Natural antibodies targeting LPS in pleural effusions of various etiologies

BACKGROUND

Respiratory infection, cancer and heart failure can cause abnormal accumulation of fluid in the pleural cavity. The immune responses within the cavity are orchestrated by leucocytes that reside in the serosal associated lymphoid tissue. Natural antibodies (NAbs) are abundant in the serum having a major role in systemic and mucosal immunity, however their occurrence in pleural fluid remains an open question. Our aim herein was to detect and measure the levels of NAbs targeting LPS of M, G, and A class in both, the pleural fluid and the serum of 78 patients with pleural effusions (PEs) of various etiologies.

METHODS

The values of anti-LPS NAb activity were extracted through a normalization step regarding the total IgM, IgG and IgA levels and in addition the ratio of PF/S values were analyzed further with other critical biochemical parameters from biopsies.

RESULTS

Anti-LPS NAbs of all Ig classes were detected in most of the samples, while a significant increase of anti-LPS activity was observed in infectious and non-infectious compared to malignant PEs. Multivariate linear regression confirmed a negative correlation of IgM and IgA anti-LPS PF/S ratio with malignancy. Moreover, anti-LPS NAbs PF/S measurements led to increased positive and negative predictive power in ROC curves generated for the discrimination between benign and malignant PEs.

CONCLUSIONS

Our results highlight a potential role of anti-LPS NAbs in the pleural cavity that should be further explored.

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

BACKGROUND

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

RESEARCH QUESTION

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

STUDY DESIGN AND METHODS

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

RESULTS

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

INTERPRETATION

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

High sensitivity flow cytometry immunophenotyping increases the diagnostic yield of malignant pleural effusions

Diagnosing malignant pleural effusions (MPE) is challenging when patients lack a history of cancer and cytopathology does not detect malignant cells in pleural effusions (PE). We investigated whether a systematic analysis of PE by flow cytometry immunophenotyping (FCI) had any impact on the diagnostic yield of MPE. Over 7 years, 570 samples from patients with clinical suspicion of MPE were submitted for the FCI study. To screen for epithelial malignancies, a 3-color FCI high sensitivity assay was used. The FCI results, qualified as "malignant" (FCI+) or "non-malignant" (FCI-), were compared to integrated definitive diagnosis established by clinicians based on all available information. MPE was finally diagnosed in 182 samples and FCI detected 141/182 (77.5%). Morphology further confirmed FCI findings by cytopathology detection of malignant cells in PE (n = 91) or histopathology (n = 29). Imaging tests and clinical history supported the diagnosis in the remaining samples. The median percentage of malignant cells was 6.5% for lymphoma and 0.23% for MPE secondary to epithelial cell malignancies. FCI identified a significantly lower percentage of EpCAM+ cells in cytopathology-negative MPE than in cytopathology-positive cases (0.02% vs. 1%; p < 0.0001). Interestingly, 29/52 MPE (55.8%) where FCI alerted of the presence of malignant cells were new diagnosis of cancer. Overall, FCI correctly diagnosed 456/522 samples (87.4%) suitable for comparison with cytopathology. These findings show that high sensitivity FCI significantly increases the diagnostic yield of MPE. Early detection of FCI + cases accelerates the diagnostic pathway of unsuspected MPE, thus supporting its implementation in clinical diagnostic work-up as a diagnostic tool.

High-Throughput Separation and Enrichment of Rare Malignant Tumor Cells from Large-Volume Effusions by Inertial Microfluidics

Detection of malignant tumor cells (MTCs) in pleural effusions is essential for determining the malignancy. However, the sensitivity of MTC detection is significantly decreased due to the existence of a massive number of background blood cells in large-volume samples. Herein, we provide a method for on-chip separation and enrichment of MTCs from malignant pleural effusions (MPEs) by integrating an inertial microfluidic sorter with an inertial microfluidic concentrator. The designed sorter and concentrator are capable of focusing cells toward the specified equilibrium positions by inducing intrinsic hydrodynamic forces, enabling the size-based sorting of cells and the removal of cell-free fluids for cell enrichment. A 99.9% removal of background cells and a nearly 1400-fold ultrahigh enrichment of MTCs from large-volume MPEs can be achieved by this method. The concentrated high-purity MTC solution can be used directly for cytological examination by immunofluorescence staining, enhancing the accurate identification of MPEs. The proposed method can also be employed for the detection and count of rare cells in various clinical samples.

