Cytopathological spectrum of unusual malignant pleural effusions at a tertiary care centre in north India

Decoding the primary tumor origin in carcinomatous serous effusions by immunocytochemistry

INTRODUCTION

Malignant effusions are commonly encountered in day-to-day cytology practice. Determining the primary site of malignancy in carcinomatous effusions is a Herculean task. Cytology coupled with immunocytochemistry is often found helpful in this context.

MATERIALS AND METHODS

This study was undertaken to evaluate diagnostic utility of immunocytochemistry (ICC) on the sections from cell blocks (CBs) to detect the primary site of origin in metastatic carcinomatous effusions. To determine the origin of the primary tumor, TTF1 (lung), PAX-8 (ovary), CDX2 (colo-rectal), GATA3 (breast), and CK19 (pancreaticobiliary) were employed depending on the clinical and radiological findings, and serum tumor markers.

RESULTS

A total of 13,459 serous effusion samples were received for cytological evaluation from January 2017 to December 2021 of which 2708 (20.1%) were carcinomatous effusions. Out of these, 1044 (38.5%), 1611 (59.5%), and 53 (2.0%) were from pleural, peritoneal and pericardial cavities, respectively. Of these, majority were adenocarcinoma. ICC was done in 309 (11.4%) cases. Ovary was the most common primary site in 179 (57.9%) cases, followed by lung (75, 24.3%), pancreaticobiliary (12, 3.9%), colo-rectal (8, 2.6%), breast (6, 1.9%), prostate (2, 0.6%) and kidney (1, 0.3). Lung was the commonest primary site in pleural (67/113, 59.3%) and pericardial (6/8, 75%) effusions. Ovary (168/188, 89.4%) was the most common primary responsible for carcinomatous effusions in the peritoneal cavity. However, in 17 (5.5%) cases, the exact primary site could not be established.

CONCLUSIONS

Judicious and methodical use of ICC on CB helps identify the primary site of the tumor in most carcinomatous effusions. This is of immense help to the treating clinician in directing appropriate therapy.

Myeloid sarcoma diagnosed on pleural effusion cytology: A case report and literature review

Myeloid sarcoma (MS) is a mass-forming, extramedullary infiltration of myeloid blasts rarely presenting in cases of acute myeloid leukemia (AML). These tumoral masses rarely occur at any and multiple anatomic sites, precedent or coincident with bone marrow evidence of AML. We report a case of MS that presented as pancreatic and cardiac masses where subsequent evaluation of pleural effusion cytology rendered the diagnosis. Primary MS diagnosed via pleural effusion cytology is not yet reported in literature. Herein, we report the case of a 45-year-old man who presented with abdominal pain. An infiltrative mass was identified in the pancreatic head, suspicious for pancreatic adenocarcinoma. Despite multiple attempts, Fine needle aspiration cytology of the pancreatic mass failed to render a definitive diagnosis. Subsequent thoracentesis of a right pleural effusion revealed cytologically malignant cells, identified as myeloid blasts after immunohistochemical and flow cytometric evaluation. Although rare, MS should be considered as a diagnostic possibility in the evaluation of malignancy with an unknown primary.

Cytomorphology, Immunophenotype, and cytogenetic profile of leukemic serous effusions

BACKGROUND

Serous effusions (SE) in leukemic patients can be due to infections, therapy, volume overload, lymphatic obstruction or malignancy having implications on treatment and mortality. The objective of the present study is to highlight the spectrum of cytomorphology, immunophenotype, and cytogenetics in leukemic serous effusions (LSE).

MATERIALS

Present study is retrospective and descriptive. We reviewed all the SE, which were reported as suspicious or positive of leukemic infiltration from 2016 to 2019 for cytomorphological features. CSF and effusions involved by lymphomas were excluded. Cyto-diagnosis was compared with primary proven diagnosis (by ancillary techniques) and disconcordant cases were analyzed.

RESULTS

Out of total 9723 effusions, only 0.4% (n = 40) showed leukemic involvement and included nine cases of AML, three of B-ALL, 13 T-ALL, 2 MPAL, 6 CML, 5CLL, one each of chronic myelomonocytic leukemia and AML with myelodysplasia. The most common site of involvement was the pleural cavity (n = 30), followed by the peritoneal cavity (n = 7) and the pericardial cavity (n = 3). T -ALL (41.9%) was the most common leukemia involving pleural fluid followed by AML (23.3%). CML (42.8%) was the most common leukemia involving the ascitic fluid followed by B-ALL (28.6%). Accurate diagnosis was given on cytomorphology in 72.5% (29/40) cases and 15.0% (6/40) were reported as non-Hodgkin lymphoma.

