Role of early definitive management for newly diagnosed malignant pleural effusion related to lung cancer

BACKGROUND AND OBJECTIVE

The advent of effective anti-cancer therapy has brought about uncertainty on the benefit of early definitive measures for newly diagnosed MPE from lung cancer. This study aims to investigate the outcomes of MPE in this setting.

METHODS

Lung cancer patients with MPE at first presentation to a tertiary care hospital were followed up till death or censored from 2011 to 2018. Early MPE control measures included chemical pleurodesis or IPC before or shortly after oncological treatment. Predictors of time to MPE re-intervention were identified with Cox proportional hazard analyses.

RESULTS

Of the 509 records screened, 233 subjects were eligible. One hundred and twenty-seven subjects received oral targeted therapy as first-line treatment and 34 (26.8%) underwent early definitive MPE control measures. Early MPE control measures in addition to targeted therapy, as compared to targeted therapy alone, significantly reduced the subsequent need of MPE re-intervention (23.5% vs 53.8%, P = 0.002). Similar benefits from MPE control measures were found in groups receiving systemic anti-cancer therapy or best supportive care (0% vs 52%, P = 0.003; 18% vs 56.7%, P = 0.024, respectively). In the group with targetable mutations, both early MPE control measures (HR: 0.25, 95% CI: 0.12-0.53, P < 0.001) and the use of targeted therapy (HR: 0.22, 95% CI: 0.10-0.46, P < 0.001) were independently associated with longer time to MPE re-interventions.

CONCLUSION

Early MPE control measures in lung cancer has additional benefits on reducing the need and prolonging the time to MPE re-intervention, independent of anti-cancer therapies.

Pleural small cell carcinoma with massive pleural effusion: A case report

RATIONALE

Small cell carcinoma (SCC) occurs mostly in the lung, and small cell lung cancer accounts for 13% of newly diagnosed lung cancers. Only 2.5% of SCC occurs in extrapulmonary sites, and SCC of pleural origin is especially very uncommon.

PATIENT CONCERNS

An 85-year-old man presenting with progressive dyspnea for more than 7 days.

DIAGNOSES

Computed tomography scan of the chest showed massive pleural effusion and diffuse nodular thickening of the pleura on the right chest. Sonography-guided needle biopsy of the pleural mass was performed and histologic and immunohistochemical findings revealed SCC. Since no parenchymal lung lesion was observed, the patient was finally diagnosed with SCC of the pleura (SCCP).

INTERVENTIONS

Due to the patient's old age and poor performance status, chemotherapy was not performed and only drainage of pleural effusion was conducted for symptom relief.

OUTCOMES

Dyspnea improved after pleural effusion drainage. The patient was discharged and transferred to a local medical center for hospice care.

LESSONS

Although primary SCCP is extremely rare, SCCP should also be considered as well as mesothelioma in case of presence of a pleural-based mass with massive pleural effusion.

PAI-1 Level Differences in Malignant Plural Effusion, Parapneumonic Pleuritis, and Cardiac Hydrothorax

Background and Objectives: Plasminogen activator inhibitor-1 (PAI-1) is a fibrinolytic system enzyme whose role in various fibrinolytic processes is currently unknown. In clinical manifestations of pleural liquids of diverse etiology, various levels of fibrinolytic activity can be observed—parapneumonic processes tend to loculate in fibrin septa, while malignant pleural effusion (MPE) does not. The purpose of this study was to determine possible differences in PAI-1 levels in pleural effusions of varied etiology. Material and Methods: PAI-1 level in pleural effusion and serum was determined in 144 patients with pleural effusions of various etiology (cardiac hydrothorax—42 patients (29.2%), MPE—67 patients (46.5%), parapneumonic pleuritis—27 (18.8%), tuberculous pleuritis—6 patients (4.1%), pancreatogenic pleuritis—1 patient (0.7%) and pulmonary artery thromboembolism with pleuritis—1 patient (0.7%)). Results: The median PAI-1 level (ng/mL) was the highest in the parapneumonic pleuritis group both in the effusion and the serum, with values of 291 (213–499) ng/mL and 204 (151–412) ng/mL, respectively, resulting in a statistically significant difference (p < 0.001) from the cardiac hydrothorax and MPE groups. However, there was no statistically significant difference between PAI-1 levels in the pleural effusion and serum in the cardiac hydrothorax and MPE groups. Conclusion: The PAI-1 level in MPE and cardiac hydrothorax was statistically significantly lower than in parapneumonic pleuritis.

Malignant Pleural Effusion and Its Current Management: A Review

Malignant pleural effusion (MPE) is an exudative effusion with malignant cells. MPE is a common symptom and accompanying manifestation of metastatic disease. It affects up to 15% of all patients with cancer and is the most common in lung, breast cancer, lymphoma, gynecological malignancies and malignant mesothelioma. In the last year, many studies were performed focusing on the pathophysiological mechanisms of MPE. With the advancement in molecular techniques, the importance of tumor-host cell interactions is becoming more apparent. Additionally, the process of pathogenesis is greatly affected by activating mutations of EGFR, KRAS, PIK3CA, BRAF, MET, EML4/ALK and RET, which correlate with an increased incidence of MPE. Considering all these changes, the authors aim to present a literature review of the newest findings, review of the guidelines and pathophysiological novelties in this field. Review of the just recently, after seven years published, practice guidelines, as well as analysis of more than 70 articles from the Pubmed, Medline databases that were almost exclusively published in indexed journals in the last few years, have relevance and contribute to the better understanding of the presented topic. MPE still presents a severe medical condition in patients with advanced malignancy. Recent findings in the field of pathophysiological mechanisms of MPE emphasize the role of molecular factors and mutations in the dynamics of the disease and its prognosis. Treatment guidelines offer a patient-centric approach with the use of new scoring systems, an out of hospital approach and ultrasound. The current guidelines address multiple areas of interest bring novelties in the form of validated prediction tools and can, based on evidence, improve patient outcomes. However, the role of biomarkers in a clinical setting, possible new treatment modalities and certain specific situations still present a challenge for new research.

