Diagnosis and management options in malignant pleural effusions

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.

Rapid Development of Primary Right Atrial Angiosarcoma

Cardiac angiosarcomas are rare and generally followed by a high level of metastasis with poor median survival outcomes. Echocardiograms, CT scans, and MRIs are the standard methods for finding sites of cardiac tumors; however, immunohistochemical confirmation is necessary for a definitive diagnosis of angiosarcoma. A 58-year-old male presented to the emergency room with one week of dyspnea on moderate exertion accompanied by chest pain and alleviated with rest. A workup done to evaluate mass found a single 5 x 3.5 x 4.8 cm mass heavily vascularized by the right coronary artery and left circumflex involving the free wall of the right atrium with no extension to the tricuspid valve. Surgical resection was performed, and immunohistochemistry was consistent with a primary cardiac angiosarcoma. An exudative fluid analysis on pericardial and pleural fluid analysis may warrant screening for malignancy more frequently in concurrence with a patient's history and presentation. Although the time from onset of symptoms to diagnosis of cardiac angiosarcoma is not well established, further investigation of such correlation may offer insight into survival post-treatment.

Prediction of TKI response in EGFR-mutant lung cancer patients-derived organoids using malignant pleural effusion

Patient-derived organoids (PDOs) are valuable in predicting response to cancer therapy. PDOs are ideal models for precision oncologists. However, their practical application in guiding timely clinical decisions remains challenging. This study focused on patients with advanced EGFR-mutated non-small cell lung cancer and employed a cancer organoid-based diagnosis reactivity prediction (CODRP)-based precision oncology platform to assess the efficacy of EGFR inhibitor treatments. CODRP was employed to evaluate EGFR-tyrosine kinase inhibitors (TKI) drug sensitivity. The results were compared to those obtained using area under the curve index. This study validated this index by testing lung cancer-derived organoids in 14 patients with lung cancer. The CODRP index-based drug sensitivity test reliably classified patient responses to EGFR-TKI treatment within a clinically suitable 10-day timeline, which aligned with clinical drug treatment responses. This approach is promising for predicting and analyzing the efficacy of anticancer, ultimately contributing to the development of a precision medicine platform.

Comparative Evaluation of Chest Ultrasonography and Computed Tomography as Predictors of Malignant Pleural Effusion: A Prospective Study

Malignant pleural effusion (MPE) is a manifestation of advanced cancer that requires a prompt and accurate diagnosis. Ultrasonography (US) and computed tomography (CT) are valuable imaging techniques for evaluating pleural effusions; however, their relative predictive ability for a malignant origin remains debatable. This prospective study aimed to compare chest US with CT findings as predictors of malignancy in patients with undiagnosed exudative pleural effusion. Fifty-four adults with undiagnosed exudative pleural effusions underwent comprehensive clinical evaluation including chest US, CT, and histopathologic biopsy. Blinded radiologists evaluated the US and CT images for features suggestive of malignancy, based on predefined criteria. Diagnostic performance measures were calculated using histopathology as a reference standard. Of the 54 patients, 33 (61.1%) had MPEs confirmed on biopsy. No significant differences between US and CT were found in detecting parietal pleural abnormalities, lung lesions, chest wall invasion, or liver metastasis. US outperformed CT in identifying diaphragmatic pleural thickening ≥10 mm (33.3% vs. 6.1%, p < 0.001) and nodularity (45.5% vs. 3%, p < 0.001), whereas CT was superior for mediastinal thickening (48.5% vs. 15.2%, p = 0.002). For diagnosing MPE, diaphragmatic nodularity detected by US had 45.5% sensitivity and 100% specificity, whereas CT mediastinal thickening had 48.5% sensitivity and 90.5% specificity. Both US and CT demonstrate reasonable diagnostic performance for detecting MPE, with particular imaging findings favoring a malignant origin. US may be advantageous for evaluating diaphragmatic pleural involvement, whereas CT is more sensitive to mediastinal abnormalities.

Metastatic papillary thyroid carcinoma in pleural effusion: a case report and review of the literature

INTRODUCTION

Papillary thyroid carcinoma accounts for the most common type of thyroid cancer of well-differentiated type. Papillary thyroid carcinoma is featured by biologically low-grade and less aggressive tumors with a survival rate of 10 years in most of the diagnosed cases. Papillary thyroid carcinoma can be presented with the involvement of cervical lymph nodes in about 50% of the patients, yet distant spread is very uncommon.

CASE PRESENTATION

Herein, we discuss a Saudi male patient in his early 50s with a history of papillary thyroid carcinoma who presented to the emergency department complaining of shortness of breath and a radiological finding of hydrothorax. Cytologic examination together with immune-histochemical staining and molecular studies of pleural effusion aspiration concluded the definitive diagnosis of metastatic papillary thyroid carcinoma in the pleural space.

CONCLUSIONS

Papillary thyroid carcinoma seldom causes metastatic niches in the pleural space; this is a rare clinical presentation, nevertheless, a differential diagnosis of thyroid metastasis needs to be excluded. A definitive diagnosis of metastatic papillary thyroid carcinoma can be made using clinical presentation, cytologic examination, immunohistochemical investigation, and molecular testing. The most common mutation found in papillary thyroid carcinoma cases is the V600E mutation found in the BRAF gene, yet these patients have a relatively low probability of cancer recurrence. Patients with papillary thyroid carcinoma who have the BRAF mutation frequently experience metastases and relapses of the disease after the cancer has progressed aggressively. To help with therapy planning and the introduction of BRAF inhibitors, genetic testing for BRAF mutation may therefore prove to be a useful tool, especially in cases of aggressive subtypes of TC.