CONCLUSION

Cytology is an effective tool available to make a diagnosis of LSE. Nuclear indentations in large atypical cells and cells with eosinophilic granular cytoplasm with sparse or abundant eosinophils in the background are an important clue in favor of leukemia over lymphoma.

Polyserositis as a primary clinical manifestation of CD7+ acute myelogenous leukemia with myeloid sarcoma: A case report

RATIONALE

Myeloid sarcomas (MS) are defined as rare extramedullary masses composed of immature myeloid cells. MS mostly develops in patients with acute myeloid leukemia (AML), and involves primarily the skin, soft tissues, bones, and lymph nodes. Pleura and pericardium involvement of MS are extremely uncommon. Polyserositis is also a very rare extramedullary presentation of acute myeloid leukemia (AML).

PATIENT CONCERNS

A 30-year-old woman with a complaint of right neck mass combined with coughing for 2 months as well as fever and systemic edema for the last 10 days, was admitted to our center on July 11, 2019. Initial positron emission tomography (PET) scan indicated systemic lymphadenopathy, bilateral pleural effusion, and pericardial effusion.

DIAGNOSIS

The initial pathological diagnosis of lymph nodes was MS. Subsequent bone marrow analysis confirmed AML.

INTERVENTIONS

Conventional IA induction regimen followed by high-dose cytarabine (HiDAC) regimen.

OUTCOMES

Complete absorption of pericardial and pleural effusion after the first cycle of IA induction chemotherapy.

LESSONS

Polyserositis can be an extramedullary presentation of AML. Patients with polyserositis should undergo routine flow cytometric analysis. For AML with extamedullary infiltration, systemic chemotherapy should be administered in all confirmed cases.

Diagnostic role of cytology in serous effusions of patients with hematologic malignancies

BACKGROUND

We investigated serous effusions occurring during the course of an already known hematologic neoplasia or as a first manifestation of it. We correlated cytology results with flow cytometry results, when available. In the absence of flow cytometry, our correlation was based on clinical follow up information obtained retrospectively. We evaluated our results in relation to the data of the literature and we considered some new suggestions for the improvement of cytology service.

METHODS

Serous effusions in hematologic patients were retrieved from the files of the Department of Cytology, Laiko Hospital, for a period of 2 years. All patients had enrolled either a previous hematologic history, or a suspicious clinical and imaging status. Seventy-three serous effusions were included. Cytology reports consisting of morphology and immunocytochemistry assessment were correlated to flow cytometry results and, occasionally, to clinical follow-up.

RESULTS

In the group of patients with previous history, sensitivity was 82.76%, positive predictive value was 100%, specificity 100%, and negative predictive value was 58.33%. In the group of patients without previous history, sensitivity and positive predictive value were both 91%, whereas specificity and negative predictive value could not be estimated.

CONCLUSION

We provide evidence that the diagnostic accuracy of cytology with the adjunct of immunocytochemistry is high compared to flow cytometry for detecting hematologic malignancies. In order to improve clinical performance, it is suggested that a cytology triage of serous effusions in all patients with hematologic malignancy must be implemented.

Video assisted thoracoscopic and open chest surgery in diagnosis and treatment of malignant pleural diseases