Efficacy of Arsenic Trioxide in the Treatment of Malignant Pleural Effusion Caused by Pleural Metastasis of Lung Cancer

The aim of the study was to investigate the mechanism of arsenic trioxide (As2O3) in the treatment of malignant pleural effusion (MPE) caused by pleural metastasis of lung cancer. A mouse model of MPE caused by pleural metastasis of lung cancer was first established, and As2O3 was then intraperitoneally injected to treat the MPE. Mice treated with bevacizumab and bleomycin were included as positive controls, and placebo equivalents were also used as negative controls. The effects of As2O3 on MPE volume, pleural vessel density, vascular permeability, expression of angiogenic function-related factors, including vascular endothelial growth factor (VEGF) and tumor necrosis factor alpha (TNF-α), as well as nuclear factor-κB (NF-κB) activity in pleural carcinomatosis, were observed. Intraperitoneal injection of As2O3 reduced the volume of MPE and decreased vascular density and permeability in pleural metastatic nodules in a dose-dependent manner. Moreover, dose-dependent decreases in VEGF and TNF-α expression in MPE, and NF-κB activity in pleural carcinomatosis, were also found after As2O3 treatment. We showed that As2O3 can down-regulate VEGF expression via inhibition of NF-κB, and decrease vascular density and permeability in pleural metastatic nodules, thereby eliciting its effects on MPE caused by pleural metastasis of lung cancer. Our results provide a foundation for an As2O3-based clinical treatment program.

Current best practice in the evaluation and management of malignant pleural effusions

Malignant pleural effusions (MPEs) are an important cause of cancer-related mortality and morbidity. It is a heterogeneous group of conditions, which leads to debilitating symptoms and confers a poor prognosis. Recent well-designed randomized trials have provided a broader evidence base for an expanding range of treatment options. Together, with new prognostic scoring systems and a greater understanding of how different patient phenotypes respond to treatment, this allows greater personalization of management. This article will discuss the current evidence on evaluation and management of MPEs.

OPTIMUM: a protocol for a multicentre randomised controlled trial comparing Out Patient Talc slurry via Indwelling pleural catheter for Malignant pleural effusion vs Usual inpatient Management

INTRODUCTION

The development of malignant pleural effusion (MPE) results in disabling breathlessness, pain and reduced physical capability with treatment a palliative strategy. Ambulatory management of MPE has the potential to improve quality of life (QoL). The OPTIMUM trial is designed to determine whether full outpatient management of MPE with an indwelling pleural catheter (IPC) and pleurodesis improves QoL compared with traditional inpatient care with a chest drain and talc pleurodesis. OPTIMUM is currently open for any centres interested in collaborating in this study.

METHODS AND ANALYSIS

OPTIMUM is a multicentre non-blinded randomised controlled trial. Patients with a diagnosis of MPE will be identified and screened for eligibility. Consenting participants will be randomised 1:1 either to an outpatient ambulatory pathway using IPCs and talc pleurodesis or standard inpatient treatment with chest drain and talc pleurodesis as per British Thoracic Society guidelines. The primary outcome measure is global health-related QoL at 30 days measured using the EORTC QLQ-C30 questionnaire. Secondary outcome measures include breathlessness and pain measured using a 100 mm Visual Analogue Scale and health-related QoL at 60 and 90 days. A sample size of 142 patients is needed to demonstrate a clinically significant difference of 8 points in global health status at 30 days, for an 80% power and a 5% significance level.

ETHICS AND DISSEMINATION

The study has been approved by the NRES Committee South East Coast-Brighton and Sussex (reference 15/LO/1018). The trial results will be published in peer-reviewed journals and presented at scientific conferences.

TRIAL REGISTRATION NUMBERS

UKCRN19615 and ISRCTN15503522; Pre-results.

Protocol of the Australasian Malignant Pleural Effusion-2 (AMPLE-2) trial: a multicentre randomised study of aggressive versus symptom-guided drainage via indwelling pleural catheters

INTRODUCTION

Malignant pleural effusions (MPEs) can complicate most cancers, causing dyspnoea and impairing quality of life (QoL). Indwelling pleural catheters (IPCs) are a novel management approach allowing ambulatory fluid drainage and are increasingly used as an alternative to pleurodesis. IPC drainage approaches vary greatly between centres. Some advocate aggressive (usually daily) removal of fluid to provide best symptom control and chance of spontaneous pleurodesis. Daily drainages however demand considerably more resources and may increase risks of complications. Others believe that MPE care is palliative and drainage should be performed only when patients become symptomatic (often weekly to monthly). Identifying the best drainage approach will optimise patient care and healthcare resource utilisation.

METHODS AND ANALYSIS

A multicentre, open-label randomised trial. Patients with MPE will be randomised 1:1 to daily or symptom-guided drainage regimes after IPC insertion. Patient allocation to groups will be stratified for the cancer type (mesothelioma vs others), performance status (Eastern Cooperative Oncology Group status 0-1 vs ≥2), presence of trapped lung (vs not) and prior pleurodesis (vs not). The primary outcome is the mean daily dyspnoea score, measured by a 100 mm visual analogue scale (VAS) over the first 60 days. Secondary outcomes include benefits on physical activity levels, rate of spontaneous pleurodesis, complications, hospital admission days, healthcare costs and QoL measures. Enrolment of 86 participants will detect a mean difference of VAS score of 14 mm between the treatment arms (5% significance, 90% power) assuming a common between-group SD of 18.9 mm and a 10% lost to follow-up rate.

ETHICS AND DISSEMINATION

The Sir Charles Gairdner Group Human Research Ethics Committee has approved the study (number 2015-043). Results will be published in peer-reviewed journals and presented at scientific meetings.

TRIAL REGISTRATION NUMBER

ACTRN12615000963527; Pre-results.

Outcome and characteristics of patients with malignant pleural effusion from differentiated thyroid carcinoma

Metastatic differentiated thyroid carcinoma (DTC) is an uncommon cause of malignant pleural effusion (MPE) and the characteristics and clinical course have been rarely described. Herein, we report a retrospective review of the clinical course of 18 patients (15 women and 3 men) with MPE from DTC who underwent treatment at our institution between January 2005 and December 2014. MPE from DTC was diagnosed based on cytology and/or level of thyroglobulin in the pleural fluid. Pathologically, papillary carcinoma was found in 16 patients and follicular carcinoma in 2 patients. Median ages at initial diagnosis of DTC and MPE were 64 years (range, 22-79) and 74 years (range, 39-86), respectively. All patients showed radiologically apparent lung metastases, with MPE developing after 0-212 months (median, 25). In 16 patients (88.9%), other coexistent distant metastases at the time of MPE diagnosis were found in the bone (n = 10), brain (n = 5), and skin (n = 2). All patients were treated conservatively with palliative thoracentesis or chest tube drainage with or without pleurodesis. Recurrent MPE after treatment was seen in 9 patients; discharge to home health care after treatment for MPE was possible for 14 patients. The overall survival after initial diagnosis varied considerably from 14 months to 37 years, but the median survival after appearance of MPE was 10 months (range, 1-28). Systemic therapy for iodine-resistant recurrent thyroid disease may need to be considered as a treatment option for patients with MPE.

