Pleural Effusion in Adults-Etiology, Diagnosis, and Treatment

Pleural effusion as a sample matrix for laboratory analyses in cancer management: a perspective

Malignant effusions, pleural effusion or ascites, represent a common problem in cancer patients. Pleural effusion in a cancer patient may be caused also by non-neoplastic conditions, and the diagnosis of malignant pleural effusion is established by the demonstration of tumor cells in pleural fluid. Microscopical detection of tumor cells in pleural fluid often fails, and there is an unmet medical need for more sensitive methods. New approaches, including isolation using magnetic beads coated with monoclonal antibodies targeting antigens expressed on tumor cells not only increase the diagnostic sensitivity, but also provide material for the analysis of predictive biomarkers. The advent of new technologies illustrates the incremental role of laboratory medicine in the management of patients with malignant effusions.

Tumor specific protein 70 targeted tumor cell isolation technology can improve the accuracy of cytopathological examination

OBJECTIVES

Although existing cytopathological examination is considered essential for the diagnosis of malignant serous effusions, its accuracy is pretty low. Tumor specific protein 70 (SP70), which is highly expressed on human tumor cell membrane, was identified in our previous study. This study aimed to explore whether SP70 targeted tumor cell isolation technology with immunomagnetic beads can improve the accuracy of cytopathological examination.

METHODS

Cytopathological analysis with SP70 targeted tumor cell isolation technology was used in this study. In total, 255 cases were enrolled. Serous effusions were analyzed by both existing cytopathological examination and the new cytopathological analysis concurrently.

RESULTS

The sensitivities of existing cytopathological examination and the new cytopathological analysis were 51.26 % and 85.43 %, respectively, while the specificities were 100 % for both. This new cytopathological analysis demonstrated a higher interobserver agreement with malignant diagnosis than the existing cytopathological examination (kappa coefficient: 0.720 vs. 0.316, p<0.001). In addition, it achieved superior diagnostic efficacy for malignancy differentiation compared to existing cytopathological examination (AUC: 0.927 vs. 0.756, p<0.001). The follow-up results showed that 74 malignant cases with final clinical diagnosis were positive only with the new cytopathological analysis. Among these cases, there were 58 negative and 16 atypical by the existing cytopathological examination. In these malignant cases, 74.3 % (55/74) had been confirmed to have serosa metastasis based on radiographic evidence, and 73.7 % (28/38) harbored tumor hotspot mutations.

CONCLUSIONS

As illustrated in this work, cytopathological analysis with SP70 targeted tumor cell isolation technology can improve the accuracy of existing cytopathological examination prominently.

Machine learning-based Diagnostic model for determining the etiology of pleural effusion using Age, ADA and LDH

BACKGROUND

Classification of the etiologies of pleural effusion is a critical challenge in clinical practice. Traditional diagnostic methods rely on a simple cut-off method based on the laboratory tests. However, machine learning (ML) offers a novel approach based on artificial intelligence to improving diagnostic accuracy and capture the non-linear relationships.

METHOD

A retrospective study was conducted using data from patients diagnosed with pleural effusion. The dataset was divided into training and test set with a ratio of 7:3 with 6 machine learning algorithms implemented to diagnosis pleural effusion. Model performances were assessed by accuracy, precision, recall, F1 scores and area under the receiver operating characteristic curve (AUC). Feature importance and average prediction of age, Adenosine (ADA) and Lactate dehydrogenase (LDH) was analyzed. Decision tree was visualized.

RESULTS

A total of 742 patients were included (training cohort: 522, test cohort: 220), 397 (53.3%) diagnosed with malignant pleural effusion (MPE) and 253 (34.1%) with tuberculous pleural effusion (TPE) in the cohort. All of the 6 models performed well in the diagnosis of MPE, TPE and transudates. Extreme Gradient Boosting and Random Forest performed better in the diagnosis of the MPE, with F1 scores above 0.890, while K-Nearest Neighbors and Tabular Transformer performed better in the diagnosis of the TPE, with F1 scores above 0.870. ADA was identified as the most important feature. The ROC of machine learning model outperformed those of conventional diagnostic thresholds.

CONCLUSIONS

This study demonstrates that ML models using age, ADA, and LDH can effectively classify the etiologies of pleural effusion, suggesting that ML-based approaches may enhance diagnostic decision-making.

Impact of preoperative pleural effusion on ultrasound- and pressure-guided thoracic paravertebral block: a prospective observational study

OBJECTIVE

To evaluate the impact of preoperative pleural effusion on the ultrasound visualization of the paravertebral space (PVS), thoracic paravertebral nerve block administered by anesthesiologists, and to investigate whether ultrasound combined with pressure guidance can assist in locating the paravertebral space in patients with pleural effusion.

METHODS

This prospective observational study enrolled patients undergoing thoracic surgery at Beijing Jishuitan Hospital between September 2021 and September 2022. Patients were categorized into two groups based on preoperative CT findings: the pleural effusion group (n = 40) and the non-pleural effusion group (n = 40). Prior to the induction of general anesthesia, all patients were placed in a lateral position. Thoracic paravertebral nerve block (TPVB) was administered using ultrasound guidance combined with pressure monitoring, with a 20 ml of 0.5% ropivacaine.

RESULTS

Parameters recorded included the duration of puncture and ultrasound pre-scan for TPVB, the ultrasound image definition score of the PVS, the pressure in the external intercostal muscle and PVS, and additional relevant indicators. Mean arterial pressure (MAP) and heart rate (HR) were measured before anesthesia induction, post-induction, and during skin incision. Compared to the non-pleural effusion group, the pleural effusion group demonstrated prolonged ultrasound pre-scan and puncture durations. The PVS definition score, the ventral displacement of the pleura, and the accuracy of resident anesthesiologists in identifying the PVS were all significantly lower in the pleural effusion group (p < 0.05). Compared to non-pleural effusion group, the pleural effusion group had significantly higher pressure in PVS. In the pleural effusion group, the pressure in PVS was significantly lower than that in external intercostal muscle (p < 0.05). No significant differences were observed in MAP and HR between the two groups before anesthesia induction, post-induction and during skin incision (p > 0.05).

CONCLUSION

Preoperative pleural effusion is associated with reduced clarity of ultrasound visualization of the PVS, and extended procedural durations for anesthesiologists, thereby increasing the complexity of TPVB. Pressure detection during TPVB implementation can assist in locating the position of the puncture needle. For anesthesiologists with less experience, TPVB should be carefully performed in patients with preoperative pleural effusion.

TRIAL REGISTRATION

The trial was prospectively registered with the Chinese Clinical Trial Registry under registration number ChiCTR2100050582, on August 30, 2021.

Evaluation of cytomorphological examination in the diagnosis of pleural effusion

Cytological examination serves as a crucial diagnostic tool for pleural effusion, with its diagnostic efficacy influenced by variations in specimen processing and staining techniques. Cellular morphological analysis of pleural effusions was performed using Wright-Giemsa staining to assess its diagnostic accuracy and clinical utility in differentiating the various etiologies of exudative pleural effusion. A routine examination was conducted on 2305 cases of unexplained pleural effusion, followed by cellular classification and morphological analysis in 1376 cases identified as exudative effusion. Among the 479 patients with malignant tumors, cytomorphological examination identified malignant cells in 295 patients, resulting in a clinical diagnosis coincidence rate of 98.6%. Abnormal cells, including malignant and heterogeneous nuclear cells, were observed in 364 cases, yielding a detection rate of 76.0%. The proportion of positive malignant cells in the newly diagnosed patient group was significantly higher than that in the previously diagnosed group (P < 0.01). Cytological analysis revealed the presence of bacteria, fungi, and phagocytes in 51 out of 1376 cases. The positivity rate for multiple bacterial infections detected through cytology was significantly greater than that identified by culture (P < 0.01). Additionally, various special morphologies and pathogens, which are rare in clinical practice, were detected, including mixed metastasis of small cell lung carcinoma and adenocarcinoma cells, as well as concurrent infections with Talaromyces marneffei and Pneumocystis jirovecii. This method enables the rapid and comprehensive differentiation between malignant tumors, tuberculosis, pneumonia, and rare exudative pleural effusions resulting from specific clinical conditions.

Utilizing thoracic ultrasonography in determining the characteristics of pleural fluid: Development of a novel sonographic scoring system

BACKGROUND

To evaluate the utility of thoracic ultrasound imaging (USI) in assessing the nature of pleural fluid (PF) using a scoring system.

METHODS

The files of patients who underwent thoracic USI and thoracentesis due to PF accumulation were retrospectively examined. PF sonographic patterns and pleural thicknesses were retrieved from the USI records. Based on the Light's criteria, PFs were classified into transudative PF (TPF) and exudative PF (EPF). A scoring system was established based on the sonographic patterns and pleural thickness. Sonographic scores and other clinical, radiological, and demographic characteristics of the two groups were comparatively analyzed.

RESULTS

Among the 64 cases analyzed, 32 (50%) were categorized as TPF. The average pleural thickness in the TPF group was 1.4 mm. The hypoechoic sonographic pattern rate in the TPF group (75%) was significantly different from that in the EPF group (p < 0.001). A hypoechoic sonographic pattern (p = 0.002) and pleural thickness >1.5 mm (p = 0.031) were independent predictors of EPF. The scoring system demonstrated a sensitivity of 84.38% and a specificity of 75.00% for predicting EPF when the sonographic score was ≥3.