Diagnosis of malignant pleural effusion with combinations of multiple tumor markers: A comparison study of five machine learning models

BACKGROUND

To evaluate the diagnostic value of combinations of tumor markers carcinoembryonic antigen (CEA), carbohydrate antigen (CA) 125, CA153, and CA19-9 in identifying malignant pleural effusion (MPE) from non-malignant pleural effusion (non-MPE) using machine learning, and compare the performance of popular machine learning methods.

METHODS

A total of 319 samples were collected from patients with pleural effusion in Beijing and Wuhan, China, from January 2018 to June 2020. Five machine learning methods including Logistic regression, extreme gradient boosting (XGBoost), Bayesian additive regression tree, random forest, and support vector machine were applied to evaluate the diagnostic performance. Sensitivity, specificity, Youden's index, and the area under the receiver operating characteristic curve (AUC) were used to evaluate the performance of different diagnostic models.

RESULTS

For diagnostic models with a single tumor marker, the model using CEA, constructed by XGBoost, performed best (AUC = 0.895, sensitivity = 0.80), and the model with CA153, also by XGBoost, showed the largest specificity 0.98. Among all combinations of tumor markers, the combination of CEA and CA153 achieved the best performance (AUC = 0.921, sensitivity = 0.85) in identifying MPE under the diagnostic model constructed by XGBoost.

CONCLUSIONS

Diagnostic models for MPE with a combination of multiple tumor markers outperformed the models with a single tumor marker, particularly in sensitivity. Using machine learning methods, especially XGBoost, could comprehensively improve the diagnostic accuracy of MPE.

Malignant pleural effusion from a case of squamous-cell carcinoma of the oral cavity: Cytological detection of a rare outcome

Distant metastases from carcinomas of the oral cavity are rare. Detection of these metastasis are essential for staging and management of the patient. These tumours may metastasize to lung, liver, brain and bone; but pleural involvement by squamous-cell carcinoma is distinctly rare. We present a case of bilateral pleural effusion arising from distant metastasis of squamous-cell carcinoma detected on cytology.

Lung Cancer: Spectral and Numerical Differentiation among Benign and Malignant Pleural Effusions Based on the Surface-Enhanced Raman Spectroscopy

We present here that the surface-enhanced Raman spectroscopy (SERS) technique in conjunction with the partial least squares analysis is as a potential tool for the differentiation of pleural effusion in the course of the cancerous disease and a tool for faster diagnosis of lung cancer. Pleural effusion occurs mainly in cancer patients due to the spread of the tumor, usually caused by lung cancer. Furthermore, it can also be initiated by non-neoplastic diseases, such as chronic inflammatory infection (the most common reason for histopathological examination of the exudate). The correlation between pleural effusion induced by tumor and non-cancerous diseases were found using surface-enhanced Raman spectroscopy combined with principal component regression (PCR) and partial least squares (PLS) multivariate analysis method. The PCR predicts 96% variance for the division of neoplastic and non-neoplastic samples in 13 principal components while PLS 95% in only 10 factors. Similarly, when analyzing the SERS data to differentiate the type of tumor (squamous cell vs. adenocarcinoma), PLS gives more satisfactory results. This is evidenced by the calculated values of the root mean square errors of calibration and prediction but also the coefficients of calibration determination and prediction (R2C = 0.9570 and R2C = 0.7968), which are more robust and rugged compared to those calculated for PCR. In addition, the relationship between cancerous and non-cancerous samples in the dependence on the gender of the studied patients is presented.

Neutrophils in Extravascular Body Fluids: Cytological-Energy Analysis Enables Rapid, Reliable and Inexpensive Detection of Purulent Inflammation and Tissue Damage

The simultaneous cytological and metabolic investigation of various extravascular body fluids (EBFs) provides clinically relevant information about the type and intensity of the immune response in particular organ systems. The oxidative burst of professional phagocytes with the concomitant production of reactive oxygen species consumes a large amount of oxygen and is the cause of switch to the development of anaerobic metabolism. We assessed the relationships between percentages of neutrophils, aerobic and anaerobic metabolism, and tissue damage via the determination of aspartate aminotransferase catalytic activities (AST) in cerebrospinal fluid (CSF), pleural effusions (PE), abdominal effusions (AE), and synovial fluids (SF). EBFs with 0.0–20.0% neutrophils: 83.0% aerobic and 1.3% strongly anaerobic cases with median of AST = 13.8 IU/L in CSF; 68.0% aerobic and 9.0% strongly anaerobic cases with median of AST = 20.4 IU/L in PE; 77.5% aerobic and 10.5% strongly anaerobic cases with median of AST = 18.0 IU/L in AE; 64.1% aerobic and 7.7% strongly anaerobic cases with median of AST = 13.8 IU/L in SF. EBFs with 80.0–100.0% neutrophils: 4.2% aerobic and 73.7% strongly anaerobic cases with median of AST = 19.2 IU/L in CSF; 7.4% aerobic and 77.3% strongly anaerobic cases with median of AST = 145.2 IU/L in PE; 11.8% aerobic and 73.7% strongly anaerobic cases with median of AST = 61.8 IU/L in AE; 25.5% aerobic and 38.2% strongly anaerobic cases with median of AST = 37.2 IU/L in SF. The significant presence of neutrophils, concomitant strong anaerobic metabolism, and elevated AST in various EBFs are reliable signs of damaging purulent inflammation.

