcinoma, often warranting lung decortication surgery for prompt resolution. Although radiological imaging is used to form a preliminary diagnosis, its true predictive value remains questionable, and intraoperative microbiological, cytological, and histopathological samples are thus instrumental in yielding helpful diagnostic information. This study aims to gauge whether intraoperative microbiological, cytological, and histopathological analyses yield any additional diagnostic information in establishing the etiology underlying empyema, necessitating decortication surgery.  Methods: Microbiological, cytological, and histopathological records of 43 patients undergoing decortication surgery were included in this study. Only patients who were diagnosed with late stages of empyema and subsequently underwent decortication surgery were included in this study.  Results: The sample consisted of 43 patients, including 23 males and 20 females. For microbiology, 4.88% of the bronchoalveolar lavage (BAL) samples, 7.69% of tissue fluid samples, and 7.32% of pleural fluid samples were positive for an infectious microorganism. For cytology/histopathology, 0.00% of BAL samples, 5.41% of pleural fluid samples, and 7.32% of tissue samples were positive for an underlying infective etiology.  Conclusion: For the study and analysis of the microbiological samples, a myriad of all three different modalities of diagnosis is essential. However, tissue sampling is the preferred modality of diagnosis for cytology/histopathology owing to its ability to detect positive cases that might otherwise evade prompt detection.

Expert consensus for diagnosis and treatment using medical thoracoscopy in China

Medical thoracoscopy is a commonly used endoscopic technique for the diagnosis and treatment of respiratory diseases. As an invasive technique, it is mainly used for pleural effusions and pleural diseases that cannot be diagnosed by non-invasive methods. It is also of great application in the diagnosis and treatment of certain other diseases. Any technical operation requires special skills. There must be a learning process for mastering these skills. Although internal thoracoscopic surgery is simple, especially for respiratory specialists who have undergone training for thoracentesis or closed drainage, there are discrepancies in thoracoscopic diagnosis and treatment in hospitals in China; furthermore, the surgical methods are not uniform, and some even lead to serious complications. Therefore, the thoracoscopic diagnostic and treatment technology in China needs to be standardized. The Respiratory Professional Committee of the Integrated Medical Branch of the Chinese Medical Doctor Association invited relevant Chinese experts to formulate this standard after several rounds of discussion.

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.

Prospective Study of the Utility of Computed Tomography Triage of Pleural Biopsy Strategies in Patients With Pleural Diseases

BACKGROUND

This study aimed to prospectively evaluate the efficacy and reliability of a diagnostic workup, triaging pleural biopsy method according to baseline computerized tomography (CT) findings in the diagnosis of pleural diseases.

METHODS

Patients with pleural pathology were divided into 3 arms according to findings on CT scan images. Arm A: patients with pleural thickening/lesion in addition to pleural effusion. These patients underwent CT scan-guided Abrams' needle pleural biopsy. Arm B: patients with pleural effusion alone or suspected benign asbestos pleurisy. This group underwent medical thoracoscopy (MT). Arm C: patients with only pleural thickening. This group underwent ultrasonography-guided cutting needle pleural biopsy. MT was planned in patients who did not have a specific diagnosis in the CT scan-guided Abrams' needle pleural biopsy group. When patients with a histopathologic diagnosis of fibrinous pleuritis after MT were assessed in terms of the risk factors for malignant pleural diseases, we offered a further invasive procedure.

RESULTS

A total of 164 patients were enrolled in the study. Diagnostic sensitivity after the initial procedure was 90.2% in Arm A, 93.3% in Arm B, 95.2% in Arm C, and 92.4% in the entire workup. The negative predictive value of the entire workup was 90.4% for malignant pleural mesothelioma, 97.1% for metastatic malignant pleural diseases, and 100% for tuberculous pleurisy. Five cases who had a diagnosis of fibrinous pleuritis after MT were detected to have risk factors, 4 of which (80%) indicated malignant disease. Complication rates were low and acceptable.

CONCLUSION

Use of CT scans to triage an appropriate pleural biopsy method is associated with high diagnostic success. We recommend that the proposed diagnostic workup in this study may be used as a diagnostic algorithm for pleural diseases that require a histopathologic analysis. Determination of risk factors predicting malignant disease in patients where fibrinous pleuritis is reported after MT would be useful for clinical practice.

Improved early diagnosis of difficult cases of tuberculous pleural effusion by combination of thoracoscopy with immunological tests

INTRODUCTION

Although pleural effusion is a common clinical manifestation, the differential diagnosis of the cause of pleural effusion is often challenging, especially in the early differentiation of tuberculous pleurisy (TP) from other pleural effusion. The aim of this study was to evaluate the performance of commonly used laboratory tests for the early diagnosis of difficult cases of pleural effusion.