CONCLUSION

Thoracic USI can serve as a noninvasive method to predict the nature of PFs by combining sonographic patterns and pleural thickness.

Diagnostic value of metagenomic next-generation sequencing combined by medical thoracoscopy surgery among infectious pleural effusion patients

BACKGROUND

Metagenomic next-generation sequencing (mNGS) is a novel method for identifying pathogens in infectious diseases. This study aimed to explored the application value of mNGS in diagnosing pulmonary infections with pleural effusion, confirmed by medical thoracoscopy.

METHODS

We retrospectively reviewed 25 patients with pulmonary infections and pleural effusion between July 2020 and December 2021. All patients had their diagnosis confirmed by medical thoracoscopy to obtain tissue samples for both traditional testing and mNGS. Samples included pleural effusion, successive sputum, and tissue obtained through medical thoracoscopy. We wanted to assess how effective mNGS was in accurately diagnosing these infections.

RESULTS

This study found that the positive predictive value of mNGS (76% (19/25)) was significantly higher than that of traditional testing (32% (8/25)). The most commonly identified pathogens were Mycobacterium tuberculosis (n = 5), followed by Fusobacterium nucleatum (n = 4), Torque teno virus (n = 4), Streptococcus intermedius (n = 3), Peptostreptococcus stomatis (n = 2), Porphyromonas endodontalis (n = 2), and Campylobacter rectus (n = 2). The percentage of mNGS-positive cases was significantly higher than that from traditional testing for bacteria, but the superiority of mNGS for tuberculosis detection was insignificant. Ten cases were identified with mixed infections by mNGS, while no mixed infections were found by traditional testing.

CONCLUSIONS

Our study showed that using mNGS in combination with biopsy samples obtained through medical thoracoscopy resulted in higher positive rates compared to traditional tests and provided more evidence of pathogens for patients with infectious pleural effusion.

Use of indwelling pleural catheter in a patient with refractory left-sided hepatic hydrothorax

A female patient in her mid-50s presented with left-sided effusion in the context of decompensated cirrhosis secondary to alcoholic hepatitis. She had a pre-existing injury to her left hemidiaphragm following a fall 2 years previously, at which point she had also developed a left-sided effusion. The diagnosis of hepatic hydrothorax (HH) was made following pleural fluid aspiration. Recurrent thoracocentesis was not sufficient to manage the effusion and diuretic use was limited by hyponatraemia. An indwelling pleural catheter (IPC) was subsequently inserted to facilitate routine drainage and management in the outpatient setting. To our knowledge, this is the first instance of IPC insertion for HH in Ireland.

Application of the metagenomic next-generation sequencing technology to identify the causes of pleural effusion

Background

Pleural effusion (PE), frequently encountered in clinical practice, can arise from a variety of underlying conditions. Accurate differential diagnosis of PE is crucial, as treatment and prognosis are heavily dependent on the underlying etiology. However, diagnosing the cause of PE remains challenging, relying on mycobacteriological methods that lack sensitivity and are time-consuming, or on histological examinations that require invasive biopsies. The recent advancements in metagenomic next-generation sequencing (mNGS) have shown promising applications in the diagnosis of infectious diseases. Despite this, there is limited research on the utility of mNGS as a comprehensive diagnostic tool for simultaneously identifying the causes of PE, particularly in cases of tuberculosis or malignancy.

Methods

This study aimed to assess the efficacy of mNGS in detecting tuberculous pleural effusion (TPE) and malignant pleural effusion (MPE). A total of 35 patients with PE were included, and their PE samples were analyzed using mNGS.

Results

Among the participants, 8 were ultimately diagnosed with TPE, and 10 were diagnosed with MPE, with lung adenocarcinoma being the most prevalent pathological type (50%, 5/10), according to established diagnostic criteria. Additionally, 7 patients were diagnosed with non-infectious PE. However, mNGS identified only 2 cases of TPE and 8 cases of MPE. The sensitivity of mNGS for detecting Mycobacterium tuberculosis was 25% (2/8), while the specificity was 100%. For tumor detection, mNGS demonstrated a sensitivity of 80%, a specificity of 92.6%, and an AUC of 0.882.

Conclusion

mNGS is effective in distinguishing MPE from non-MPE, but is not suitable for diagnosing TPE.

Use of the Hounsfield unit scale in differentiating transudate and exudate in pleural effusion in the emergency department

Attenuation values in computed tomography (CT) are used as a diagnostic aid in certain clinical conditions. In our study, we investigated the effectiveness of attenuation values, obtained through the noninvasive method of CT, in determining the type of pleural effusions in the emergency department. Patients who presented to the emergency department with a diagnosis of pleural effusion and underwent thoracentesis within 48 hours between January 1, 2023, and January 1, 2024, were included in the study. Exclusion criteria were patients under 18 years of age, those without CT imaging, those presenting due to trauma, those with >48 hours between CT and thoracentesis, patients with chest tubes, a history of thoracic surgery/intervention within the last month, or incomplete data. Attenuation values measured on CT were compared with pleural fluid samples interpreted according to Light criteria. A total of 207 patients were evaluated. The mean age in the exudate group (66.00 ± 15.63) was significantly lower than in the transudate group (72.98 ± 10.38) (P < .001). The prevalence of malignancy was significantly higher in the exudate group (34.0%) compared to the transudate group (4.4%) (P < .001). Heart failure was more common in the transudate group (31.1%) (P = .041). The mean Hounsfield unit (HU) value was 16.64 ± 8.04 in the exudate group and 12.22 ± 7.01 in the transudate group, with a statistically significant difference between the groups (P = .001, 95% confidence interval [CI]: 1.79-7.05). At the cutoff point of 14.2, sensitivity was 62.73%, specificity was 75.00%, and the Youden index reached its highest value at 0.377. The area under the curve was 0.710 (95% CI: 0.626-0.794, P < .001), and the positive predictive value at the 14.2 cutoff point was 90.18%. In conclusion, our study demonstrated that the use of CT attenuation in managing pleural effusions in the emergency department can accurately detect exudative effusions as a noninvasive method. However, HU values should be evaluated alongside clinical parameters, and the varying cutoff values reported in different studies suggest that this method may not be sufficient on its own. In the emergency department setting, the use of the HU scale could improve patient management by avoiding complications associated with invasive procedures like diagnostic thoracentesis.

Nadir Hemoglobin Concentration After Spinal Tumor Surgery: Association With Risk of Composite Adverse Events

STUDY DESIGN

Retrospective case-control study.

OBJECTIVE

To explore the association of early postoperative nadir hemoglobin with risk of a composite outcome of anemia-related and other adverse events.

METHODS

We retrospectively analyzed data from spinal tumor patients who received intraoperative blood transfusion between September 1, 2013 and December 31, 2020. Uni- and multivariate logistic regression was used to explore relationships of clinicodemographic and surgical factors with risk of composite in-hospital adverse events, including death. Subgroup analysis explored the relationship between early postoperative nadir hemoglobin and composite adverse events.

RESULTS

Among the 345 patients, 331 (95.9%) experienced early postoperative anemia and 69 (20%) experienced postoperative composite adverse events. Multivariate logistic regression analysis showed that postoperative nadir Hb (OR = .818, 95% CI: .672-.995, P = .044), ASA ≥3 (OR = 2.007, 95% CI: 1.086-3.707, P = .026), intraoperative RBC infusion volume (OR = 1.133, 95% CI: 1.009-1.272, P = .035), abnormal hypertension (OR = 2.199, 95% CI: 1.085-4.457, P = .029) were correlated with composite adverse events. The lumbar spinal tumor was associated with composite adverse events with a decreased odds compared to thoracic spinal tumors (OR = .444, 95% CI: .226-.876, P = .019). Compared to patients with postoperative nadir hemoglobin ≥11.0 g/dL, those with nadir <9.0 g/dL were at significantly higher risk of postoperative composite adverse events (OR = 2.709, 95% CI: 1.087-6.754, P = .032).

CONCLUSION

Nadir hemoglobin <9.0 g/dL after spinal tumor surgery is associated with greater risk of postoperative composite adverse events in patients who receive intraoperative blood transfusion.

Ultrasound analysis of hemidiaphragm function in case of pleural effusion

Background

Diaphragm dysfunction is frequently observed in patients with pleural effusion. The aim of the study was to determine the criteria for estimating the impact of pleural fluid on diaphragm function and detecting impairment of diaphragmatic muscle.

Methods

This was a retrospective observational study carried out in a university hospital. Cases of free pleural effusion were recruited from the ultrasound consultation of the lung function test laboratory. The quantification of pleural effusion and analysis of diaphragmatic function were performed using chest ultrasound performed while sitting. In case of abnormal diaphragmatic motion, the examination was repeated in supine position.

Results

109 pleural effusions (57 left, 52 right) were included in the analysis. Pleural effusions were detected after thoracic surgery in 89% of cases and in the context of medical disease in other cases. Excursion during deep inspiration was reduced by the amount of fluid (4.3 ± 2.1 cm for small effusions, 3.2 ± 1.7 cm for moderate effusions and 1.1 ± 1.8 cm for large effusions). In 23 cases of large pleural effusion, the excursions during deep inspiration were always below the lower limit of normal. In some cases, a paradoxical motion suggesting hemidiaphragm paralysis was observed. When the inspiratory thickening was normal, the paradoxical excursions disappeared in supine position. In moderate pleural effusion (53 cases), hemidiaphragm excursion was above lower limit of normal in 68% of cases. In cases of paradoxical motions, repeated ultrasound examinations were in favor of hemidiaphragm paralysis. In small pleural effusion (32 cases) the excursion was most often normal.