DIFFERENCES IN CLINICAL MANIFESTATIONS AND PLEURAL FLUID CHARATERISTICS BETWEEN TUBERCULOUS AND MALIGNANT PLEURAL EFFUSIONS

Tuberculous and malignant pleural effusions share similar clinical and radiographic findings and both may produce lymphocytic-predominant exudative effusions. This study aimed to determine distinguishing clinical features between the two diseases. We conducted a retrospective study among 47 patients with tuberculous pleural effusions (TBPE) and 73 with malignant pleural effusions (MPE). Demographic data, clinical features, pleural fluid characteristics, and radiographic findings were obtained for each patient and the 2 groups were compared. Sixty-nine (57.5%) patients were males. The mean (+/- SD, range) age was 60.2 (+/- 16.9, 19-94) years. Mean (+/- SD) symptom duration was 31.6 (+/- 51.6) days. Univariate analysis identified 20 clinical, pleural fluid and radiological differences between the two groups. Multivariate logistic regression analysis revealed 3 independent predictors of TBPE: fever (OR=8.2; 95% CI: 1.9 - 35.9; p=0.005), having a non-serosanguinous effusion (OR=6.1; 95% CI: 1.1 - 33.6; p=0.038), and a fluid adenosine deaminase level > 30 U/I (OR=86.7; 95% CI: 4.3 - 1735; p=0.004). Fever, non-serosanguinous pleural effusions and high adenosine deaminase levels were suggestive of a TBPE and could be clinically useful when evaluating a pleural effusion of unknown etiology.

Defining the minimal important difference for the visual analogue scale assessing dyspnea in patients with malignant pleural effusions

Background

The minimal important difference (MID) is essential for interpreting the results of randomised controlled trials (RCTs). Despite a number of RCTs in patients with malignant pleural effusions (MPEs) which use the visual analogue scale for dyspnea (VASD) as an outcome measure, the MID has not been established.

Methods

Patients with suspected MPE undergoing a pleural procedure recorded their baseline VASD and their post-procedure VASD (24 hours after the pleural drainage), and in parallel assessed their breathlessness on a 7 point Likert scale.

Findings

The mean decrease in VASD in patients with a MPE reporting a ‘small but just worthwhile decrease’ in their dyspnea (i.e. equivalent to the MID) was 19mm (95% CI 14-24mm). The mean drainage volume required to produce a change in VASD of 19mm was 760ml.

Interpretation

The mean MID for the VASD in patients with a MPE undergoing a pleural procedure is 19mm (95% CI 14-24mm). Thus choosing an improvement of 19mm in the VASD would be justifiable in the design and analysis of future MPE studies.

Paradoxical hemodynamic instability complicating pericardial window surgery for cardiac tamponade in a cancer patient

Paradoxical hemodynamic instability is defined as unexpected hemodynamic compromise that develops in a patient after pericardial fluid drainage. The overall incidence of the condition is about 5%, and it has a high in-hospital mortality rate. The condition has been reported to occur regardless of the approach that is used to drain the fluid or the underlying cause of the disease. The pathophysiology of paradoxical hemodynamic instability and the appropriate intervention are not very clear, and further studies are needed to identify appropriate preventive measures.We report a rare manifestation of paradoxical hemodynamic instability in a 65-year-old woman who had a history of stage IV lung cancer. She presented with a one-week history of pleuritic chest pain and shortness of breath on exertion. Echocardiography revealed a large circumferential pericardial effusion with right atrial and ventricular collapse during diastole, suggesting a compressive effect of the pericardial fluid; however, left ventricular systolic function was well preserved. The patient underwent the scheduled creation of a subxiphoid pericardial window. Immediately after the pericardial fluid was evacuated, her heart began to beat more vigorously, but this was abruptly followed by an episode of asystole. Pacing and medical therapy were unsuccessful in preventing repeated episodes of asystole, and the patient died.To our knowledge, this is the 2nd report of unexpected asystole after the creation of a subxiphoid pericardial window, and it is the first report of a takotsubo-like contractile pattern associated with paradoxical hemodynamic instability.

Host-derived interleukin-5 promotes adenocarcinoma-induced malignant pleural effusion

RATIONALE

IL-5 is a T helper 2 cytokine important in the trafficking and survival of eosinophils. Because eosinophils can be found in malignant pleural effusions (MPE) from mice and humans, we asked whether IL-5 is involved in the pathogenesis of MPE.

OBJECTIVES

To determine the role of IL-5 in MPE formation.

METHODS

The effects of IL-5 on experimental MPE induced in C57BL/6 mice by intrapleural injection of syngeneic lung (Lewis lung cancer [LLC]) or colon (MC38) adenocarcinoma cells were determined using wild-type (il5(+/+)) and IL-5-deficient (il5⁻(/)⁻) mice, exogenous administration of recombinant mouse (rm) IL-5, and in vivo antibody-mediated neutralization of endogenous IL-5. The direct effects of rmIL-5 on LLC cell proliferation and gene expression in vitro were determined by substrate reduction and microarray.

MEASUREMENTS AND MAIN RESULTS

Eosinophils and IL-5 were present in human and mouse MPE, but the cytokine was not detected in mouse (LLC) or human (A549) lung and mouse colon (MC38) adenocarcinoma-conditioned medium, suggesting production by host cells in MPE. Compared with il5(+/+) mice, il5⁻(/)⁻ mice showed markedly diminished MPE formation in response to both LLC and MC38 cells. Exogenous IL-5 promoted MPE formation in il5(+/+) and il5⁻(/)⁻ mice, whereas anti-IL-5 antibody treatment limited experimental MPE in il5(+/+) mice. Exogenous IL-5 had no effects on LLC cell proliferation and gene expression; however, IL-5 was found to be responsible for recruitment of eosinophils and tumor-promoting myeloid suppressor cells to MPE in vivo.

CONCLUSIONS

Host-derived IL-5 promotes experimental MPE and may be involved in the pathogenesis of human MPE.

Angiogenic molecule Tie-2 and VEGF in the pathogenesis of pleural effusions

BACKGROUND

The role of angiogenesis in the pathogenesis of pleural effusion (PE) has not been determined. The expression of angiogenic factors may represent useful markers for the diagnosis and prediction of disease outcome. To measure the pleural fluid (PF) and serum levels of vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF) and Tie receptor tyrosine kinase (Tie-2) in order to investigate their role in the pathogenesis of PEs.

METHODS

Sixty-seven, 17 with transudative PEs due to heart failure and 50 with exudative PEs (malignant, 22; inflammatory, 15; undiagnosed, 13) were included in the study. PF and serum levels of the growth factors (VEGF, bFGF and Tie-2) were measured using enzyme-linked immunosorbent assays.