Malignant Pleural Effusions

Malignant pleural effusions have a significant burden on patients and the health care system. Diagnosis is typically via thoracentesis, although other times more invasive procedures are required. Management centers around relief of dyspnea and patient quality of life and can be done via serial thoracentesis, indwelling pleural catheter, or pleurodesis. This article focuses on the diagnosis and management of malignant pleural effusion.

Deep Mining Generation of Lung Cancer Malignancy Models from Chest X-ray Images

Lung cancer is the leading cause of cancer death and morbidity worldwide. Many studies have shown machine learning models to be effective in detecting lung nodules from chest X-ray images. However, these techniques have yet to be embraced by the medical community due to several practical, ethical, and regulatory constraints stemming from the “black-box” nature of deep learning models. Additionally, most lung nodules visible on chest X-rays are benign; therefore, the narrow task of computer vision-based lung nodule detection cannot be equated to automated lung cancer detection. Addressing both concerns, this study introduces a novel hybrid deep learning and decision tree-based computer vision model, which presents lung cancer malignancy predictions as interpretable decision trees. The deep learning component of this process is trained using a large publicly available dataset on pathological biomarkers associated with lung cancer. These models are then used to inference biomarker scores for chest X-ray images from two independent data sets, for which malignancy metadata is available. Next, multi-variate predictive models were mined by fitting shallow decision trees to the malignancy stratified datasets and interrogating a range of metrics to determine the best model. The best decision tree model achieved sensitivity and specificity of 86.7% and 80.0%, respectively, with a positive predictive value of 92.9%. Decision trees mined using this method may be considered as a starting point for refinement into clinically useful multi-variate lung cancer malignancy models for implementation as a workflow augmentation tool to improve the efficiency of human radiologists.

Tumor and tumorlike conditions of the pleura and juxtapleural region: review of imaging findings

Pleural lesions form a diagnostic challenge for the radiologist. Whereas lesions can be initially detected on chest radiographs, CT and MRI imaging are the imaging modalities of choice for further characterization. In a number of cases, imaging findings can be relatively specific. In general unfortunately, imaging findings are rather aspecific. Evolution and extrathoracic imaging findings are important clues toward the diagnosis.

Narrative review of theoretical considerations regarding HITHOC between past and future

Hyppocrates constructed the medicines-surgery-energy triangle which includes all therapeutical modalities. Hyperthermic intraoperative chemotherapy (HITHOC) is a synergy-based single stage multimodality treatment encompassing the locoregional manifestation of the systemic malignant process. Pleural space, thermal effect, lavage/irrigation and chemotherapy represent the basic science ports of the network hub: HITHOC. The malignant transformation and process of the pleural surface (and underlying lung) challenges space management and tissue control. Thermotherapy without local chemotherapy is insufficient, similar to the normothermic local irrigation aligned with anticancer agents. The local administration of combined heat-transfer fluid and chemotherapy with or without subsequent surgical removal offers reasonable outcome in extensive primary pleural neoplasms (malignant mesothelioma), advanced (> Stage IIIA) NSCLC, functionally inoperable lung cancer and pleural carcinosis from extrathoracic malignancies. Measured by symptom-free survival and the quality of life, HITHOC in its present form, offers a modest yet fully substantiated solution. HITHOC in combination with the local application of targeted therapy and/or immunotherapy administered in the pleural space are currently under investigation. Additional development including new acting substances, their solvents and the means regarding surgical delivery and anesthesiology techniques are sign posts up ahead. Level 2 evidence are required in order to stepping up the recommendation levels, rewriting protocols and guidelines, in which HITHOC earns its revered position in the decision making process it deserves.

Cytological-energy analysis of pleural effusions with predominance of neutrophils

Background:

The predominance of neutrophils in pleural effusions of patients with different serious impairments of the pleural cavity organs is often found. The aim of this study was to identify the type of injury using the cytological-energy analysis of pleural effusions.

Methods:

We analysed 635 samples of pleural effusions with predominance of neutrophils. We compared the values of the coefficient of energy balance (KEB), lactate dehydrogenase (LDH) and aspartate aminotransferase (AST) catalytic activities in the following subgroups of patients: with transudative effusions, purulent pneumonia, chest empyema and after chest surgery with and without purulent complications. Statistical analysis was performed using the ANOVA Kruskal–Wallis test (p < 0.05 was considered as significant).

Results:

We found the lowest KEB values in pleural effusions of patients with chest empyema and their gradual increases in patients with purulent pneumonia and with transudative effusions. We observed the highest LDH and AST enzymes activity in patients with chest empyema and their gradual decrease in patients with purulent pneumonia and with transudative effusions. LDH and AST enzymes activity was significantly higher in pleural effusions of patients after chest surgery with purulent complications compared with non-purulent cases.

Conclusion:

The most intensive inflammation and the most extensive tissue destruction in the pleural cavity were found in patients with chest empyema. Significantly better parameters were observed in patients with purulent pneumonia. The absence of serious inflammation and the absence of tissue destruction were typical for patients with transudative effusions. Finally, our results confirmed an anticipated higher tissue destruction in patients after chest surgery. Significantly worse injury was found in surgical patients with purulent complications compared with non-purulent ones.

The reviews of this paper are available via the supplemental material section.

