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Tsim S, Alexander L, Kelly C, Shaw A, Hinsley S, Clark S, Evison M, Holme J, Cameron EJ, Sharma D, Wright A, Grundy S, Grieve D, Ionescu A, Breen DP, Paramasivam E, Psallidas I, Mukherjee D, Chetty M, Cox G, Hart-Thomas A, Naseer R, Edwards J, Daneshvar C, Panchal R, Munavvar M, Ostroff R, Alexander L, Hall H, Neilson M, Miller C, McCormick C, Thomson F, Chalmers AJ, Maskell NA, Blyth KG. Serum Proteomics and Plasma Fibulin-3 in Differentiation of Mesothelioma From Asbestos-Exposed Controls and Patients With Other Pleural Diseases. J Thorac Oncol 2021; 16:1705-1717. [PMID: 34116230 PMCID: PMC8514249 DOI: 10.1016/j.jtho.2021.05.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/20/2021] [Accepted: 05/09/2021] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Malignant pleural mesothelioma (MPM) is difficult to diagnose. An accurate blood biomarker could prompt specialist referral or be deployed in future screening. In earlier retrospective studies, SOMAscan proteomics (Somalogic, Boulder, CO) and fibulin-3 seemed highly accurate, but SOMAscan has not been validated prospectively and subsequent fibulin-3 data have been contradictory. METHODS A multicenter prospective observational study was performed in 22 centers, generating a large intention-to-diagnose cohort. Blood sampling, processing, and diagnostic assessment were standardized, including a 1-year follow-up. Plasma fibulin-3 was measured using two enzyme-linked immunosorbent assays (CloudClone [used in previous studies] and BosterBio, Pleasanton, CA). Serum proteomics was measured using the SOMAscan assay. Diagnostic performance (sensitivity at 95% specificity, area under the curve [AUC]) was benchmarked against serum mesothelin (Mesomark, Fujirebio Diagnostics, Malvern, PA). Biomarkers were correlated against primary tumor volume, inflammatory markers, and asbestos exposure. RESULTS A total of 638 patients with suspected pleural malignancy (SPM) and 110 asbestos-exposed controls (AECs) were recruited. SOMAscan reliably differentiated MPM from AECs (75% sensitivity, 88.2% specificity, validation cohort AUC 0.855) but was not useful in patients with differentiating non-MPM SPM. Fibulin-3 (by BosterBio after failed CloudClone validation) revealed 7.4% and 11.9% sensitivity at 95% specificity in MPM versus non-MPM SPM and AECs, respectively (associated AUCs 0.611 [0.557-0.664], p = 0.0015) and 0.516 [0.443-0.589], p = 0.671), both inferior to mesothelin. SOMAscan proteins correlated with inflammatory markers but not with asbestos exposure. Neither biomarker correlated with tumor volume. CONCLUSIONS SOMAscan may prove useful as a future screening test for MPM in asbestos-exposed persons. Neither fibulin-3 nor SOMAscan should be used for diagnosis or pathway stratification.
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Affiliation(s)
- Selina Tsim
- Glasgow Pleural Disease Unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom; Institute of Cancer Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Laura Alexander
- Cancer Research UK Clinical Trials Unit Glasgow, University of Glasgow, Glasgow, United Kingdom
| | - Caroline Kelly
- Cancer Research UK Clinical Trials Unit Glasgow, University of Glasgow, Glasgow, United Kingdom
| | - Ann Shaw
- Cancer Research UK Clinical Trials Unit Glasgow, University of Glasgow, Glasgow, United Kingdom
| | - Samantha Hinsley
- Cancer Research UK Clinical Trials Unit Glasgow, University of Glasgow, Glasgow, United Kingdom
| | - Stephen Clark
- Cancer Research UK Clinical Trials Unit Glasgow, University of Glasgow, Glasgow, United Kingdom
| | - Matthew Evison
- Department of Respiratory Medicine, University Hospital of South Manchester, United Kingdom
| | - Jayne Holme
- Department of Respiratory Medicine, University Hospital of South Manchester, United Kingdom
| | - Euan J Cameron
- Department of Respiratory Medicine, Forth Valley Royal Hospital, Larbert, United Kingdom
| | - Davand Sharma
- Department of Respiratory Medicine, Inverclyde Royal Hospital, Greenock, United Kingdom
| | - Angela Wright
- Department of Respiratory Medicine, Glasgow Royal Infirmary, Glasgow, United Kingdom
| | - Seamus Grundy
- Department of Respiratory Medicine, Salford Royal Hospital, Salford, United Kingdom
| | - Douglas Grieve
- Department of Respiratory Medicine, Royal Alexandra Hospital, Paisley, United Kingdom
| | - Alina Ionescu
- Department of Respiratory Medicine, Royal Gwent Hospital, Newport, United Kingdom
| | - David P Breen
- Department of Respiratory Medicine, Galway University Hospital, Galway, Ireland
| | | | - Ioannis Psallidas