RESULTS

PF and serum VEGF levels but not bFGF and Tie-2 levels were higher (p<0.005) in exudates than in transudates. PF VEGF levels were significantly higher in malignant than inflammatory and undiagnosed PEs (p=0.03). In addition, PF Tie-2 levels were not found different in malignant or in parapneumonic PEs.

CONCLUSION

Our results showed that VEGF is one of the main mediators in exudative PEs, but this effect is not mediated through the angiogenetic pathway Ang-1/Tie-2. However, the role of angiogenesis and its pathways in the pathogenesis of exudative PEs needs further exploration.

A simple laboratory measurement for discrimination of transudative and exudative pleural effusion: Pleural viscosity

BACKGROUND

The initial step in establishing the cause of an effusion is to determine whether the fluid is a transudate or exudate. Plasma viscosity is influenced by the concentration of plasma proteins and lipoproteins with the major contribution resulting from fibrinogen. In this study we aimed to evaluate the role of pleural fluid viscosity in discrimination of transudate and exudates.

MATERIALS AND METHODS

We studied prospectively 63 consecutive patients with pleural effusion in whom diagnostic or therapeutic thoracentesis had been performed. The criteria of Light were applied to differentiate transudates from exudates: 33 patients (23 male, 13 female, mean age=68+/-4 years) had exudates and 30 patients (17 male, 13 female, mean age=68+/-5) had transudates (due to congestive heart failure). Measurements of pleural fluid and plasma viscosity were performed using a viscometer.

RESULTS

There was no statistically significant difference between patients with transudate and exudates in respect to plasma viscosity. However, pleural viscosities of the patients with exudates were significantly higher than those of patients with transudate (1.37+/-0.16 mPa vs 0.93+/-0.03 mPa s p<0.001, respectively). Pleural viscosity has a high sensitivity, specificity (94%, 93%, respectively), positive and negative predictive value (97%, 97%, respectively) for the discrimination of transudative or exudatetive pleural fluid.

CONCLUSION

We have demonstrated for the first time that pleural viscosity of the exudative effusion is higher than that of transudative effusion with high sensitivity, specificity, positive and negative predictive value. Regarding the simplicity of this measurement, it may play a valuable role in the accurate and fast discrimination of pleural fluid.

Autocrine IL-6-induced Stat3 activation contributes to the pathogenesis of lung adenocarcinoma and malignant pleural effusion

Malignant pleural effusion (MPE) is a poor prognostic sign for patients with non-small-cell lung cancer (NSCLC). The generation of MPE is largely regulated by vascular endothelial growth factor (VEGF), and upregulation of VEGF by Stat3 has been observed in several types of tumor cells. In this study, we demonstrate constitutively activated Stat3 in several human lung cancer cell lines and in tumor cells infiltrated in the pleurae of patients with adenocarcinoma cell lung cancer (ADCLC) and MPE. The observations suggest that activated Stat3 plays a role in the pathogenesis of ADCLC. In PC14PE6/AS2 cells, a Stat3-positive human ADCLC cell line, autocrine IL-6 activated Stat3 via JAKs, not via Src kinase. PC14PE6/AS2 cells express higher VEGF mRNA and protein than do Stat3-negative PC14PE6/AS2/dnStat3 cells. In an animal model, PC14P6/AS2/dnStat3 cells produced no MPE and less lung metastasis than did PC14P6/AS2 cells. PC14PE6/AS2 cells also expressed higher VEGF protein, microvessel density, and vascular permeability in tumors than did PC14P6/AS2/dnStat3 cells. Therefore, we hypothesize that autocrine IL-6 activation of Stat3 in ADCLC may be involved in the formation of malignant pleural effusion by upregulating VEGF. Higher levels of IL-6 and VEGF were also found in the pleural fluids of patients with ADCLC than in patients with congestive heart failure. The autocrine IL-6/Stat3/VEGF signaling pathway may also be activated in patients with ADCLC and MPE. These findings provide novel targets for the management of MPE.

Influence of lymphocytes in malignant pleural effusion on the therapeutic efficacy of intrapleural OK-432 in lung cancer patients

OBJECTIVES

Malignant pleural effusion, a common complication seen in advanced lung cancer patients, is often treated with intrapleural administration of chemical agents. In Japan, OK-432, a biological response modifiers, which activates the cytotoxic activity of lymphocytes and boosts antitumor immunity, is among the most frequently used chemical agents. The purpose of this study was to determine, in a case-control study, whether or not the rate of lymphocytes in malignant pleural effusion (lymphocyte rate) influences the therapeutic efficacy of intrapleural OK-432.

PATIENTS AND METHODS

We enrolled 20 lung cancer patients with malignant pleural effusion treated with intrapleural OK-432 who were admitted to our hospital between January 2000 and December 2004. Therapeutic efficacy was assessed from the response rate, duration of chest drainage after treatment with intrapleural OK-432, time to progression of malignant pleural effusion, and survival time.

RESULTS

Response rate in patients who had a high lymphocyte rate (the High lymphocyte rate group) was significantly higher than in patients who had a low lymphocyte rate (the Low lymphocyte rate group). Lymphocyte rate did not correlate with duration of chest drainage after treatment with intrapleural OK-432, time to progression of malignant pleural effusion, or survival time.

CONCLUSIONS

The lymphocyte rate in malignant pleural effusion influences the response rate to treatment by intrapleural OK-432. In the High lymphocyte rate group, intrapleural OK-432 for malignant pleural effusion was effective. We conclude that intrapleural OK-432 is useful for malignant pleural effusion patients with a high lymphocyte rate before treatment.

Malignant pleural/pericardial effusion with tamponade and life-threatening reversible myocardial depression in a case of an initial presentation of lung adenocarcinoma

We present a case of a middle-aged woman in cardiac tamponade. Following pericardiocentesis that removed 1,500 ml of hemorrhagic fluid, the patient exhibited cardiogenic shock; LVEF, at its nadir, on inotrope, was less than 20%. Ventricular function slowly improved, with inotropic support, to the normal range by the 25th day of hospitalization. Cardiac failure in malignancy has often been attributed to multi-system failure; this case showed a hereto unrecognized clinical phenomenon - 'malignancy-associated myopericarditis'. While the direct link of cause and effect cannot be made with certainty, the case should be instructive to other clinicians who encounter similar life-threatening presentations of cardiac decompensation in malignancy.