Clinical course of asymptomatic malignant pleural effusion in non-small cell lung cancer patients: A multicenter retrospective study

The British Thoracic Society guidelines recommend observation for patients with asymptomatic malignant pleural effusion (MPE). However, asymptomatic MPE can become symptomatic. This study examined the clinical course of asymptomatic MPE in patients with non-small cell lung cancer (NSCLC), including the incidence and timing of symptom development of asymptomatic MPE and the associated factors.Retrospective data of 4822 NSCLC patients between January 2012 and December 2017 were reviewed. Symptom development of asymptomatic MPE was defined as the development of symptoms requiring additional treatment, such as insertion of a chest tube, within 1 year in patients who lacked MPE symptoms at the time of diagnosis. Clinical information, pathological parameters, and radiological characteristics were reviewed. Patient data up to 1 year from the initial diagnosis were reviewed.Of 113 patients with asymptomatic MPE, 46 (41%) became symptomatic within 1 year despite appropriate anticancer treatment. The median time to symptom development was 4 months, and 38 patients (83%) developed symptoms within 6 months. Multivariate logistic regression showed that female sex (odds ratio [OR], 0.256; 95% confidence interval [CI], 0.101-0.649; P = .004) and the depth of pleural effusion on initial computed tomography (CT) (OR, 0.957; 95% CI, 0.932-0.982; P = .001) were independently associated with symptom development of asymptomatic MPE.A fraction of 41% of patients with asymptomatic MPE became symptomatic within 1 year. Female sex and larger MPE on initial CT were independently associated with symptom development of asymptomatic MPE.

ExoProK: A Practical Method for the Isolation of Small Extracellular Vesicles from Pleural Effusions

Extracellular vesicles (EVs) are cell-secreted, lipid membrane-enclosed nanoparticles without functional nucleus. EV is a general term that includes various subtypes of particles named microvesicles, microparticles, ectosomes or exosomes. EVs transfer RNA, DNA and protein cargo between proximal and distant cells and tissues, thus constituting an organism-wide signal transduction network. Pathological tissues secrete EVs that differ in their cargo composition compared to their healthy counterparts. The detection of biomarkers in EVs from biological fluids may aid the diagnosis of disease and/or monitor its progression in a minimally invasive manner. Among biological fluids, pleural effusions (PEs) are integrated to clinical practice, as they accompany a wide variety of lung disorders. Due to the proximity with the pleura and the lungs, PEs are expected to be especially enriched in EVs that originate from diseased tissues. However, PEs are among the least studied biofluids regarding EV-specialized isolation methods and related biomarkers. Herein, we describe a practical EV isolation method from PEs for the screening of EV RNA biomarkers in clinical routine. It is based on a Proteinase K treatment step to digest contaminants prior to standard polyethylene-glycol precipitation. The efficiency of the method was confirmed by transmission electron microscopy, nanoparticle tracking analysis and Western blot. The reliability and sensitivity of the method towards the detection of EV-enriched RNA biomarkers from multiple PEs was also demonstrated.

A Retrospective Analysis of the Palliative Surgical Treatment in Patients with Malignant Pleural Effusion

Introduction: The formation of malignant pleural effusion (MPE) is a clinical manifestation of an advanced malignancy or its dissemination. The focus of treatment is primarily palliative and aimed at relieving symptoms, especially dyspnoea.

Material and Methods: Clinical data from patients who were hospitalized at the Clinic of Thoracic Surgery, JFMED CU and Martin University Hospital, in the years 2015–2019 were retrospectively explored and statistically analyzed based on their medical records.

Results: From the group of patients with proven MPE (n=67), 32 patients were male (48%) and 35 were female (52%). The mean age was 62.3 years (65.4 for males and 59.4 for females). The three most common primary malignancies were lung cancer (n=24), breast cancer (n=14), and kidney cancer (n=6). In 38 patients with MPE a talc pleurodesis via VATS was performed, with a median survival of 341 days (95% CI 256–859). Drainage following the talc slurry pleurodesis was performed in 10 patients with a median survival of 91.5 days (95% CI 64-NA). Ten patients with MPE underwent drainage only. The overall median survival time after all types of surgical interventions was 301 days (95% CI 207-389 days).

Conclusion: Management of MPE depends on the patient´s prognosis. A definitive intervention is required in patients with a long-term survival, while in patients with a short life expectancy procedures leading to the shortest hospital stay are preferred. Videothoracoscopic procedures with pleurodesis represent an effective treatment for patients with symptomatic MPE with a good performance status, presence of lung re-expansion following pleural drainage or expected survival.

Malignant pleural neoplasm with both differentiation of epithelioid mesothelioma and squamous-cell carcinoma, a rare phenomena

Malignant mesothelioma, a neoplasm arising within the serosal surfaces, has been linked closely to asbestos exposure. We present a case of 72-year-old male with a 27 year work-related history of asbestos exposure who presented with dyspnea. Chest computed tomography scan showed a large, right pleural effusion with compressive right lung atelectasis. Biopsies, subsequent pleurectomy and lung wedge resections revealed epithelioid malignant mesothelioma with associated focal non-keratinizing squamous-cell carcinoma, supported by extensive immunohistochemical stains and molecular studies. The patient was treated with 6 cycles of carboplatin/pemetrexed, showing no new metastases. Seven months post-treatment, the patient presented with progressive dyspnea and large pleural effusions. Bilateral pleural fluid was collected and showed malignant epithelioid cells, morphologically similar to the patient's pleural neoplastic cells. However, the tumor was positive for squamous cells markers and showed BAP1 loss, while negative for mesothelial markers. The findings support the diagnosis of squamous-cell carcinoma and were consistent with the patient's previously diagnosed pleural neoplastic origin. A malignant mesothelioma associated with squamous-cell carcinoma is a rare phenonmenon. To our knowledge, only two case reports are available in current literature. This unique case shows a single pleura tumor differentiating as both malignant mesothelioma and squamous-cell carcinoma. Squamous-cell carcinoma is the predominating malignancy seen within the bilateral pleural effusions, a potential pitfall for cytology specimen diagnosis.

