Pleural procedures in the management of malignant effusions

Trapped Lung as a Sequela of Dramatic Tumor Shrinkage of Lung Cancer

Herein, we report a case of 72-year-old man who had L858R EGFR-mutated lung adenocarcinoma. Chest computed tomography revealed a large lung mass that had completely replaced the right upper lobe. Although the mass dramatically shrank after initiating chemotherapy, non-malignant pleural effusion appeared. Because diffuse pleural thickening and shrinking of the thoracic cage gradually became apparent, the patient was diagnosed with trapped lung. Despite the stabilization of his lung cancer, he experienced severe dyspnea and significant weight loss, ultimately leading to a decreased performance status. Chest physicians should recognize that trapped lung can develop as a sequela of dramatic tumor shrinkage in lung cancer.

Non-specific pleuritis: long-term follow-up outcomes

BACKGROUND

The definitive etiology of nonspecific pleuritis (NSP), the influence of the type of pleural biopsy on clinical results and the minimum duration of follow-up is controversial.

RESEARCH DESIGN AND METHODS

A retrospective, observational study of patients ≥ 18 years with NSP confirmed by closed pleural biopsy (CPB), local anesthesia pleuroscopy (LAP), or video-assisted thoracic surgery (VATS).

RESULTS

A total of 167 patients were included (mean follow-up, 14.4 months), of which 25 (15%) were diagnosed within one month; [15 (60%) malignant]. Of the remaining 142 pleural effusions (PEf), 69 (48.6%) were idiopathic; 49 (34.5%) not-malignant and 24 (16.9%) malignant (4 mesotheliomas and 20 metastasic). The diagnosis of NSP was established by CPB (7; median time to diagnosis, 9.4 months), LAT (5; 15.8 months), and VATS (8; 13.5 months) (p = 0.606). Sixty-eight patients (40.7%) died during follow-up (mean time, 12 months).

CONCLUSIONS

In a substantial percentage of patients diagnosed with NSP, a definitive diagnosis will not be obtained, a relevant number of patients will develop a malignant PEf. The diagnostic procedure used for the diagnosis of NSP does not seem to influence delay in the diagnosis of malignant PEf. The data obtained suggest that follow-up should be maintained for at least 24 months.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Postoperative outcome after palliative treatment of malignant pleural effusion

BACKGROUND

The objective of this nationwide, registry-based study was to compare the two most frequently used procedures for the palliative treatment of a malignant pleural effusion (MPE) and to evaluate differentiated indications for these two procedures.

METHODS

This was a retrospective observational study based on data of the "PLEURATUMOR" registry of the German Society for Thoracic Surgery. Patients who were documented in the period from January 2015 to November 2021 and had video-assisted thoracic surgery (VATS) talc pleurodesis or implantation of an indwelling pleural catheter (IPC) were included.

RESULTS

A total of 543 patients were evaluated. The majority suffered from secondary pleural carcinomatosis (n = 402; 74%). VATS talc pleurodesis (n = 361; 66.5%) was performed about twice as often as IPC implantation (n = 182; 33.5%). The duration of surgery was significantly shorter in IPC-patients with 30 min compared to VATS talc pleurodesis (38 min; p = 0.000). Postoperative complication rate was 11.8% overall and slightly higher after VATS talc pleurodesis (n = 49; 13.6%) than after IPC implantation (n = 15; 8.2%). After VATS talc pleurodesis patients were hospitalized significantly longer compared to the IPC group (6 vs. 3.5 days; p = 0.000). There was no significant difference in postoperative wound infections between the groups (p = 0.10). The 30-day mortality was 7.9% (n = 41).

CONCLUSION

The implantation of an IPC can significantly shorten the duration of surgery and the hospital stay. For this reason, the procedure should be matched with the patient's expectations preoperatively and the use of an IPC should be considered not only in the case of a trapped lung.

Diagnostic accuracy of adenosine deaminase for pleural tuberculosis in a low prevalence setting: A machine learning approach within a 7-year prospective multi-center study

OBJECTIVE

To analyze the performance of adenosine deaminase in pleural fluid combined with other parameters routinely measured in clinical practice and assisted by machine learning algorithms for the diagnosis of pleural tuberculosis in a low prevalence setting, and secondly, to identify effusions that are non-tuberculous and most likely malignant.