Conclusion

The ultrasound analysis of diaphragm excursion and thickening in sitting and supine positions is useful to assess the impact of pleural effusion and detect impairment in diaphragm muscle function.

Investigation of the Prevalence of Chronic Pulmonary Effusion Causes and Response to Treatment (Pleurodesis) in Patients

Background

Pleural effusion, the pathological accumulation of fluid in the pleural space, is widespread. This study investigates pleural effusion in terms of malignancy among patients referred to tertiary health care centers and evaluates the response rates to different pleurodesis techniques.

Methods

This cross-sectional study enrolled all patients with pleural effusion referred to a tertiary health care center. Laboratory data, including White Blood Cell count and differentiation (WBC), Hemoglobin levels (HB), Erythrocyte Sedimentation Rate (ESR), and biochemical analysis results of the pleural fluid (protein, glucose, and lactate dehydrogenase) were recorded. Data from pleural fluid cytopathological examination, including cell count, cell types, gram staining, and pleural fluid culture, were also documented. Patients undergoing pleurodesis were assessed for response rates, which were categorized as complete, partial, or no response based on clinical and radiological criteria. Collected data were subjected to statistical analysis.

Results

The study investigated 144 patients with chronic pleural effusion, with an average age of 47.59 years. Of these, 97 patients (66%) were male and 47 patients (34%) were female. The most common cause of chronic pleural effusion was malignancy, with a prevalence of 65.9%. Among patients treated with pleurodesis, the overall response rate was 78.4%, with chemical pleurodesis achieving a higher complete response rate (65%) compared to mechanical pleurodesis (55%). Other prevalent causes of chronic pleural effusion, in descending order, included heart failure, liver cirrhosis, chronic kidney failure, and unknown factors.

Conclusion

This study highlights malignancy and chronic heart failure as the predominant etiologies of chronic pleural effusion in a tertiary healthcare setting. Furthermore, it emphasizes the efficacy of pleurodesis techniques, with chemical pleurodesis demonstrating superior outcomes. These findings offer valuable insights into the pathogenesis and management of chronic pleural effusion.

C. difficile Infection Complicated by a Large Pleural Effusion

Clostridiodes difficile is a gram-positive, spore-forming obligate anaerobe bacillus found in the intestines of healthy individuals without signs of disease. It may cause diarrhea after antibiotic use due to the eradication of the normal gut flora. Most cases resolve with proper treatment, but complications may arise. This case report is about a hospitalized patient who acquired a C. difficile infection after taking ceftriaxone, vancomycin, and linezolid for a cellulitis infection. During his hospitalization, the patient developed dyspnea with decreased breath sounds in the right lower lung lobe. A large pleural effusion in the right lung was observed on imaging, and analysis of the pleural fluid after thoracentesis revealed an exudative pleural effusion likely resulting from the C. difficile infection. The possible physiopathological mechanisms of pleural effusion in the setting of C. difficile infection are discussed.

Novel serous effusion-related risk models and biomarkers for predicting prognosis in T-cell lymphoma patients

T-cell lymphomas (TCLs) are a cluster of lymphoproliferative diseases with high heterogeneity, which lack accurate prognostic models and standard treatment regimen at present. Serous effusion (SE) is a relatively common manifestation and poses more challenges for risk stratification in TCLs. In this study, entire of 518 newly diagnosed TCLs patients were included. SE was found to be tightly correlated to clinical characteristics and prognosis in TCL patients, and SE volume (SEV) > 1000 ml was identified as a potential prognostic factor. Novel AEBS risk model, including age > 60, ECOG PS > 1, β2-microglobulin (BMG) > 3.0 mg/L and SEV > 1000 ml, which exerted superior efficacy for risk stratification compared to the current risk systems in TCL patients with SE. Besides, multiple RNA-seq datasets were used for the identification and function analysis of SE-related genes (SERGs). TCL patients in different SERGs-associated subgroups exhibited discrepancy in the infiltration of immunocytes and the expression of immune checkpoints. SERGs signature, including HIF1A, FERMT2, NFATC1 and COL1A1, was established and demonstrated to have distinguishing capacity for predicting prognosis in TCL patients. Moreover, immunohistochemistry revealed that SE-related molecule HIF1A was reductively expressed and related to inferior prognosis in TCL patients, especially in SE group. Pan-cancer analysis found HIF1A expression was decreased in several tumors, and chemosensitivity analysis revealed that HIF1A was associated with sensitivity of several anti-tumor drugs, such as Sorafenib, Navitoclax, and Venetoclax. Our findings provide evidence for identifying high-risk population and facilitating individualized treatment in TCL patients with SE.

Renal Cell Carcinoma Presenting As Isolated Malignant Pleural Effusion: A Case Report

Renal cell carcinoma (RCC) of the clear cell type is the most common form of renal malignancy. Malignant pleural effusion (MPE) as the initial presentation of RCC is very rare. This case report presents a case of RCC that initially manifested as a pleural effusion, without the typical symptoms of flank pain, hematuria, or a palpable abdominal mass. The patient, a 45-year-old male, arrived with complaints of dyspnea and a dry cough, with no notable medical history or risk factors. Imaging revealed a left-sided pleural effusion, which was identified as MPE based on pleural fluid analysis, cytology, and immunohistochemistry. Subsequent investigation revealed a large, solid cystic mass in the left kidney, with a biopsy confirming RCC. Uniquely, the patient exhibited pleural metastasis without involvement of the lung parenchyma, a rare scenario in RCC that is linked to a poor prognosis. This case emphasizes the variable presentation of RCC and the need to consider malignancy in patients with unexplained pleural effusion. An indwelling pleural catheter was placed for the patient considering the poor prognosis; furthermore, he declined to undergo sessions of palliative chemotherapy and was subsequently lost to follow-up.

Lenvatinib treatment strategy for thyroid carcinoma with malignant pleurisy: a case report

Background

Although lenvatinib is effective for unresectable thyroid carcinoma, it may cause adverse events owing to rapid tumor shrinkage or necrosis. Pneumothorax during lenvatinib therapy is rare. However, once it occurs, it can become a refractory and fatal complication. Herein, we report two cases of thyroid carcinoma with malignant pleurisy treated with lenvatinib and discuss treatment strategies to prevent pneumothorax.

Case Description

The first case involved a 78-year-old male with papillary thyroid carcinoma and malignant bilateral pleural effusion. He underwent pleurodesis with talc for the left pleural effusion due to respiratory distress, and lenvatinib therapy was initiated. Forty days after lenvatinib therapy, the patient developed a right pneumothorax and underwent surgery for a prolonged air leak. However, the left pneumothorax was prevented by pleurodesis. During surgery, the visceral pleura was fragile, and repair of the pulmonary fistula was difficult. Pathological examination revealed an anaplastic carcinoma in the visceral pleura. The air leak disappeared 20 days after surgery; however, the patient died 22 days after surgery due to progression of the underlying disease. The second case involved a 65-year-old female with a poorly differentiated thyroid carcinoma and lung metastasis. She underwent ablation with 30 mCi 131I after total thyroidectomy, and there was no accumulation in the metastatic sites. Chest computed tomography (CT) revealed the progression of malignant pleurisy in the right thoracic cavity, and iodine-resistant disease was confirmed. She was treated with lenvatinib after talc pleurodesis and showed good progress without any adverse events.

Conclusions

The presence of malignant pleurisy results in a risk of developing lenvatinib-associated pneumothorax. Therefore, pleurodesis should be considered before lenvatinib therapy for thyroid carcinomas with malignant pleurisy.

Long- and short-term outcomes for resectable gallbladder carcinoma patients treated with curative-intent laparoscopic versus open resection: a multicenter propensity score-matched comparative study

Background

Gallbladder cancer (GBC) was once considered a contraindication for laparoscopic surgery, but it is becoming more common to use laparoscopic surgery for GBC treatment. The aim of this study was to analyze the long- and short-term outcomes of patients with more advanced T-staged GBC treated with curative intent as defined by the National Comprehensive Cancer Network (NCCN) after laparoscopic resection (LR) versus open resection (OR).

Methods

A multicenter database was used to select consecutive GBC patients treated with curative-intent resection as defined by the NCCN between 2016 and 2020. The patients were divided into the LR group and the OR group. Propensity score matching (PSM) was used to eliminate selection bias. The endpoints were overall survival (OS), progression-free survival (PFS), and short-term outcomes. Risk factors that were independently associated with OS and PFS were identified.

Results

Of 626 GBC patients treated with curative-intent resection, after PSM, 51 patients were in the LR group and 153 patients were in the OR group. The LR group had more patients who were suitable to receive adjuvant chemotherapy (AC), a longer operation time, more harvested lymph nodes, and a lower overall morbidity rate. The rates of OS and PFS were not significantly different between the two groups. AC was independently associated with better OS and PFS.

Conclusions

The overall morbidity of GBC patients after LR was lower, but the long-term outcomes between LR and OR were not significantly different. The GBC patients treated with LR were more likely to receive AC, and the use of AC after curative-intent resection of GBC helped achieve better long-term survival outcomes.

Apolipoprotein E in patients with undiagnosed pleural effusion: a prospective diagnostic test accuracy study

INTRODUCTION

Pleural effusion is common in clinical practice, and its differential diagnosis remains challenging for clinicians. This study investigates the diagnostic value of apolipoprotein E (apoE) in patients with undetermined pleural effusion.

