Malignant Pleural Effusion and Its Current Management: A Review

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.

Pleural Space Diseases and Their Management: What is the Role of Intrapleural Fibrinolytic Therapy?

Pleural space diseases are a significant cause of morbidity in the United States with a reported 25% mortality rate within a year of diagnosis. Pleural space diseases, including intrapleural infections, retained hemothorax (RH), and malignant pleural effusions (MPE), often indicate advanced disease. Despite options like video-assisted thoracoscopy (VATS), tube thoracostomy, and intrapleural fibrinolytic therapy (IPFT), treatment remains a significant clinical challenge. IPFT, which describes a combination of administrating tissue plasminogen activator (tPA) and DNase through a chest tube, has shown effectiveness in improving fluid drainage and reducing surgery frequency in a large, randomized control trial and is widely used. However, the success of IPFT varies based on infection severity, patient health, and treatment timing, with a failure rate around 20-25%. This highlights the need for further research to enhance the therapy's efficacy, investigating both disease mechanisms and optimizing treatment protocols. This review seeks to provide a comprehensive overview of IPFT, highlighting recent advancements, current trends, and existing research gaps.

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.

Diagnostic Accuracy of Shear Wave Elastography in Predicting Malignant Origins of Pleural Effusions in Emergency Departments

Objective: Ultrasound is a valuable diagnostic tool in the diagnostic work-up of dyspnea and can identify even small pleural effusions. The incorporation of shear wave elastography (SWE) represents a possible tool in stratifying pleural effusions by the risk of underlying malignancy. No previous studies on ultrasound with the incorporation of SWE have been conducted in an emergency department (ED), where such stratification might have a clinical impact by hastening referrals for the diagnostic work-up of underlying malignancy. The objective of this study was to appraise the diagnostic accuracy of ultrasonographic findings associated with thoracic malignancy as well as to calculate the optimal cutoff values for SWE in this regard. Methods: Patients with a unilateral pleural effusion of unknown origin were included in the ED and subjected to a thoracic ultrasound (TUS) scan during their first 48 h after admittance. Two index tests were applied: (i) traditional B-mode TUS examination registering the presence of diaphragmatic nodules, pleural thickenings and other findings associated with malignancy and (ii) an SWE examination of different regions of interest. The reference test was defined as the subsequent diagnosis of malignant pleural effusion (MPE) in the three months following inclusion. Results: In total, 39 patients were included. The B-mode TUS index test yielded a sensitivity of 28.57% (95%CI 3.67-70.96%) and a specificity of 90.62% (95%CI 74.98-98.02%). The SWE max of the intercostal space yielded a sensitivity of 100% (95%CI 47.82-100%) and a specificity of 59.09% (95%CI 36.35-79.29%). Conclusions: A TUS with integrated SWE may aid in identifying MPEs and improving referrals for the diagnostic work-up of underlying malignancy. Larger, adequately powered studies are warranted.

Tumor Markers in Pleural Fluid: A Comprehensive Study on Diagnostic Accuracy

Background/Objectives: Malignant pleural effusions (MPEs) pose a significant challenge in clinical practice and exert a considerable socio-economic burden on the healthcare system, affecting approximately 1 million individuals annually. These effusions are a leading cause of debilitating dyspnea and a diminished quality of life among cancer patients, with distant metastasis to the pleural layers occurring in about 20% of cases during treatment. Methods: A cross-sectional, observational case-control study was conducted on 151 Bulgarian patients with a hydrothorax. The control group included 72 patients with benign diseases, confirmed via biopsy, with 38 having inflammatory and 34 non-inflammatory pleural effusions. The other 79 patients had malignant pleural involvement. These groups are representative of the main types of pleural pathology. Results: The study found that all of the tumor markers, except for PIVKA-II (Protein induced by vitamin K absence-II), showed statistically significant differences between the malignant and non-malignant patient groups, with CAE (carcinoembryonic antigen) and CA19-9 showing the most notable differences. The Receiver Operating Characteristic (ROC) analysis revealed that CA72-4 had the best ability to distinguish between the two groups, while PIVKA was the weakest, with optimal cut-off values for all of the relevant tumor markers being derived using the Youden index. Conclusions: In conclusion, our study highlights the transformative potential of pleural fluid tumor markers as precise and minimally invasive resources for distinguishing malignant from non-malignant pleural effusions. These findings pave the way for improved diagnostic accuracy and personalized clinical management, addressing a critical gap in the care of patients with pleural pathologies.

Activity behaviours and quality of life in patients with malignant pleural effusion

Background and objective

Accelerometery is used to measure activity behaviours in patients with malignant pleural effusion (MPE). This study aimed to evaluate physical activity and sedentary behaviour profiles of patients with MPE in Hong Kong, and to explore relationships between activity behaviours and quality of life (QoL). We also compared clinician-recorded performance status measures with objective measures of activity levels.

Methods

Participants wore an Actigraph GT3X+ accelerometer continuously for 7 consecutive days. The EuroQoL 5 Dimensions 5 Levels (EQ-5D-5L) was used to assess five dimensions of QoL and correlate with activity behaviours. The Eastern Cooperative Oncology Group (ECOG) performance status was documented by clinicians at baseline.

Results

Fifty-one patients with MPE received accelerometers; 94% had ≥1 valid day of data. Participants spent 76% (sd 2.32) of waking hours sedentary, 23% (sd 1.40) of waking hours in light activity and 0.3% (median, interquartile range 0.0-1.5) in moderate-to-vigorous physical activity (MVPA). Higher light activity and MVPA behaviours were associated with increased participation in self-care tasks (rs=-0.43, p=0.003; rs=-0.45, p=0.001, respectively) and usual activities (rs=-0.42, p=0.003; rs=-0.45, p=0.001, respectively). Patients with an ECOG status of 0 or 1 spent an average of 75% of waking hours sedentary.

Conclusion

This is the first report of physical activity behaviours in patients with MPE in Hong Kong, demonstrating high sedentary behaviours and low physical activity which correlated to dimensions of QoL. Clinician-rated performance status was not reflected in accelerometery data, suggesting a discrepancy between performance status measures and objective measures of activity in patients with MPE.

Predictors for spontaneous pleurodesis in patients with indwelling pleural catheters for malignant pleural effusion: a safety net hospital experience

BACKGROUND

Malignant pleural effusion (MPE) affects approximately 150,000 patients in the United States each year and usually signifies advanced-stage cancer. The optimal treatment remains a challenge but indwelling pleural catheters (IPC) offer several advantages and may help achieve spontaneous pleurodesis (SP) in some patients.

OBJECTIVES

We aim to investigate the predictors of SP among patients with MPE, particularly in a resource-limited community-based safety net hospital.

DESIGN

This is a retrospective cohort study done at a community-based safety net hospital.

METHODS

Adults diagnosed with or suspected of having MPE between January 2015 and December 2023 who underwent IPC placement were included. Data was collected retrospectively from December 2023 to June 2024. Data encompassed demographics, imaging, post-procedural complications, pleural fluid analysis, oncology treatment history, and utilization of medical thoracoscopy without chemical pleurodesis (MTWCP) for diagnosis.

RESULTS

A total of 173 patients underwent IPC insertion. Most of our patients were women (64.2%), and Latin American (65.9%), with a mean age of 55.3 years. The most common type of primary cancer was breast (28.9%) followed by lung (23.1%) and lymphoma (6.9%). Pleural fluid characteristics such as glucose, eosinophils, Lactate Dehydrogenase (LDH), and protein concentration were not significantly associated with SP. Most patients had low Eastern Cooperative Oncology Group scores of 0-2 (64.6%) and low LENT (Lactate Dehydrogenase (L), Eastern Cooperative Oncology Group (E) Performance Score, Neutrophil-to-Lymphocyte Ratio (N), and Tumor type (T) score) scores of 0-4 (59%). Lower scores (better functional status) were significantly associated with SP. Post-IPC chemotherapy and/or radiotherapy and immunotherapy were significantly associated with SP, adjusted odds ratio (OR) 7.295 (95% CI: 3.05-17.4, p = 0.001) and adjusted OR 6.261 (95% CI: 2.73-14.36, p = 0.001) respectively. MTWCP was also a predictor of SP with an adjusted OR of 4.031 (95% CI: 1.452-11.19, p = 0.007).

CONCLUSION

Our study is the first to assess predictors of SP in a resource-limited safety net hospital representing under-represented and underserved patients. We identify several factors associated with higher rates of SP such as higher functional status, MTWCP, chemotherapy, immunotherapy, and radiation post-IPC placement. The study findings can help clinicians consider IPC placement and guide them regarding the duration and possible complications of IPC. MTWCP appears to improve the success of SP. Further studies are needed to assess these findings further.

