The role of closed pleural needle biopsy in the diagnosis of malignant mesothelioma of the pleura

Cytological Diagnostic Procedures in Malignant Mesothelioma

Malignant mesotheliomas (MM) are rare tumors with high mortality rates, whose incidence varies regionally and nationally, and the diagnosis is difficult. Histology-based diagnosis is considered the gold standard despite its low sensitivity of 57-84%. However, recent advances in cytological analysis offer promise for diagnostic advancements. In this study, we reappraised the current cytological guidelines for the MM diagnosis and concluded on their practicability and reliability. The study included 5731 consecutive specimens of pleural effusions from 4552 patients (3026 males of the average age of 67.5 years and 1526 females of the average age of 65.4 years) between December 2017 and January 2000. Out of these patients, 444 (9.8%) were diagnosed with MM. The effusions were examined by immunocytochemistry using routine Giemsa staining. Additionally, hyaluronic acid (HA) was assessed. Cytological findings confirmed 223 out of the 444 MM. The additional 88 cases with negative cytology were corroborated by supplemental assessments of HA above 30 mg/L. Cytological evaluation accomplished the sensitivity of 0.50, specificity of 0.99, and a positive predictive value (PPV) of 0.97 for MM diagnosis. The use of HA determination raised the sensitivity to 0.70 without affecting the specificity or PPV. We conclude that cytological evaluation of effusions aided by the assessment of HA demonstrates the diagnostic sensitivity and specificity for MM no less than the hitherto standard histological evaluation. The cytology-based MM diagnosis may thus be routinely considered when MM is suspected and may offer confirmatory advantages in difficult or doubtful diagnostic cases.

Diagnostic value of biopsy sampling in predicting histology in patients with diffuse malignant pleural mesothelioma

BACKGROUND

The classification of diffuse malignant mesothelioma into epithelioid, biphasic, and sarcomatoid types is based on histologic patterns. The diagnosis is made on biopsies, and because of intratumoral heterogeneity, they may not be representative of the entire tumor. The number and volume of biopsies needed to reach diagnostic accuracy in diffuse malignant mesothelioma and their prognostic value remain unclear.

METHODS

This study examined 759 consecutive patients with pleural diffuse malignant mesothelioma treated by pleurectomy/decortication or extrapleural pneumonectomy for the presence of epithelioid and/or sarcomatoid histology and classified both the presurgery biopsies (core-needle or thoracoscopic) and surgical resection specimens. The number and volume of biopsies were correlated with pre- and postsurgery histologies and overall survival.

RESULTS

Diffuse malignant mesothelioma was classified as epithelioid (76%), biphasic (18%), sarcomatoid (5%), or indeterminate (1%) in biopsies and as epithelioid (64%), biphasic (32%), and sarcomatoid (4%) in surgical resection specimens (overall concordance, 80.6%). The positive likelihood ratios were 2.4, 13.6, and 90.1 for biopsies with epithelioid, biphasic, and sarcomatoid histologies, respectively. Concordant histologies between biopsies and resections were associated with a higher number of biopsies (median tissue blocks for concordant histologies vs discordant histologies, 3 vs 2; P < .002) but were less associated with a higher volume (median, 1.2 vs 1.1 cm³ ; P = .06). In a multivariate analysis, overall survival was independently predicted by histology in the resection specimen (P < .0001) but not in the biopsy (P = .09).

CONCLUSIONS

In contrast to epithelioid histology, sarcomatoid histology in biopsies is highly accurate. Despite intratumoral heterogeneity, the accuracy of histologic classification increases with the number of tissue blocks examined, emphasizing the diagnostic value of extensive sampling by presurgery biopsies.

Diagnostic role of interleukin -33 in the differentiation of pleural effusions especially tuberculous and malignant effusions

BACKGROUND

Tuberculous pleurisy and malignancy are two of the most common causes of pleural effusion. IL-33 is expressed in the epithelial lining and endothelial cells and is released after cell damage; it is proposed to have an essential role in sensing damage in various infectious and inflammatory diseases. This work aimed to determine the diagnostic role of IL-33 in pleural effusions.