METHODS

This prospective, double-blind study enrolled 152 patients with undiagnosed pleural effusion. Their pleural fluid apoE levels were measured, and a receiver operating characteristics (ROC) curve was used to evaluate the diagnostic accuracy of apoE. Decision curve analysis (DCA) was used to assess apoE's net benefit. Subgroup analyses were performed to investigate the effect of age on the diagnostic accuracy of apoE.

RESULTS

Among the included participants, 23 had heart failure (HF). HF patients had the lowest apoE level among pleural effusion patients. The area under the curve (AUC) of apoE for HF was 0.79 (95% CI: 0.69-0.89). At the threshold of 40 mg/L, the sensitivity and specificity of apoE were 0.96 (95% CI: 0.87-1.00) and 0.33 (95% CI: 0.25-0.42), respectively. The decision curve for apoE was above reference lines. The AUC of apoE decreased in older patients.

CONCLUSION

Pleural fluid apoE has moderate diagnostic value for HF and has net benefits in patients with undiagnosed pleural effusion. The diagnostic accuracy of apoE decreases with age.

Elusive Unilateral Pleural Effusion: Keys to Clinching the Diagnosis

Unilateral pleural effusions may sometimes be difficult to diagnose. The cause may vary widely, including congestive heart failure, chronic liver and kidney disease, various drugs, and underlying undiagnosed disorders of the lung and pleura. With advancements in chest imaging, new biomarkers, and less invasive methods for obtaining tissue samples, it may be possible to identify the cause of the unilateral pleural effusions whose etiology is unclear. Even reviewing patient history, re-examining pleural fluid, classifying effusions based on Light's criteria, and ruling out pseudoexudates can help understand the cause. We aim to discuss a case of unilateral pleural effusion and, on its backdrop, discuss an approach to elusive unilateral pleural effusion.

A Rare Case of a Splenic Abscess as the Origin of Illness in Exudative Pleural Effusion

Background

Pleural effusion, the presence of fluid within the pleural space, is a common condition secondary to a wide range of pathological causes. Splenic abscess, which is rare, has previously been described as a cause of exudative pleural effusion. Splenic abscess is thought to be associated with bacteremia, iatrogenic inoculation, or hematogenous spread from another bacterial focus. However, there are no documented cases of pleural effusion with the spleen as the source of infection.

Case Presentation

An 80-year-old male presented with shortness of breath, weight loss, and fever. Imaging revealed a left pleural effusion and a splenic mass. Following several unsuccessful attempts to drain the effusion, attention shifted to the splenic mass, which proved to be a bacterial abscess. After targeted antibiotic treatment for the splenic abscess and surgical decortication for pleural adhesions, the patient showed significant improvement and was discharged.

Conclusions

This clinical scenario underscores the importance of identifying and addressing the source of pleural effusion, including consideration of splenic abscess as the primary process. By process of exclusion, we determined that the spleen was the origin of the disease, challenging the conventional perception of the spleen as exclusively a secondary locus of infection, without direct iatrogenic inoculation or bacteremia. The patient's presentation, hospital course, and response to treatment should encourage clinicians to consider a wider range of differential diagnoses for the primary pathologies underlying pleural effusions, facilitating earlier identification and intervention.

The role of day-case thoracoscopy at a district general hospital: A real world observational study

Objective

To assess the feasibility and safety of talc pleurodesis performed as part of day-case medical thoracoscopy.

Methods

A Richard Wolf® 5 mm mini thoracoscope through a 5.5 mm port was used with eligible cases having talc poudrage followed by insertion of indwelling pleural catheter (IPC). District nurses drain the IPC daily for the first 5 days. Once the drain output is <150 mL, the frequency is progressively reduced to once weekly. The drain is removed after two consecutive dry taps 1 week apart.

Results

Overall, 51 patients underwent day-case thoracoscopy. Median time to removal of IPC for our day-case protocol was 14 days. There were seven deaths within 70 days among 41 patients with malignant pleural effusion in the day-case cohort, compared to eight deaths in the 33 conventional thoracoscopy controls. Overall, the day-case cohort observed a statistically significant reduction in all-cause mortality at 180 days compared to the conventional cohort (log rank p = 0.024). The average cost per patient of the day-case and inpatient cohort was £1,328.0 ± 106.0 and £1,835.0 ± 295.0 (p = 0.961).

Conclusion

This study suggests that thoracoscopy and talc poudrage can be performed safely as a day-case procedure. Further data are needed to ascertain long-term outcomes.

A retrospective analysis of transudative pleural effusion due to fibrosing mediastinitis

BACKGROUND

Pleural effusion caused by fibrosing mediastinitis is rarely reported. This study aimed to summarize the clinical manifestations, diagnosis and treatment of transudative pleural effusion due to fibrosing mediastinitis.

METHODS

Medical records and follow-up data of 7 patients with transudative pleural effusion due to fibrosing mediastinitis in Beijing Chaoyang Hospital between May 2014 and Feb 2018 were retrospectively analyzed.

RESULTS

These patients included 4 males and 3 females, with an average age of (64 ± 9) years. There were 3 left-sided effusions, 2 right-sided effusions and 2 bilateral effusions. Previous or latent tuberculosis was found in 6 patients. Pulmonary hypertension was indicated by echocardiography in all the 7 patients. Computed tomography pulmonary angiography (CTPA) of all the 7 cases showed increased soft tissue images visible in the mediastinum and bilateral hilus, different degrees of stenosis or occlusion in the pulmonary artery and pulmonary vein. In addition, 4 cases were found of right middle lobe atelectasis with a mediastinal window setting. There was interstitial pulmonary edema on the side of pleural effusion with a lung window setting. All the 7 patients were treated with intermittent drainage of pleural effusion combined with diuretic therapy. Five patients were treated with antituberculosis therapy. Up to now, two patients died of right heart failure and respiratory failure after 2 and 16 months respectively; The remaining 5 patients were still in follow up.

CONCLUSION

Fibrosing mediastinitis can lead to pulmonary vein stenosis or occlusion, and thus cause transudative pleural effusion, which can be detected by CTPA. Pulmonary hypertension, long time of cough, and a history of tuberculosis are common in these patients. The common therapy is intermittent drainage of pleural effusion combined with diuretic therapy.

Intradural Extramedullary Pyogenic Abscess: Incidence, Management, and Clinical Outcomes in 45 Patients With a Mean Follow Up of 2 Years

STUDY DESIGN

Retrospective review.

OBJECTIVES

Spinal intradural extramedullary abscess (SIEA) is a rare disease with an unknown incidence. In this study, we systematically described the clinical course of SIEA in a large cohort with acute onset of neurological illness, assessed the morbidity and mortality rates, and determined the potential risk factors for mortality.

METHODS

Electronic medical records of patients diagnosed with SIEA at a single institution for the period between September 2005 and December 2020 were retrieved.

RESULTS

Over a period of 15 years, 881 patients with spinal infections were treated either conservatively or surgically at our center, of whom 45 patients (45/881, 5.1%) had SIEA. The overall mean age was 69.6 ± 5.6 years of patients diagnosed with SIEA and all of them underwent posterior decompression via laminectomy. The mean Charlson Comorbidity Index (CCI) was 6.9 ± 2.5, indicating a poor baseline reserve. Progressive neurological decline was observed in all patients (mean motor score, 88.6 ± 9.7). The in-hospital rate and 90-day mortality were 4.4% and 10%, respectively. Mortality was not surgery related. Most importantly, the patients' motor deficits and blood infection parameters significantly improved after surgery. Risk factors for mortality were increased age, comorbidities as measured by CCI, and preoperative motor weakness (MS).

CONCLUSIONS

Immediate surgical decompression via laminectomy, with antiseptic irrigation and drainage of the subdural space, followed by antibiotic therapy, appears to be the key to ensuring beneficial clinical outcomes to treatment of rare diseases such as SIEA.

When Rhythm Correction Turns Risky: Rare Right-Sided Haemorrhagic Pleural Effusion Post Maze Procedure

The maze procedure for atrial fibrillation carries risks, including pleural effusion. We report a case of a 54-year-old woman with right-sided pleural effusion post maze surgery, presenting with dyspnoea. Despite treatment, complications arose, including atrial flutter. Prompt recognition and multidisciplinary management led to a favourable outcome. This case underscores the importance of vigilance for rare post-operative complications and highlights the need for collaborative care in optimising patient outcomes following cardiac surgeries. Further research is warranted to refine management strategies for such occurrences.

LEARNING POINTS

Healthcare providers should remain vigilant for rare complications, for example right-sided haemothorax, following cardiac surgeries such as the maze procedure to initiate timely management and ensure favourable outcomes.The post-maze procedure, atrial flutter or macroreentrant atrial tachycardia may resist standard medical treatment, emphasising the importance of considering catheter ablation as a therapeutic option to improve patient outcomes.Empowering patients with knowledge about potential post-procedure complications and associated symptoms facilitates early reporting, enabling prompt intervention by healthcare providers and leading to improved treatment outcomes.