The double face of licorice-kansui herb pair: Cure or curse, depending on the combining ratio and mediated by hydrogen sulfide

BACKGROUND

The safety and efficacy of herbal medicines including traditional Chinese medicine (TCM) has been one of the major scientific problems in the medical field. In TCM prescriptions, reasonable herbal combinations bring stronger efficacy and low risk of toxicity. However, the rules and mechanisms for herbal combinations are far from complete understood yet.

PURPOSE

In this study, we investigated the efficacy-toxicity transformation of the licorice-kansui herbal combination under clinical equivalent doses, and study the inside mechanisms.

STUDY DESIGN

Licorice-kansui or glycyrrhetinic acid-kansuinine A combinations of different combining ratio were given to malignant pleural effusion mice as well as the IEC-6 and S-180 cells.

METHODS

The therapeutic and toxic effects were characterized by various indicators; the chemical changes were analyzed by LC-MS method; the role of H2S was also studied through its inhibitors.

RESULTS

Low-proportion of licorice combined with kansui exerted comparable therapeutic effects to cisplatin, by reducing pleural effusion, promoting respiration, increasing urine volume, protecting lung tissue, and inhibiting tumor cells by inducing oxidative stress and apoptosis. On the other hand, high-proportion of licorice combined with kansui had poor therapeutic effect but induced oxidative stress, inflammation and tissue damages, especially to the small intestine. This efficacy-toxicity transformation was also reproduced by the glycyrrhetinic acid-kansuinine A combination on IEC-6 epithelial cells and S-180 tumor cells. The transformation was not simply caused by the in-solution solubilization effects of licorice during co-decocted with kansui. Furthermore, the therapeutic and toxic effects were both highly related to the hydrogen sulfide level and its anabolic enzymes, cystathionine-gamma-lyase (CSE) or cystathionine beta-synthase (CBS), either in tissues or in-vitro cells. By inhibiting CSE or CBS, all the therapeutic or toxic effects were abolished both in-vivo and in-vitro. Moreover, the intestinal sulfide-reducing bacteria Desulfovibrio and body drug-metabolism were also important variants influencing the efficacy-toxicity transformation of licorice-kansui herbal combination.

CONCLUSION

This study comprehensively uncovered the rules of licorice-kansui herbal combination, and for the first time confirmed that H2S plays a crucial role in mediating its efficacy-toxicity transformation. Our study not only supports the reasonable clinical usage of these two herbs but also provide ideas and methods for the study of other herb pairs in TCM prescriptions.

Comparison of five scores to predict mortality in malignant pleural effusion

Malignant pleural effusion (MPE) is a complication of malignancy. Treatment of MPE is based on predicted outcome. The aim of this study was to compare the performance characteristics of LENT, PROMISE, RECLS, AL and pNLR scores for prediction of mortality in lung cancer patients who have MPE. Patients who were diagnosed with MPE that was associated with underlying lung cancer between January 2010 and December 2019 were included and analyzed retrospectively in a single center. Outcomes considered were 30-day, 6 months, and 1-year mortality. A total of 180 patients were examined. For 30-day mortality, the areas under the ROC curves (AUC) (95% CI) were: LENT 0.83 (0.76-0.87), RECLS 0.71 (0.63-0.77), and PROMISE 0.70 (0.17-0.38). For 6-month and 1-year mortality the order of these AUCs was similar. Cox regression showed that none of the scores were significantly associated with 30-day mortality, but LENT and RECLS were significantly associated with 6-month and 1-year mortality. Comparison of - 2log likelihood ratios showed that LENT score was more, strongly associated with 6-month mortality than PROMISE (p = 0.001) or RECLS (p = 0.02). LENT score was also more strongly associated with 1-year mortality than PROMISE (p = 0.001) but there was no difference between LENT and RECLS score (p = 0.64). We observed that the LENT score was more predictive than the other scores in mortality in patients who have lung cancer and MPE. The LENT and RECLS scores have similar performance characteristics for prediction of 1-year mortality in these patients.

Analysis of Cellular DNA Content in Pleural Effusion by Flow Cytometry During Lung Cancer Progression: A Case Report

Malignant pleural effusion (MPE) is a common feature in patients with advanced or metastatic malignancies. While significant progress has been made in understanding the biology of pleural effusions, further research is needed to uncover the subsequent behavior of tumor cells following their invasion into the pleural space. This report utilizes flow cytometry to analyze DNA content abnormalities (aneuploidy) and cell cycle status, shedding light on the tumor cell populations present in MPE samples from a patient with lung adenocarcinoma during treatment. The findings suggest that under selective pressure, certain tumor cell subpopulations within the pleural effusion were suppressed, while therapy-resistant subpopulations emerged, driving disease progression. MPE serves as a valuable model for studying tumor heterogeneity and clonal dynamics in real time, offering insights that may inform diagnosis, prognosis, and therapeutic strategies.

Predictors of lung entrapment in malignant pleural effusion

INTRODUCTION

Malignant pleural effusion (MPE) is a common complication in advanced stages of malignancy and is associated with poor prognosis. Non-expandable lung (NEL) often occurs and its presence influences the MPE approach. Our main objective was to assess risk factors for malignant NEL.

METHODS

Patients diagnosed with pathologically confirmed MPE between January 2012 and December 2018 in our institution were retrospectively analyzed. Demographic and clinical data of patients were reviewed and compared according to the presence or absence of NEL. A univariate and multivariate binary logistic regression analysis were used to determine predictors of the development of NEL.

RESULTS

Of 365 patients included, 68 (18.6%) had NEL. After multivariate analysis, we found that loculated MPE (OR 8.63, 95%CI 4.30-17.33, p<0.001), complete hemithorax opacification (OR 2.81, 95%CI 1.17-6.76, p<0.021), lung cancer (OR 2.09, 95%CI 1.01-4.31, p=0.047) and higher effusion-serum LDH ratio (OR 1.09, 95%CI 1.00-1.17, p=0.039) were independent predictors of malignant NEL. There were no significant differences compared with expandable lung group regarding time from primary malignancy diagnosis to MPE diagnosis (3.0, IQR 0.0-75.8 vs 2.0, IQR 0.0-75.5 weeks, p=0.942) or MPE symptoms onset to MPE diagnosis (4.0, IQR 1.0-9.0 vs 3.0, IQR 1.0-9.0 weeks, p=0.497). Patients with NEL had a higher number of therapeutic pleural drainages (3.0, IQR 2.0-6.0 vs 2.0, IQR 1.0-3.0; p<0.001) and longer hospital stay (32.5, IQR 15.5-46.3 vs 21.0, IQR 11.0-36.0, p=0.007), measured in hospitalization days until the end of life, than patients with expandable lung. The rate of recurrence of pleural effusion was not significantly different between groups (p=0.291). Overall survival (OS) was 3.0 (95%CI, 2.3-3.7) months, regardless of lung expandability (p=0.923).

CONCLUSION

Loculated MPE, complete hemithorax opacification, lung cancer and a higher effusion-serum LDH ratio were found to be independent predictors for NEL. These patients underwent thoracocenteses more frequently and had longer hospitalization days, although without significant impact in the OS.

Malignant Pleural Effusion: A Multidisciplinary Approach

Malignant pleural effusion (MPE) has become an increasingly prevalent complication in oncological patients, negatively impacting their quality of life and casting a shadow over their prognosis. Owing to the pathophysiological mechanisms involved and the heterogeneous nature of the underlying disease, this entity is both a diagnostic and therapeutic challenge. Advances in the understanding of MPE have led to a shift in the treatment paradigm towards a more personalized approach. This article provides a comprehensive review and update on the pathophysiology of MPE and describes the diagnostic tools and the latest advances in the treatment of this complex clinical entity.

Talc slurry versus thoracoscopic talc insufflation for malignant pleural effusion: a systematic review and meta-analysis

OBJECTIVE

Talc pleurodesis is a widely used treatment option for malignant pleural effusion (MPE). However, the optimal form of administration remains controversial. Thus, we performed a systematic review and meta-analysis to assess the effectiveness of talc slurry (TS) in comparison with thoracoscopic talc insufflation/poudrage (TTI) for MPE treatment.

METHODS

We searched PubMed, EMBASE, and Cochrane Library databases for studies that compared TS with TTI in patients with MPE. We used a random-effects model with a 95% CI to pool the data. Heterogeneity was assessed with I2 statistics.