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Dipak Mukherjee
- Department of Respiratory Medicine, Basildon University Hospital, Basildon, United Kingdom
| | - Mahendran Chetty
- Department of Respiratory Medicine, Aberdeen Royal Infirmary, Aberdeen, United Kingdom
| | - Giles Cox
- Department of Respiratory Medicine, King's Mill Hospital, Sutton-in-Ashfield, United Kingdom
| | - Alan Hart-Thomas
- Department of Respiratory Medicine, Huddersfield Royal Infirmary, Huddersfield, United Kingdom
| | - Rehan Naseer
- Department of Respiratory Medicine, Huddersfield Royal Infirmary, Huddersfield, United Kingdom
| | - John Edwards
- Department of Cardiothoracic Surgery, Northern General Hospital, Sheffield, United Kingdom
| | - Cyrus Daneshvar
- Department of Respiratory Medicine, Derriford Hospital, Plymouth, United Kingdom
| | - Rakesh Panchal
- Department of Respiratory Medicine, Glenfield Hospital, Leicester, United Kingdom
| | - Mohammed Munavvar
- Department of Respiratory Medicine, Royal Preston Hospital, Preston, United Kingdom
| | | | | | - Holly Hall
- Cancer Research UK Beatson Institute, Glasgow, United Kingdom
| | - Matthew Neilson
- Cancer Research UK Beatson Institute, Glasgow, United Kingdom
| | - Crispin Miller
- Institute of Cancer Sciences, University of Glasgow, Glasgow, United Kingdom; Cancer Research UK Beatson Institute, Glasgow, United Kingdom
| | - Carol McCormick
- Institute of Cancer Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Fiona Thomson
- Institute of Cancer Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Anthony J Chalmers
- Institute of Cancer Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Nick A Maskell
- Academic Respiratory Unit, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Kevin G Blyth
- Glasgow Pleural Disease Unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom; Institute of Cancer Sciences, University of Glasgow, Glasgow, United Kingdom; Cancer Research UK Beatson Institute, Glasgow, United Kingdom.
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Corcoran JP, Psallidas I, Gerry S, Piccolo F, Koegelenberg CF, Saba T, Daneshvar C, Fairbairn I, Heinink R, West A, Stanton AE, Holme J, Kastelik JA, Steer H, Downer NJ, Haris M, Baker EH, Everett CF, Pepperell J, Bewick T, Yarmus L, Maldonado F, Khan B, Hart-Thomas A, Hands G, Warwick G, De Fonseka D, Hassan M, Munavvar M, Guhan A, Shahidi M, Pogson Z, Dowson L, Popowicz ND, Saba J, Ward NR, Hallifax RJ, Dobson M, Shaw R, Hedley EL, Sabia A, Robinson B, Collins GS, Davies HE, Yu LM, Miller RF, Maskell NA, Rahman NM. Prospective validation of the RAPID clinical risk prediction score in adult patients with pleural infection: the PILOT study. Eur Respir J 2020; 56:2000130. [PMID: 32675200 DOI: 10.1183/13993003.00130-2020] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 06/06/2020] [Indexed: 11/05/2022]
Abstract
BACKGROUND Over 30% of adult patients with pleural infection either die and/or require surgery. There is no robust means of predicting at baseline presentation which patients will suffer a poor clinical outcome. A validated risk prediction score would allow early identification of high-risk patients, potentially directing more aggressive treatment thereafter. OBJECTIVES To prospectively assess a previously described risk score (the RAPID (Renal (urea), Age, fluid Purulence, Infection source, Dietary (albumin)) score) in adults with pleural infection. METHODS Prospective observational cohort study that recruited patients undergoing treatment for pleural infection. RAPID score and risk category were calculated at baseline presentation. The primary outcome was mortality at 3 months; secondary outcomes were mortality at 12 months, length of hospital stay, need for thoracic surgery, failure of medical treatment and lung function at 3 months. RESULTS Mortality data were available in 542 out of 546 patients recruited (99.3%). Overall mortality was 10% at 3 months (54 out of 542) and 19% at 12 months (102 out of 542). The RAPID risk category predicted mortality at 3 months. Low-risk mortality (RAPID score 0-2): five out of 222 (2.3%, 95% CI 0.9 to 5.7%); medium-risk mortality (RAPID score 3-4): 21 out of 228 (9.2%, 95% CI 6.0 to 13.7%); and high-risk mortality (RAPID score 5-7): 27 out of 92 (29.3%, 95% CI 21.0 to 39.2%). C-statistics for the scores at 3 months and 12 months were 0.78 (95% CI 0.71-0.83) and 0.77 (95% CI 0.72-0.82), respectively. CONCLUSIONS The RAPID score stratifies adults with pleural infection according to increasing risk of mortality and should inform future research directed at improving outcomes in this patient population.