Parenchymal cancers of lung, breast, gastrointestinal tract and ovaries as well as lymphomas and mesotheliomas are among the most common cancer types causing malignant effusions, though almost all tumour types have been reported to cause a malignant effusion. The prognosis heavily depends on patients' response to systemic therapy however, regardless of the causing pathology and histopathologic form, malignant pleural disease is normally associated with a poor prognosis. To date, there are not sufficient data to allow accurate predictions of survival that would facilitate decision making for managing patients with malignant pleural diseases. Interventions are directed towards drainage of the effusion and, when appropriate, concurrent or subsequent pleurodesis or establishing long-term drainage to prevent re-accumulation. The rate of re-accumulation of the pleural effusion, the patient's prognosis, and the severity of the patient's symptoms should guide the subsequent choice of therapy. In contemporary medicine, not many cancers have managed to generate as intense debates concerning treatment, as malignant pleural mesothelioma. The relative advantages of surgery, radiation, chemotherapy and any combination of the three are continuously reassessed and reconsidered, even though not always based on scientific evidence. The aim of surgery in mesothelioma may be prolongation of life, in addition to palliation of symptoms. Longer recovery periods from more extensive surgical procedures could be justified, in carefully selected patients. Surgical options include: Video assisted thoracoscopic (VATS) pleurodesis, VATS partial pleurectomy (VATS PP)-both parietal and visceral; open pleurectomy decortication (PD)-with an extended option (EPD) and extrapleural pneumonectomy (EPP). Current evidence implies that EPD can be performed reliably in specialised centres with good results, both in terms of mortality and survival; however, no operation has yet been shown to be beneficial in a prospective randomized controlled clinical trial.

Evaluation of cytology in lung cancer diagnosis based on EBUS-TBNA

AIMS

Endobronchial ultrasound (EBUS) is a relatively new modality that can be used to guide transbronchial needle aspiration (TBNA) of mediastinal lymph nodes. At present, researches on the sensitivity and specificity of cytopathology based on the EBUS-TBNA are deficient; therefore, we want to evaluate the value of cytology based on the EBUS-TBNA in this article.

MATERIALS AND METHODS

We reviewed the 379 cases that underwent the EBUS-TBNA in Shanghai Pulmonary Hospital from April 2010 to May 2011. Discarding the 139 cases with insufficient cells, we analyzed the remaining 240 cases that had enough cells on the smears.

STATISTICAL ANALYSIS USED

The Statistical Package for the Social Sciences version 15.0 (SPSS Inc., Chicago, IL) was used for data analysis. A P value of <0.05 was considered significant.

RESULTS

We found that the cytologic diagnosis of sensitivity and specificity reached 94.52% and 95.12%, respectively. The sensitivity of squamous cell carcinoma, adenocarcinoma, and small cell carcinoma was up to 88.24%, 100.00%, and 96.00%, respectively. The specificity of squamous cell carcinoma, adenocarcinoma, and small cell carcinoma reached to 100.00%, 100.00%, and 99.25%, respectively.

CONCLUSION

Here, we report that the cytological examination of EBUS-TBNA should be acknowledged as a simple, fast, and safe procedure that provides a reasonable sensitivity and specificity of diagnosis in lung cancer.

Myeloid Sarcoma: An Unusual Case of Mediastinal Mass and Malignant Pleural Effusion with Review of Literature

Myeloid sarcoma is an extramedullary tumor seen most commonly in patients with acute myeloid leukemia and less frequently in chronic myeloid leukemia, myelodysplastic syndrome and rarely, in an isolated form without any other underlying malignancy. Malignant pleural effusion in hematological malignancies is rare when compared with solid tumors. We present an unusual case of myeloid sarcoma in which a mediastinal mass with pleural effusion was the initial presentation. A 27 year old gentleman presented with complaints of fever, chest pain and swelling in the anterior chest wall for 6 months. Examination revealed a lump measuring 5 × 5 cm on the left side of the chest wall. Hematological evaluation showed hemoglobin-14.2 g/dL, platelet count-233 × 10(9)/L, TLC-117 × 10(6)/L with normal differential counts. Contrast enhanced computerised tomography (CECT) confirmed the presence of a soft tissue mass in the superior mediastinum abutting against the chest wall. Core biopsy was suggestive of myeloid sarcoma and immunohistochemistry was positive for myeloperoxidase and negative for CD3, CD 20 and CD 23. Pleural fluid analysis showed the presence of malignant cells. Bone marrow examination did not show an excess of blasts. A final diagnosis of extramedullary myeloid sarcoma with malignant pleural effusion was made. The patient was given induction chemotherapy (3 + 7 regimen) with daunorubicin and cytosine arabinoside. Repeat CECT done on day 28 showed complete resolution of pleural effusion and significant reduction in the size of mediastinal mass. The patient has successfully completed three cycles of consolidation therapy following which there has been complete resolution of the mass. He remains asymptomatic on close follow up.