METHODS

One hundred seventeen patients with pleural effusions of different etiologies had a quantitative measurement of IL-33 in their pleural effusion and serum samples by ELISA technique.

RESULTS

The concentrations of IL-33 (mean ± SD) in tuberculous pleural effusion (TPE) group (22.5 ± 0.90 ng/l) were significantly higher than that of malignant pleural effusion (MPE) group (14.6 ± 2.35 ng/l; P <  0.001). There is no significant difference between the serum levels of IL-33 in (TPE) group and (MPE) group (P >  0.05). The concentrations of IL-33 in the pleural effusions were significantly correlated to that of the serum concentrations in each group (TPE: r = 0.848, P = < 0.001; MPE: r = 0.881, < 0.001) and pleural ADA in patients with tuberculous pleural effusions, (r = 0.38, P <  0.001). The cut-off value of pleural IL33 for (TPE) was 19.16 ng/l, with a sensitivity of 91.7%, a specificity of 96.4%. The cutoff point of a pleural/ serum IL-33 ratio for the diagnosis of TPE was > 1.4 with a sensitivity of 91.7% and specificity of 100% while for the determination of (MPE) was < 0.9 with a sensitivity of 83.3% and specificity of 96.4%.

CONCLUSION

IL-33 level may serve as a novel biomarker to differentiate pleural effusions, especially tuberculous from malignant effusions.

Novel systemic therapy against malignant pleural mesothelioma

Malignant pleural mesothelioma is an aggressive tumor of the pleura with an overall poor prognosis. Even with surgical resection, for which only a subset of patients are eligible, long term disease free survival is rare. Standard first-line systemic treatment consists of a platinum analog, an anti-metabolite, and sometimes anti-angiogenic therapy, but there is currently no well-established standard therapy for refractory or relapsed disease. This review focuses on efforts to develop improved systemic therapy for the treatment of malignant pleural mesothelioma (MPM) including cytotoxic systemic therapy, a variety of tyrosine kinase inhibitors and their downstream effector pathways, pharmacologic targeting of the epigenome, novel approaches to target proteins expressed on mesothelioma cells (such as mesothelin), arginine depletion therapy, and the emerging role of immunotherapy. Overall, these studies demonstrate the challenges of improving systemic therapy for MPM and highlight the need to develop therapeutic strategies to control this disease.

Modern management of malignant pleural mesothelioma

Malignant pleural mesothelioma (MPM) is a deadly disease that produces a significant worldwide health care burden. The majority of cases are associated with prior asbestos exposure, but recent studies have identified a possible genetic predisposition in a minority of patients. Historically, obtaining a pathologic diagnosis of MPM was challenging, but with current pathological techniques, a secure diagnosis is possible in the majority of patients. Curative therapy for MPM remains elusive, and the primary treatment option for fit patients is platinum-based chemotherapy. Encouraging recent reports suggest that there may be a benefit to the addition of bevacizumab to standard chemotherapy as well as with the use of immune checkpoint inhibitors in MPM. Selected patients may be considered for aggressive surgical approaches, but there is considerable controversy regarding the true benefit of surgery and multimodality therapy in this disease.

Role of blind closed pleural biopsy in the managment of pleural exudates

INTRODUCTION

The performance of blind closed pleural biopsy (BCPB) in the study of pleural exudates is controversial.

OBJECTIVE

To assess the diagnostic yield of BCPB in clinical practice and its role in the study of pleural exudates.

METHODS

Data were retrospectively collected on all patients who underwent BCPB performed between January 1999 and December 2011.