METHODS

Patients with undiagnosed pleural effusion were enrolled and subjected to five laboratory tests including thoracoscopy, pleural fluid adenosine deaminase assay (ADA), serum tuberculosis antibody test (TB-antibody), tuberculin skin test (TST), and T-SPOT.TB assay. The diagnosis of TP was established based on pleural histology and mycobacterial culture. The different tests were compared for diagnostic performance.

RESULTS

A total of 106 patients were enrolled; their mean age was 53 years and 70.8% were male. Seventy-two (68%) of them were confirmed to have TP. When used individually, the five laboratory tests showed highly variable performance parameters, including sensitivity ranging from 46% to 92% and specificity ranging from 33% to 82%. When used in different combinations, thoracoscopy combined with TST or TB-antibody showed the optimal performance parameters, with a sensitivity of 80.8% and a specificity of 85.7%.

CONCLUSIONS

The results of this study suggest that the combination of thoracoscopy with TST or TB-antibody test is the best choice for the early diagnosis of difficult cases of TP in high TB burden countries.

Thoracic ultrasound versus artificial pneumothorax in complications of medical thoracoscopy-a propensity score matching analysis

Background

Evaluation and location of the approaches is the key step of medical thoracoscopy. The previous standard for the step in many countries is artificial pneumothorax (AP). Recently, thoracic ultrasound (TU) has been considered as one of the choices for the development of technology. While there was a lack of data in investigating the complications of medical thoracoscopy locating approach with AP comparing TU.

Methods

A total of 108 patients who underwent medical thoracoscopy were retrospectively observed in Peking University First Hospital from January 2011 to April 2017, including 92 patients of the AP group and 16 patients of the TU group. Propensity score matching (PSM) was used to balance the covariance between the two groups. And the complications of the procedures between the groups were compared.

Results

Before PSM, there was one unbalanced covariates in the two groups. The overall complication rate was 7.6% (7/92) in the AP group, comparing 6.2% (1/16) in the TU group. There was no significant difference between the two groups (P=0.848). After balancing the covariate with 2:1 matched, the overall complication rate was 9.4% (3/32) in the AP group, comparing 6.2% (1/16) in the TU group. There was still no significant difference between the two groups (P=0.712).

Conclusions

TU is a locating approach method which does not increase the complication rate comparing with AP. And it could be a good choice in medical thoracoscopy.

Malignant pleural mesothelioma: diagnostic value of medical thoracoscopy and long-term prognostic analysis

BACKGROUND

Malignant pleural mesothelioma (MPM) is marked by its difficult diagnosis and poor prognosis. Medical thoracoscopy (MT) is an effective and safe procedure for the diagnosis of exudative pleural effusions and many factors associated with poor prognosis of MPM. We conducted this study to investigate the value of MT for diagnosing of MPM and to identify prognostic factors for MPM patients.

METHODS

From July 2005 through June 2014, a total of 833 patients with undiagnosed pleural effusions underwent MT and pleural biopsies were taken. Clinical data of all patients with MPM were retrospectively analyzed, and those with complete follow-up data were analyzed for prognostic factors.

RESULTS

Eventually, MPM was the final diagnosis in 40 patients. Diagnostic efficiency of MT for MPM was 87.5%, since diagnosis of MPM failed to be established in 5 patients during the initial MT. Median survival was 17.1 mo (95% confidence interval: 13.6-20.7 mo). MT findings of pleural adhesion and plaques were adverse prognostic factors for MPM. In addition, old age, male gender, smoking history, histological type, poor staging, no treatment, low total protein level in pleural fluid, and computed tomographic findings such as pulmonary consolidation or infiltration, mediastinal lymphopathy, pulmonary mass or nodules, and pleural nodularity were also poor prognostic factors for MPM.

CONCLUSIONS

MT is safe with a high positive rate in the diagnosis of MPM, and pleural adhesion and plaques seen under MT may be the adverse prognostic factors for MPM. Multiple clinical characteristics can affect the survival of MPM patients.

Bedside pleuroscopy in Taiwan : a great vision for critically-ill patients and intensivists

Bedside pleuroscopy can be used in daily practice by medical pulmonologists if a patient cannot tolerate either general anesthesia or being moved to an operating or endoscopy room due to their critical condition. It is a simple and safe technique that rarely has complications. The aim of this review is to summarize recent literatures about bedside pleuroscopy and share our experiences with using it in Taiwan.

Proteomic study of benign and malignant pleural effusion

BACKGROUND

Lung adenocarcinoma can easily cause malignant pleural effusion which was difficult to discriminate from benign pleural effusion. Now there was no biomarker with high sensitivity and specificity for the malignant pleural effusion.