Laboratory and radiological discrimination between tuberculous and malignant pleural effusions with high adenosine deaminase levels

BACKGROUND/AIMS

Pleural fluid adenosine deaminase (ADA) levels are useful in discriminating tuberculous pleural effusions (TPEs) from malignant pleural effusions (MPEs). However, some patients with MPE exhibit high-ADA levels, which may mimic TPEs. There is limited data regarding the differential diagnosis between high-ADA MPE and high-ADA TPE. This study aimed to identify the predictors for distinguishing high-ADA MPEs from high-ADA TPEs.

METHODS

Patients with TPE and MPE with pleural fluid ADA levels ≥ 40 IU/L were included in this study. Clinical, laboratory, and radiological data were compared between the two groups. Independent predictors and their diagnostic performance for high-ADA MPEs were evaluated using multivariate logistic regression analysis and receiver operating characteristic curve.

RESULTS

A total of 200 patients (high-ADA MPE, n = 30, and high-ADA TPE, n = 170) were retrospectively included. In the multivariate analysis, pleural fluid ADA, pleural fluid carcinoembryonic antigen (CEA), and pleural nodularity were independent discriminators between high-ADA MPE and high-ADA TPE groups. Using pleural ADA level of 40 to 56 IU/L (3 points), pleural CEA level ≥ 6 ng/mL (6 points), and presence of pleural nodularity (3 points) for predicting high-ADA MPEs, a sum score ≥ 6 points yielded a sensitivity of 90%, specificity of 96%, positive predictive value of 82%, negative predictive value of 98%, and area under the receiver operating characteristic curve of 0.965.

CONCLUSION

A scoring system using three parameters may be helpful in guiding the differential diagnosis between high-ADA MPEs and high-ADA TPEs.

Complications of thoracoscopic talc insufflation for the treatment of malignant pleural effusions: a meta-analysis

Background

Talc pleurodesis is an effective treatment for malignant pleural effusions (MPEs). This study was designed to estimate complication rates of thoracoscopic talc insufflation.

Methods

Literature search was conducted in electronic databases and studies were selected if they reported complication rates of thoracoscopic talc insufflation in cancer patients with MPEs. Meta-analyses of proportions were performed to obtain incidence rates of complications.

Results

Twenty-six studies (4482 patients; age 62.9 years [95% confidence interval (CI): 61.5, 64.4]; 50% [95% CI: 43, 58] females) were included. Intraoperative, perioperative, 30-day, and 90-day mortality rates were 0% [95% CI: 0, 1], 2% [95% CI: 0, 4], 7% [95% CI: 3, 13] and 21% [95% CI: 5, 43] respectively. Incidence rates [95% CI] of various complications were: pain (20% [1, 2]), fever (14% [3, 4]), dyspnea (13% [5, 6]), pneumothorax (6% [7, 8]) pneumonia (4% [0, 12]), emphysema (3% [3, 7]), prolonged air leakage (3% [0, 7]), prolonged drainage (3% [9, 10]), thromboembolism (3% [9, 11]), lung injury (2% [7, 12]), respiratory insufficiency (2% [0, 5]), re-expansion pulmonary edema (1% [0, 3]), empyema (1% [0, 2]), respiratory failure (0% [0, 1]), and acute respiratory distress syndrome (ARDS; 0% [0, 1].

Conclusions

Whereas pain and fever were the most frequent complications of thoracoscopic talc insufflation, the incidence of ARDS was low. Pneumothorax, pneumonia, emphysema, prolonged air leakage, pulmonary embolism, arrythmia, re-expansion pulmonary edema, and empyema are important complications of thoracoscopic talc insufflation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-021-01475-1.

A case of hemothorax secondary to intrapleural fibrinolytic therapy: Considerations for use of fibrinolytics in high-risk patients

Indwelling Pleural Catheters (IPC) are increasingly being used for management of recurrent pleural effusions (RPEs). Use of IPC for management of both malignant and non-malignant recurrent pleural effusions has been associated with complications such as dysfunctional or nonfunctioning IPCs. Alteplase, a tissue plasminogen activator (tPA) is often used to restore flow of non-draining IPC in symptomatic patients. We present a case of a sixty-eight-year old patient with life-threatening pleural hemorrhage following intrapleural catheter instillation of tPA that was managed successfully by thoracotomy. Our case describe the importance of individualizing the fibrinolytic dose, frequency and the indwelling time in high risk patients. We have reviewed the current literature and recommendations for use of fibrinolytic therapy for IPC in high risk patients on anticoagulation.