RESULTS

A total of 658 BCPBs were performed on 575 patients. Pleural tissue was obtained in 590 (89.7%) of the biopsies. A malignant pleural effusion was found in 35% of patients. The cytology and the BCPB were positive in 69.2% and 59.2% of the patients, respectively. Of the patients with negative cytology, 21 had a positive BCPB (diagnostic improvement, 15%), which would have avoided one pleuroscopy for every seven BCPBs that were performed. Of the 113 patients with a tuberculous effusion, granulomas were observed in 87 and the Lowenstein culture was positive in an additional 17 (sensitivity 92%). The overall sensitivity was 33.9%, with a specificity and positive predictive value of 100%, and a negative predictive value of 71%. Complications were recorded in 14.4% of patients (pneumothorax 9.4%; chest pain 5.6%; vasovagal reaction, 4.1%; biopsy of another organ 0.5%).

CONCLUSIONS

BCPB still has a significant role in the study of a pleural exudate. If an image-guided technique is unavailable, it seems reasonable to perform BCPB before resorting to a pleuroscopy. These results support BCPB as a relatively safe technique.

Clinical characteristics, treatment and survival outcomes in malignant mesothelioma: eighteen years' experience in Turkey

BACKGROUND

Malignant mesothelioma (MM) is an insidious tumor with poor prognosis, arising from mesothelial surfaces such as pleura, peritoneum and pericardium. We here aimed to evaluate the demographic, clinical, and radiological features of patients with MM followed in our center as well as their survival.

METHODS

The study included 228 patients (131 male, 97 female) who were followed up in our institution between 1993 and 2010 with the diagnosis of MM.

RESULTS

The mean age was 59.1 years in men and 58.7 years in women and the sex ratio was 1.4:1 in favor of males. Environmental asbestos exposure was present in 86% of the patients for a mean duration of 40±20 years (range: 3-70). Pleural effusion and thoracic/abdominal pain were the most common presenting signs and symptoms (70.2% and 57.8%, respectively). One hundred-thirteen (66%) patients were treated with platinum-based combination chemotherapy (PBCT) plus supportive care (SC) and 67 (34%) patients received SC alone. The median follow-up time was 10.0 months. The median overall survival was significantly improved with PBCT plus SC compared to SC alone (11.4 vs. 5.1 months; p=0.005). The 6, 12, 18, and 24-month survival rates were significantly improved with PBCT plus SC compared to SC alone (72%, 43%, 19%, and 2% vs. 49%, 31%, 11%, and 1%).

CONCLUSION

The survival of patients with MM improved in patients treated with PBCT. The survival advantage continued 12- and 24-month after the initial time of combination chemotherapy.

Thoracic computed tomography findings in malignant mesothelioma

Background

Malignant pleural mesothelioma (MPM) is an uncommon neoplasm. MPM occurs more frequently in patients born or living in certain villages of Turkey.

Objectives

We aimed to review radiological findings of MPM.

Patients and Methods

We reviewed the CT findings in 219 biopsy-proven MPM patients admitted to our clinic between 1993 and 2008.

Results

The most common CT findings included pleural thickening (n=197, 90%) classified as diffuse (n=138, 63%), nodular (n=49, 22%) and mass-type (n=16, 7%). Pleural effusion was found in 173 patients (79%), involvement of the interlobar fissures in 159 (73%), mediastinal pleural involvement in 170 (78%), volume contraction in 142 (65%), mediastinal shift in 102 (47%) and mediastinal lymphadenopathy in 54 (25%).

Conclusion

MPM may present with diverse radiological features. Pleural thickening and pleural effusion were the most frequent radiological findings. Thoracic CT scans might be assessed more cautiously in patients with environmental exposure to asbestos.