RESULTS

We included eight studies involving 1,163 patients, 584 of whom (50.21%) underwent TS. Pleurodesis failure rates were similar between the procedures (OR = 1.07; 95% CI: 0.56-2.06; p = 0.83; I2 = 62%); and 68% of patients (95% CI: 0.31-1.47; p = 0.33; I2 = 58%) had postoperative complications, which were lower in patients in the TS group than in the TTI group. In a subgroup analysis considering only randomized clinical trials, the failure rate was significantly lower in the TS treatment group (OR = 0.62; 95% CI: 0.42-0.90; p = 0.01; I2 = 0%). Similarly, dyspnea was less common in the TS group (OR = 0.74; 95% CI: 0.41-1.34; p = 0.32; I2 = 55%). Adverse effects were reported in 86 patients, and no significant difference was seen between the TS and TTI groups: empyema (OR = 1.43; 95% CI: 0.36-5.64; p = 0.86; I2 = 0%), pain (OR = 1.22 (95% CI: 0.67-2.21; p = 0.51; I2 = 38%), and pneumonia (OR = 1.15; 95% CI: 0.30-4.46; p = 0.86; I2 = 27%).

CONCLUSIONS

Our findings suggest that TS is an effective treatment for MPE, with no significant increase in adverse events. Results suggest equivalent efficacy and safety for both procedures.

Pleural fluid biomarkers: a narrative review

Background and Objective

Pleural fluid is a source from which various biomarkers can be obtained and measured to facilitate the management and prognostication of various conditions. This narrative review aims to summarise a few selected applications of pleural fluid biomarker analysis based on the latest literature.

Methods

A literature search for articles published in English regarding human subjects from the period January 2000 to December 2023 was performed through PubMed. Publications considered by the authors to be relevant were included in this review, with additional references added based on the authors' judgement. This review considered both prospective and retrospective cohort studies analysing the clinical value of a range of pleural fluid biomarkers.

Key Content and Findings

The biomarkers selected in this narrative review have either established clinical applicability or promising initial results which require further research. Pleural fluid adenosine deaminase, mesothelin and N-terminal pro-B-type natriuretic peptide can optimize the diagnosis of tuberculous pleuritis, malignant mesothelioma and heart failure-related pleural effusion respectively. The detection rate for epidermal growth factor receptor mutations for lung cancer is higher in the pleural fluid than in the pleural tissue or plasma. Suitable targeted therapy in patients with detectable mutations can offer survival benefits. The pleural fluid neutrophil-lymphocyte ratio, soluble urokinase plasminogen activator receptor and plasminogen activator inhibitor 1 carry prognostic implications and can potentially guide subsequent treatment decisions. These biomarkers used individually, or in conjunction with other clinical parameters, should only be utilised in pre-defined, appropriate clinical conditions to maximize their clinical value.

Conclusions

A great variety of different biomarkers are available for analysis in pleural fluid. Further research and development are necessary to widen the spectrum and enhance the clinical utility of pleural fluid biomarkers. Comparison with the diagnostic utilities of serum biomarkers and other investigation parameters, such as radiological findings, could be considered when evaluating the performance of pleural fluid biomarkers.

Contribution of crosstalk of mesothelial and tumoral epithelial cells in pleural metastasis of lung cancer

Background

Tumor metastasis commonly affects pleura in advanced lung cancer and results in malignant pleural effusion (MPE). MPE is related to poor prognosis, but without systematic investigation on different cell types and their crosstalk at single cell resolution.

Methods

We conducted single-cell RNA-sequencing (scRNA-seq) of lung cancer patients with pleural effusion. Next, our data were integrated with 5 datasets derived from individuals under normal, non-malignant disease and lung carcinomatous conditions. Mesothelial cells were re-clustered and their interactions with epithelial cells were comprehensively analyzed. Taking advantage of inferred ligand-receptor pairs, a prediction model of prognosis was constructed. The co-culture of mesothelial cells and malignant epithelial cells in vitro and RNA-seq was performed. Epidermal growth factor receptor (EGFR) antagonist cetuximab was utilized to prevent the lung cancer cells' invasiveness. Spatial distribution of cells in lung adenocarcinoma patients' samples were also analyzed to validate our findings.

Results

The most distinctive transcriptome profiles between tumor and control were revealed in mesothelial cells, which is the predominate cell type of pleura. Five subtypes were divided, including one predominately identified in MPE which was characterized by enriched cancer-related pathways (e.g., cell migration) along evolutionary trajectory from normal mesothelial cells. Cancer-associated mesothelial cells (CAMCs) exhibited varied interactions with different subtypes of malignant epithelial cells, and multiple ligands/receptors exhibited significant correlation with poor prognosis. Experimentally, mesothelial cells can increase the migration ability of lung cancer cells through co-culturing. EGFR was the only affected gene in cancer cells that exhibited interaction with mesothelial cells and was associated with poor prognosis. Using EGFR antagonist cetuximab prevented the lung cancer cells' increased invasiveness caused by mesothelial cells. Moreover, epithelial mitogen (EPGN)-EGFR interaction was supported through spatial distribution analysis, revealing the significant proximity between EPGN+ mesothelial cells and EGFR+ epithelial cells.

Conclusions

Our findings highlighted the important role of mesothelial cells and their interactions with cancer cells in pleural metastasis of lung cancer, providing potential targets for treatment.

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.

Diagnosis of malignant body fluids via cancer-universal methylation in cell-free DNA

BACKGROUNDDifferentiating malignant from nonmalignant body fluids remains a clinical challenge because of the unsatisfying performance of conventional cytology. We aimed to improve the sensitivity and ubiquity of cancer cell detection by assaying universal cancer-only methylation (UCOM) markers in supernatant cell-free DNA (cfDNA).METHODSAn observational prospective cohort including 1,321 nonmalignant and malignant body fluids of multiple cancers was used to develop and validate a cfDNA UCOM methylation diagnostic assay. All samples were divided into 2 portions for cytology and supernatant cfDNA methylation analysis.RESULTSThe significant hypermethylation of a potentially novel UCOM marker, TAGMe, together with the formerly reported PCDHGB7, was identified in the cfDNA of malignant body fluid samples. The combined model, cell-free cancer-universal methylation (CUE), was developed and validated in a prospective multicancer cohort with markedly elevated sensitivity and specificity, and was further verified in a set containing additional types of malignant body fluids and metastases. In addition, it remained hypersensitive in detecting cancer cells in cytologically negative malignant samples.CONCLUSIONcfDNA methylation markers are robust in detecting tumor cells and are applicable to diverse body fluids and tumor types, providing a feasible complement to current cytology-based diagnostic analyses.TRIAL REGISTRATIONThis study was registered at Chictr.org.cn (ChiCTR2200060532).FUNDINGNational Natural Science Foundation of China (32270645, 31872814, 32000505, 82170088), the National Key R&D Program of Ningxia Hui Autonomous region (2022BEG01003), Shanghai Municipal Key Clinical Specialty (shslczdzk02201), Science and Technology Commission of Shanghai Municipality (20DZ2261200, 20DZ2254400), and Major Special Projects of Basic Research of Shanghai Science and Technology Commission (18JC1411101).

Intrapleural nivolumab in cancer patients with pleural effusion

ABSTRACT

We assessed the preliminary efficacy and toxicity of intrapleural instillation of nivolumab in patients with large pleural effusion. Patients with metastatic cancers who have a large volume of pleural effusion and required evacuation were eligible. Thoracentesis followed by nivolumab (40 mg, single intrapleural instillation) was performed. The primary endpoint was 3-month recurrence-free survival. A total of 13 patients were enrolled. The study was terminated after stage 1 as no efficacy was observed; 7 patients (54%) had a recurrence of pleural effusion at 3 months. Thirteen (100%) patients had no recurrence, dyspnea, or cough within 1 month, and the median time to recurrence was 1.9 months (95% confidence interval [CI], 1.35-2.5). No adverse events were identified. We concluded that a single intrapleural instillation of the nivolumab at 40 mg was ineffective and well-tolerated in cancer patients with pleural effusion.