Toxicity reduction and water expelling effect preservation of Shizaotang after its toxic members processing with vinegar on rats with malignant pleural effusions

ETHNOPHARMACOLOGICAL RELEVANCE

Shizaotang (SZT), consisted of Euphorbia kansui S.L.Liou ex S.B.Ho (EK), Euphorbia pekinensis Rupr. (EP), Daphne genkwa Sieb. et Zucc. (DG，fried) and Ziziphus jujuba Mill. (ZJ), is usually used for treating malignant pleural effusions (MPE), but the toxicity of EK and EP limits its clinical safe application. It was reported that vinegar processing can reduce the toxicity of EK and EP. Whether EK and EP processing with vinegar can cause the reduced toxicity and retained pharmacological effects of SZT, it still remains unknown.

AIM OF THE STUDY

We aimed to evaluate whether using vinegar processed EK and EP would reduce toxicity and preserve water expelling effect of SZT.

MATERIALS AND METHODS

Network pharmacology and qualitative analysis of SZT/VSZT were used to construct compound-target-pathway network of their effects and toxicity. Pleural fluid weight, urine volume, uric electrolyte, pH, pro-inflammatory cytokines in pleural fluid, serum Renin-Angiotensin-Aldosterone System (RAAS), anti-diuretic hormone (ADH) and intestinal aquaporin 8 (AQP8) protein were used to evaluate the effect mechanisms involved in rats experiments. And liver damage, oxidative damage and HE staining (liver, stomach, and intestine) were used to determine the toxicity.

RESULTS

Network pharmacology analysis reviewed inflammation-related pathways of the effect and toxicity of SZT/VSZT: VEGF-PI3K-AKT pathway inhibited MPE by changing the vasopermeability; PI3K-Akt/Mitogen-activated protein kinase (MAPK)/TNF-NF-κB signaling pathway inhibited MPE by up-regulating expression of AQP8 protein. In vivo experiments displayed that SZT/VSZT could reduce pleural fluid, increase urine volume, lower pro-inflammatory cytokines levels and up-regulate AQP8 protein expression significantly (P < 0.05, P < 0.01). In addition, disorders on electrolyte (Na⁺, K⁺ and Cl^-) and pH were ameliorated (P < 0.05, P < 0.01). The levels of RAAS and ADH were significantly dose-dependently called back (P < 0.01). These findings were partly consistent with the results of network pharmacology analysis. Results of toxicity experiments demonstrated that SZT and VSZT exhibited certain toxicity on normal rats, and VSZT had lower toxicity than that of SZT. Interestingly, SZT and VSZT exerted alleviation effect to the liver damage and oxidative damage on model rats.

CONCLUSION

SZT/VSZT improved MPE by regulating associated inflammation pathways. Besides, compared to SZT, VSZT showed lower toxicity and equivalent expelling MPE effect. This study may provide scientific basis for guiding the clinical application of SZT.

Talc pleurodesis in malignant pleural effusion: a systematic review and meta-analysis

OBJECTIVE

Malignant pleural effusion is a severe and common complication in patients with primary or metastatic malignancies of the pleura. Although talc pleurodesis is widely used for managing malignant pleural effusions, there is still controversy in the literature regarding its superiority compared to other approaches. We conducted this meta-analysis to further investigate its efficacy compared to alternative interventions.

METHODS

We systematically reviewed the PubMed, Cochrane, and Scopus databases to identify studies that fulfilled our inclusion criteria. Study quality was evaluated using validated tools and the pooled Risk Ratio (RR) and confidence interval (CI) were calculated. We performed sensitivity analyses based on the meta-analysis method and type of study.