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

INTRODUCTION AND AIMS

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

Evaluation of intracavitary carboplatin chemotherapy for treatment of pleural carcinomatosis in cats: a retrospective study of eight cases

OBJECTIVES

The aim of this study was to evaluate the benefit of intracavitary carboplatin chemotherapy in cats with malignant pleural effusion of epithelial origin.

METHODS

The medical records of cats with a cytological diagnosis of neoplastic pleural effusion of epithelial origin were reviewed at three referral institutions between January 2013 and June 2018. Only cats treated with intracavitary carboplatin chemotherapy were enrolled. Data collection included signalment, medical history, clinical signs, pleural effusion analysis, diagnostic imaging findings, intracavitary carboplatin chemotherapy protocol, adverse events, response to chemotherapy, outcome and underlying primary tumour, if possible.

RESULTS

Eight cats met the inclusion criteria. Three cats had previous surgical removal of a tumour, including a poorly differentiated primary lung carcinoma, a uterine adenocarcinoma and a benign mammary tumour. The main clinical signs were tachypnoea and/or dyspnoea, inappetence and weight loss. Thoracic radiographs revealed marked bilateral pleural effusion in all cats. Pleural fluid analysis was consistent with a modified transudate, with malignant epithelial cells on cytology, leading to a diagnosis of pleural carcinomatosis. All cats received only one cycle of intracavitary carboplatin chemotherapy at a dose of 200-240 mg/m2. Recurrence of pleural effusion was reported in 7/8 cats within 4-15 days of chemotherapy, and death was recorded in all cats within 5-16 days, owing to recurrent pleural effusion or poor general condition. The primary cancer was suspected to be of pulmonary, mammary and pancreatic origin in four cats, two cats and one cat, respectively, and of unknown origin in the remaining cat.

CONCLUSIONS AND RELEVANCE

In this study, intracavitary carboplatin chemotherapy seems ineffective in managing neoplastic pleural effusion of epithelial origin in cats with pleural carcinomatosis. Other cytotoxic drugs and/or techniques should be investigated in the future to improve the quality of life and survival of cats with pleural carcinomatosis.

Micronucleus and Its Significance in Effusion Fluids

Background:

Micronucleus (MN) is an extranuclear body within the cell formed due to failure of incorporation of whole chromosomes or their fragments during cell division. MN scoring can be done to identify malignant effusions.

Aims:

This study aimed to score micronuclei to distinguish malignant effusion from benign effusions and to correlate MN score with type of malignant effusion.

Methods and Materials:

A retrospective study was conducted on 30 malignant and 30 benign effusions. The number of micronucleated cells per 1,000 cells was counted in effusion smears stained with Papanicolaou stain under oil immersion (1,000×).

Results:

The mean MN score in malignant effusions was 3.77 with standard deviation (SD) of 2.13. The mean MN score in benign effusions was 0.50 with SD of 0.57. The difference in MN score between malignant and benign effusions is statistically significant (P < 0.001). A cut-off MN score of 6.5 was seen to distinguish malignant and benign effusions with 100% specificity and 100% sensitivity in this study.

Conclusions:

MN score is higher in malignant effusions when compared with benign effusions. This can be used to differentiate malignant effusions from benign effusions in low resource setting.

Diagnostic accuracy of E-cadherin for malignanteffusions: a systematic review and meta-analysis

BACKGROUND

The differential diagnosis of malignant effusion remains a clinical challenge. We aim to summarise all relevant literature studies in order to determine the overall clinical value of E-cadherin in the diagnosis of malignant effusion by meta-analysis.

METHODS

PubMed, the Cochrane Library Database, Medline (Ovid), Web of Science, CNKI, WANFANG and WEIPU databases are thoroughly searched up to 15 March2018. The calculated pooled sensitivity, specificity, likelihood ratio (LR), diagnostic OR(DOR) and the summary receiver operating characteristic (SROC) curve were plotted.

RESULTS

A total of 15 studies were included in the analysis. The sensitivity and specificity of E-cadherin in the diagnosis of malignant effusion were determined to be high, with a sensitivity of 0.83(95%CI0.79 to 0.87) and a specificity of 0.96(95%CI0.90 to 0.98). The positive LR was determined to be 21.10(95%CI 8.54 to 52.11), the negative LR was determined to be 0.17(95% CI 0.14 to 0.22) and the DOR was determined to be 121.34(95%CI 49.11 to 299.80). The SROC curve exhibited a high overall diagnostic, with the area under the curve measured to be 0.91(95% CI 0.89 to 0.93). Subgroup analysis showed the method (cell blocks or smears), sample size (≥100 or<100), geographical location (Asia, Europe or USA) and impact factor of each article (≥3 or<3) were not the sources of overall heterogeneity.

CONCLUSION

E-cadherin exhibits very good diagnostic accuracy for the diagnosis for malignant effusion; thus, it can be helpful in the process of clinical decisions.

High fluorescence cell count in pleural fluids for malignant effusion screening

Malignant pleural effusion (MPE) is mainly secondary to pleural metastasis. Its prevalence is 15 to 35% of all the pleural effusions, and the median of survival oscillates between 4 and 6 months, reason why it is very important to know how to diagnose it. The Sysmex XN-350® is an automated hematological analyzer that allows white blood cell count and differentiation, as well as high fluorescence cells (HFC) which includes macrophages, mesothelial and neoplastic cells. For MPE screening, the best combinations obtained were HF-BF# ≥ 17/μL and HF-BF# > 10/μL, both in the absence of heart failure and/or low respiratory infection. The results of this study show that the automated analysis of the pleural fluid with the Sysmex XN-350® analyzer is effective for the screening of the MPE.