Prospective Evaluation of Safety and Diagnostic Efficacy of Medical Thoracoscopy in Undiagnosed Exudative Pleural Effusion: Experience From a Tuberculosis High-Burden Country

INTRODUCTION

Pleural effusion is due to the pathological accumulation of pleural fluid in the pleural space, 25%-30% of which may remain undiagnosed despite the combination of biochemical, microbiological, and pathological tests and closed pleural biopsy. Medical thoracoscopy may help physicians diagnose such cases. We aimed to study the diagnostic yield of medical thoracoscopy in patients with undiagnosed exudative pleural effusion and assess the safety profile of the medical thoracoscopy.

METHODOLOGY

A cross-sectional descriptive study was conducted on 105 patients with undiagnosed pleural effusion. Medical thoracoscopy was performed using an Olympus semi-rigid thoracoscope (LTF 160 Evis Pleurovideoscope, Japan) as per standard protocol. Multiple pleural biopsies were taken and sent for histopathology examination, NAAT (nucleic acid amplification test), and MGIT (mycobacteria growth indicator tube). Post-procedure, the patients were evaluated for any complications.

RESULTS

A total of 105 patients were enrolled in the study. The mean ± SD age was 55.1 ± 13.6 years. Sixty-three (60%) patients were males. The diagnostic utility of medical thoracoscopy was found in 94 (89.5%) patients. The diagnosis of tuberculosis (TB) was made in 34 (32.3%) patients, and 48 (45.7%) patients were diagnosed with malignant pleural effusion. Adenocarcinoma of the lung was the most common malignancy diagnosed (32 patients, 66.6%). Five (5.31%) patients had dual etiology of pleural effusion: tubercular and malignancy. The most common complication was chest pain following the procedure (99.4%). One patient developed pneumomediastinum and was managed conservatively. There were no major adverse events after the procedure.

CONCLUSIONS

Medical thoracoscopy has a high diagnostic yield and favorable safety profile with minimal complications. Excessive reliance on the level of ADA (adenosine deaminase) may further delay the diagnosis. Dual etiologies like TB coexisting with malignancy should be considered in TB high-burden countries.

Natural antibodies targeting LPS in pleural effusions of various etiologies

Respiratory infection, cancer, and heart failure can cause abnormal accumulation of fluid in the pleural cavity. The immune responses within the cavity are orchestrated by leucocytes that reside in the serosal-associated lymphoid tissue. Natural antibodies (NAbs) are abundant in the serum (S) having a major role in systemic and mucosal immunity; however, their occurrence in pleural fluid (PF) remains an open question. Our aim herein was to detect and measure the levels of NAbs (IgM, IgG, IgA) targeting lipopolysaccharides (LPS) in both the pleural fluid and the serum of 78 patients with pleural effusions (PEs) of various etiologies. The values of anti-LPS NAb activity were extracted through a normalization step regarding the total IgM, IgG, and IgA levels, all determined by in-house ELISA. In addition, the ratios of PF/S values were analyzed further with other critical biochemical parameters from pleural fluids. Anti-LPS NAbs of all Ig classes were detected in most of the samples, while a significant increase of anti-LPS activity was observed in infectious and noninfectious compared with malignant PEs. Multivariate linear regression confirmed a negative correlation of IgM and IgA anti-LPS PF/S ratio with malignancy. Moreover, anti-LPS NAbs PF/S measurements led to increased positive and negative predictive power in ROC curves generated for the discrimination between benign and malignant PEs. Our results highlight the role of anti-LPS NAbs in the pleural cavity and demonstrate the potential translational impact that should be further explored.NEW & NOTEWORTHY Here we describe the detection and quantification of natural antibodies (NAbs) in the human pleural cavity. We show for the first time that IgM, IgG, and IgA anti-LPS natural antibodies are detected and measured in pleural effusions of infectious, noninfectious, and malignant etiologies and provide clinical correlates to demonstrate the translational impact of our findings.

Performance verification of a biochemical detection system for hydrothorax and ascites and clinical diagnostic accuracy evaluation of exudate and tuberculous effusion

Background

Lactate dehydrogenase (LDH), total protein (TP) and glucose (Glu) in pleural hydrothorax and ascites can be used in the diagnosis of exudate, and adenosine deaminase (ADA) can be used in the diagnosis of tuberculous effusion. However, the manufacturers do not claim that their biochemical reagents can be used to detect hydrothorax and ascites samples. Therefore, medical laboratories must conduct suitability studies on biochemical reagents for hydrothorax and ascites samples to comply with regulatory requirements for humor detection. This study aimed to verify the analytical performance and clinical diagnostic accuracy of the Mindray biochemical reagents, including LDH, TP, Glu and ADA, for hydrothorax and ascites.

Methods

The repeatability, detection limits and reference intervals of Mindray biochemical reagents (LDH, TP, Glu, ADA) in detecting hydrothorax and ascites were determined. The comparison of different measurement procedures was performed. Meanwhile, the diagnostic accuracy of LDH, TP, Glu and ADA were assessed.

Results

The quality control results of LDH, TP, Glu, and ADA were all under control. The repeatability coefficient of variation (%) of LDH, TP, Glu, and ADA were all less than 1%. The limits of blank of LDH, TP, Glu, and ADA were 0.33 U/L, 0.45 g/L, 0.00 mmol/L, and 0.04 U/L, respectively; the limits of detection were 1.57 U/L, 1.85 g/L, 0.05 mmol/L, and 0.12 U/L, respectively. Compared with the reference measurement program, the correlation coefficients of LDH, TP, Glu and ADA were 0.9931, 0.9983, 0.9996 and 0.9966, respectively; the regression equations were y=1.0082x-10.06, y=0.9965x-0.4732, y=0.9903x+0.0522 and y=1.0051x-0.0232, respectively. The reference intervals of LDH, TP, Glu, and ADA in hydrothorax and ascites were ≤198.39 U/L, ≤32.97 g/L, ≥5.03 mmol/L. and ≤11.00 U/L respectively. For differentiating between exudates and transudates, the area under the curve (AUC) of LDH, TP, and Glu were 0.913, 0.875, and 0.767, respectively; the AUC of ADA for the differential diagnosis of tuberculous and nontuberculous effusions was 0.876.

Conclusions

The LDH, TP, Glu, and ADA assays were validated for use with the Mindray BS-2800 analyzer for hydrothorax and ascites evaluation. LDH, TP, and Glu in hydrothorax and ascites are applicable to the differential diagnosis of exudates and transudates; ADA in hydrothorax and ascites can be employed to differentiate and diagnose tuberculous and nontuberculous effusions.

Pleural carbohydrate antigen 50 and malignant pleural effusion: a prospective, double-blind diagnostic accuracy test

Background

Serum carbohydrate antigen 50 (CA50) is an auxiliary diagnostic marker for various solid tumors, but it remains unclear whether CA50 in pleural fluid can assist in the diagnosis of malignant pleural effusion (MPE). This study aimed to evaluate the diagnostic accuracy of pleural fluid CA50 for MPE in pleural effusion patients with undetermined causes.

Methods

This study prospectively recruited pleural effusion patients with undetermined causes who visited the Affiliated Hospital of Inner Mongolia Medical University between September 2018 and July 2021. We measured pleural fluid CA50 level with an electrochemiluminescence assay. We analyzed the diagnostic accuracy of CA50 and carcinoembryonic antigen (CEA) for MPE with the receiver operating characteristic (ROC) curve. The net benefits of CA50 and CEA were analyzed using the decision curve analysis (DCA).

Results

We enrolled 66 MPEs and 87 benign pleural effusions (BPEs). MPE patients had significantly higher CA50 and CEA than BPE patients. The area under the ROC curve (AUC) of CA50 was 0.72 (95% CI: 0.63-0.80). CA50 had a sensitivity of 0.30 (95% CI: 0.19-0.41) and a specificity of 1.00 (95% CI: 1.00-1.00) at the threshold of 15 IU/mL. The decision curve of CA50 was above the reference line at the calculated risk probability of between 0.30 and 1.00. Venn diagram indicated that some patients with low CEA (<50 or <150 ng/mL) and/or negative cytology can be identified by positive CA50 (>15 IU/mL).

Conclusions

Pleural fluid CA50 has moderate accuracy and net benefit for detecting MPE. CA50 >15 IU/mL can be used to diagnose MPE. The combination of CA50 and CEA improves the diagnostic sensitivity for MPE.

Effectiveness of Physiotherapy Interventions in Pleural Effusion Patients: A Comprehensive Review

Pleural effusion, characterized by the accumulation of fluid between the parietal and visceral pleura, presents significant challenges in patient management, particularly in cases of malignant pleural effusion. Despite various therapeutic options, there is a need to evaluate the effectiveness of physiotherapy interventions specifically for pleural effusion patients, as current literature predominantly focuses on medical and surgical treatments. This comprehensive review aims to address this research gap by systematically analyzing the impact of physiotherapy on pleural effusion management, with a focus on symptom relief and improvement in quality of life. The objective is to determine the role of physiotherapy in reducing hospital stay and enhancing patient outcomes. Methodologically, this review synthesizes data from clinical studies and case reports that document physiotherapy interventions, such as breathing exercises, postural drainage, and mobilization techniques, in the treatment of pleural effusion. Our findings suggest that physiotherapy interventions can significantly alleviate dyspnoea and improve respiratory function, contributing to better overall patient outcomes. These results underscore the importance of incorporating physiotherapy into the standard care protocol for patients presenting with pleural effusion to optimize recovery and quality of life.

Clinical value of combined detection of Carcinoembryonic Antigen and CA125 in the diagnosis of non-small cell lung cancer combined with Malignant Pleural Effusion

Objective

To investigate the clinical value of combined detection of carcinoembryonic antigen(CEA) and CA125 in the diagnosis of non-small cell lung cancer(NSCLC) combined with malignant pleural effusion.