RESULTS

Twenty-four studies were included in the current systematic review meta-analysis. Talc pleurodesis was associated with statistically significant higher successful pleurodesis rates when compared with all controls [RR (95% CI) 1.15 (1.00, 1.31); P_z = 0.04], only chemical controls [RR (95% CI) 1.26 (1.13, 1.40); P_z < 0.0001], and bleomycin [RR (95% CI) 1.22 (1.05, 1.42); P_z = 0.008]. The comparison between talc pleurodesis and controls at the > 1-month follow-up time point favored talc pleurodesis [RR (95% CI): 1.62 (1.15, 2.27); P_z = 0.005]. Finally, talc poudrage was associated with a statistically significant higher successful pleurodesis rate when compared with all controls. Sensitivity analyses verified the robustness of our results.

CONCLUSION

Talc pleurodesis is an effective MPE management approach presenting borderline statistically significant superiority compared to control methods especially compared to bleomycin as well as when pleurodesis success is evaluated later than 1 month postoperatively.

Management of Respiratory Symptoms in Those with Serious Illness

Respiratory symptoms are common in patients living with serious illness, both in cancer and nonmalignant conditions. Common symptoms include dyspnea (breathlessness), cough, malignant pleural effusions, airway secretions, and hemoptysis. Basic management of respiratory symptoms is within the scope of primary palliative care. There are pharmacologic and nonpharmacologic approaches to treating respiratory symptoms. This article provides clinicians with treatment approaches to these burdensome symptoms.

Cytological-negative pleural effusion can be an alternative liquid biopsy media for detection of EGFR mutation in NSCLC patients

OBJECTIVE

Though the possibility of using malignant pleural effusions (MPEs) as alternatives for tumor tissues in epidermal growth factor receptor (EGFR) mutation test has been examined, the diagnosis of MPE is often clinically challenging, especially if the cytology is negative for malignancy. The aim of this study was to examine whether cytological-negative PE (CNPE) is useful in detecting EGFR mutation and evaluated its feasibility for predicting clinical outcomes.

METHOD

In this study, we performed capture-based targeted sequencing using a panel consisting of 520 lung cancer-related genes to detect EGFR mutation status in 121 MPEs and 40 CNPE samples from 161 advanced lung adenocarcinoma patients. Patients underwent TKI treatment with gefitinib, icotinib or erlotinib if EGFR sensitizing mutations were detected at their tumor biopsies or pleural effusion sediment.

RESULTS

We revealed a mutation detection rate of 99.2% and 100% for MPE and CNPE, respectively (p = 1). The maximum allelic fraction (maxAF) of MPE and CNPE were 57.4% and 56.8%, respectively (p = 0.77). CNPE supernatant is comparable to MPE in reflecting the mutational profile of lung adenocarcinoma. EGFR activating mutations were detected in 47.5% (19/40) of CNPE supernatant sample and 32.5% (13/40) of matched tumor biopsies. CNPE sample is superior to tumor tissues in identifying EFGR mutation. Among the 72 EGFR-TKI treated patients, 51 were cytology positive and the remaining 21 were cytology negative. Our data showed that MPE patients exhibited comparable PFS (p = 0.41) and OS (p = 0.26) with CNPE patients treated with EGFR-TKI. Among the 21 CNPE patients received TKI treatment, patients harboring either L858R or exon 19 deletion had longer PFS than patients without a detectable mutation (p = 0.036).

CONCLUSION

Collectively, we demonstrated that CNPE supernatant provided a comprehensive profile of NSCLC, and can serve as a reliable lipid biopsy media for EGFR mutational detection.

Thoracic injection of low-dose interleukin-2 as an adjuvant therapy improves the control of the malignant pleural effusions: a systematic review and meta-analysis base on Chinese patients

BACKGROUND

Interleukin-2 (IL-2) is an important immunotherapy cytokine for various diseases including cancer. Some studies reported the efficacy and safety on cisplatin combined with IL-2 versus cisplatin alone for treating malignant pleural effusion (MPE) through thoracic injection.

METHODS

We searched these studies from medical electronic database. A total of 18 studies that met the inclusion criteria were recruited in this meta-analysis. Pooled odds ratios (OR) with 95% confidence intervals (CI) were determined by the fixed effects model of meta-analysis.

RESULTS

The objective response rate (ORR) and disease control rate (DCR) of cisplatin plus IL-2 for controlling MPE was significantly higher than that of cisplatin alone (p < 0.001). In addition, compared with cisplatin alone, the presence of IL-2 improved the quality of life (QOL) of patients with MPE (p < 0.001). Although the use of IL-2 seemed to increase the probability of fever in patients (p = 0.001), it did not lead to extra other side effects (AEs) including myelotoxicity, nausea/vomiting and chest pain (p > 0.05).