PURPOSE

This study used proteomics technology to acquire and analyze the protein profiles of the benign and malignant pleural effusion, to seek useful protein biomarkers with diagnostic value and to establish the diagnostic model.

METHODS

We chose the weak cationic-exchanger magnetic bead (WCX-MB) to purify peptides in the pleural effusion, used matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF-MS) to obtain peptide expression profiles from the benign and malignant pleural effusion samples, established and validated the diagnostic model through a genetic algorithm (GA) and finally identified the most promising protein biomarker.

RESULTS

A GA diagnostic model was established with spectra of 3930.9 and 2942.8 m/z in the training set including 25 malignant pleural effusion and 26 benign pleural effusion samples, yielding both 100 % sensitivity and 100 % specificity. The accuracy of diagnostic prediction was validated in the independent testing set with 58 malignant pleural effusion and 34 benign pleural effusion samples. Blind evaluation was as follows: the sensitivity was 89.6 %, specificity 88.2 %, PPV 92.8 %, NPV 83.3 % and accuracy 89.1 % in the independent testing set. The most promising peptide biomarker was identified successfully: Isoform 1 of caspase recruitment domain-containing protein 9 (CARD9), with 3930.9 m/z, was decreased in the malignant pleural effusion.

CONCLUSIONS

This model is suitable to discriminate benign and malignant pleural effusion and CARD9 can be used as a new peptide biomarker.

Diagnostic value and safety of medical thoracoscopy in tuberculous pleural effusion

BACKGROUND

Differentiating tuberculous pleural effusion from other lymphocytic pleural effusions is often challenging. This retrospective study aimed to assess the efficacy and safety of medical thoracoscopy in patients with suspected tuberculous pleural effusion.

METHODS

Between July 2005 and June 2014, patients with pleural effusions of unknown etiologies underwent medical thoracoscopy in our institute after less invasive means of diagnosis had failed. Demographic, radiographic, procedural, and histological data of patients with tuberculous pleural effusion were analyzed.

RESULTS

During this 9-year study, 333 of 833 patients with pleural effusion were confirmed to have tuberculous pleurisy. Under thoracoscopy, we observed pleural nodules in 69.4%, pleural adhesion in 66.7%, hyperemia in 60.7%, plaque-like lesions in 6.0%, ulceration in 1.5% of patients with tuberculous pleurisy. Pleural biopsy revealed the presence of Mycobacterium tuberculosis in the pleural tissue or/and demonstration of caseating granulomas in 330 (99.1%) patients. No serious adverse events were recorded, and the most common minor complication was transient chest pain (43.2%) from the indwelling chest tube.

CONCLUSIONS

Our data showed that medical thoracoscopy is a simple procedure with high diagnostic yield and excellent safety for the diagnosis of tuberculous pleural effusion.

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.

Diagnostic value of interleukin 21 and carcinoembryonic antigen levels in malignant pleural effusions

The aim of this study was to evaluate the diagnostic value of interleukin 21 (IL-21) and carcinoembryonic antigen (CEA) in tuberculous pleural effusions (TPEs) and malignant pleural effusions (MPEs). Pleural effusion samples from 103 patients were classified on the basis of diagnosis as TPE (n=51) and MPE (n=52). The concentration of IL-21 was determined by ELISA. Lactate dehydrogenase (LDH), adenosine dehydrogenase (ADA) and CEA levels were also determined in all patients. A significant difference was observed in the levels of ADA and CEA (P<0.01), but not in the levels of LDH (P>0.05) between TPE and MPE. The concentration of IL-21 in MPE was significantly higher compared to TPE (P<0.01). With a threshold value of 4.32 pg/ml, IL-21 had a sensitivity of 76.9% (40/52) and a specificity of 80.4% (41/51). Combined detection of IL-21 and CEA had a sensitivity of 69.2% (36/52) and a specificity of 92.2% (47/51). These two markers can contribute to the differential diagnosis of MPEs.

Diagnostic value of mesothelin in pleural fluids: comparison with CYFRA 21-1 and CEA