Biopsy techniques for the diagnosis of mesothelioma

The incidence of mesothelioma continues to increase in the Western world and is likely to do so until 2011-2015. It commonly presents with breathlessness secondary to a pleural effusion, and whilst guidelines still advise thoracocentesis as the first line investigation, the sensitivity of this is low and a tissue diagnosis is usually required. Abrams needle biopsy also has a low diagnostic yield and high complication rate and is not recommended in guidelines on the investigation of mesothelioma. Computed tomography-guided biopsy or thoracoscopy both have a comparable sensitivity and low complication rates. Local anaesthetic thoracoscopy is increasingly used by respiratory physicians and has a comparable diagnostic sensitivity to Video-Assisted Thoracoscopic Surgery (VATS) without the need for a general anaesthetic. The requirement for prophylactic radiotherapy after pleural procedures in cases of mesothelioma is contentious, as the results from early trials suggesting it reduces tract seeding have been disputed by more recent trials.

The comparative accuracy of different pleural biopsy techniques in the diagnosis of malignant mesothelioma

AIMS

To evaluate the diagnostic accuracy of closed and open pleural biopsies in diagnosing malignant pleural mesothelioma.

METHODS AND RESULTS

The autopsy study group comprised 45 malignant mesotheliomas. All prior pleural biopsy investigations were reviewed. Forty-one of 45 (91%) had had an antemortem diagnosis of malignant mesothelioma. In these 41 cases, 57 prior diagnostic pleural biopsies had been performed [36 closed needle biopsies: 31 blind; five computed tomography (CT)-guided and 21 open pleural biopsies]. For definitive diagnosis open pleural biopsy yielded a sensitivity of 95% and specificity of 100%. For definitive diagnosis closed blind pleural biopsies yielded a sensitivity of 16% and specificity of 94%. Thirty-two per cent of 'blind' biopsies were inadequate. CT-guided pleural biopsies yielded a definitive diagnostic accuracy of 100% (5/5). Biopsy specimen size was important in obtaining a positive definitive diagnosis. Diagnosis was attained in 75% of specimens >10 mm in size compared with 8% <10 mm in size.

CONCLUSIONS

Overall, all procedures had utility but definitive diagnostic accuracy for 'blind' closed pleural biopsy was low (16%), dependent on biopsy specimen size and tumour subtype. Sarcomatoid subtype malignant mesothelioma yielded the lowest diagnostic accuracy. For all subtypes of malignant mesothelioma, open pleural biopsy produced the highest diagnostic accuracy (100% sensitivity, 95% specificity).

The Role of Abrams Percutaneous Pleural Biopsy in the Investigation of Exudative Pleural Effusions

INTRODUCTION

Blind percutaneous pleural biopsy has traditionally been performed to investigate the etiology of exudative pleural effusion in which the initial thoracentesis has been nondiagnostic. In view of the increasing use of image-guided and thoracoscopic pleural biopsies, this study examines the role of blind Abrams pleural biopsy in the investigation of pleural effusion in a large urban hospital.

METHOD

Patients undergoing blind Abrams needle biopsy between January 1997 and 2003 were identified from the hospital pathology database. The case notes and pathology records of these patients were analyzed retrospectively. All patients had presented to respiratory teams with an exudative pleural effusion and had initial nondiagnostic thoracentesis.

RESULTS

Seventy-five patients undergoing blind biopsy were identified. Pleural tissue was obtained in 59 biopsies (79%), with no statistically significant difference in pleural yield between respiratory specialist registrars (equivalent to pulmonary fellows in training) and senior house officers/preregistration house officers (equivalent to junior residents and interns, respectively) performing the biopsy (chi(2) test, p = 0.43). When up to three samples were obtained per episode, sufficient pleural tissue was obtained in 18 of 25 patients (72%) compared to 80% (32 of 40 patients) in whom four to six samples were taken (chi(2) test, p = 0.55 [not significant]). For all diagnoses, blind biopsy had a sensitivity of 38%, which rose to 43% when reviewing patients in whom sufficient pleural tissue was obtained (for malignant diagnosis alone, sensitivity values were 43% and 51%, respectively; specificity, 100%; negative and positive predictive values, 51%). No fatalities were reported, and pneumothorax was seen in eight patients (11%), with only two patients requiring specific intervention.