CONCLUSIONS

The low-dose IL-2 improved the ORR, DCR and QOL of patients in the treatment of MPE. Although it may cause fever in patients, it did not increase other AEs.

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.

Thoracic perfusion of recombinant human endostatin (Endostar) combined with chemotherapeutic agents versus chemotherapeutic agents alone for treating malignant pleural effusions: a systematic evaluation and meta-analysis

Background

Endostar is a new endogenous angiogenic inhibitor with implicated anti-tumor activity. This study was to investigate whether thoracic perfusion of Endostar could be used to control malignant pleural effusions (MPE).

Methods

We searched the databases of MEDLINE, Web of Science, EMBASE, Goggle, Cochrance Library and CNKI to select the studies regarding the efficacy of Endostar to treat MPE. A total of 13 randomised controlled trials (RCTs) with 1066 patients were included.

Results

The overall response rate (ORR) (P < 0.001; odds ratio = 3.58) and disease control rate (DCR) (P < 0.001; odds ratio = 2.97) of Endostar combined with chemotherapeutic agents were significantly higher than those of chemotherapeutic agents alone. In addition, Endostar combined treatment remarkably promoted quality of life (QOL) of patients (P < 0.001; odds ratio = 3.04) compared with that of chemotherapeutic agents alone. Moreover, Endostar combined treatment did not have an impact on the incidence of adverse reactions (AEs) (P < 0.05).

Conclusions

The efficacy of Endostar combined chemotherapeutic agents was superior to chemotherapeutic agents alone through thoracic perfusion in treating MPE, which indicated that Endostar could be an effective agent for controlling MPE.

Regulatory T cells in malignant pleural effusions subsequent to lung carcinoma and their impact on the course of the disease

Tumors exert suppressive effects on the host immune system and tumor progression can be linked to functional impairments of immune cells. Regulatory T cells (Treg) are a subpopulation of T lymphocytes and play a key role in suppressing immune responses against autoimmune diseases and cancer. The aim of the study was to investigate the prevalence of Treg in malignant and benign pleural effusions and to evaluate the relationship between Treg frequency and disease advance. Pleural effusions from 76 patients were subjected to a routine laboratory diagnosis and analyzed by conventional cytology. Biological materials were divided into three groups: malignant pleural effusions with malignant cells, effusions from patients with malignancy but without malignant cells, and non-malignant pleural effusions. The frequency of Treg in malignant pleural effusions was significantly higher compared to non-malignant effusions. In general, the increase in Treg frequency was correlated with a decrease in the percentage of lymphocytes and an increase in T CD4+ and T CD4+ CD25+ cells. The highest percentage of Treg was observed among patients with the most advanced clinical stage of lung cancer in terms of size and location of a primary tumor, T4. A Kaplan-Meier survival analysis showed a statistically significant trend towards an adverse outcome for patients representing higher Treg counts. Overall, our results support the extraordinary potential of Treg control in future anticancer therapy.

Evaluation of predictive value of pleural CEA in patients with pleural effusions and histological findings: A prospective study and literature review

OBJECTIVES

Pleural effusion recognizes heterogeneous etiology and pathogenesis and requires invasive diagnostic procedures. Usually, after pleural fluid analysis, 30-50% of patients with malignant pleural effusion exhibit negative pleural cytology, and the sensitivity of image-guided pleural needle-aspiration biopsy ranges between 60% and 70%. With the aim of differentiating between benign (BPE) and malignant (MPE) pleural effusions, several tumor markers have been assayed in the pleural fluid and the majority of studies focus on pleural carcinoembryonic antigen (p-CEA). The aims of this study were to evaluate (i) the diagnostic accuracy of p-CEA of patients with pleural effusions undergoing video-assisted thoracoscopic surgery (VATS) for diagnostic purpose, (ii) the relationship between p-CEA and serum CEA (s-CEA), and (iii) the usefulness of the p-CEA/s-CEA ratio in the diagnosis of malignant pleural effusions (MPE).