Inhibition of phosphatidylinositol 3'-kinase/AKT signaling promotes apoptosis of primary effusion lymphoma cells

PURPOSE

Phosphatidylinositol 3'-kinase (PI3'-kinase) can be activated by the K1 protein of Kaposi sarcoma-associated herpes virus (KSHV). However, the role of PI3'-kinase in KSHV-associated primary effusion lymphoma (PEL) is not known. To assess this, we studied survival and apoptosis in PEL cell lines following inhibition of PI3'-kinase.

EXPERIMENTAL DESIGN

Constitutive activation of several targets of PI3-kinase and apoptotic proteins were determined by Western blot analysis using specific antibodies. We used LY294002 to block PI3'-kinase/AKT activation and assess apoptosis by flow cytometric analysis.

RESULTS

Blocking PI3'-kinase induced apoptosis in PEL cells, including BC1, BC3, BCBL1, and HBL6, whereas BCP1 was refractory to LY294002-induced apoptosis. LY294002-induced apoptosis did not seem to involve Fas/Fas-L but had an additive effect to CH11-mediated apoptosis. We also show that AKT/PKB is constitutively activated in all PELs and treatment with LY294002 causes complete dephosphorylation in all cell lines except BCP1 where a residual AKT phosphorylation remained after 24 hours of treatment. FKHR and GSK3 were also constitutively phosphorylated in PELs and treatment with LY294002 caused their dephosphorylation. Although inhibition of PI3'-kinase induced cleavage of BID in all cell lines, cytochrome c was released from the mitochondria and caspase-9 and caspase-3 were activated in LY294002-induced apoptotic BC1 but not in resistant BCP1. Similarly, XIAP, a target of AKT, was down-regulated after LY294002 treatment only in sensitive PEL cells.

CONCLUSIONS

Our data show that the PI3'-kinase pathway plays a major role in survival of PEL cells and suggest that this cascade may be a promising target for therapeutic intervention in primary effusion lymphomas.

Immunosuppressive mechanisms in the microenvironment of malignant pleural effusions

Malignant effusions in serous cavities constitute a unique milieu for direct contact of tumor cells with host lymphoid cells in a fluid phase. The aim of this study was to depict agents responsible for suppression of lymphoid cells with putative anti-tumor potential. Pleural effusions drawn from 44 (18 non-malignant and 26 malignant) patients were tested for selected cytokines--interleukin-10 (IL-10), transforming growth factor beta (TGF-beta1) and soluble Fas ligand (sFasL) and nuclear membrane proteins (NMPs) content by ELISA. TCR-zeta expression of T cells and TUNEL reaction for apoptosis were evaluated by three color flow cytometry. Both cytokine concentrations were found to be significantly elevated in malignant pleural effusions (MPE) as compared to non-malignant ones. It was also true for sFasL content. Moreover, NMPs corresponding to decoy cell fragments, were also heightened in MPE. Concentrations of NMPs correlated with the percent of apoptotic (TUNEL+) T CD3+ lymphocytes and inversely correlated with the percent of T cells. The low expression of TCR-zeta chain on T cells corresponded to high concentration of sFasL in MPE. In conclusion, the above data suggest that out of three suppression agents tested, only sFasL appears to show correlation with the downregulation of T cells in MPE.

Rapid pleurodesis in symptomatic malignant pleural effusion

OBJECTIVE

The objective of the study was to see whether a rapid method of pleurodesis was superior to the standard protocol in patients with symptomatic malignant pleural effusion.

METHODS

Between January 2000 and February 2003, a prospective randomised trial was carried out in a sequential sample of 27 patients with malignant pleural effusions documented cytopathologically. Twelve patients were allocated to group 1 (standard protocol) and 15 to group 2 (new protocol). A small-bore catheter (12 Fr) and oxytetracycline (35 mg/kg of body weight) were used in both groups. In group 1, patients had drainage until radiological evidence of lung re-expansion was obtained and the amount of fluid drained was less than 150 ml/day, before oxytetracycline was instilled. The catheter was removed when the amount of fluid drained after instillation was less than 150 ml/day. In group 2, patients had the oxytetracycline instilled in a fractionated-dose manner following frequent aspirations at 6h intervals. The catheter was removed when the total amount of fluid drained after instillation of the oxytetracycline [OT] was less than 150 ml/last three aspirations. Response was evaluated at 1, 3 and 6 months after pleurodesis.

RESULTS

There was no statistically significant difference in the demographic features, site of the primary tumour, disease characteristics, and response rates in any evaluation period in both groups (P>0.05). However, the number of days of drainage and hospitalisation, and the cost were significantly lower in the second group (P<0.001).

CONCLUSIONS

This new pleurodesis method provided shorter hospital stay resulting in superior cost-effectiveness and palliation without sacrificing the efficacy of pleurodesis.

Management of malignant pleural effusions

Malignant pleural effusion is a common clinical problem. Evacuation of the pleural fluid and prevention of its reaccumulation are the main aims of management. Pleurodesis should be attempted early, although considerable practice variations exist in the way it is performed. There is a lack of consensus among respiratory physicians worldwide on the optimal method and agent for pleurodesis. Talc remains the most commonly used pleurodesing compound in most countries. While talc produces a higher success rate than other compounds, it generates more side-effects. The association between talc and ARDS continues to be debated. Ambulatory small-bore pleural catheter drainage followed by intrapleural instillation of a pleurodesing agent is increasingly accepted as an alternative to conventional in-patient pleurodesis. Development of novel methods to control pleural fluid formation should be made a high priority in future pleural research.

Unilateral Breast Edema in two Patients with Malignant Pleural Effusion

Unilateral breast edema usually signifies an underlying pathology of the breast and prompts extensive investigations for the purpose of an early treatment. Although breast edema has been reported with other systemic etiologies, it has not been described in patients with lung cancer. We report two cases of unilateral breast edema occurring in patients with non-small cell lung cancer and ipsilateral pleural effusion. Mammography and ultrasound of the breast both revealed increased interstitial density suggestive of fluid retention without any underlying masses. We performed a therapeutic pleurocentesis on one patient for symptomatic relief, and there was simultaneous improvement of the breast edema. We postulate a possible pathophysiology for the association between breast edema and malignant pleural effusion. The principle of management when one encounters similar cases would be to treat the underlying pleural effusion.

Interleukin-2 stimulation activates mesothelial cellular functioning against autologous tumor cells

BACKGROUND

The present study was designed to determine the different effects of cytokines or antibodies (IL-2, IL-4, IL-7, IL-10, IL-12, alphaCD3) in stimulating the cellular functions of mesothelial cells isolated from malignant pleural effusion.