CONCLUSIONS

Blind Abrams needle biopsy obtaining pleural tissue was diagnostic in approximately 50% of patients presenting with malignant effusion in the sample, and can be performed safely by all grades of medical staff with due attention to technique and supervision. The data support the continued use of the Abrams needle in the investigation of malignant pleural disease.

Multimodality treatment of diffuse malignant pleural mesothelioma

Diffuse malignant pleural mesothelioma (DMPM) is a challenging disease in all of its aspects, from presentation and diagnosis to staging and treatment. Single-modality therapy was the initial approach to this disease. It generally has not been effective in changing the natural history of DMPM. As a result, multimodality regimens involving surgery with radiation, chemotherapy, or immunotherapy delivered regionally or systemically have been evaluated. Randomized controlled studies comparing various strategies are lacking and, thus, the debate continues regarding the effectiveness of different treatment approaches.

The role of imaging in malignant pleural mesothelioma

Imaging plays an essential role in the diagnosis, staging, and follow-up of patients with malignant pleural mesothelioma (MPM). The diagnosis is often suggested by a unilateral pleural mass with a moderate to large pleural effusion seen on chest radiographs, but computerized tomography (CT) is the most frequently used technique for evaluation of the lungs in patients with MPM. CT not only suggests pulmonary metastases typically manifested as nodules or masses, but also can demonstrate underlying lung disease often caused by prior asbestos exposure. Magnetic resonance (MR) imaging may be helpful in selected patients with potentially resectable disease to further examine the local extent of tumor. Imaging with positron emission tomography (PET) using the radionuclide imaging agent (18)F fluoro-deoxyglucose (FDG) takes advantage of a basic property of tumor cells, increased glucose metabolism to identify malignant lesions. PET provides not only anatomic information, especially regarding mediastinal node metastasis, but also biochemical information about the lesion. These imaging modalities help triage patients to the most appropriate diagnostic and treatment options. Following patients after therapy usually relies on chest radiographs, although CT can more accurately describe response to therapy. This review will focus on radiologic evaluation in diagnosing, staging, and follow-up patients with MPM.

Computed tomography features in malignant pleural mesothelioma and other commonly seen pleural diseases

OBJECTIVE

To investigate the computed tomography (CT) features of malignant pleural mesothelioma (MPM) cases, comparing them to those in other malignant and benign pleural diseases.

MATERIALS AND METHODS

We reviewed the CT findings of 215 patients; 99 with MPM, 39 with metastatic pleural disease (MPD), and 77 with benign pleural disease. The findings were evaluated in univariate and multivariate analysis for differentiation of pleural diseases.

RESULTS

In patients with MPM, the most common CT features were circumferential lung encasement by multiple nodules (28%); pleural thickening with irregular pleuropulmonary margins (26%); and pleural thickening with superimposed nodules (20%). In the majority (70%) of cases, there was rind-like extension of tumor on the pleural surfaces. In multivariate analysis, the CT findings of "rind-like pleural involvement", "mediastinal pleural involvement", and "pleural thickness more than 1 cm" were independent findings in differentiating MPM from MPD with the sensitivity/specificity values of 70/85, 85/67, and 59/82, respectively. "Rind-like pleural involvement", "mediastinal pleural involvement", "pleural nodularity" and "pleural thickness more than 1 cm" were independent findings for differentiation of malignant pleural diseases (MPM+MPD) from benign pleural disease with the sensitivity/specificity values of 54/95, 70/83, 38/96, and 47/64, respectively. Invasion of thoracic structures such as pericardium, chest wall, diaphragm, mediastinum, with pleural disease and nodular involvement of fissures, was detected infrequently; however, since these invasions were not seen in benign pleural diseases, it was concluded these invasions, if detected on a CT scan, directly suggested malignancy.

CONCLUSION

A patient has extremely high probability of malignant pleural disease if one or more of these CT findings are found and the possibility of MPM is high. These findings may be important for patients in bad state or patients who do not want any invasive biopsy procedures. It is also possible to identify cases with a low probability of malignant disease.