Methods

This was retrospective research. Fifty-six NSCLC patients combined with malignant pleural effusion in Baoding No.1 Hospital, China, from January 2020 to January 2022 were recruited as the malignant group, and another 56 NSCLC patients combined with pleural effusion in the same period were recruited as the benign group. Pleural effusion and serum specimens were collected from both groups and their carcinoembryonic antigen (CEA), carbohydrate antigen 125(CA125) and SP70 antigen levels were measured respectively. The differences in index levels between the two groups were compared, and the value of the index in diagnosing NSCLC combined with malignant pleural effusion was analyzed.

Results

The positive rates of CEA, CA125 and SP70 antigen in pleural effusion were higher in the malignant group than in the benign group (p>0.05); The positive rates of CEA and CA125 in the malignant group were higher than those in the benign group (p>0.05), with no statistically significant difference between the two groups in the positive rates of SP70 antigen (p>0.05). ROC curve analysis revealed the value of serum CEA and CA12 in the diagnosis of NSCLC combined with malignant pleural effusion, while serum SP70 antigen had no diagnostic value (p>0.05).

Conclusion

The combined detection of CEA, CA125 and SP70 antigen boasts a higher diagnostic value for NSCLC-mediated pleural effusion, with higher diagnostic value than the combined detection of serum indexes.

Deep learning model for pleural effusion detection via active learning and pseudo-labeling: a multisite study

BACKGROUND

The study aimed to develop and validate a deep learning-based Computer Aided Triage (CADt) algorithm for detecting pleural effusion in chest radiographs using an active learning (AL) framework. This is aimed at addressing the critical need for a clinical grade algorithm that can timely diagnose pleural effusion, which affects approximately 1.5 million people annually in the United States.

METHODS

In this multisite study, 10,599 chest radiographs from 2006 to 2018 were retrospectively collected from an institution in Taiwan to train the deep learning algorithm. The AL framework utilized significantly reduced the need for expert annotations. For external validation, the algorithm was tested on a multisite dataset of 600 chest radiographs from 22 clinical sites in the United States and Taiwan, which were annotated by three U.S. board-certified radiologists.

RESULTS

The CADt algorithm demonstrated high effectiveness in identifying pleural effusion, achieving a sensitivity of 0.95 (95% CI: [0.92, 0.97]) and a specificity of 0.97 (95% CI: [0.95, 0.99]). The area under the receiver operating characteristic curve (AUC) was 0.97 (95% DeLong's CI: [0.95, 0.99]). Subgroup analyses showed that the algorithm maintained robust performance across various demographics and clinical settings.

CONCLUSION

This study presents a novel approach in developing clinical grade CADt solutions for the diagnosis of pleural effusion. The AL-based CADt algorithm not only achieved high accuracy in detecting pleural effusion but also significantly reduced the workload required for clinical experts in annotating medical data. This method enhances the feasibility of employing advanced technological solutions for prompt and accurate diagnosis in medical settings.

A nomogram to predict lung cancer in pulmonary lesions for tuberculosis infection patients

Similar clinical features make the differential diagnosis difficult, particularly between lung cancer and pulmonary tuberculosis (TB), without pathological evidence for patients with concomitant TB infection. Our study aimed to build a nomogram to predict malignant pulmonary lesions applicable to clinical practice. We retrospectively analyzed clinical characteristics, imaging features, and laboratory indicators of TB infection patients diagnosed with lung cancer or active pulmonary TB at Xiangya Hospital of Central South University. A total of 158 cases from January 1, 2018 to May 30, 2019 were included in the training cohort. Predictive factors for lung cancer were screened by a multiple-stepwise logistic regression analysis. A nomogram model was established, and the discrimination, stability, and prediction performance of the model were analyzed. A total of 79 cases from June 1, 2019, to December 30, 2019, were used as the validation cohort to verify the predictive value of the model. Eight predictor variables, including age, pleural effusion, mediastinal lymph node, the number of positive tumor markers, the T cell spot test for TB, pulmonary lesion morphology, location, and distribution, were selected to construct the model. The corrected C-statistics and the Brier scores were 0.854 and 0.130 in the training cohort, and 0.823 and 0.163 in the validation cohort. Calibration plots showed good performance, and decision curve analysis indicated a high net benefit. In conclusion, the nomogram model provides an effective method to calculate the probability of lung cancer in TB infection patients, and it has excellent discrimination, stability, and prediction performance in detecting a malignant diagnosis of undiagnosed pulmonary lesions.

Comparison of outcomes of surgical and other invasive treatment modalities for malignant pleural effusion in patients with pleural carcinomatosis

Background

Treatment modalities for malignant pleural effusion (MPE) are diverse. The objectives were to analyze actual clinical data from patients with MPE and pleural carcinomatosis and to compare the outcomes of different treatment modalities with regard to effectiveness, survival, morbidity, and mortality as well as the duration of hospitalization.

Methods

Patients with pathologically proven pleural carcinomatosis or MPE from 2018 to 2020 were included in this retrospective-observational study with additional questionnaires. We identified four treatment modalities: (I) video-assisted thoracic surgery with pleurodesis (VATS, mechanical/chemical); (II) VATS with pleurodesis combined with indwelling pleural catheter (IPC) placement; (III) VATS (without pleurodesis) combined with IPC placement; and (IV) management with IPC placement alone.

Results

We enrolled 91 patients aged 38-90 years who were treated by either VATS-pleurodesis (N=22), VATS-IPC placement (N=21), a combination of VATS with pleurodesis and IPC placement (N=22), or IPC placement alone (N=26). The mean survival time was 138.3 days. No significant differences were detected among treatment groups regarding the outcome of pleurodesis failure, either initially or later. Patients in the VATS-pleurodesis with IPC group experienced significantly more complications than those in the other treatment modality groups [odds ratio (OR): 3.288, P=0.026]. However, no statistically significant differences were observed regarding the type of adverse event and survival. Hypoalbuminemia, systemic therapy, and successful pleurodesis (P=0.008; P=0.011; P=0.044, respectively) were significantly correlated with survival. In multiple linear regression, hypoalbuminemia persisted as an independent predictor of survival (P=0.031). The type of intervention showed significant differences regarding the duration of hospitalization (P=0.017). IPC placement alone shortened the mean total hospitalization time by 7.9, 5.9, and 7.0 days compared to VATS-pleurodesis (P≤0.001), VATS-IPC placement (P=0.004), and VATS-pleurodesis with IPC placement (P≤0.001), respectively.

Conclusions

The survival time was very short, and each treatment group had pros and cons. Therefore, decisions should be made on a case-by-case basis. The use of an IPC, even if the lung is not trapped, can significantly reduce the length of hospital stay. VATS is needed when histology is needed. The ideal method for treating recurrent MPE should be simple, effective, and inexpensive, with minimal disturbance to the patient.

Cell-free DNA methylation analysis as a marker of malignancy in pleural fluid

Diagnosis of malignant pleural effusion (MPE) is made by cytological examination of pleural fluid or histological examination of pleural tissue from biopsy. Unfortunately, detection of malignancy using cytology has an overall sensitivity of 50%, and is dependent upon tumor load, volume of fluid assessed, and cytopathologist experience. The diagnostic yield of pleural fluid cytology is also compromised by low abundance of tumor cells or when morphology is obscured by inflammation or reactive mesothelial cells. A reliable molecular marker that may complement fluid cytology for the diagnosis of malignant pleural effusion is needed. The purpose of this study was to establish a molecular diagnostic approach based on pleural effusion cell-free DNA methylation analysis for the differential diagnosis of malignant pleural effusion and benign pleural effusion. This was a blind, prospective case-control biomarker study. We recruited 104 patients with pleural effusion for the study. We collected pleural fluid from patients with: MPE (n = 48), indeterminate pleural effusion in subjects with known malignancy or IPE (n = 28), and benign PE (n = 28), and performed the Sentinel-MPE liquid biopsy assay. The methylation level of Sentinel-MPE was markedly higher in the MPE samples compared to BPE control samples (p < 0.0001) and the same tendency was observed relative to IPE (p = 0.004). We also noted that the methylation signal was significantly higher in IPE relative to BPE (p < 0.001). We also assessed the diagnostic efficiency of the Sentinel-MPE test by performing receiver operating characteristic analysis (ROC). For the ROC analysis we combined the malignant and indeterminate pleural effusion groups (n = 76) and compared against the benign group (n = 28). The detection sensitivity and specificity of the Sentinel-MPE test was high (AUC = 0.912). The Sentinel-MPE appears to have better performance characteristics than cytology analysis. However, combining Sentinel-MPE with cytology analysis could be an even more effective approach for the diagnosis of MPE. The Sentinel-MPE test can discriminate between BPE and MPE. The Sentinel-MPE liquid biopsy test can detect aberrant DNA in several different tumor types. The Sentinel-MPE test can be a complementary tool to cytology in the diagnosis of MPE.