METHODS

Mesothelial cells were isolated from 27 patients with malignant pleural effusion. The cultured cellular interferon-gamma (IFNgamma) and IL-10 production, proliferative response, and cytolytic activity against autologous tumors and K-562 cells were measured.

RESULTS

Stimulation with IL-2 alone significantly increased the mesothelial cells' proliferative response (p < 0.001) and cytolytic activity against autologous tumors (p = 0.025). The further addition of other cytokines did not increase these functions. The IFNgamma/IL-10 ratio data showed that the T-helper (Th) pathway was shifted from the Th-2 pathway to the Th-1 pathway (increase of IFNgamma/IL-10 ratio) when mesothelial cells were stimulated with IL-2. Further stimulation with IL-2 plus IL-12 or alphaCD3 shifted the Th pathway further in the Th-1 direction, but without statistical significance.

CONCLUSIONS

The mesothelial cell proliferative response is enhanced with IL-2 stimulation alone. The T-helper pathway is also shifted from the Th-2 to the Th-1 response (increase of IFNgamma/IL-10 ratio) after IL-2 stimulation of mesothelial cells. Mesothelial cells had cytolytic activity against tumor cells, and this activity could be augmented by IL-2 stimulation.

The significance of thoracoscopic mechanical pleurodesis for the treatment of malignant pleural effusions

BACKGROUND

Malignant pleural effusion (MPE) is a frequent and serious complication of numerous malignant tumors in the human organism. The patients are suffering from the primary disease, and the pleural effusion causes dyspnea, thus reducing the quality of their survival time. In our study we wished to establish the significance of thoracoscopic mechanical pleurodesis (TMP) as a new method for the resolution of this pathology, by comparing the results with those of thoracotomy with pleurectomy (TP) and thoracic drainage (TD). The main criterion for the effectiveness of each method was the absence of pleural effusion in a certain time interval.

PATIENTS AND METHODS

84 patients with recurrent MPE and primary tumors at various locations were divided into three groups according to the type of palliative intervention. The patients were classified according to the indication guidelines for individual procedures and their general condition. Group 1 consisted of 44 patients in whom TMP was performed, group 2 consisted of 17 patients with primary tumors in the thoracic region in whom thoracotomy with pleurectomy (TP) was performed, and in group 3 there were 26 patients with TD. We compared the effectiveness of individual palliative methods by periodical X-ray checks, numbers of complications, length of TD and hospitalization, and changes in spirometric values after individual procedures. The t-test was used in statistic processing of the data.

RESULTS

After six months, radiological investigation revealed recurrence of pleural effusion in three patients in group 1 (93.2% efficacy), no recurrence in group 2 (100% efficacy), and recurrence in 18 patients in group 3 (25.0% efficacy). There were fewer postoperative complications in group 1, the duration of TD and hospitalization was significantly shorter, and spirometric values increased.

CONCLUSION

TMP is an effective palliative method for the treatment of recurrent pleural effusions, with a minimum number of complications and a short period of hospitalization. After TMP there is significant improvement in respiratory functions, and for the patient it represents a relatively simple surgical procedure. TP is indicated in the treatment of tumors and subsequent MPE in the thoracic region, and TD is indicated in patients who are not suitable candidates for one of the palliative pleurodesis procedures, because of either their poor general condition or a trapped lung.

Malignant pleural effusions

The management of pleural effusions and, in particular, recurrent MPE require an accurate assessment of the characteristics of the pleural fluid and the relief of the patient's symptoms. Although a common problem, treatment of pleural effusions and MPE is highly variable. Selection of optimal treatment for the individual patient (or population of patients) requires a careful assessment of the benefits and associated risks of the therapy. Pleurodesis is an artificial measure of success that is hospital centered, not patient centered. Because patients with MPE have limited life expectancy, efforts to palliate or eliminate dyspnea, optimize function, eliminate hospitalization, and reduce excessive end-of-life medical care costs may be best achieved with a chronic indwelling pleural catheter. The need for expensive supplies may temper the use of such outpatient management. Alternative techniques of tube thoracostomy, drainage, and sclerosis or thoracoscopy with drainage and talc poudrage also have benefits but are associated with variable hospitalization and increased medical costs.

[Biological criteria for distinguishing exudative and transudative pleural effusions. Usefulness in a general hospital]

The first step in the diagnosis of a pleural effusion is to determine the exudative or transudative nature of the fluid. The purpose of this work was to compare different biological criteria commonly used in clinical practice. Among 118 pleural effusion fluids studied, 24.6% were exudates and 75.6% were transudates. The different parameters studied were Light criteria, Costa criteria, protein content, cholesterol content, and lactate dehydrogenase activity in the pleural fluid. The results showed that the Light criteria enabled classing all the fluids as exudates or transudates. We were also able to demonstrate that simple assay of lactate dehydrogenase activity in the pleural fluid gave comparable results, avoiding the need for further blood samples.

Reduction of lung parenchyma compliance as a factor in the genesis of pleural effusion in neoplasms

It is well known that bronchial obstruction causes an increase in negative pressure in the pleural cavity and is considered to be one of the factors giving rise to pleural fluid. We suggest that a reduction in the compliance of the lung parenchyma, whatever its cause (apart from bronchial obstruction), may also lead to an increase in negative pressure in the pleural cavity and may contribute, together with the other known factors, as an additional mechanism in the appearance of pleural fluid. We believe that this factor is valid in neoplastic pleurisy and may also apply in pleurisy, and possibly in other pathological conditions. The presence of pleural effusion may be better interpreted if we bear this factor in mind. We arrived at this view principally through the study of simple chest X-rays of normal subjects and of patients, mainly cancer patients.

Diagnostic DNA-flow- vs. -image-cytometry in effusion cytology

AIMS

To determine the sensitivity and specificity of flow- and image-cytometry for the detection of DNA-aneuploidy as a marker for malignant cells in effusions.

METHODS

200 effusions (80 tumor cell-positive, 74 negative and 46 cytologically equivocal) were stained with DAPI-SR for DNA-flow- and with Feulgen-Pararosaniline for -image-cytometry. They were measured using a PAS-flow-cytometer and an AutoCyte-QUIC-DNA-workstation according to the ESACP consensus reports for DNA-flow- and -image-cytometry, respectively [7,23,29,49].

RESULTS

Sensitivity of DNA-aneuploidy for the identification of malignant cells was 32.1% for DNA-flow- and 75.0% for -image-cytometry, specificity of -euploidy in benign cells was 100.0% for both methods. Positive predictive value of DNA-aneuploidy for the identification of malignant cells was 100.0% for both techniques, negative predictive value of DNA-euploidy was 48.6% for DNA-flow- and 72.0% for -image-cytometry.