CYFRA 21-1 and CEA have been applied for the differential diagnosis of malignant pleural mesothelioma (MPM). The soluble mesothelin-related peptide (SMRP) has been proposed as a specific marker for distinguishing MPM from benign diseases and other malignancies in pleural effusions (PEs). In this study, we evaluated the usefulness of SMRP in PEs in the detection of mesotheliomas by comparing it with that of CYFRA 21-1, CEA, and with cytological examination. One hundred and seventy-seven consecutive patients (57 MPM, 64 metastatic tumors, and 56 benign diseases) were evaluated using commercial tests. The performance of the markers was analyzed by standard ROC analysis methods, using the area under a ROC curve (AUC) as a measure of accuracy. CYFRA 21-1 better differentiated malignant from benign effusions. The corresponding area under the receiver operating characteristic curve was 0.87, while it was 0.74 for SMRP and 0.64 for CEA (p < 0.001). Conversely, SMRP differentiated MPM from all other PEs better than both CYFRA 21-1 and CEA (AUC = 0.84, 0.76, and 0.32, respectively, p = 0.003). Low levels of CEA were associated with a MPM diagnosis. The AUC for differentiating MPM from metastases was 0.81 for SMRP, 0.61 for CYFRA 21-1, and 0.20 for CEA (p < 0.001). In cases with negative or suspicious cytology, SMRP and CYFRA 21-1 identified 36/71 and 46/66 malignant PEs (29 and 31 MPM, respectively). Only 1 MPM showed a high CEA concentration. No single marker showed the best performance in any comparison. Results suggest that SMRP could improve CYFRA 21-1 and CEA accuracy in the differential diagnosis of MPM.

Diagnosis of ovarian cancers using thoracoscopy: Three case reports and review of the literature

Thoracoscopy is a useful method for diagnosing plural lesions. We diagnosed 3 cases of ovarian adenocarcinoma by thoracoscopy. All patients were middle-aged and elderly women. Initial examination revealed intrathoracic lesions including pleural effusion, but intraperitoneal lesions were unclear. In all cases, adequate samples of tumor cells obtained using thoracoscopy were used in the identification of tumor origin. Elevated serum levels of cancer antigen 125 (CA-125) and Krebs von den lungen-6 (KL-6) were observed in 2 of the 3 patients. Diagnoses of ovarian cancer were based on immunohistochemical examinations and clinical course. This report describes the diagnostic usefulness of thoracoscopy and serum KL-6 in cases of ovarian cancer with predominantly intrathoracic lesions.

Outcome of patients diagnosed with fibrinous pleuritis after medical thoracoscopy

BACKGROUND

In patients with post- medical thoracoscopy histopathological diagnoses of fibrinous pleuritis, confusion can occur concerning subsequent procedures. This issue is particularly important in regions where mesothelioma is prevalent. We aimed to identify false negatives among patients where mesothelioma was common due to asbestos exposure whose histopathological diagnosis following thoracoscopy was fibrinous pleuritis. We also determined risk factors associated with patients that required additional advanced invasive procedures for diagnosis.

METHODS

Overall, 287 patients who underwent thoracoscopy were included in the study. Patients diagnosed with fibrinous pleuritis as a result of thoracoscopy were followed for 2 years regarding this condition. More invasive procedures were performed on patients who showed no recuperation or developed pleural disease again during the follow-up period.

RESULTS

Fibrinous pleuritis was observed in 101 (35.2%) patients. Follow-up of these patients revealed that the false negative rate was 18% for malignant pleural diseases. The thoracoscopist's opinion regarding the pleural space, computed tomography scan findings indicating malignancy, pain and female gender were determined to be risk factors for malignant pleural diseases.

CONCLUSIONS

In regions where mesothelioma is prevalent and one of the above-stated risk factors is present, patients whose post-thoracoscopy histopathological diagnosis is fibrinous pleuritis should be treated with a more advanced invasive diagnosis procedure.

Diagnostic molecular biomarkers for malignant pleural effusions

Malignant pleural effusions (MPEs) are a common and important cause of cancer-related mortality and morbidity. Prompt diagnosis using minimally invasive tests is important because the median survival after diagnosis is only 4–9 months. Pleural fluid cytology is pivotal to current MPE diagnostic algorithms but has limited sensitivity (30–60%). Consequently, many patients need to undergo invasive diagnostic tests such as thoracoscopic pleural biopsy. Recent genomic, transcriptomic, methylation and proteomic studies on cells within pleural effusions have identified novel molecular diagnostic biomarkers that demonstrate potential in complementing cytology in the diagnosis of MPEs. Several challenges will need to be addressed prior to the incorporation of these molecular tests into routine clinical diagnosis, including validation of molecular diagnostic markers in well-designed prospective, comparative and cost–effectiveness studies. Ultimately, minimally invasive diagnostic tests that can be performed quickly will enable clinicians to provide the most effective therapies for patients with MPEs in a timely fashion.

Management of malignant pleural effusions

Malignant pleural effusions are a common clinical problem in patients with primary thoracic malignancy and metastatic malignancy to the thorax. Symptoms can be debilitating and can impair tolerance of anticancer therapy. This article presents a comprehensive review of pharmaceutical and nonpharmaceutical approaches to the management of malignant pleural effusion, and a novel algorithm for management based on patients' performance status.