Anaplastic Lymphoma Kinase (ALK)-Negative Anaplastic Large Cell Non-Hodgkin Lymphoma as a Rare Differential Diagnosis of Lung Cancer: A Case Report

Anaplastic large cell lymphomas (ALCL) are a group of sporadic malignancies that generally have an aggressive clinical course, especially the subtype of anaplastic lymphoma kinase (ALK)-negative ALCL. The appropriate diagnostic study modalities must be chosen to make an accurate diagnosis and promptly initiate specific treatment. We present the clinical case of a 72-year-old male patient with dyspnea on small efforts accompanied by diaphoresis and a weight loss of 10 kg in two months. Physical examination revealed adenopathy in the cervical region and bilateral pleural effusion. The pleural and lung biopsies revealed poorly differentiated metastatic adenocarcinomas. A multidisciplinary analysis was carried out; the typical clinical-radiographic presentation of adenocarcinoma was ruled out with immunohistochemistry, thus determining a diagnosis of ALK-negative anaplastic large cell non-Hodgkin's lymphoma. This case represented a diagnostic and therapeutic challenge since it is a rare entity with a poor prognosis, and there are only a few studies about the choice of appropriate chemotherapy in these patients.

Unveiling Insights: A Comprehensive Review of the Role of Medical Thoracoscopy in Pleural Effusion Assessment

Pleural effusion, characterized by abnormal fluid accumulation in the pleural cavity, poses diagnostic and therapeutic challenges across various medical conditions. This comprehensive review explores the role of medical thoracoscopy in assessing pleural effusions, providing insights into its historical context, procedural intricacies, diagnostic performance, safety considerations, and clinical applications. Medical thoracoscopy, a minimally invasive endoscopic procedure, offers advantages such as high diagnostic yield, therapeutic interventions, real-time assessment, and a minimally invasive nature. The review critically analyzes the procedure's advantages and disadvantages, including technical expertise, risk of complications, resource intensity, and patient selection criteria. Comparative analyses with alternative diagnostic modalities highlight the unique benefits of medical thoracoscopy in specific clinical scenarios. The diagnostic yield of medical thoracoscopy is examined, considering sensitivity and specificity in various contexts. Patient selection criteria, complications, and safety measures are discussed, emphasizing the importance of careful consideration in integrating thoracoscopy into clinical practice. The review further explores its clinical applications, including differentiating exudative and transudative effusions, identifying specific etiologies, and its role in treatment planning. In conclusion, medical thoracoscopy emerges as a valuable tool in the comprehensive management of pleural effusions, offering a nuanced approach to diagnosis and treatment. The evolving landscape of diagnostic modalities underscores the continued significance of medical thoracoscopy and potential advancements in the field.

A Rapidly Enlarging Asymptomatic Parapneumonic Effusion: A Case Report

A pleural effusion is an accumulation of fluid in the pleural space due to an imbalance between formation and removal. They're commonly caused by heart failure or infections. We report a case of a 56-year-old male with community-acquired pneumonia and a trace pleural effusion on presentation. Despite clinical improvement with antibiotic therapy, the effusion significantly increased on day two. This case report is unique because the patient had an enlarging effusion, but remained asymptomatic and denied worsening shortness of breath, chest pain, or cough. The patient was treated successfully with chest tube placement and intrapleural fibrinolytic therapy. This report emphasizes the importance of repeat imaging for asymptomatic parapneumonic effusions (PPE) that can complicate community-acquired pneumonia. We aim to raise awareness of the atypical presentation and management of parapneumonic effusions through a case report.

A Case Report of Tension Hydrothorax Incited by Bowel Perforation

We report the case of a 34-year-old man who developed cardiac arrest due to tension hydrothorax from colonic perforation. Tension hydrothorax, an entity characterized by pleural effusion leading to mediastinal compression, has not been reported in association with intraabdominal inflammation. Our patient developed respiratory insufficiency after repair of colonic perforation, followed by respiratory failure and cardiac arrest. Transthoracic echocardiography provided rapid diagnosis during decompensation and prompted a lifesaving thoracostomy. Clinicians should consider tension hydrothorax as a rare cause of hemodynamic collapse, even in the absence of liver failure, and use bedside tools like transthoracic echocardiography to facilitate diagnosis and intervention.

Idiopathic Chylothorax During Pregnancy: A Case Report

The diagnosis of chylothorax during pregnancy is rare and is generally triggered during labor. The study of pleural fluid and imaging studies can facilitate diagnosis, even though determining its etiology can be complicated. This case involves a young pregnant woman presenting with disabling dyspnea and chest pain due to pleural effusion. The conventional study of the pleural fluid was not conclusive; however, the measurement of chylomicrons guided us to determine the diagnosis of chylothorax. Based on imaging studies and specific markers, some of the main etiologies were not determined, leading to classification as idiopathic. After drainage and dietary adjustment, a significant improvement in symptoms was achieved with the help of an interdisciplinary team, which is crucial for the prevention of complications and adequate resolution of the pregnancy.

Simultaneous diagnosis of tuberculous pleurisy and malignant pleural effusion using metagenomic next-generation sequencing (mNGS)

BACKGROUND

Metagenomic next-generation sequencing (mNGS) has become a powerful tool for pathogen detection, but the value of human sequencing reads generated from it is underestimated.

METHODS

A total of 138 patients with pleural effusion (PE) were diagnosed with tuberculous pleurisy (TBP, N = 82), malignant pleural effusion (MPE, N = 35), or non-TB infection (N = 21), whose PE samples all underwent mNGS analysis. Clinical TB tests including culture, Acid-Fast Bacillus (AFB) test, Xpert, and T-SPOT, were performed. To utilize mNGS for MPE identification, 25 non-MPE samples (20 TBP and 5 non-TB infection) were randomly selected to set human chromosome copy number baseline and generalized linear modeling was performed using copy number variant (CNV) features of the rest 113 samples (35 MPE and 78 non-MPE).

RESULTS

The performance of TB detection was compared among five methods. T-SPOT demonstrated the highest sensitivity (61% vs. culture 32%, AFB 12%, Xpert 35%, and mNGS 49%) but with the highest false-positive rate (10%) as well. In contrast, mNGS was able to detect TB-genome in nearly half (40/82) of the PE samples from TBP subgroup, with 100% specificity. To evaluate the performance of using CNV features of the human genome for MPE prediction, we performed the leave-one-out cross-validation (LOOCV) in the subcohort excluding the 25 non-MPE samples for setting copy number standards, which demonstrated 54.1% sensitivity, 80.8% specificity, 71.7% accuracy, and an AUC of 0.851.

CONCLUSION

In summary, we exploited the value of human and non-human sequencing reads generated from mNGS, which showed promising ability in simultaneously detecting TBP and MPE.

Unraveling the Predictive Potential of Rapid Scoring in Pleural Infection: A Critical Review

Pleural infection, or pleural empyema, is a severe medical condition associated with high morbidity and mortality rates. Timely and accurate prognostication is crucial for optimizing patient outcomes and resource allocation. Rapid scoring systems have emerged as promising tools in pleural infection prognostication, integrating various clinical and laboratory parameters to assess disease severity and quantitatively predict short-term and long-term outcomes. This review article critically evaluates existing rapid scoring systems, including CURB-65 (confusion, uremia, respiratory rate, blood pressure, age ≥ 65 years), A-DROP (age (male >70 years, female >75 years), dehydration, respiratory failure, orientation disturbance, and low blood pressure), and APACHE II (acute physiology and chronic health evaluation II), assessing their predictive accuracy and limitations. Our analysis highlights the potential clinical implications of rapid scoring, including risk stratification, treatment tailoring, and follow-up planning. We discuss practical considerations and challenges in implementing rapid scoring such as data accessibility and potential sources of bias. Furthermore, we emphasize the importance of validation, transparency, and multidisciplinary collaboration to refine and enhance the clinical applicability of these scoring systems. The prospects for rapid scoring in pleural infection management are promising, with ongoing research and data science advances offering improvement opportunities. Ultimately, the successful integration of rapid scoring into clinical practice can potentially improve patient care and outcomes in pleural infection management.

Characterization of the pleural microenvironment niche and cancer transition using single-cell RNA sequencing in EGFR-mutated lung cancer

Background: Lung cancer is associated with a high mortality rate and often complicated with malignant pleural effusion (MPE), which has a very poor clinical outcome with a short life expectancy. However, our understanding of cell-specific mechanisms underlying the pathobiology of pleural metastasis remains incomplete. Methods: We analyzed single-cell transcriptomes of cells in pleural effusion collected from patients with lung cancer and congestive heart failure (as a control), respectively. Soluble and complement factors were measured using a multiplex cytokine bead assay. The role of ferroptosis was evaluated by GPX4 small interfering RNA (siRNA) transfection and overexpression. Results: We found that the mesothelial-mesenchymal transition (MesoMT) of the pleural mesothelial cells contributed to pleural metastasis, which was validated by lung cancer/mesothelial cell co-culture experiments. The ferroptosis resistance that protected cancer from death which was secondary to extracellular matrix detachment was critical for pleural metastasis. We found a universal presence of immune-suppressive lipid-associated tumor-associated macrophages (LA-TAMs) with complement cascade alteration in the MPE of the lung cancer patients. Specifically, upregulated complement factors were also found in the MPE, and C5 was associated with poor overall survival in the lung cancer patients with epidermal growth factor receptor mutation. Plasmacytoid dendritic cells (pDCs) exhibited a dysfunctional phenotype and pro-tumorigenic feature in the primary cancer. High expression of the gene set extracted from pDCs was associated with a poor prognosis in the lung cancer patients. Receptor-ligand interaction analysis revealed that the pleural metastatic niche was aggravated by cross-talk between mesothelial cells-cancer cells/immune cells via TNC and ICAM1. Conclusions: Taken together, our results highlight cell-specific mechanisms involved in the pathobiological development of pleural metastasis in lung cancer. These results provide a large-scale and high-dimensional characterization of the pleural microenvironment and offer a useful resource for the future development of therapeutic drugs in lung cancer.