PATIENTS AND METHODS

We prospectively analyzed 230 consecutive patients diagnosed with lymphocytic exudative pleural effusion from March 2013 to June 2020. Diagnosis according to the composite reference standard was achieved in all cases. Pre-test probability of pleural tuberculosis was 3.8% throughout the study period. Parameters included were: levels of adenosine deaminase, pH, glucose, proteins, and lactate dehydrogenase, red and white cell counts and lymphocyte percentage in pleural fluid, as well as age. We tested six different machine learning-based classifiers to categorize the patients. Two different classifications were performed: a) tuberculous/non-tuberculous and b) tuberculous/malignant/other.

RESULTS

Out of a total of 230 patients with pleural effusion included in the study, 124 were diagnosed with malignant effusion and 44 with pleural tuberculosis, while 62 were given other diagnoses. In the tuberculous/non-tuberculous classification, and taking into account the validation predictions, the support vector machine yielded the best result: an AUC of 0.98, accuracy of 97%, sensitivity of 91%, and specificity of 98%, whilst in the tuberculous/malignant/other classification, this type of classifier yielded an overall accuracy of 80%. With this three-class classifier, the same sensitivity and specificity was achieved in the tuberculous/other classification, but it also allowed the correct classification of 90% of malignant cases.

CONCLUSION

The level of adenosine deaminase in pleural fluid together with cell count, other routine biochemical parameters and age, combined with a machine-learning approach, is suitable for the diagnosis of pleural tuberculosis in a low prevalence scenario. Secondly, non-tuberculous effusions that are suspected to be malignant may also be identified with adequate accuracy.

Tuberculosis-Infected Giant Bulla Treated by Percutaneous Drainage Followed by Obliteration of the Pulmonary Cavity Using Talc: Case Report

Tuberculosis (TB)-infected giant bullae are rare. A 55-year-old man was referred when an infected bulla did not respond to empirical treatment. Computed tomography showed a giant bulla in the right upper lobe with an air-fluid level and surrounding infiltrate. Sputum culture, acid-fast bacilli (AFB) stain, and polymerase chain reaction (PCR) for TB were negative. Percutaneous drainage of the bullous fluid was performed. AFB stain and PCR were positive in the drained fluid. The patient was given anti-TB drugs and later underwent obliteration of the pulmonary cavity using talc. To summarize, we report a patient with a TB-infected giant bulla that was treated successfully with anti-TB drugs and obliteration of the pulmonary cavity using talc.

The investigation of the volatile metabolites of lung cancer from the microenvironment of malignant pleural effusion

For malignant pleural effusions, pleural fluid cytology is a diagnostic method, but sensitivity is low. The pleural fluid contains metabolites directly released from cancer cells. The objective of this study was to diagnose lung cancer with malignant pleural effusion using the volatilomic profiling method. We recruited lung cancer patients with malignant pleural effusion and patients with nonmalignant diseases with pleural effusion as controls. We analyzed the headspace air of the pleural effusion by gas chromatography-mass spectrometry. We used partial least squares discriminant analysis (PLS-DA) to identify metabolites and the support vector machine (SVM) to establish the prediction model. We split data into a training set (80%) and a testing set (20%) to validate the accuracy. A total of 68 subjects were included in the final analysis. The PLS-DA showed high discrimination with an R² of 0.95 and Q² of 0.58. The accuracy of the SVM in the test set was 0.93 (95% CI 0.66, 0.998), the sensitivity was 83%, the specificity was 100%, and kappa was 0.85, and the area under the receiver operating characteristic curve was 0.96 (95% CI 0.86, 1.00). Volatile metabolites of pleural effusion might be used in patients with cytology-negative pleural effusion to rule out malignancy.

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.

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.