Extramedullary acute myeloid leukemia: leukemic pleural effusion, case report and review of the literature

Objective and Importance: Malignant pleural effusions occur in the setting of both solid and hematologic malignancies. Pleural effusion caused by leukemic infiltration is an unusual extramedullary manifestation of acute myeloid leukemia (AML) with fewer than 20 cases reported (1–11). We report a case of pericardial and pleural effusions in a patient with AML and review the literature.

Clinical Presentation: In this case, a 55-year-old man with previous history of myeloproliferative neoplasm experienced transformation AML, heralded by appearance of leukemic pleural effusions. The patient was identified to have leukemic pleural effusion based on the extended cytogenetic analysis of the pleural fluid, as morphologic analysis alone was insufficient.

Intervention: The patient was treated with hypomethylator-based and intensive chemotherapy strategies, both of which maintained resolution of the effusions in the remission setting.

Conclusion: Due to the rarity of diagnosis of leukemic pleural effusions, both cytogenetic and fluorescence in situ hybridization testing are recommended. Furthermore, systemic chemotherapy directed at the AML can lead to complete resolution of leukemic pleural effusions.

Pleural effusion as an unusual initial presentation of acute myeloid leukemia

Pleural effusions in acute myeloid leukemia (AML) can have wide differential diagnosis, however AML presenting as pleural effusion with leukemic infiltration is rarely documented. A 22 year old male presented with pleural effusion for 3 months and subsequently diagnosed as AML M2, which prompted us for this communication.

The treatment of pleural carcinosis with malignant pleural effusion

BACKGROUND

Pleural carcinosis is caused by tumors of the chest (e.g., lung and breast cancer) or elsewhere in the body (e.g., ovarian carcinoma) that metastasize to the visceral and/or parietal pleura. Recurrent malignant pleural effusion due to pleural carcinosis is one of the most common findings in oncology. It affects about 56 000 patients per year in Germany alone.

METHODS

This review is based on pertinent literature retrieved by a selective search of the Medline database (key words: malignant pleural effusion, pleural carcinosis) and on the authors' clinical experience.

RESULTS

Although many retrospective studies have been published, there has been only one randomized controlled trial of treatment, in which permanent pleural catheters were compared with talcum pleurodesis. Patients with pleural carcinosis have a median survival of less than 12 months. Many are suffering from progression of their underlying disease, with generalized tumor involvement; thus, the symptomatic treatment of pain and dyspnea is often the main therapeutic issue. The underlying tumor, usually an adenocarcinoma, can be diagnosed either by histology or by cytology. The main complication is progressive respiratory failure. The treatment is palliative, rather than curative. The main approaches are drainage of the effusion (by thoracocentesis or with permanent pleural catheters) and pleurodesis (obliteration of the pleural space by causing the visceral and parietal pleura to adhere to each other).

CONCLUSION

Pleural carcinosis with symptomatic malignant pleural effusion is treated palliatively. The appropriate treatment in each case should be determined through discussion with the patient, with the goal of improving the patient's quality of life.

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.

Pleural effusion: diagnosis, treatment, and management

A pleural effusion is an excessive accumulation of fluid in the pleural space. It can pose a diagnostic dilemma to the treating physician because it may be related to disorders of the lung or pleura, or to a systemic disorder. Patients most commonly present with dyspnea, initially on exertion, predominantly dry cough, and pleuritic chest pain. To treat pleural effusion appropriately, it is important to determine its etiology. However, the etiology of pleural effusion remains unclear in nearly 20% of cases. Thoracocentesis should be performed for new and unexplained pleural effusions. Laboratory testing helps to distinguish pleural fluid transudate from an exudate. The diagnostic evaluation of pleural effusion includes chemical and microbiological studies, as well as cytological analysis, which can provide further information about the etiology of the disease process. Immunohistochemistry provides increased diagnostic accuracy. Transudative effusions are usually managed by treating the underlying medical disorder. However, a large, refractory pleural effusion, whether a transudate or exudate, must be drained to provide symptomatic relief. Management of exudative effusion depends on the underlying etiology of the effusion. Malignant effusions are usually drained to palliate symptoms and may require pleurodesis to prevent recurrence. Pleural biopsy is recommended for evaluation and exclusion of various etiologies, such as tuberculosis or malignant disease. Percutaneous closed pleural biopsy is easiest to perform, the least expensive, with minimal complications, and should be used routinely. Empyemas need to be treated with appropriate antibiotics and intercostal drainage. Surgery may be needed in selected cases where drainage procedure fails to produce improvement or to restore lung function and for closure of bronchopleural fistula.