Nomogram construction for predicting survival of patients with non-small cell lung cancer with malignant pleural or pericardial effusion based on SEER analysis of 10,268 patients

Determining the accurate outcome of patients with non-small cell lung cancer (NSCLC) and malignant pleural effusion (MPE) or malignant pleural pericardial effusion (MPCE) at the initial diagnosis remains a challenge. The aim of the present study was to develop an effective nomogram for individualized estimation of overall survival in these patients. Patients diagnosed between January 2010 and December 2015 were selected from the Surveillance, Epidemiology, and End Results (SEER) database. Age, race, sex, grade, histology, laterality, stage and status of MPE or MPCE at initial diagnosis were included as covariates. Several survival models were created and the performance of each was evaluated. The most effective model was then validated by internal bootstrap resampling and by using an independent external cohort. A nomogram was created based on this survival model and the predictive accuracy of the nomogram was evaluated by calibration plots. Data from 10,268 patients with lung cancer with MPE or MPCE at initial diagnosis were collected. The multivariate analysis with a lognormal model suggested that age, race, sex, histology, stage and status of MPE or MPCE at initial diagnosis were significant independent factors to predict survival. A nomogram was constructed based on the lognormal survival model, which showed the best performance. The concordance index of the survival model in the SEER cohort was 0.736. Both internal and external validation showed an acceptable level of agreement between the nomogram-predicted survival probability and actual survival. The nomogram of the present study based on a large cohort from the SEER database may improve prognostic prediction of patients with NSCLC with MPE or MPCE at initial diagnosis, and allow physicians to make appropriate decisions for disease management of their patients.

Evaluation of Efficacy and Safety for Lentinan in the Control of the Malignant Pleural Effusions via Intrapleural Injection

BACKGROUND

Many studies have investigated the efficacy and safety of lentinan combined with cisplatin versus cisplatin alone for controlling malignant pleural effusion (MPE). This study is a meta-analysis of available evidence.

MATERIALS AND METHODS

Seventeen studies reporting lentinan combined with cisplatin versus cisplatin alone for controlling MPE were reviewed. Pooled odds ratios and hazard ratio with 95% confidence intervals were calculated using the fixed effects model of meta-analysis.

RESULTS

The overall response rate (ORR) of lentinan combined with cisplatin for controlling MPE was significantly higher than that of cisplatin alone (P < 0.001). In addition, lentinan combined with cisplatin showed a better benefit of quality of life (QOL) compared with cisplatin alone (P < 0.001). The main adverse effects (AEs) found in the control plan were hematological reactions, nausea/vomiting, chest pain and fever. However, the presence of lentinan did not have an extra influence on the incidence of AEs (P > 0.05).

CONCLUSIONS

Intrapleural injection of lentinan combined with cisplatin had a better benefit of ORR and QOL for controlling MPE, compared with cisplatin alone. Moreover, lentinan combined with cisplatin had a similar incidence of AEs with cisplatin alone.

Malignant pleural effusion and cancer of unknown primary site: a review of literature

Malignant pleural effusions (MPE) are most frequently (50-65%) noted from lung and breast cancers. They are commonly unilateral and are reflective of poorer prognosis. Cancer of unknown primary (CUP) account for 4-5% of all invasive cancers. These are metastatic tumors in which the primary is unknown despite an extensive medical evaluation. About 11% of MPE are from CUP. These MPEs present a clinical dilemma to physicians as there is a paucity of literature on their management and no consensus or guideline statement. This paper provides an overview of MPE from CUP in regard to diagnosis, prognosis, and treatment options. A selective search was performed in Medline and PubMed, with the keywords "Malignant pleural effusion" and "Cancer of unknown primary" up to December 2018. A review of literature would suggest that a thoracentesis is the first step in all cases but additional work up such as thoracoscopy & pleural biopsies is frequently warranted. With advances in immunohistochemical staining and biomarker development, MPE with CUP maybe profiled in a similar manner as lung cancer. Similarly, liquid biopsy or identification of circulating tumor cell free DNA may have a role in the work up of CUP in the future. There is some experience in managing these patients with gene directed therapies and immune checkpoint inhibitors, however, with mixed results. Given the poor prognosis associated with MPE from CUP, symptom alleviating measures such as indwelling pleural catheters should be part of the management strategy.

Cytological-energy analysis of pleural effusions

Background

Simultaneous cytological and metabolic investigation of the pleural effusion provides clinically relevant information about the type and intensity of immune response in the pleural cavity.

Methods

We investigated 1329 pleural effusions from patients with different pathological changes in the pleural cavity. Evaluated parameters were differential cell count of neutrophils, eosinophils, lymphocytes and monocytes, and values of the coefficient of energy balance.

Results

We found the lowest numbers of cells and the highest coefficient of energy balance values in patients with heart failure and sepsis; relatively high frequency of eosinophils and slightly decreased coefficient of energy balance values in patients with pneumothorax and haemothorax; the predominance of lymphocytes and low coefficient of energy balance values in patients with tuberculous pleuritis; the predominance of neutrophils and variable coefficient of energy balance values in patients after chest surgery; the highest presence of neutrophils and very low coefficient of energy balance values in patients with chest empyema and the predominance of lymphocytes and normal to low coefficient of energy balance values in patients with pleural malignancy.

Conclusions

Our findings in patients with heart failure and sepsis suggest the absence of inflammation in the pleural cavity. We observed the manifestation of tissue repair in patients with pneumothorax and haemothorax. Patients with tuberculous pleuritis were predominantly characterized by T cell-driven immune response and oxidative burst of macrophages. We found different intensities of immune responses to the chest surgery. The typical finding in patients with empyema was oxidative burst of neutrophils. In patients with pleural malignancy, weak cytotoxic inflammation predominates together with the intensive inflammation characterized by oxidative burst of macrophages.