Rapid on-site evaluation of touch imprints of medical thoracoscopy biopsy tissue for the management of pleural disease

Background and objective

Medical thoracoscopy (MT) plays an important role in the diagnosis and treatment of pleural diseases, and rapid on-site evaluation (ROSE) has long been used for transbronchial needle aspiration or fine-needle aspiration to evaluate the adequacy of biopsy materials for the diagnosis of peripheral lung lesions. However, research on ROSE combined with MT for the management of pleural disease has been rarely reported. We aimed to evaluate the diagnostic performance of ROSE for pleura biopsies and visual diagnosis by thoracoscopists for gross thoracoscopic appearance. The secondary objective was to assess the intermodality agreement between ROSE and the final histopathologic diagnosis.

Methods

A total of 579 patients with exudative pleural effusion (EPE) who underwent MT combined with ROSE from February 2017 to December 2020 at Taihe Hospital were included in the study. Thoracoscopists' visual diagnosis of gross thoracoscopic appearance, ROSE results, histopathologic findings, and the final diagnosis was recorded.

Results

Thoracoscopic pleural biopsies were performed in 565 patients (97.6%); 183 patients were confirmed to have malignant pleural effusion (MPE), and 382 patients were confirmed to have benign pleural effusion (BPE). The area under the curve of ROSE for the diagnosis of MPE was 0.96 (95% CI: 0.94-0.98, p < 0.001), with a sensitivity of 98.7%, a specificity of 97.2%, a diagnostic accuracy of 97.1%, a positive predictive value of 97.2%, and a negative predictive value of 97.2%. Diagnostic consistency between ROSE and histopathology was good (κ ± SE = 0.93 ± 0.02, p < 0.001). The area under the curve of the thoracoscopists' visual diagnosis of gross thoracoscopic appearance was 0.79 (95% CI: 0.75-0.83, p < 0.01), with a sensitivity of 76.7%, a specificity of 80.9%, a positive predictive value of 62.4%, and a negative predictive value of 89.3%.

Conclusion

ROSE of touch imprints of MT biopsy tissue during MT showed high accuracy for distinguishing between benign and malignant lesions. In addition, ROSE was in good agreement with the histopathological diagnosis, which may help thoracoscopists perform pleurodesis (talc poudrage) directly during the procedure, especially in patients with malignant results.

Spontaneous Resolution of Recurrent Pleural Effusion in Atraumatic Splenic Rupture

Spontaneous splenic rupture is an uncommon cause of acute-onset left-sided pleural effusion. It is often immediate with a high preponderance for recurrence, sometimes even requiring splenectomy. We report a case of spontaneous resolution of recurrent pleural effusion presenting a month after the initial atraumatic splenic rupture. Our patient was a 25-year-old male without significant medical history who was taking Emtricitabine/Tenofovir for pre-exposure prophylaxis. He presented to the pulmonology clinic for left-sided pleural effusion, diagnosed in the emergency department a day prior. He had a history of spontaneous grade III splenic injury one month before, where he was diagnosed with cytomegalovirus (CMV) and Epstein-Barr virus (EBV) co-infection on polymerase chain reaction (PCR) testing and was managed conservatively. The patient underwent thoracentesis in the clinic, which showed exudative lymphocyte predominant pleural effusion and no malignant cells. The remainder of the infective workup was negative. He was readmitted two days later with worsening chest pain, and imaging revealed re-accumulation of pleural fluid. The patient declined thoracentesis, and a chest X-ray was repeated a week later, showing worsening pleural effusion. The patient insisted on continuing conservative management, and he was seen a week later with a repeat chest X-ray that showed near resolution of pleural effusion. Splenomegaly and splenic rupture can lead to pleural effusion due to posterior lymphatic obstruction, which can be recurrent. There are no current guidelines on management, and treatment options include watchful monitoring, splenectomy, or partial splenic embolization.

Hydropneumothorax With Bronchopleural Fistula Following the Activation of Mycobacterium tuberculosis: A Case Report

Tuberculosis is not a disease of the current era; failure to eradicate it continues to cause unusual complications, which results in detrimental sequelae to the patients. It usually presents with respiratory symptoms such as shortness of breath, cough, and fever, in addition to extrapulmonary symptoms. While there have been a few published case reports on patients presenting with hydropneumothorax due to tuberculosis, its occurrence is relatively rare. Furthermore, to the best of our knowledge, this is the first published case of hydropneumothorax due to tuberculosis within the United Arab Emirates, as confirmed by a search on PubMed. Here, we present a case of a young farmer from Bangladesh who presented with shortness of breath and fever and was found to have decreased air entry along with hyperresonance sounds on examination. Fortunately, the patient was in a stable state, required minimum oxygen therapy, and was not escalated for further noninvasive or invasive mechanical ventilation. The patient was admitted to a tertiary hospital to receive initial medical therapy interim to transfer the patient to a facility where thoracic surgeons are found.

Clinical characteristics and risk factors of patients with eosinophilic fasciitis associated with pleural effusion

To investigate the risk factors of eosinophilic fasciitis (EF) associated with pleural effusion (PE). A retrospective analysis was performed on 22 patients with EF diagnosed by skin biopsy in our hospital, and they were divided into EF-PE and EF according to chest computed tomography examination. The clinical characteristics, clinical manifestations, comorbidities and laboratory test indicators of the two groups were collected and compared, and the risk factors for occurring PE in patients with EF were determined by multivariate logistic regression analysis. Among 22 patients with EF, 8 had PE. The age, course of disease, incidence of fever, weight loss, cough and shortness of breath, pulmonary infection, hypothyroidism, hydronephrosis and kidney stone, swelling rate of small vascular endothelial cells, consolidation shadows, C-reactive protein and thyroid stimulating hormone in EF-PE group were higher than those in EF group, while free triiodothyronine and thyroxine were lower than those in EF group. Age, fever, shortness of breath, C-reactive protein, ESR, thyroid stimulating hormone, pulmonary infection, hypothyroidism, hydronephrosis, kidney stones, swollen small vascular endothelial cells and chest CT consolidation shadows were identified as risk factors for happening PE in patients with EF, while free triiodothyronine and free thyroxine were identified as protective factors against PE in patients with EF. The incidence of EF-PE was 36.36% in this study. Advanced age, high C-reactive protein, ESR, thyroid stimulating hormone, incidence of fever, shortness of breath, pulmonary infection, hydronephrosis, kidney stones, swollen small vascular endothelial cells, chest CT consolidation shadows, and low free triiodothyronine and thyroxine suggest that patients with EF are significantly at increased risk of PE.

Rare capture: The detection of synchronous diffuse large B-cell lymphoma and lung adenocarcinoma diagnosed by effusion cytology

The diagnosis of two primary synchronous malignancies in a single pleural effusion cytology specimen is exceedingly rare. We describe, to the best of our knowledge, the first reported case of lung adenocarcinoma and suspected relapse of Diffuse Large B-Cell Lymphoma (DLBCL) diagnosed from a solitary effusion sample.

Cytology of malignant pleural mesothelioma: Diagnostic criteria, WHO classification updates, and immunohistochemical staining markers diagnostic value

Malignant pleural mesothelioma (MPM) is a rare but aggressive malignancy with a poor prognosis. Because of this tumor rarity and overlapping histologic features with other malignancy types, the histopathological findings and diagnostic immunohistochemical workup are essential in establishing the final diagnosis of MPMs. We aimed to review the diagnostic criteria, WHO tumor classification updates, and immunohistochemical staining markers diagnostic value to achieve an appropriate clinical diagnosis.

Characteristics and negative impacts of pleural effusion in hospitalized patients undergoing maintenance hemodialysis

BACKGROUND

Hospitalized patients on maintenance hemodialysis often develop pleural effusion (PE). The prognosis of these patients is likely to be affected by the PE. This study examined the characteristics of PE, identified risk factors for its development, and explored its negative effects.

METHODS

In this retrospective study, we analyzed medical records of 1,077 patients who underwent maintenance hemodialysis between October 2014 and January 2022. According to the chest computed tomography (CT) imaging results, patients were categorized into two groups: PE and non-PE. A definitive diagnosis of PE was made after a nephrologist, a pulmonary physician, and a radiologist reviewed the case.

RESULTS

Of the 1,077 patients, 343 (31.85%) were diagnosed with PE. These patients had a mean age of 55.28±15.21 years old and 61.47% of them were men. There were 77.84% patients with PE resulting from heart failure, and 82.02% of these patients had bilateral effusions. The occurrence of PE was associated with cardiovascular disease, clinic-systolic blood pressure (SBP), chest tightness, leg edema, and pro-brain natriuretic peptide (pro-BNP). PE patients had a poorer survival rate than patients without PE (unadjusted hazard ratio [HR]: 4.17; 95% CI: 3.12-5.57). The survival rates of patients with small PE did not differ from those with moderate to large PE. Similarly, no difference was found in survival between the bilateral PE and unilateral PE groups, as well as between the heart failure and non-heart failure groups.

CONCLUSIONS

Hospitalized patients undergoing maintenance hemodialysis have a high incidence of PE. PE (even a small amount) is an risk factor for increased mortality. These poor prognostic features should be noted by physicians and managed accordingly.