Home Ultrasound: A Contemporary and Valuable Tool for Palliative Medicine

This narrative review explores the application of point-of-care ultrasound (POCUS) in palliative care and its feasibility in home care settings. POCUS has the potential to streamline diagnostic strategies without patient transfer to the hospital, expedite timely symptomatic relief, and reduce complications from specific palliative interventions. The advent of handheld ultrasound devices has made it an attractive diagnostic and interventional adjunct in acute palliative care. POCUS has gained widespread acceptance as part of routine care in emergency medicine and intensive care, guiding certain procedures and increasing their safety. The modernization and miniaturization of ultrasound equipment have made ultra-portable devices available, allowing for better-quality images at affordable prices. Handheld devices have the potential to revolutionize everyday clinical practice in home-based palliative care, contributing to important bedside clinical decisions. Palliative care patients often require diagnostic examinations in the last months of their lives, with CT being the most frequently performed imaging procedure. However, CT imaging is associated with high costs and burdens, leading to increased suffering and impaired quality of life. Clinical ultrasound, a dialogic imaging modality, offers a safer and more efficient approach to palliative care. POCUS applications, which are cost-effective, non-invasive, and well-tolerated, can be used to improve patient satisfaction and diagnostic understanding. POCUS is a valuable tool in palliative care, improving diagnostic accuracy and reducing the time to diagnosis for various pathologies. It is a standard of care for many procedures and improves patient safety. However, there are limitations to POCUS in palliative care, such as operator-dependent examination variability and limited availability of trained professionals. To overcome these limitations, palliative care physicians should receive mandatory training in POCUS, which can be incorporated into the core curriculum. Additionally, ultrasound teleconsulting can assist less experienced examiners in real-time examinations. The literature on POCUS in palliative care is limited, but research on patient-oriented outcomes is crucial. POCUS should be considered a supplement to good clinical reasoning and regulated radiological evaluations.

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.

Treatment and Management of the Clinical Manifestations of Advanced Breast Cancer

OBJECTIVES

People with advanced breast cancer (ABC) experience complex and debilitating physical symptoms of their disease that can have a profound effect on quality of life. This report provides an overview of the clinical manifestations related to different metastatic sites in ABC and potential oncologic emergencies.

DATA SOURCES

Date sources include peer-reviewed papers sourced in electronic databases (CINAHL, MEDLINE, Google Scholar) and national and international best practice guidelines.

CONCLUSION

People living with ABC experience multiple symptoms of disease that can impact on quality of life and physical functioning. The most common sites of metastatic disease are bone, lung, liver and brain. Clinical manifestations of ABC include pain, pathologic fractures, pleural effusions, and ascites. Potential oncologic emergencies related to these metastatic sites include hypercalcemia, malignant spinal cord compression, superior vena cava obstruction, and raised intracranial pressure.

IMPLICATIONS FOR NURSING PRACTICE

It is important for nurses to have informed knowledge and understanding of these clinical manifestations. This will enable them to be vigilant and perform targeted patient evaluation to assess signs and symptoms with a view to identifying potentially life-threatening emergencies and initiating interventions or appropriate referral or follow-up accordingly.

Evaluation of Surgical Clinic Nurses' Knowledge Levels About Palliative Surgery

BACKGROUND

Currently, palliative care plays an important role in increasingly aging populations and their long-term care needs. Surgical palliative care is important for improving quality of life. This study aimed to determine the knowledge level of nurses working in surgical clinics about palliative surgery.

METHOD

This research was conducted as a descriptive study. We included 182 nurses working in surgical clinics who agreed to participate and met the inclusion criteria for participation in the study. The Personal Information and Palliative Surgery Information Forms were used to collect data. Data were collected between November 30, and December 15, 2022. The analysis of the data obtained was performed using the Statistical Program in Social Sciences (SPSS), Version 25. The level of significance was set at P < .05.

RESULTS

Nurses referred to palliative care as end-of-life care, 73.1% did not care for palliative care patients, and 84.6% did not receive training in palliative care. Surgical clinic nurses were found to have "moderate knowledge about palliative surgery. A statistically significant difference was found between the average palliative surgery knowledge of surgical clinic nurses and those trained in education and palliative care (P < .05).

CONCLUSIONS

The results of the study showed that surgical clinic nurses had moderate knowledge about palliative surgery. Moreover, the nurses who have received training in palliative care and had high level of education exhibited a higher level of knowledge.

Expression of cytokines in pleural effusions and corresponding cell lines of small cell lung cancer

Background

Small cell lung cancer (SCLC) is a neuroendocrine aggressive tumor with a dismal prognosis due to the lack of curative therapeutic modalities. Approximately 11% of these patients show a malignant pleural effusion (MPE) that increase in frequency with progression of the disease. In MPE, fluid accumulates due to leaky vessels and mesothelial surfaces as well as impaired removal of fluid due to impaired drainage.

Methods

For this investigation, three SCLC MPE samples and supernatants of the corresponding isolated cell lines were analyzed for the content of 105 cytokines, chemokines, and growth factors. Overexpressed pathways including these cytokines were identified using Reactome analysis tools.

Results

A large range of cytokines, including vascular endothelial growth factor A (VEGFA), were found to be expressed in the MPEs and conditioned media of the corresponding cell line. These mediators are involved in pathways such as interleukin (IL) signaling, growth factor stimulation, modulation of cell adhesion molecules and proliferative cell signaling. Cytokine expression by the corresponding SCLC cell lines revealed the specific contributions of the tumor cells and included high expression of VEGFA, tumor-promoting factors and mediators exerting immunosuppressive and protumor effects. MPEs used here showed marked stimulation of the proliferation of four permanent SCLC cell lines.

Conclusions

MPEs comprise a large number of cytokines with mixed activities on tumor cells and the invading SCLC cells release a number of protumor mediators and induce an immunosuppressive pleural environment.

IR808@MnO nano-near infrared fluorescent dye's diagnostic value for malignant pleural effusion

BACKGROUND

Malignant pleural effusion is mostly a complication of advanced malignant tumors. However, the cancer markers such as carbohydrate antigen 125 (CA 125), carbohydrate antigen 15-3 (CA 15-3), carbohydrate antigen 19-9 (CA 19-9), and cytokeratin fragment 21-1 (CYFRA 21-1) have low sensitivity and organ specificity for detecting malignant pleural effusion.

RESEARCH QUESTION

Is IR808@MnO nano-near infrared fluorescent dye worthy for the diagnosis in differentiating benign and malignant pleural effusions.

STUDY DESIGN AND METHODS

This experiment was carried out to design and characterize the materials for in vitro validation of the new dye in malignant tumor cells in the A549 cell line and in patients with adenocarcinoma pleural effusion. The dye was verified to possess tumor- specific targeting capabilities. Subsequently, a prospective hospital-based observational study was conducted, enrolling 106 patients and excluding 28 patients with unknown diagnoses. All patients underwent histopathological analysis of thoracoscopic biopsies, exfoliative cytological analysis of pleural fluid, and analysis involving the new dye. Statistical analyses were performed using Microsoft Excel, GraphPad Prism, and the R language.

RESULTS

The size of IR808@MnO was 136.8 ± 2.9 nm, with peak emission at 808 nm, and it has near-infrared fluorescence properties. Notably, there was a significant difference in fluorescence values between benign and malignant cell lines (p < 0.0001). The malignant cell lines tested comprised CL1-5, A549, MDA-MB-468, U-87MG, MKN-7, and Hela, while benign cell lines were BEAS-2B, HUVEC, HSF, and VE. The most effective duration of action was identified as 30 min at a concentration of 5 μl. This optimal duration of action and concentration were consistent in patients with lung adenocarcinoma accompanied by pleural effusion and 5 μl. Of the 106 patients examined, 28 remained undiagnosed, 39 were diagnosed with malignant pleural effusions, and the remaining 39 with benign pleural effusions. Employing the new IR808@MnO staining method, the sensitivity stood at 74.4%, specificity at 79.5%, a positive predictive value of 69.2%, and a negative predictive value of 82.1%. The area under the ROC curve was recorded as 0.762 (95% CI: 0.652-0.872). The confusion matrix revealed a positive predictive value of 75.7%, a negative predictive value of 75.6%, a false positive rate of 22.5%, and a false negative rate of 26.3%.

INTERPRETATION

The IR808@MnO fluorescent probe represents an efficient, sensitive, and user-friendly diagnostic tool for detecting malignant pleural fluid, underscoring its significant potential for clinical adoption.

Lung cancer tumor markers in serous effusions and other body fluids

From its onset and during its progression, lung cancer may affect various extrapulmonary structures. These include the serous membranes, the pleura and pericardium, and less frequently the central nervous system, with leptomeningeal involvement. In these cases, fluid accumulates in the serous membranes which may contain substances secreted by the tumor. Measuring the concentrations of these substances can provide useful information for elucidating the origin of the fluid accumulation, either in pleural and pericardial effusions or in cerebrospinal fluid. This paper describes the histological types of lung cancer that most frequently affect the serosa and leptomeninges. It also reviews the literature on tumor markers in different fluids and makes recommendations for their interpretation.