Acute myeloid leukemia with leukemic pleural effusion

Acute myeloid leukemia (AML) may be associated with extramedullary tumor growth, which is commonly known as myeloid sarcoma. Although AML with leukemic pleural effusion is considered rare, the true incidence is not clear. We report three cases of AML involving pleural effusion in this study. The cases were encountered in a single institute within two years, suggesting that leukemic effusion is more common than previously reported. Leukemic cells showed evidence of monocytic differentiation in all cases. Two patients presented with advanced AML. Both had concurrent myeloid sarcoma. Both were ineligible for intensive treatment and died soon after diagnosis of myeloid sarcoma. The third patient had pleural effusion upon diagnosis of AML. Remission was achieved and the effusion disappeared after treatment. We conclude leukemic effusion may become more common in an era of improved care and prolonged survival for AML patients. The prognostic impact is unclear and patients should be given standard AML treatment whenever possible.

An update in the management of malignant pleural effusion

Malignant pleural effusion (MPE) usually presents in the disseminated and advanced stage of malignancy. Dyspnea is the debilitating symptom which needs palliation in these patients. Various modalities are available in the management of MPE. Careful consideration of the patient's expected survival and quality of life is needed when deciding the optimum treatment modality in such patients. In this article, different modalities of the palliative management of MPE are discussed with an attempt to derive a treatment algorithm for the management of MPE.

The cytomorphologic spectrum of small-cell carcinoma and large-cell neuroendocrine carcinoma in body cavity effusions: A study of 68 cases

Background:

Small-cell carcinoma (SCC) and large-cell neuroendocrine carcinoma (LCNEC) are uncommon in serous body cavity effusions. The purpose of this study is to examine the cytomorphological spectrum of SCC and LCNEC in body cavity serous fluids.

Materials and Methods:

We have 68 cases from 53 patients who had metastatic SCC or LCNEC diagnoses. All cytology slides and the available clinical data, histological follow-up, and ancillary studies were reviewed.

Results:

A total of 68 cases (60 pleural, 5 peritoneal, and 3 pericardial effusions) from 53 patients with an average age of 73 years (age range 43-92 years) were reported as diagnostic or suspicious of SCC (52 cases) or LCNEC (16 cases). The primary site was lung in 56 cases, pancreas in 6 cases, and 2 cases each from cervix, colon, and the head and neck region. Of the 68 cases, 48 cases had no history of malignancy of the same type. Ancillary studies were used in 46 cases (68%) including flow cytometric studies in 5 cases. There were three predominant cytomorphological patterns observed including small-cell clusters with prominent nuclear molding (33 cases, 49%), large-cell clusters mimicking non-small-cell carcinoma (18 cases, 26%), and single-cell pattern mimicking lymphoma (17 cases, 25%). Significant apoptosis was seen in 22 cases (33%) and marked tumor cell cannibalism was seen in 11 cases (16%). Nucleoli were prominent in 16 cases (24%). The most frequent neuroendocrine markers performed were synaptophysin and chromogranin.

Conclusions:

The most common cytomorphologic patterns seen in body cavity effusions of SCC and LCNEC were small-cell clusters with nuclear molding. However, in 51% of the cases either a predominant single-cell pattern mimicking lymphoma or large-cell clusters mimicking non-small carcinoma were noted. In our experience, effusions were the first manifestation of disease in the majority of patients diagnosed with neuroendocrine carcinoma. Therefore, familiarity with the cytomorphological spectrum of neuroendocrine carcinomas in fluid cytology may help in rapidly establishing an accurate diagnosis and in directing appropriate management.

A review of uncommon cytopathologic diagnoses of pleural effusions from a chest diseases center in Turkey

BACKGROUND

After pneumonia, cancer involving the pleura is the leading cause of exudative pleural effusion. Cytologic examination of pleural effusions is an important initial step in management of malignant effusions. The aim of this study is to evaluate the spectrum of uncommon malignant pleural effusions in a chest disease center in Turkey.

MATERIALS AND METHODS

A retrospective study of samples of pleural effusions submitted to Ataturk Chest Diseases and Chest Surgery Education and Research Hospital Department of Pathology between March 2005 and November 2008 was performed.