CONCLUSIONS

Searching for DNA-aneuploidy as a diagnostic marker for neoplastic cells in serous effusions image-cytometry revealed superior sensitivity as compared with monoparametric flow cytometry.

Management of malignant pleural effusion

Malignant pleural effusion, an abnormal accumulation of fluid in the intrapleural space, is a common complication of cancer resulting in debilitating symptoms including dyspnea, pain, and fatigue. The goal of treatment is aimed at symptomatic control, relief and control of dyspnea, and obliteration of the intrapleural space to prevent reaccumulation of pleural fluid. Treatment options include chemotherapy, radiation, intrapleural instillation of sclerosing agents, indwelling pleural catheters with intermittent drainage, pleuroperitoneal shunts, and pleurectomy. Therapeutic approaches used in the management of malignant effusions must be directed at maintaining or improving the quality of life for the individual.

[Treatment of pleural effusion caused by lung carcinoma with circular intrapleural hyperthermic perfusion and its mechanism]

OBJECTIVE

To assess the comprehensive effectiveness of intrapleural hyperthermic perfusion in treatment of malignant pleural effusion (MPE) caused by lung carcinoma and to explore its nechanism.

METHODS

45 patients with MPE caused by lung carcinoma underwent circular intrapleural hyperthermic perfusion with 43 warmed normal saline for 60 minutes. Response of pleural effusion and the original lung tumor, sife-effects, life qualty and survival time of the patients were followed up. Flow cytometry, optical microscopy, electron microscopy, and TUNEL method were used to compare the cytology and biochemistry of pleural effusion and cancer cells planted to the surface of pleura before and after the therapy.

RESULTS

The control rate of pleural effusion was 100% (CR 93.3%, PR 6.7%). No recurrence of pleural effusion was observed in 44 cases. Pleural effusion reoccured 12 months after the thermotherapy in one case. The time without pleural effusion lasted 16.5 months on average with the longest time of 40 months. CT performed one month after the thermotherapy in 13 cases showed that the primary focus in lung dwindled in 13 cases, and remained unchanged in 5 cases. Neither operative death nor post-operative complication was found. The life quality was improved in all the cases. The medium survival time was 16.8 months. One-year survival rate was 87%. One case survived more than 3 years, 4 cases survives more than 2 years (29, 30, 31, and 40 months respectively). Carcinoembryonic antigen decreased to normal and no carcinoma cell was found in pleural effusion. Flow cytometry showed that the tumor heteroploid peak diasappeared. Pyknosis and disintegration of nuclei, and apoptotic bodies of tumor cells planted on the surface of pleura were found by optical and electron microscopy. TUNEL showed apoptotic cells with brilliant yellow fluorescence.

CONCLUSION

(1) Circular intrapleural hyperthermic perfusion is a new, safe, and effective treatment for MPE. (2) Apoptosis-mediated cytocidal function, improvement of body immunity after hyperthermic perfusion and continuous wash of the perfusion fluid are important mechanisms of intrapleural hyperthermic perfusion in treatment of MPE caused by lung carcinoma.

Malignant pleural effusion: prognostic factors for survival and response to chemical pleurodesis in a series of 120 cases

Chemical pleurodesis is an effective treatment of malignant pleural effusions, but indications must be individualised to optimise its results. The aim of the present study was to investigate the relationship of various prognostic features with both the response rate to pleurodesis and the probability of patient survival. A non-concurrent cohort study was carried out in which 120 evaluable patients with malignant pleural effusion underwent pleurodesis. Lung (40%), breast (26.6%), and unknown primary site (12.5%) carcinomas were the most frequent neoplasms. Clinical data and pleural fluid parameters were analysed. Median overall survival was 9 months. Pleural fluid glucose (< 60 mg/dl), Karnofsky performance status (< 70), size of the effusion in chest radiographs (massive effusion), pleural fluid pH (< 7.20), presence of concomitant alterations in chest radiographs, and pleural lactic acid dehydrogenase levels (> 600 U/l) showed a significant association with the probability of failure. Patients with these features, along with those having non-chemosensitive tumours (in particular, non-small cell lung cancer), had a significantly worse actuarial survival. This study confirms that some pretreatment clinical data and pleural fluid parameters can predict both the outcome of pleurodesis and the survival of patients with malignant pleural effusion.

Lymphatic drainage of carbon particles injected into the pleural cavity of the monkey, as studied by video-assisted thoracoscopy and electron microscopy

OBJECTIVES

The aim of this study was to clarify the dynamics of lymphatic drainage of the pleural cavity to understand the mechanism of malignant pleural effusion.

METHODS

We injected carbon particles into the pleural cavity of monkeys subjected to general anesthesia. We then observed the parietal pleura with a video-assisted thoracoscope and scanning and transmission electron microscopes to examine the regions of the parietal pleura where the carbon particles had been absorbed.

RESULTS

The video-assisted thoracoscope showed that the carbon particles had gone directly to the costal, mediastinal, and diaphragmatic pleura by 10 to 15 minutes after injection. From the scanning and transmission electron microscopes, we found that the parietal pleura in the costal and mediastinal regions consisted of 3 elements: a layer of small mesothelial cells, the macula cribriformis, and lymphatic lacunae. Stomata (3-5 microm in diameter) were found between the small mesothelial cells. The macula cribriformis was composed of densely packed collagen fibrils and had many foramina (3-10 microm in diameter). Intrapleurally injected carbon particles were carried into the lymphatic lacunae via the stomata and vesicles of the mesothelial cells and the foramina of the macula cribriformis. The lymphatic lacunae filled with carbon particles were richly distributed in both the anterior costal pleura and the mediastinal pleura.

CONCLUSION

We suggest that the mesothelial stomata and the macula cribriformis are structures essential to the absorption of macromolecules and cellular elements from the pleural cavity into the lymphatic system.

The impact of pleurodesis in malignant effusion on respiratory function

Pleurodesis of malignant pleural effusion provides for a substantially better quality of life compared to onging exudation with the need for repeated evacuation of fluid. Successful pleurodesis leads to permanent cessation of fluid production as a result of the formation of fibrous adhesion between the lung and costal pleura which in theory, however, might restrict lung mobility. In patients with poor lung function, or with need for bilateral pleurodesis, the apprehension of further impairment of lung function often arises. The aim of this study was to evaluate the effects of pleurodesis on lung function. Therefore 10 patients with malignant pleurisy with very limited tumour were investigated. They were without radiological signs of tumour infiltration in the lung parenchyma, without visible tumour growth in the pleural space during thoracoscopy and had undergone a successful one-sided pleurodesis. Respiratory function tests were performed at different times, 1-102 months after pleurodesis. The assessment consisted of: static and dynamic spirometry, exercise testing with blood gas determination and radiospirometry. Spirometric values were slightly low, but in general within the reference limits. Blood gas determination showed no signs of alveolar hypoventilation. Radiospirometry showed a slight attenuation of activity in the treated lung but similar turnover of gas of the treated vs. the untreated side. The study showed that pleurodesis in malignant pleurisy has only minor impact on respiratory function.