The International System for Reporting Serous Fluid Cytopathology-An Updated Review

The International System (TIS) for reporting serous fluid cytopathology was published in December 2020 as a joint project by the International Academy of Cytology and the American Society of Cytopathology. The purpose was to standardize the diagnostic criteria and nomenclature used in reporting serous fluid samples, thereby improving the reproducibility of reports and improving communication between pathologists and clinicians. TIS defines a five-tier system consisting of nondiagnostic, negative for malignancy, atypia of uncertain significance, suspicious for malignancy and malignant categories. This review provides an updated summary of the reporting system, risk of malignancy, potential diagnostic pitfalls, and a practical diagnostic approach to serous fluid specimens.

Comparison between pleurodesis results by 50% glucose solution, versus Bleomycin pleurodesis in patients with malignant pleural effusion

BACKGROUND

Following parapneumonic effusions, malignant pleural effusions (MPEs) stand as the second most common cause of exudative pleural effusions. These effusions typically remain unresponsive to systemic chemotherapy, necessitating novel therapeutic approaches. This study aims to ascertain the effectiveness of intrapleural injection with a 50% glucose solution and to compare it with intrapleural injection of Bleomycin sulfate in treating malignant pleural effusion.

METHODS

This prospective, double-blind, randomized clinical trial was conducted at Al-Zahra Hospital in Isfahan. The study protocol gained approval from the Iranian Registry of Clinical Trials (IRCT code: IRCT20201013049017N1) (https://en.irct.ir/trial/52739). The study population encompassed patients with malignant pleural effusion. Sampling occurred through a census approach from October 2019 to March 2020. The first group received a pleurodesis solution containing 12.5 cc of 2% lidocaine with Bleomycin, while the second group received a solution comprising 200 cc of 50% glucose solution (10 grams of glucose) and 12.5 ml of 2% lidocaine, within the same volume. These solutions were injected into the pleural space via the chest tube.

RESULTS

The complete response rate to treatment three months post-injection was 71.9% in the Bleomycin sulfate group and 65.6% in the 50% dextrose group. However, the difference between the two groups did not achieve statistical significance (P = 0.689). The incidence of post-injection fever and pain intensity exhibited comparability in both groups.

CONCLUSION

The treatment involving a combination of 50% glucose solution with Bleomycin for pleurodesis in patients with malignant pleural effusion demonstrated outcomes akin to other treatment options.

Clinical importance of serum and pleural fluid prominin-1 and hypoxia-inducible factor-1α concentration in the evaluation of lymph node involvement in patients with malignant pleural effusion

Introduction

Malignant pleural effusion (MPE) and lymph node metastasis (LNM) presence are poor prognostic factors that have importance for cancer patients. The study objective was to determine whether hypoxia-inducible factor-1α (HIF-1α) and prominin-1 (CD133) in pleural fluid (P) and serum (S) could be used as biomarkers for diagnosis of lymph node involvement in patients with MPE.

Materials and methods

Fifty-six patients with MPE and 30 healthy control subjects were included. Computerized tomography (CT) and positron emission tomography (PET) were used to diagnose pleural effusion. Patients with malignant cells in pleural fluid cytological examination were included in the MPE group. Thirty-five patients with lymph node metastases on CT were included in the LNM-positive MPE group. Serum and pleural fluid HIF-1α and CD-133 concentrations were measured manually via enzyme-linked immunosorbent assay (ELISA).

Results

Serum concentrations of HIF-1α and CD133 were higher in MPE patients. It was found that CD133/HIF-1α (S) ratio was higher in the malignant patient group with positive lymph node involvement than in the negative group, while concentrations of HIF-1α (P) were lower. Pleural fluid HIF-1α and CD133/HIF-1α (S) ratio had sufficient performance in diagnosing lymphatic metastases in patients with MPE (AUC = 0.90 and 0.83, respectively).

Conclusions

In conclusion, serum HIF-1α and CD133 concentrations were higher in patients with MPE, consistent with our hypothesis. Concentrations of HIF-1α (P) and CD133/HIF-1α (S) ratio can be used as biomarkers in diagnosing lymph node involvement in MPE patients, according to this experiment.

Single-cell RNA sequencing captures patient-level heterogeneity and associated molecular phenotypes in breast cancer pleural effusions

BACKGROUND

Malignant pleural effusions (MPEs) are a common complication of advanced cancers, particularly those adjacent to the pleura, such as lung and breast cancer. The pathophysiology of MPE formation remains poorly understood, and although MPEs are routinely used for the diagnosis of breast cancer patients, their composition and biology are poorly understood. It is difficult to distinguish invading malignant cells from resident mesothelial cells and to identify the directionality of interactions between these populations in the pleura. There is a need to characterize the phenotypic diversity of breast cancer cell populations in the pleural microenvironment, and investigate how this varies across patients.

METHODS

Here, we used single-cell RNA-sequencing to study the heterogeneity of 10 MPEs from seven metastatic breast cancer patients, including three Miltenyi-enriched samples using a negative selection approach. This dataset of almost 65 000 cells was analysed using integrative approaches to compare heterogeneous cell populations and phenotypes.

RESULTS

We identified substantial inter-patient heterogeneity in the composition of cell types (including malignant, mesothelial and immune cell populations), in expression of subtype-specific gene signatures and in copy number aberration patterns, that captured variability across breast cancer cell populations. Within individual MPEs, we distinguished mesothelial cell populations from malignant cells using key markers, the presence of breast cancer subtype expression patterns and copy number aberration patterns. We also identified pleural mesothelial cells expressing a cancer-associated fibroblast-like transcriptomic program that may support cancer growth.

CONCLUSIONS

Our dataset presents the first unbiased assessment of breast cancer-associated MPEs at a single cell resolution, providing the community with a valuable resource for the study of MPEs. Our work highlights the molecular and cellular diversity captured in MPEs and motivates the potential use of these clinically relevant biopsies in the development of targeted therapeutics for patients with advanced breast cancer.

Acute Oncologic Complications: Clinical-Therapeutic Management in Critical Care and Emergency Departments

Introduction. It is now known that cancer is a major public health problem; on the other hand, it is less known, or rather, often underestimated, that a significant percentage of cancer patients will experience a cancer-related emergency. These conditions, depending on the severity, may require treatment in intensive care or in the emergency departments. In addition, it is not uncommon for a tumor pathology to manifest itself directly, in the first instance, with a related emergency. The emergency unit proves to be a fundamental and central unit in the management of cancer patients. Many cancer cases are diagnosed in the first instance as a result of symptoms that lead the patient's admittance into the emergency room. Materials and Methods. This narrative review aims to analyze the impact of acute oncological cases in the emergency setting and the role of the emergency physician in their management. A search was conducted over the period January 1981-April 2023 using the main scientific platforms, including PubMed, Scopus, Medline, Embase and Google scholar, and 156 papers were analyzed. Results. To probe into the main oncological emergencies and their management in increasingly overcrowded emergency departments, we analyzed the following acute pathologies: neurological emergencies, metabolic and endocrinological emergencies, vascular emergencies, malignant effusions, neutropenic fever and anemia. Discussion/Conclusions. Our analysis found that a redefinition of the emergency department connected with the treatment of oncology patients is necessary, considering not only the treatment of the oncological disease in the strict sense, but also the comorbidities, the oncological emergencies and the palliative care setting. The need to redesign an emergency department that is able to manage acute oncological cases and end of life appears clear, especially when this turns out to be related to severe effects that cannot be managed at home with integrated home care. In conclusion, a redefinition of the paradigm appears mandatory, such as the integration between the various specialists belonging to oncological medicine and the emergency department. Therefore, our work aims to provide what can be a handbook to detect, diagnose and treat oncological emergencies, hoping for patient management in a multidisciplinary perspective, which could also lead to the regular presence of an oncologist in the emergency room.

Overview of the role of liquid biopsy in cancer management

With the emergence of novel targeted therapeutic options in early-stage and advanced-stage malignancies, researchers have shifted their focus on developing personalized treatment plans through molecular profiling. Circulating tumor DNA (ctDNA) is a cell-free DNA (ctDNA) fragment, originating from tumor cells, and circulating in the bloodstream as well as biological fluids. Over the past decade, many techniques were developed for liquid biopsies through next-generation sequencing. This alternative non-invasive biopsy offers several advantages in various types of tumors over traditional tissue biopsy. The process of liquid biopsy is considered minimally invasive and therefore easily repeatable when needed, providing a more dynamic analysis of the tumor cells. Moreover, it has an advantage in patients with tumors that are not candidates for tissue sampling. Besides, it offers a deeper understanding of tumor burden as well as treatment response, thereby enhancing the detection of minimal residual disease and therapeutic guidance for personalized medicine. Despite its many advantages, ctDNA and liquid biopsy do have some limitations. This paper discusses the basis of ctDNA and the current data available on the subject, as well as its clinical utility. We also reflect on the limitations of using ctDNA in addition to its future perspectives in clinical oncology and precision medicine.