Malignant Pleural Effusion: Still a Long Way to Go

BACKGROUND

Malignant pleural effusion, which is a common clinical problem in patients with cancer, may be due to both primary thoracic tumours or to a metastatic spread in the chest and constitutes the first sign of disease in approximately 10% of patients. Almost all cancers can potentially produce a pleural effusion. The presence of malignant tumour cells in the pleural fluid is generally indicative of advanced disease and is associated with high morbidity and mortality with reduced therapeutic options. Dyspnoea during mild physical activity or at rest is generally the typical sign of restrictive respiratory failure.

METHODS

This is a systematic review of all the main articles in the English language on the topic of malignant pleural effusion and reported by the Pubmed database from 1959 to 2018. I reviewed the literature and guidelines with the aims to focus on what is known and on future pathways to follow the diagnosis and treatment of malignant pleural effusions.

RESULTS

The main goal of palliation of a malignant pleural effusion is a quick improvement in dyspnoea, while thoracentesis under ultrasound guidance is the treatment of choice for patients with a limited life expectancy or who are not candidates for more invasive procedures such as drainage using an indwelling small pleural catheter, chemical pleurodesis with sclerosing agents, pleurectomy or pleuro-peritoneal shunt.

CONCLUSION

Despite progress in therapeutic options, the prognosis remains severe, and the average survival is 4-9 months from the diagnosis of malignant pleural effusion. Moreover, mortality is higher for patients with malignant pleural effusion compared with those with metastatic cancer but no malignant pleural effusion. Therefore, the prognosis of these patients primarily depends on the underlying disease and the extension of a primary tumour. This review focuses on the most relevant updates in the management of malignant pleural effusion.

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.

Diagnostic Accuracy of Lateral Decubitus Chest Radiography before Pleural Maneuvers for the Management of Pleurisies in the Era of Chest Ultrasound

BACKGROUND

Chest ultrasound (CUS) is the gold standard to detect pleural adhesions before pleural maneuvers. However, the CUS technique is not available in all countries where the assessment is only based on clinical examination and chest radiography.

OBJECTIVE

To assess the value of lateral decubitus chest radiography (LDCR) to detect pleural adhesions.

METHODS

Consecutive patients with pleural effusions undergoing LCDR followed by medical thoracoscopy the day after were identified from an institutional database. The diagnostic sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy for LDCR were calculated.

RESULTS

Eighty-six patients were included in the study. The sensitivity, specificity, PPV, and NPV of LDCR for the presence of adhesions taking into account the shape of the horizontal level were 71.2% (56.7-82.5), 44.1% (27.6-61.9), 66.1% (52.1-77.8), and 50% (31.7-68.3), respectively. The accuracy to predict pleural adhesions for the sign "incomplete horizontal level" was 60.5 (49.3-70.7). The accuracy to predict pleural adhesions in case of irregular aspect of the horizontal level was 53.5 (42.5-64.2).

CONCLUSIONS

The accuracy of LDCR for the detection of pleural adhesions is low in patients with pleural effusion and LDCR is not sufficient before pleural maneuvers. This has to be taken into account in countries with a high prevalence of pleural tuberculosis which usually lead to loculated pleural effusions. CUS has to be urgently included in dedicated educational programs in these areas in order to decrease the complications related to unexpected pleural adhesions and achieve better planning for the management of pleural effusions.

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.

Medical thoracoscopy and its evolving role in the diagnosis and treatment of pleural disease

Establishing the etiology of exudative pleural effusions in the setting of an unrevealing pleural fluid analysis often requires biopsies from the parietal pleura. While closed pleural biopsy (CPB) has been a popular minimally-invasive approach, it has a poor diagnostic yield, barring a diagnosis of tuberculous pleurisy. Medical thoracoscopy (MT) is a minimally-invasive ambulatory procedure performed under local anesthesia or moderate sedation which allows for direct visualization of biopsy targets as well as simultaneous therapeutic interventions, including chemical pleurodesis and indwelling tunneled pleural catheter (ITPC) placement. The excellent yield and favorable safety profile of MT has led to it replacing CPB for many indications, particularly in the management of suspected malignant pleural effusions. As experience with MT amongst interventional pulmonologists has grown, there is an increased appreciation for its important role alongside percutaneous and surgical approaches in the diagnosis and treatment of pleural disease.