RESULTS

Out of a total of 4684 samples reviewed 364 (7.8%) were positive for cancer cells. Of the malignant pleural effusions 295 (81%) were classified as adenocarcinoma or carcinoma not otherwise specified (NOS). Pleural effusion specimens revealing a diagnosis other than adenocarcinoma/carcinoma NOS were: 32 (8.8%) malignant mesotheliomas, 14 (3.8%) small cell carcinomas, 13 (3.5%) hematolymphoid malignancies and 10 (2.7%) squamous cell carcinoma. Hematolymphoid malignancies included non- Hodgkin lymphoma (diffuse B large cell lymphoma, mantle cell lymphoma), multiple myeloma, chronic myeloid leukemia, and acute myeloid leukemia.

CONCLUSIONS

Despite that adenocarcinoma is the most common cause of malignant pleural effusions, there is a significant number of hematological and non-hematological uncommon causes of such effusions. Cytopathologists and clinicians must keep in mind these uncommon entities in routine practice for an accurate diagnosis.

Acute myeloid leukemia with myelodysplasia-related changes with erythroid differentiation involving pleural fluid: a case report and brief cytopathologic review

The vast majority of malignant pleural effusions are caused by metastatic adenocarcinoma, most frequently from breast or lung primaries. However, a minority of cases show evidence of involvement by a hematopoietic neoplasm such as lymphoma or leukemia. We report a rare case of a 54-year-old male with a prior diagnosis of acute myeloid leukemia with myelodysplastic-related changes (AML-MDS) with erythroid differentiation having new onset pleural effusions containing leukemic blasts. The pleural specimen was comprised of blast forms having large round nuclei with finely dispersed chromatin and prominent nucleoli, with scattered binucleate forms. The blasts expressed CD45 and CD34 and were negative for epithelial and mesothelial markers. Previous bone marrow biopsies had shown that the blasts exhibited strong staining for hemoglobin and lacked expression of Factor VIII and myeloperoxidase, consistent with erythroid differentiation. Although rare, this case indicates the need for consideration of unusual disease states presenting within a pleural fluid and highlights the differential diagnosis and immunohistochemical profile of AMLs with erythroid differentiation.

Diagnosis and management of malignant pleural effusions

Malignant pleural effusions (MPEs) complicate the clinical course of patients with a broad array of malignancies, which are most often due to lymphomas or carcinomas of the breast, lung, gastrointestinal tract or ovaries. Patients may present with a MPE as the initial manifestation of a cancer or develop an effusion during the advanced phases of a known malignancy. In either circumstance, the median survival after presentation with a MPE is 4 months. Effusions may result from direct pleural invasion (MPE) or indirect effects (paraneoplastic effusions), such as impairment of fluid efflux from the pleural space by lymphatic obstruction or pleural effects of cancer radiation or drug therapy. Because only 50% of patients with cancer who develop a pleural effusion during their clinical course have a MPE, careful evaluation of the effusion to establish its aetiology is required to direct therapy. Management is palliative with interventions directed towards decreasing the volume of intrapleural fluid and the severity of associated symptoms.

Recent advances in the diagnosis and management of malignant pleural effusions

Malignant pleural effusions (MPEs) are an important complication for patients with intrathoracic and extrathoracic malignancies. Median survival after diagnosis of an MPE is 4 months. Patients can present with an MPE as a complication of far-advanced cancer or as the initial manifestation of an underlying malignancy. Common cancer types causing MPEs include lymphomas, mesotheliomas, and carcinomas of the breast, lung, gastrointestinal tract, and ovaries. However, almost all tumor types have been reported to cause MPEs. New imaging modalities assist the evaluation of patients with a suspected MPE; however, positive cytologic or tissue confirmation of malignant cells is necessary to establish a diagnosis. Even in the presence of known malignancy, up to 50% of pleural effusions are benign, underscoring the importance of a firm diagnosis to guide therapy. Rapidly evolving interventional and histopathologic techniques have improved the diagnostic yield of standard cytology and biopsy. Management of an MPE remains palliative; it is critical that the appropriate management approach is chosen on the basis of available expertise and the patient's clinical status. This review summarizes the pathogenesis, diagnosis, and management of MPE. Studies in the English language were identified by searching the MEDLINE database (1980-2007) using the search terms pleura, pleural, malignant, pleurodesis, and thoracoscopy.