Tension hydrothorax in a patient with a history of pulmonary tuberculosis

A tension hydrothorax is a massive pleural effusion that leads to hemodynamic instability. Here we present a case of tension hydrothorax secondary to poorly differentiated carcinoma. A 74-year-old male smoker presented after a one-week history of dyspnea and unintentional weight loss. Physical exam demonstrated tachycardia, tachypnea, and decreased breath sounds diffusely over the right lung. Imaging revealed a massive pleural effusion causing mass effect on the mediastinum with tension physiology. Chest tube placement revealed an exudative effusion with negative cultures and cytology. Pleural biopsy revealed atypical epithelioid cells consistent with poorly differentiated carcinoma.

Impact of the Cancer Cell Secretome in Driving Breast Cancer Progression

Breast cancer is a complex and heterogeneous disease resulting from the accumulation of genetic and epigenetic alterations in breast epithelial cells. Despite remarkable progress in diagnosis and treatment, breast cancer continues to be the most prevalent cancer affecting women worldwide. Recent research has uncovered a compelling link between breast cancer onset and the extracellular environment enveloping tumor cells. The complex network of proteins secreted by cancer cells and other cellular components within the tumor microenvironment has emerged as a critical player in driving the disease's metastatic properties. Specifically, the proteins released by the tumor cells termed the secretome, can significantly influence the progression and metastasis of breast cancer. The breast cancer cell secretome promotes tumorigenesis through its ability to modulate growth-associated signaling pathways, reshaping the tumor microenvironment, supporting pre-metastatic niche formation, and facilitating immunosurveillance evasion. Additionally, the secretome has been shown to play a crucial role in drug resistance development, making it an attractive target for cancer therapy. Understanding the intricate role of the cancer cell secretome in breast cancer progression will provide new insights into the underlying mechanisms of this disease and aid in the development of more innovative therapeutic interventions. Hence, this review provides a nuanced analysis of the impact of the cancer cell secretome on breast cancer progression, elucidates the complex reciprocal interaction with the components of the tumor microenvironment and highlights emerging therapeutic opportunities for targeting the constituents of the secretome.

A maladaptive pleural environment suppresses preexisting anti-tumor activity of pleural infiltrating T cells

Introduction

Treatment options for patients with malignant pleural effusions (MPE) are limited due, at least in part, to the unique environment of the pleural space, which drives an aggressive tumor state and governs the behavior of infiltrating immune cells. Modulation of the pleural environment may be a necessary step toward the development of effective treatments. We examine immune checkpoint molecule (ICM) expression on pleural T cells, the secretomes of pleural fluid, pleural infiltrating T cells (PIT), and ability to activate PIT ex vivo.

Methods

ICM expression was determined on freshly drained and in vitro activated PIT from breast, lung and renal cell cancer. Secretomics (63 analytes) of activated PIT, primary tumor cultures and MPE fluid was determined using Luminex technology. Complementary digital spatial proteomic profiling (42 analytes) of CD45+ MPE cells was done using the Nanostring GeoMx platform. Cytolytic activity was measured against autologous tumor targets.

Results

ICM expression was low on freshy isolated PIT; regulatory T cells (T-reg) were not detectable by GeoMx. In vitro activated PIT coexpressed PD-1, LAG-3 and TIGIT but were highly cytotoxic against autologous tumor and uniquely secreted cytokines and chemokines in the > 100 pM range. These included CCL4, CCL3, granzyme B, IL-13, TNFα, IL-2 IFNγ, GM-CSF, and perforin. Activated PIT also secreted high levels of IL-6, IL-8 and sIL-6Rα, which contribute to polarization of the pleural environment toward wound healing and the epithelial to mesenchymal transition. Addition of IL-6Rα antagonist to cultures reversed tumor EMT but did not alter PIT activation, cytokine secretion or cytotoxicity.

Discussion

Despite the negative environment, immune effector cells are plentiful, persist in MPE in a quiescent state, and are easily activated and expanded in culture. Low expression of ICM on native PIT may explain reported lack of responsiveness to immune checkpoint blockade. The potent cytotoxic activity of activated PIT and a proof-of-concept clinical scale GMP-expansion experiment support their promise as a cellular therapeutic. We expect that a successful approach will require combining cellular therapy with pleural conditioning using immune checkpoint blockers together with inhibitors of upstream master cytokines such as the IL-6/IL-6R axis.

Time to FOCUS - 'Palliative Medicine Point-of-Care Ultrasound'

Point-of-care diagnosis has become the need of the hour and along with its guided interventions, ultrasound could be utilised bedside in a palliative care patient. Point-of-care ultrasound (POCUS) in palliative care medicine is fast emerging and has varied applications ranging from performing bedside diagnostic evaluation to the performance of interventional paracentesis, thoracocentesis and chronic pain interventions. Handheld ultrasound devices have transformed the application of POCUS and should revolutionise the future of home-based palliative care. Palliative care physicians should be enabled to carry out bedside ultrasounds at home care and hospice setting for achieving rapid symptom relief. The aim of POCUS in palliative care medicine should be adequate training of palliative care physicians, transforming the applicability of this technology to OPD as well as community driven to achieve home outreach. The goal is towards empowering technology by reaching out to the community rather than the terminally ill patient transported for the hospital admission. Palliative care physicians should receive mandatory training in POCUS to enable diagnostic proficiency and early triaging. The inclusion of ultrasound machine in an outpatient palliative care clinic brings about value addition in rapid diagnosis. Limiting POCUS application to certain selected sub-specialities such as emergency medicine, internal medicine and critical care medicine should be overcome. This would need acquiring higher training as well as improvised skill sets to perform bedside interventions. Ultrasonography competency among palliative care providers proposed as palliative medicine point-of-care ultrasound (PM-POCUS) could be achieved by imparting dedicated POCUS training within the core curriculum.

Diagnostic accuracy of pleural fluid to serum carcinoembryonic antigen ratio and delta value for malignant pleural effusion: findings from two cohorts

BACKGROUND

Pleural fluid (PF) carcinoembryonic antigen (CEA) is a widely used diagnostic marker for malignant pleural effusion (MPE). Recent studies revealed that PF to serum CEA was also a promising diagnostic parameter for MPE.

OBJECTIVE

We aimed to investigate whether PF to serum CEA ratio and delta CEA (PF minus serum CEA) provided added value to PF CEA in diagnosing MPE.

METHODS

Patients with pleural effusion in a retrospective cohort (BUFF) and a prospective cohort (SIMPLE) were included. The clinical characteristics of the patients were extracted from their medical records. The diagnostic value of CEA ratio and delta CEA was estimated by a receiver operating characteristics (ROC) curve, net reclassification improvement (NRI), and integrated discrimination improvement (IDI).

RESULTS

A total of 148 patients in the BUFF cohort and 164 patients in the SIMPLE cohort were enrolled. The BUFF cohort had 46 MPE patients and 102 benign pleural effusion (BPE) patients, and the SIMPLE cohort had 85 MPE patients and 79 BPE patients. In both cohorts, MPE patients had significantly higher PF CEA, serum CEA, CEA ratio, and delta CEA. The area under ROC curves (AUCs) of PF CEA, CEA ratio, and delta CEA were 0.78 (95% CI: 0.67-0.88), 0.80 (95% CI: 0.72-0.89) and 0.83 (95% CI: 0.75-0.91) in the BUFF cohort, and 0.89 (95% CI: 0.83-0.94), 0.86 (95% CI: 0.80-0.92), and 0.84 (95% CI: 0.78-0.91) in the SIMPLE cohort. The differences between the AUCs of PF CEA, CEA ratio, and delta CEA did not reach statistical significance. The continuous NRI and IDI of CEA ratio and delta CEA were <0.

CONCLUSION

CEA ratio and delta value cannot provide added diagnostic value to PF CEA. The simultaneous determination of serum and PF CEA should not be adopted in clinical practice.

A Novel Clinical Prognostic Model for Breast Cancer Patients with Malignant Pleural Effusion: Avoiding Chemotherapy in Low-Risk Groups?