Clinical factors affecting the survival of patients diagnosed with non-small cell lung cancer and metastatic malignant pleural effusion, treated with hyperthermic intrathoracic chemotherapy or chemical talc pleurodesis: a monocentric, prospective, randomized trial

Background

There is a plethora of treatment algorithms for managing patients with malignant pleural effusions (MPEs), sharing many common points and principles. Our study aims to compare hyperthermic intrapleural chemotherapy (HITHOC) and talc pleurodesis (TALC), as treatment options for patients with non-small cell lung cancer (NSCLC) and metastatic MPE.

Methods

This prospective, randomized trial was conducted at a single thoracic surgery center, the "Theagenio" Cancer Institute, in Greece, under the identification code NCT01409551 and was completed. All 40 patients enrolled were adults with histologically proven metastatic, unilateral, MPE caused by NSCLC. Exclusion criteria included patients >80 years, trapped lung, and major comorbidities. Patients were randomly and equally assigned 1:1 to either HITHOC (group A) or TALC (group B) by video assisted thoracic surgery (VATS). The primary outcome was the median overall survival (OS) from trial intervention to death, while secondary outcome was the identification of clinical factors affecting the survival.

Results

The patients were followed up for 45 months. The OS of the full group was 8 months (95% CI: 7.046-8.954). Participants who underwent HITHOC had an OS of 8 months (95% CI: 7.141-8.859), whereas the participants of TALC had an OS of 9 months (95% CI: 7.546-10.454), with no significant difference between groups. Among fifty-four factors that were tested for their effects on survival, only TNM stage and creatinine values both preoperatively and 7 days postoperatively could be regarded as risk-factors for survival. Other recorded parameters, which had significant variance between the two groups, were urea levels, C-reactive protein, white blood cells and total in hospital length of stay (LOS).

Conclusions

Both HITHOC and TALC are equally effective and safe therapeutic options in treating patients with MPE and NSCLC with acceptable survival. The study revealed independent clinical risk factors influencing survival, which could be utilized as starting points for larger clinical studies.

Keywords

Pleurodesis; pleural effusion; malignant; carcinoma; non-small cell lung; hyperthermia.

Elevated Hsp90-beta contributes to differential diagnosis of pleural effusion caused by lung cancer and correlates with malignant biological behavior of lung cancer

Background

Hsp90-beta has been investigated to be correlated with the occurrence and development of tumor. The intention of this research was to test the level of Hsp90-beta in malignant pleural effusion (MPE) of patients with lung cancer and disclose the clinical significance of Hsp90-beta as a potential tumor marker for differential diagnosis of pleural effusion caused by lung cancer.

Methods

The level of Hsp90-beta was determined using enzyme-linked immunosorbent assay. Calculations of the Hsp90-beta threshold, the sensitivity and specificity for distinguishing MPE from benign pleural effusion were performed using receiver operator characteristic curve.

Results

The level of Hsp90-beta in MPE of lung cancer patients was higher than that in control individuals (P < 0.05) and increased MPE Hsp90-beta was correlated with the pathological differentiation, tumor size and lymphatic metastasis (P < 0.05). The cutoff value of Hsp90-beta produced by receiver operator characteristic curve for distinguishing lung cancer from control individuals were 1.659 ng/mL and the sensitivity and specificity were 93.46 and 79%.

Conclusions

Increased Hsp90-beta in MPE was correlated with malignant biological behavior of lung cancer patients, indicating that the level of Hsp90-beta could be a tool of referential value for differential diagnosis of pleural effusion caused by lung cancer.

A novel approach for preventing recurrence of malign pleural effusion: early phase pleurodesis

INTRODUCTION

The effective control of malignant pleural effusion (MPE) is of paramount importance in the treatment of patients with disseminated cancer. In this study, we compared two different approaches (early pleurodesis versus late pleurodesis) to MPE.

MATERIAL AND METHODS

Patients (188 cases) whose primary tumor type was known and who were confirmed to have MPE, were included in the study and were separated into two groups. One group consisted of patients who were asymptomatic and who underwent early phase pleurodesis (group I, n = 79). The other group (group II, n = 109) was composed of patients who were symptomatic and whose pleurodesis was performed later. In all cases, pleural effusion was evaluated by means of direct radiography. Computed tomography was performed with the goal of confirming the parenchymal or mediastinal lesions accompanying the pleural fluid.

RESULTS

The rate of complete success in group I cases was observed to be higher, while the rate of recurrence was lower (p = 0.001 and p = 0.002, respectively) than group II. In multiple logistic regression analysis, co-morbidities and the group that patient belong were found to be significant in terms of pleurodesis success (p = 0.02 and p = 0.03). There was a significant difference in survival time between group I and group II, with group I exhibiting longer average survival time (log rank test p < 0.001).

CONCLUSIONS

We observed that the success rate was lower and the rate of recurrence higher in the late pleurodesis group, whose members already had greater volumes of pleural effusion.