Vascular endothelial growth factor levels and induction of permeability in malignant pleural effusions

Vascular endothelial growth factor (VEGF) is an important mediator of angiogenesis and vascular permeability. We hypothesized that malignant pleural effusions may contain high levels of VEGF protein as well as other cytokines implicated in these processes. Pleural effusions cytologically proven to be malignant were collected from 39 patients with various types of cancer, and VEGF, interleukin-8, and angiogenin levels in the effusions were determined by immunoassay. Negative controls were nonmalignant ascites and serum samples from healthy individuals. VEGF levels were significantly higher than those of control samples in pleural effusions secondary to breast, mesothelioma, and non-small cell lung cancer and when all malignant pleural effusion samples were pooled. Neither interleukin-8 nor angiogenin levels were elevated in malignant pleural effusions relative to the control samples. Vascular permeability, which was measured by using the Miles assay in nude mice, was increased proportionately with VEGF levels in the malignant pleural effusions; this increase in permeability induced by injection of recombinant VEGF or the malignant effusions was reduced by pretreating the mice with a VEGF receptor antibody.

Antibacterial activity of human pleural fluid: alone and in combination with antibiotics

This study investigated the antibacterial activity of human pleural fluid (HPF) and its interaction with gentamicin (GM), meropenem (MRPM), ciprofloxacin (CPFX) and clarithromycin (CLTM) against Escherichia coli K-12, Proteus rettgeri (Sanelli) and Staphylococcus aureus. Minimal inhibitory concentrations or volumes, expressed as MIC or volume percentage (MIV, V/V%), were measured using a micro-dilution technique in microtiter plates. The antimicrobial activity of HPF combinations with antimicrobial drugs was evaluated by the chequerboard method calculating the fractional inhibitory concentration index (FIC) values. HPF MIVs (%) were: 37.54; 19.85; 1.74 for E. coli, P. rettgeri and S. aureus, respectively. FIC values indicated a synergistic effect with GM, MRPM and CPFX against E. coli and P. rettgeri and an additive effect for the combination HPF plus CLTM or indifference with HPF plus GM and CPFX against S. aureus. The presence of antibodies, complement factors, lysozyme, alpha-defensins and enzymes could explain the antimicrobial activity of HPF and its synergistic effect with certain antibiotics.

Pleural effusion in patients with non-Hodgkin's lymphoma: a case-controlled study

BACKGROUND

Pleural effusion is reported in up to 20% of patients with non-Hodgkin's lymphoma (NHL), most often at presentation. However, the prognostic implications of such findings are not clear. The majority of the information in the literature is based on minor observational studies or case reports. Therefore, a case-controlled study was performed to verify the clinical significance of pleural effusion in NHL.

METHODS

Seventeen patients with pleural effusion at the time of presentation of NHL were identified. They were categorized by grade of NHL (based on the Working Formulation). Twenty-nine control patients with similar histopathologic characteristics who had Stage III/IV NHL without pleural effusion were matched to these cases by age, time of diagnosis, and treatment.

RESULTS

Ten patients with intermediate grade NHL were matched with 23 controls. No statistically significant difference in complete remission or survival rates between these groups was found (P=0.69 and P=0.7, respectively). The remission and survival rates also were similar in the subgroup of patients and controls who were treated with aggressive chemotherapy. Similarly, no difference was found in these parameters between four cases and six matched controls with low grade lymphoma. No matched controls were found for the patients with high grade lymphoma, but these patients had an unfavorable outcome. Fourteen of the 17 studied patients had an exudative type of pleural effusion. Thoracentesis yielded a positive cytologic finding in every case.

CONCLUSIONS

The presence of pleural effusion at the time of presentation of NHL does not adversely affect complete remission or survival rates.

Evaluating diagnostic tests in the pleural space. Differentiating transudates from exudates as a model

Physicians have a staggering variety of diagnostic tests available for directing their diagnostic and therapeutic decisions. Technologic advances in laboratory science have increased the sophistication of new tests and accelerated their rate of adoption into clinical practice. Unfortunately, studies that report the value of new diagnostic tests often fail to follow accepted methodologic standards for unbiased test assessment or provide clinicians with sufficient information for the intelligent evaluation of a test's performance and applicability. The following review of pleural fluid tests that discriminate between exudative and transudative effusions serves to highlight important methodologic considerations in the assessment of diagnostic tests.

Transudative malignant pleural effusions: prevalence and mechanisms

BACKGROUND

Malignant pleural effusions are classically exudative, though occasionally they can be transudative. We attempted to determine the prevalence of transudative malignant pleural effusions and to describe their clinical and radiographic characteristics.

METHODS

We studied the medical records of 215 patients with malignant pleural effusion, which contained complete data on pleural fluid analysis for 171 of them.

RESULTS

Eight cases of transudative malignant effusion were found. Seven of these eight patients had a concomitant disorder known to cause transudative pleural effusion. One patient had fluid overload due to renal failure, and another had been admitted earlier with congestive heart failure. Two patients had definite evidence of deep venous thrombosis, allowing us to postulate pulmonary embolism as a factor contributing to transudation. Three patients had CT evidence of superior vena cava obstruction. Only one patient had no known associations with causes of transudative effusion.

CONCLUSION

Malignant pleural effusions were transudative in 5% of our patients. In all except one patient, some evidence suggested the concomitant presence of a transudative state.

Malignant effusive disease of the pleura and pericardium

Malignant pleural and pericardial effusions are a common problem in the treatment of patients with lung cancer, breast cancer, or lymphoma and may occur with any malignancy. These effusions are frequently symptomatic and, in the case of the pleural space, may be the presenting sign of cancer. In other patients, they represent markers of recurrent, disseminated, or advanced disease. Given the poor prognosis of most patients presenting with these effusions, reducing symptoms and improving quality of life are the primary goals of treatment. Permanent drainage and/or obliteration of the pleural or pericardial space are crucial to the effective management of the effusion and will provide long-term palliation. Immediate relief can be accomplished via external drainage, but definitive therapy may often also require interventional radiology, cardiology, and thoracic surgery, as well as medical and radiation oncology. The pathophysiology, diagnosis, and treatment of malignant pleural and pericardial effusions are discussed in this article.