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Affiliation(s)
- John P Corcoran
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- Joint first authors, with equal contribution to study recruitment and manuscript writing
| | - Ioannis Psallidas
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- Joint first authors, with equal contribution to study recruitment and manuscript writing
| | - Stephen Gerry
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Francesco Piccolo
- Dept of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | | | - Tarek Saba
- Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | | | | | | | - Alex West
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Jayne Holme
- University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | | | - Henry Steer
- Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, UK
| | - Nicola J Downer
- Sherwood Forest Hospitals NHS Foundation Trust, Mansfield, UK
| | - Mohammed Haris
- University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Emma H Baker
- Institute of Infection and Immunity, St George's, University of London, London, UK
| | | | | | - Thomas Bewick
- Derby Teaching Hospitals NHS Foundation Trust, Derby, UK
| | - Lonny Yarmus
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Fabien Maldonado
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt-Ingram Cancer Center, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Burhan Khan
- Dartford and Gravesham NHS Trust, Dartford, UK
| | - Alan Hart-Thomas
- Calderdale and Huddersfield NHS Foundation Trust, Huddersfield, UK
| | | | | | | | - Maged Hassan
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- Chest Diseases Dept, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | | | - Anur Guhan
- University Hospital Ayr, NHS Ayrshire and Arran, Ayr, UK
| | | | - Zara Pogson
- United Lincolnshire Hospitals NHS Trust, Lincoln, UK
| | - Lee Dowson
- Royal Wolverhampton Hospital NHS Trust, Wolverhampton, UK
| | - Natalia D Popowicz
- Dept of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Judith Saba
- Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - Neil R Ward
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Rob J Hallifax
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Melissa Dobson
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Rachel Shaw
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Emma L Hedley
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Assunta Sabia
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Barbara Robinson
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Gary S Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Ly-Mee Yu
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Robert F Miller
- Institute for Global Health, University College London, London, UK
| | - Nick A Maskell
- Academic Respiratory Unit, University of Bristol, Bristol, UK
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- Oxford NIHR Biomedical Research Centre, Oxford, UK
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Mishra EK, Clive AO, Wills GH, Davies HE, Stanton AE, Al-Aloul M, Hart-Thomas A, Pepperell J, Evison M, Saba T, Harrison RN, Guhan A, Callister ME, Sathyamurthy R, Rehal S, Corcoran JP, Hallifax R, Psallidas I, Russell N, Shaw R, Dobson M, Wrightson JM, West A, Lee YCG, Nunn AJ, Miller RF, Maskell NA, Rahman NM. Randomized Controlled Trial of Urokinase versus Placebo for Nondraining Malignant Pleural Effusion. Am J Respir Crit Care Med 2019; 197:502-508. [PMID: 28926296 DOI: 10.1164/rccm.201704-0809oc] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Patients with malignant pleural effusion experience breathlessness, which is treated by drainage and pleurodesis. Incomplete drainage results in residual dyspnea and pleurodesis failure. Intrapleural fibrinolytics lyse septations within pleural fluid, improving drainage. OBJECTIVES To assess the effects of intrapleural urokinase on dyspnea and pleurodesis success in patients with nondraining malignant effusion. METHODS We conducted a prospective, double-blind, randomized trial. Patients with nondraining effusion were randomly allocated in a 1:1 ratio to intrapleural urokinase (100,000 IU, three doses, 12-hourly) or matched placebo. MEASUREMENTS AND MAIN RESULTS Co-primary outcome measures were dyspnea (average daily 100-mm visual analog scale scores over 28 d) and time to pleurodesis failure to 12 months. Secondary outcomes were survival, hospital length of stay, and radiographic change. A total of 71 subjects were randomized (36 received urokinase, 35 placebo) from 12 U.K. centers. The baseline characteristics were similar between the groups. There was no difference in mean dyspnea between groups (mean difference, 3.8 mm; 95% confidence interval [CI], -12 to 4.4 mm; P = 0.36). Pleurodesis failure rates were similar (urokinase, 13 of 35 [37%]; placebo, 11 of 34 [32%]; adjusted hazard ratio, 1.2; P = 0.65). Urokinase was associated with decreased effusion size visualized by chest radiography (adjusted relative improvement, -19%; 95% CI, -28 to -11%; P < 0.001), reduced hospital stay (1.6 d; 95% CI, 1.0 to 2.6; P = 0.049), and improved survival (69 vs. 48 d; P = 0.026). CONCLUSIONS Use of intrapleural urokinase does not reduce dyspnea or improve pleurodesis success compared with placebo and cannot be recommended as an adjunct to pleurodesis. Other palliative treatments should be used. Improvements in hospital stay, radiographic appearance, and survival associated with urokinase require further evaluation. Clinical trial registered with ISRCTN (12852177) and EudraCT (2008-000586-26).