Mediastinal recurrence after curative resection of colon cancer: A case report and review of literature

Colorectal carcinoma is one of the most common and significant causes of cancer-related death. Metastasis to mediastinal lymph nodes and/or pleura without liver or lung involvement is an atypical pattern of colon cancer metastasis. A 70-year-old male underwent curative right side hemicolectomy and omentectomy for ascending colon cancer followed by adjuvant chemotherapy. Around nine months after surgery, the patient was noted to have bilateral large pleural effusions on the restaging computed tomography scan of the chest/abdomen/pelvis. No intraabdominal or intrathoracic mass/metastasis was seen on the imaging. Multiple thoracentesis performed over the course of next few months revealed exudative effusion but failed to demonstrate malignant cells. A few months later, new mediastinal and right hilar lymphadenopathy was noted on the repeat computed tomography scan. A subsequent positron-emission tomography scan revealed multiple sites of fluorodeoxyglucose (FDG)-avid mediastinal lymphadenopathy. The sites of pleural effusion were not fluorodeoxyglucose-avid. Endobronchial ultrasound and biopsy of mediastinal nodes showed adenocarcinoma with signet-ring features. Immunohistochemistry confirmed the diagnosis of metastatic colon cancer. Systemic treatment with chemotherapy was initiated. Our case highlights the importance of mediastinal evaluation by imaging during the follow-up of patients with colorectal carcinoma. The ideal management strategy for mediastinal metastasis of colorectal carcinoma remains a question, two major options being local metastasectomy or systemic chemotherapy.

Characteristics of cellular composition in malignant pericardial effusion and its association with the clinical course of carcinomatous pericarditis

To date, the cellular composition of malignant pericardial effusion (MPE) and its association with the clinical course of carcinomatous pericarditis remain unclear. We aimed to determine the MPE cellular composition and its association with carcinomatous pericarditis. Forty-four cases indicated for pericardial drainage due to symptomatic carcinomatous pericarditis were retrospectively reviewed; the blood cell count and composition of MPE were examined. The most dominant cells in MPE were neutrophils. The appearance ratio of an atypical cell in cytologically positive MPE was 95.5%. Low neutrophil and high lymphocyte counts were significantly associated with good effusion failure-free survival at 1 month. The survival after pericardial drainage was significantly shorter when the neutrophil/lymphocyte ratio was 3.5 or more (P = 0.041). Patients whose performance status improved due to drainage had significantly high leukocyte counts in MPE (P = 0.02). Prediction of the course of drainage through basic examination of MPE cellular composition might be beneficial in clinical practice.

Evaluation of efficacy and safety for Brucea javanica oil emulsion in the control of the malignant pleural effusions via thoracic perfusion

Background

Brucea javanica oil emulsion (BJOE) is traditional Chinese medicine with implicated anti-tumor activity, which has been used for treating lung cancer in China. The aim of this investigation was to evaluate the effects and safety of intrapleural injection of BJOE in treating malignant pleural effusion (MPE).

Methods

The randomised controlled trials (RCTs) on the effects and safety of BJOE in treating MPE were searched from electronic medical database including MEDLINE, SCI, EMBASE, Cochrance Library and CNKI. A total of 14 RCTs with 1085 patients were involved in this meta-analysis.

Results

The overall response rate (ORR) of traditional chemotherapy drugs plus BJOE was higher than that of traditional chemotherapy drugs alone (p = 0.001; odds ratio = 1.39). Meanwhile, the combination of BJOE and traditional chemotherapy drugs improved the quality of life (QOL) of patients with MPE (p < 0.001; odds ratio = 1.56) compared with traditional chemotherapy drugs alone. Moreover, the participation of BJOE reduced the myelotoxicity and digestive reactions caused by traditional chemotherapy drugs (p < 0.05).

Conclusions

The efficacy and safety of traditional chemotherapy drugs plus BJOE was superior to traditional chemotherapy drugs alone via intrapleural injection in controlling MPE, which suggested that BJOE can be used to treat MPE.

Comparison of Efficiency of Pleurodesis Between Video Assisted Thoracoscopic Surgery (VATS) and Standard Thoracostomy

Background

Chemical pleurodesis is generally accepted palliative dyspnea therapy and preventive of re-accumulation of pleural fluid in patients with malignant pleural effusions.

Aim

Comparative analyses of efficiency of chemical pleurodesis between Video Assisted Thoracoscopic Surgery (VATS) and standard thoracostomy.

Methods

From 01.01.2016-01.01.2017 at the Clinic for Thoracic Surgery of University Clinical Center (UCC) Sarajevo retrospective analysis was performed. Studied patients underwent VATS pleurodesis (G1) and standard thoracostomy pleurodesis (G2), with 60 in each group, respecting defined inclusion and exclusion criteria. Pleurodesis success was examined radiologically over the next three months.

Results

Average age of all patients was 63.97±8.75 years. Gender related, 45% were men and 55% were women (F/M=1.47:1). Average hospitalization was 7.22±1.37 (G1: 6.68±1.16; G2: 7.44±1.40; Mann-Whitney U-test: p=0.0016) days. Average thoracic drainage duration was 5.45±1.69, (G1: 4.28±1.15,G2: 6.05±1.58; Mann-Whitney U-test p<0.0001) days. Pleurodesis success after first month was 98.30% in G1, 91.60% in G2 (G1 vs. G2; p=0.2089); after second month was 98.30% in G1, 78.30% in G2 (G1 vs. G2; p=0.0011) and after three months was 91.60% in G1, 63.30% in G2(G1 vs. G2; p=0.0006). Average dyspnea degree (0-5) after the pleurodesis was 0.050±0.22 in G1 and 0.62±0.76 in G2 (Mann-Whitney U-test; p=0.0001). Complication were noticed in 9.2% patients, in G1 3.3%, 15.0% in G2.

Conclusion

Difference in pleurodesis efficiency between the G1 and G2 was established after second month and was even more evident after third month in favor of G1. Results show the significant statistical improvement of the degree of dyspnea in G1 as opposite to the G2.