Purpose

Malignant pleural effusion (MPE) is a severe complication in patients with advanced cancer that is associated with a poor prognosis. Breast cancer is the second leading cause of MPE after lung cancer. We therefore aim to describe clinical characteristics of the patients with MPE combined with breast cancer and construct a machine learning-based model for predicting the prognosis of such patients.

Methods

This study is a retrospective and observational study. Least absolute shrinkage and selection operator (LASSO) and univariate Cox regression analyses were applied to identify eight key clinical variables, and a nomogram model was established. Model performance was evaluated by receiver operating characteristic (ROC) curve, calibration curve, and decision curve analyses.

Results

196 patients with both MPE and breast cancer (143 in the training group and 53 in the ex-ternal validation group) were analyzed in this study. The median overall survival in two cohorts was 16.20 months and 11.37 months. Based on the ROC curves for 3-, 6-, and 12-month survival, the areas under the curves were 0.824, 0.824, and 0.818 in the training set and 0.777, 0.790, and 0.715 in the validation set, respectively. In the follow-up analysis, both systemic and intrapleural chemotherapy significantly increased survival in the high-risk group compared to the low-risk group.

Conclusion

Collectively, MPE confers a poor prognosis in breast cancer patients. We have developed a first-ever survival prediction model for breast cancer patients with newly diagnosed MPE and validated the model using an independent cohort.

A comparative study of diagnostic accuracy in 3026 pleural biopsies and matched pleural effusion cytology with clinical correlation

BACKGROUND

Pleural effusion can be caused by a wide range of benign and malignant conditions. Pleural biopsy and effusion cytology represent two key methods of pathological diagnosis. To compare the performance these two methods, a large cohort of matched pleural biopsy and effusion cytology with clinical follow-up was reviewed.

METHODS

Pleural biopsies and effusion cytology specimens over a period of 18 years were retrieved. Cytology specimens collected within 7 days of pleural biopsy were matched. Reports were reviewed, and the cause for pleural effusion was determined by hospital disease coding and clinical data.

RESULTS

Totally, 3026 cases were included. The leading cause of benign effusion was tuberculosis (n = 650). Malignant pleural effusion (MPE) was more common in older females (p < 0.001) and mostly due to lung cancer (n = 959), breast cancer (n = 64), and mesothelioma (n = 48). The inadequate/insufficient (B1/C1) rate of biopsy was higher than cytology (15.6% vs. 0.3%) but the rates for other diagnostic categories were similar. Biopsy and cytology showed a correlation coefficient of 0.315, improving to 0.449 when inadequate/insufficient (B1/C1) cases were excluded. The ROM for benign cytology (C2) was lower than biopsy (B2) (p < 0.001). Compared with biopsy, the diagnostic accuracy was higher in cytology overall and for metastatic carcinomas (p < 0.001) but lower for hematolymphoid malignancies (p = 0.014) and mesotheliomas (p = 0.002).

CONCLUSIONS

These results suggest that effusion cytology may be better for confirming benignity and diagnosing carcinomatous MPE. In these cases, pleural biopsy may be withheld to reduce procedural risks. However, for suspected hematolymphoid malignancies and mesothelioma, biopsy should be considered.

Transthoracic sonographic scores in evaluating the success of different scelerosing modalities in patients with malignant pleural effusion

Background

Malignant pleural effusions (MPE) mostly arises from metastases to the pleura from other sites. Management of malignant effusions aims to palliate dyspnea and prevent the reaccumulation of pleural fluid to improve patients’ quality of life. Pleurodesis is the most common palliative treatment for patients with refractory MPE. This study was carried out to evaluate the performance of transthoracic sonographic (TUS) scores (pleural sliding and pleural adherence score) in predicting the success of pleurodesis by different modalities in patients with malignant pleural effusion. One hundred malignant pleural effusion patients were enrolled to an interventional clinical trial from September 2019 to April 2021 for palliative management of dyspnea. Pleurodesis for palliative treatment of dyspnea was done either spontaneously by the intercostal chest tube or by a sclerosing agent such as tetracycline solution or tetracycline poudrage or iodopovidine. Patients were randomly allocated to one of these four groups where each group included 25 patients. Transthoracic ultrasound was performed at baseline, and 1 month after pleurodesis and the lung sliding score and pleural adherence score were evaluated.

Results

Majority of patients (78%) had high baseline lung sliding score (7-8). Post pleurodesis only 11.4% had high scores (p<0.001), also the mean lung sliding score decreased significantly in comparison to the baseline values (p˂ 0.001) in the spontaneous, tetracycline solution, tetracycline poudrage, and iodopovidine groups (7.04 ± 1.02 vs. 4.85 ± 1.60, 7.28± 0.98 vs. 4.48± 1.75, 7.20±0.96 vs. 4.44 ± 1.45, 7.04±0.93 vs. 3.35±1.81, respectively). Iodopovidine pleurodesis group in comparison to the other modalities showed the highest pleural adherence score (12.64 ± 2.98) and absent lung sliding in 72.7% of cases and 70 % success rate. Pleural adherence score at cut off ≥ 12 showed 92.75% sensitivity, 89.47% specificity, 92.1 accuracy, and 0.911 area under the curve (AUC) for predicting successful pleurodesis.

Conclusion

TUS scores is a feasible, bedside, and accurate method to detect the outcome of pleurodesis. Iodopovidone was more effective than tetracycline solution, tetracycline poudrage, and spontaneous pleurodesis.

Trial registration

ClinicalTrials.gov. NCT04074902. Registered on 29 August 2019

A Rare Case of Metastatic Gastric Signet Ring Cell Adenocarcinoma in a 23-Year-Old Female Presenting as Malignant Pleural Effusion

Signet ring cell carcinoma (SRCC) is a poorly differentiated mucin-producing adenocarcinoma with greater than 50% signet ring cells. It commonly arises from the gastrointestinal (GI) tract and rarely from extraintestinal organs. This is a rare case of a young African American female who presented with metastatic spread of signet ring cell gastric cancer (pleural and lymph nodal involvement) as the initial presentation of SRCC. Knowledge of the various clinical manifestations of SRCC can help with its early diagnosis, and there is a high need for detailed physical examination, early referral, and prompt treatment in patients with SRCC.

Intrapleural infusion of tumor cell-derived microparticles packaging methotrexate or saline combined with pemetrexed-cisplatin chemotherapy for the treatment of malignant pleural effusion in advanced non-squamous non-small cell lung cancer: A double-blind, randomized, placebo-controlled study

Background

Preclincal studies showed the promising efficacy of tumor cell-derived microparticles packaging methotrexate (TMPs-MTX) to treat advanced non-squamous non-small cell lung cancer (NSCLC) with malignant pleural effusion (MPE).

Methods

This randomized, double-blind, placebo-controlled study was conducted at six hospitals in China from 20 July 2015 to 25 April 2019. Patients newly diagnosed with non-squamous NSCLC with MPE were randomly assigned to receive TMPs-MTX (group A) or saline (group B). Patients in both groups received pemetrexed (500 mg/m2 d1) and cisplatin (75 mg/m2 in total for d1-d2). Intrapleural infusion (50 mL saline containing 5 units of TMPs-MTX per perfusion, once every 48 hours, six total perfusions) was initiated on day 5 after pemetrexed-cisplatin chemotherapy. The primary outcome was the objective response rate (ORR) of MPE. Secondary outcomes included the ORR of target lesions, progression-free survival (PFS), overall survival (OS), toxicity, and pleural fluid properties.

Results

A total of 86 patients were enrolled in this study and randomly assigned to either group A or group B. Of these, 79 patients were evaluable for response. The ORR of MPE in group A was significantly higher than that in group B (82.50% vs. 58.97%, P = 0.0237). The ORR of target lesions was 25.64% in group A and 20.51% in group B (P = 0.5909), respectively. With a median follow-up time of 18.8 months, median PFS were 6.4 (95% CI, 4.5-12.3) months in group A and 7.3 (95% CI, 6.1-10.4) months in group B (P = 0.6893), and median OS were 19.9 (95% CI, 17.1-28.5) months and 17.5 (95% CI, 11.6-25.0) months (P = 0.4500), respectively. The incidence rates of adverse events were similar in the two groups. The most common treatment-related adverse events were chemotherapy-induced toxicities, including fever, gastrointestinal reactions, hepatic dysfunction, and leukopenia.

Conclusion

Intrapleural infusion of TMPs-MTX combined with pemetrexed-cisplatin chemotherapy is safe and effective against MPE in patients with advanced non-squamous NSCLC.

Clinical trial registration

http://www.chictr.org.cn (ChiCTR-ICR-15006304).