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Affiliation(s)
- Eleanor K Mishra
- 1 Norfolk and Norwich Pleural Unit, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, United Kingdom
| | - Amelia O Clive
- 2 Academic Respiratory Unit, School of Clinical Sciences, Southmead Hospital, University of Bristol, Bristol, United Kingdom
| | | | - Helen E Davies
- 4 Cardiff and Vale University Health Board, Cardiff, United Kingdom
| | | | - Mohamed Al-Aloul
- 6 University Hospital of South Manchester NHS Foundation Trust, Manchester, United Kingdom
| | - Alan Hart-Thomas
- 7 Calderdale and Huddersfield NHS Foundation Trust, Huddersfield, United Kingdom
| | - Justin Pepperell
- 8 Somerset Lung Centre, Musgrove Park Hospital, Taunton, United Kingdom
| | - Matthew Evison
- 6 University Hospital of South Manchester NHS Foundation Trust, Manchester, United Kingdom
| | - Tarek Saba
- 9 Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, United Kingdom
| | - Richard Neil Harrison
- 10 North Tees and Hartlepool Hospitals NHS Foundation Trust, North Tees, United Kingdom
| | - Anur Guhan
- 11 University Hospital Ayr, Ayr, United Kingdom
| | | | | | - Sunita Rehal
- 3 Medical Research Council Clinical Trials Unit and
| | - John P Corcoran
- 14 Oxford Respiratory Trials Unit and Oxford Pleural Diseases Unit, Churchill Hospital, Oxford, United Kingdom
| | - Robert Hallifax
- 14 Oxford Respiratory Trials Unit and Oxford Pleural Diseases Unit, Churchill Hospital, Oxford, United Kingdom
| | - Ioannis Psallidas
- 14 Oxford Respiratory Trials Unit and Oxford Pleural Diseases Unit, Churchill Hospital, Oxford, United Kingdom
| | - Nicky Russell
- 14 Oxford Respiratory Trials Unit and Oxford Pleural Diseases Unit, Churchill Hospital, Oxford, United Kingdom
| | - Rachel Shaw
- 14 Oxford Respiratory Trials Unit and Oxford Pleural Diseases Unit, Churchill Hospital, Oxford, United Kingdom
| | - Melissa Dobson
- 14 Oxford Respiratory Trials Unit and Oxford Pleural Diseases Unit, Churchill Hospital, Oxford, United Kingdom
| | - John M Wrightson
- 14 Oxford Respiratory Trials Unit and Oxford Pleural Diseases Unit, Churchill Hospital, Oxford, United Kingdom
| | - Alex West
- 15 Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Y C Gary Lee
- 16 School of Medicine and Pharmacology, University of Western Australia, Perth, Australia; and
| | | | - Robert F Miller
- 17 Research Department of Infection and Population Health, Institute of Epidemiology and Healthcare, University College London, London, United Kingdom
| | - Nick A Maskell
- 2 Academic Respiratory Unit, School of Clinical Sciences, Southmead Hospital, University of Bristol, Bristol, United Kingdom
| | - Najib M Rahman
- 14 Oxford Respiratory Trials Unit and Oxford Pleural Diseases Unit, Churchill Hospital, Oxford, United Kingdom.,18 National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
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