Determining the optimal number of specimens to obtain with needle biopsy of the pleura

The aim of this study was to define the number of pleural biopsy samples necessary for optimum diagnostic performance and determine to what extent they are complementary. Eighty-four closed pleural biopsies were performed in our department between June 1996 and January 1998 on 55 males and 29 females with an average age of 64.4 +/- 16.7 years. The study of the pleural fluid included: pH, biochemical testing of pleura/serum (proteins, lactate dehydrogenase, glucose, cholesterol, triglycerides, albumin and adenosine deaminase), haemogram, cytology and microbiological testing (Gram-staining, aerobes, anaerobes and mycobacteriae cultures). The biopsies were performed using a Cope needle, with a total of five biopsies for each patient: four for pathological examination (taken numerically in the order in which they were performed: D1, D2, D3 and D4) and one for microbiological testing. In those cases in which the diagnosis was uncertain or effusion persisted, a thoracoscopy or thoracotomy was performed. There were no significant differences in the diagnostic yield of each individual sample (D1, D2, D3 and D4), but there were differences in the sum of the samples, depending on the number of biopsies performed.This was true for total group and the group with carcinomas, but not for the group with tuberculosis. The increase in diagnostic yield with the number of biopsies was more remarkable in the carcinoma cases, where it increased by 35% when four biopsies were performed (54% with one biopsy versus 89% with four biopsies, P < 0.002). In conclusion, the diagnostic yield increased with the number of biopsy samples in the total group and the group with malignancy but not in the group with tuberculous effusions. The best diagnostic performance for malignant pathology was obtained with four samples. In pleural tuberculosis, the diagnostic yield did not increase with more biopsy samples. One high quality sample should be enough to obtain a diagnosis.

Basal lamina reduplication in malignant epithelioid pleural mesothelioma

Malignant mesothelioma of the pleura is divided in three morphological variants: epithelioid, sarcomatous, and biphasic. Histological similarities between epithelioid malignant mesothelioma (EMM) and lung adenocarcinoma are responsible for the difficult differential diagnosis. Monoclonal antibodies are useful for distinguishing the two neoplasms through immunohistochemical phenotyping, although many cases require ultrastructural characterization for definitive diagnosis. In this study, transmission electron microscopic observations of EMM were compared with those of peripheral adenocarcinoma of the lung (PAL). More specifically, the morphology of the basal lamina is described in 23 cases of EMM and 12 cases of PAL. Reduplication of the basal lamina (RBL) was found in 11 cases (48%) of EMM and in none of the PAL cases. The same cases were immunostained for type IV collagen and the localization of this basement membrane component corresponded to the areas where basal lamina was observed. Since RBL has been associated with neoplastic differentiation in other tumors, this novel feature in EMM needs to be evaluated in future prognostic studies in malignant mesothelioma of the pleura. Moreover, RBL expression in EMM may be an additional ultrastructural parameter used in the differential diagnosis between EMM and adenocarcinoma.

Mechanisms of carcinogenesis and clinical features of asbestos-associated cancers

Exposure to asbestos, particularly members of the amphibole subgroup (crocidolite, amosite), is associated with the development of malignant mesothelioma and lung cancer. Although management of asbestos in buildings and increased regulation of asbestos in workplace settings are viable approaches to the prevention of disease, the prognosis of asbestos-associated tumors is generally dismal. Moreover, although a vast amount of information is available on the responses of cells and tissues to fibers, understanding the pathogenesis of asbestos-associated malignancies is hampered by the complexity of and differences between various fiber types. Multiple interactions between components of cigarette smoke and asbestos may be important in the development of lung cancer. In this article, the general properties of asbestos fibers will be discussed with an emphasis on chemical and physical features implicated in tumorigenesis. We will then provide a brief overview of the clinical features and treatment of cancers associated with exposure to asbestos. Finally, we will review recent experimental data providing some insight into the cellular and molecular mechanisms of carcinogenesis by asbestos.