Circulating tumour DNA - looking beyond the blood

Over the past decade, various liquid biopsy techniques have emerged as viable alternatives to the analysis of traditional tissue biopsy samples. Such surrogate 'biopsies' offer numerous advantages, including the relative ease of obtaining serial samples and overcoming the issues of interpreting one or more small tissue samples that might not reflect the entire tumour burden. To date, the majority of research in the area of liquid biopsies has focused on blood-based biomarkers, predominantly using plasma-derived circulating tumour DNA (ctDNA). However, ctDNA can also be obtained from various non-blood sources and these might offer unique advantages over plasma ctDNA. In this Review, we discuss advances in the analysis of ctDNA from non-blood sources, focusing on urine, cerebrospinal fluid, and pleural or peritoneal fluid, but also consider other sources of ctDNA. We discuss how these alternative sources can have a distinct yet complementary role to that of blood ctDNA analysis and consider various technical aspects of non-blood ctDNA assay development. We also reflect on the settings in which non-blood ctDNA can offer distinct advantages over plasma ctDNA and explore some of the challenges associated with translating these alternative assays from academia into clinical use.

Survival Benefit of Statin with Anti-Angiogenesis Efficacy in Lung Cancer-Associated Pleural Fluid through FXR Modulation

Simple Summary

Our previous works showed that pleural fluid from lung cancer significantly induced endothelial proliferation, migration, and angiogenesis. Since endothelial metabolism was a key step in angiogenesis, we investigated the role of bile acid signaling and FXR expression in pleural angiogenesis. Elevated bile acid levels in lung-cancer-associated pleural fluid (LCPF) were characterized with positive FXR staining in pleural microvessels. We then confirmed the inhibitory effect of an FXR antagonist on LCPF-induced endothelial migration and angiogenesis. Due to the elevated protein expression in the cholesterol metabolism caused by LCPF, lipid-lowering agents with the efficacy needed to counteract LCPF-regulated angiogenesis were evaluated. Statin showed the potent efficacy needed to suppress LCPF-induced endothelial proliferation, migration, and angiogenesis through FXR inhibition. Following that, Kaplan–Meier analysis showed the survival benefit of statin exposure in patients with lung adenocarcinoma with LCPF. Our results suggest that targeting endothelial FXR signaling with statin treatment could ameliorate the angiogenesis activity of LCPF.

Abstract

Lung cancer-related pleural fluid (LCPF) presents as a common complication with limited treatment. Beyond its function in lipid digestion, bile acid was identified as a potent carcinogen to stimulate tumor proliferation. Previous research indicated a correlation between serum bile acid levels and the risk of developing several gastrointestinal cancers. Our study identified elevated bile acid levels in LCPF and increased farnesoid X receptor (FXR) expression as bile acid nuclear receptors in pleural microvessels of lung adenocarcinoma. Additionally, LCPF stimulated the expression of proteins involved in bile acid synthesis and cholesterol metabolism in HUVECs including CYP7A1, StAR, HMGCR, and SREBP2. LCPF-induced endothelial motility and angiogenesis were counteracted by using β-muricholic acid as an FXR antagonist. Moreover, we investigated the efficacy of cholesterol-lowering medications, such as cholestyramine, fenofibrate, and atorvastatin, in regulating LCPF-regulated angiogenesis. Along with suppressing endothelial proliferation and angiogenesis, atorvastatin treatment reversed cholesterol accumulation and endothelial junction disruption caused by LCPF. Statin treatment inhibited LCPF-induced endothelial FXR expression as well as the downstream proteins RXR and SHP. Based on the positive findings of suppressing endothelial angiogenesis, our group further incorporated the effect of statin on clinical patients complicated with LCPF. A Kaplan–Meier analysis revealed the clinical benefit of statin exposure in patients with lung adenocarcinoma with LCPF. Conclusively, our study demonstrated the ability of statin to alleviate LCPF-induced angiogenesis in patients with LCPF via FXR modulation.

Use of Platelet Parameters in the Differential Diagnosis of Lung Adenocarcinoma-Associated Malignant Pleural Effusion and Tuberculous Pleural Effusion

Background

Both malignant pleural effusion (MPE) and tuberculous pleural effusion (TPE) are common etiologies of pleural effusion; the present study was conducted to establish the diagnostic value of platelet parameters in the differential diagnosis of MPE and TPE.

Methods

This retrospective study enrolled patients with lung adenocarcinoma-associated MPE and TPE. Platelet parameter data, including platelet count (PLT), mean platelet volume (MPV), plateletcrit (PCT), platelet distribution width (PDW), and platelet-larger cell ratio (P-LCR), were collected. Principal component analysis and multiple logistic regression modelling were carried out to assess the diagnostic value of these platelet parameters.

Results

The MPE group and the TPE group enrolled 270 and 433 patients, respectively. Demographic characteristics of patients were more female and higher age in the MPE group. MPV, PDW, and P-LCR were significantly higher in MPE patients, while PLT and PCT were significantly higher in TPE patients. Principal component analysis generated two principal components (PCs) based on above platelet parameters. After adjusting for confounding factors including gender and age, multiple logistic regression showed positive association between PC1 and MPE.

Conclusion

Platelet parameters were potential biomarkers in distinguishing lung adenocarcinoma-associated MPE from TPE. A patient with lower PLT and PCT and higher MPV, PDW, and P-LCR was more likely to be diagnosed as the former. Principal component analysis and multiple logistic regression performed well in improving multicollinearity, adjusting confounding factors, and identifying important risk factors for MPE.

The Mechanism of Ginseng and Astragalus Decoction in the Treatment of Malignant Pleural Effusion Based on Network Pharmacology and Molecular Docking Technology

Introduction

The objective of our study is to explore the potential active ingredients and activity of Ginseng and Astragalus decoction (GAD) in the treatment of malignant pleural effusion (MPE) by using network pharmacology and molecular docking technologies.

Methods

The active ingredients and corresponding targets of Ginseng and Astragalus were extracted from the Traditional Chinese Medicine System Pharmacology Database and Analysis Platform. The relevant targets of malignant pleural effusion (MPE) were searched in the disease databases. Overlapping targets of Ginseng and Astragalus and the corresponding targets of MPE were obtained to define the effective target of GAD for the treatment of MPE. The STRING database was applied to construct a predicted protein-protein interaction network for intersected targets. The Cytoscape software was used to screen key targets with a therapeutic potential. Using the Metascape database, we performed Gene Ontology and Kyoto Encyclopedia of Genes and Genomes functional enrichment analysis on the targets identified in the study. PyMOL and AutoDock Vina were used to molecularly dock the selected key components to their respective key targets for MPE treatment.

Results

The core target network revealed 22 main active ingredients, 26 main targets, and 16 signaling pathways in GAD. Molecular docking revealed 6 targets (AKT serine/threonine kinase 1, intercellular adhesion molecule, Jun proto-oncogene, peroxisome proliferator activated receptor gamma, prostaglandin-endoperoxide synthase 2, and tumor necrosis factor) that could partially dock with kaempferol, frutinone A, ginsenoside RH2, formononetin, and quercetin.

Conclusions

Several components, targets, and signaling pathways of GAD contribute to the treatment of MPE, which suggests a rationale for further investigation on GAD's active molecule and mechanism of action in the clinical application of MPE.

Echogenic swirling pattern, carcinoembryonic antigen, and lactate dehydrogenase in the diagnosis of malignant pleural effusion

The echogenic swirling pattern has a role in predicting malignant pleural effusion (MPE). However, its predictive ability is suboptimal, and its clinical utility remains to be defined. The aim of this study was to assess the diagnostic potential of the echogenic swirling pattern combined with pleural carcinoembryonic antigen (CEA) and routine laboratory tests of pleural effusion in MPE. The 80 consecutive patients with underlying malignancy and pleural effusions were recruited. All patients underwent one diagnostic thoracentesis with a cytologic examination of pleural fluid. Our study showed that the sensitivity of echogenic swirling patterns in MPE diagnosis was 67.7%, specificity was 72.2%, positive predictive value (PPV) was 89.4%, and negative predictive value (NPV) was 39.4%. Both CEA and lactate dehydrogenase (LDH) had acceptable sensitivity (71.0% and 60.7%) and specificity (72.2% and 77.8%). Combining the echogenic swirling pattern, pleural CEA, and pleural LDH, the highest sensitivity (95.2%) with a good PPV (86.8) was reached. In this clinical study, we found that combining the echogenic swirling pattern, pleural CEA, and pleural LDH had a higher sensitivity and a high positive predictive value for the diagnosis of MPE. This combination is a potentially suitable method for MPE screening in cancer patients with pleural effusions.