DESIGN & METHODS

We prospectively enrolled in the study 134 consecutive patients with pleural effusions, scheduled for having VATS and biopsy. The final diagnosis, based on histopathology of the VATS-guided specimens, was available for all patients. p-CEA and s-CEA was assayed with a chemiluminescence immunoassay method (CLIA), applied on the Maglumi 2000 Plus automated platform (SNIBE, Shenzen, China).

RESULTS

The sensitivity and accuracy of p-CEA was significantly higher than that of pleural cytology at the same specificity comparing BPE with MPE and BPE with non-small lung cancer. The sensitivity of p-CEA and PC together reached 100% (BPE vs. NSCLC) and 91.5% (BPE vs. MPE excluding mesothelioma), respectively.

CONCLUSIONS

The p-CEA measurement in patients with pleural effusion of uncertain etiology is a safe and cost-effective procedure, everywhere easily available, which may help clinicians in selecting patients for further evaluations. An elevated p-CEA level in a patient with pleural effusion and negative pleural cytology suggests the need of more invasive procedure (e.g. VATS-guided biopsies), whilst low p-CEA may support a follow-up.

Drug sensitivity profiling and molecular characteristics of cells from pleural effusions of patients with lung adenocarcinoma

We propose to assess the therapeutic value of biomarker-guided individualized chemotherapy in patients with metastasizing lung adenocarcinoma. In this study, we used primary cells from pleural effusions from sixteen patients diagnosed with adenocarcinomas originating in the lung and from four patients with no malignant diagnosis. The ex vivo drug sensitivity of primary cells was assessed for 32 chemotherapeutical drugs. Linear regression analyses were performed to examine possible correlations between the drug sensitivity, overall survival and expression of ERCC1 and RRM1. The ex vivo drug sensitivity profiles of the patients revealed considerable heterogeneity in drug response. Vinblastine, vinorelbine, paclitaxel and actinomycin D showed high efficiency against 50% of the tested primary cells. Significant correlation was detected between the ex vivo sensitivity to platinum based drugs and gemcitabine and the level of ERCC1 and RRM1. No significant correlation was however seen between overall survival and drug sensitivity. The heterogeneity of the drug response suggests that optimal care of the adenocarcinoma patients should include the determination of drug sensitivity of the primary cells and would benefit to use personalized therapy.

Malignant pleural effusions: a review

Malignant pleural effusions are a cause of significant symptoms and distress in patients with end-stage malignancies and portend a poor prognosis. Management is aimed at symptom relief, with minimally invasive interventions and minimal requirement for hospital length of stay. The management options include watchful waiting if no symptoms are present, repeat thoracentesis, medical or surgical thoracoscopic techniques to achieve pleurodesis, pleuroperitoneal shunts, placement of tunneled pleural catheters, or a combination of modalities. To determine the best modality for management, patients must be assessed individually with concern for symptoms, functional status, prognosis, and their social and financial situations.

Medical pleuroscopy

There has been an exciting expansion in the practice of medical pleuroscopy in recent years. As technology has become more available and confidence in the use of equipment has grown, medical thoracoscopy has become a core diagnostic and therapeutic tool in pleural disease care. Despite this, many areas of medical pleuroscopy practice remain conspicuously devoid of well-established evidence. More knowledge is needed in those areas where there is currently a degree of equipoise. Many areas where pleuroscopy currently has a marginal role require high-quality randomized trials be undertaken with a view to informing future practice and guidelines.

Malignant pleural effusions: appropriate treatment approaches

Malignant pleural effusion (MPE) is a common and important clinical condition. A complication in many types of tumors, its presence indicates the onset of the terminal stages of cancer. Dyspnea is the most common symptom of MPE. The most common underlying tumors are lymphomas and cancers of the lung, breast and ovaries, which account for 75% of cases. The diagnosis of MPE can be established by the presence of malignant cells in the pleural fluid or tissue. Median survival in these patients ranges from 3 to 12 months, with the shortest survival period presenting in lung cancer patients. The aim of MPE therapeutic approaches should be effective treatment and a short hospital stay. There are many different treatment options for patients who suffer from MPE, including serial thoracentesis, tube thoracostomy, pleurodesis, long term pleural catheter, pleuroperitoneal shunt, decortication, chemotherapy and radiotherapy. The choice of therapy is determined based on a patient's clinical situation as well as the underlying disease. Today, intercostal tube insertion and chemical pleurodesis are the most commonly prescribed treatment modalities.