Practical management of pleural empyema.

Empyema is defined as pus in the thoracic cavity due to pleural space infection and has a multifactorial underlying cause, although the majority of cases are post-bacterial pneumonia. Despite treatment with antibiotics, patients with empyema have a considerable morbidity and mortality due at least in part to inappropriate management of the effusion. Timely diagnosis of pleural space infection and rapid initiation of effective pleural drainage represent fundamental principles for managing patients with empyema. Ultrasound is particularly useful to identify early fibrin membranes and septations in the pleural cavity conditioning treatment strategy. Empyema and large or loculated effusion with a pH < 7.20 need to be drained. Thoracoscopy has largely been used in pleural effusion due to lung infection. Whereas the efficacy of video-assisted thoracic surgery (VATS) in empyema management has been evaluated in several retrospective studies showing favourable results, less is known about the role of medical thoracoscopy (MT) in pleural infection. MT, appears to be safe and successful in multiloculated empyema treatment. It is also lower in cost and in frail patients is better tolerated than VATS which requires tracheal intubation.

Malignant mesothelioma and the working environment: the viewpoint of the occupational physician.

BACKGROUND: Firm scientific evidence supports the causal association between malignant mesothelioma (MM) and occupational exposure to asbestos. Risk attributable to occupation varies from 30 to 80% across different populations. The existence of a threshold level below which there is no risk of MM is still debated. A prompt and thorough assessment of exposure is essential to evaluate and manage MM cases, from diagnostic and epidemiological points of view. OBJECTIVES AND METHODS: To highlight the multiple areas of intervention by Occupational Physicians (OP) in MM evaluation and management, to describe an experience of OP in the province of Brescia. RESULTS: The main areas of interest of the OP are exposure assessment, diagnosis (clinical, etiological), medico-legal issues, social consequences, preventive strategies, risk communication, scientific dispute/uncertainties. By means of an active search, the Brescia MM registry, managed by OP belonging to the local health authority observed 309 MM from 1977 to 2003; the local Institute of Occupational Health, hosted in a hospital of national relevance, evaluated about 200 MM in the last decade. The main outcomes of OP activity are the high percentage of direct interviews, individual case management, expert exposure assessment, etiological diagnosis, counselling, medico-legal assistance, better knowledge of occupational risks, enhanced cooperation among health professionals (oncologists, pathologists, surgeons, pneumologists, general practitioners and OP), important contribution to Registries and to epidemiology (estimates of attributable risks, incidence, survival rates), with positive social and scientific consequences (insurance agencies, trade union organizations, public events, teaching opportunities). CONCLUSIONS: This experience highlights the multifaceted role of OP in active research and evaluation of MM cases, in the context of a multidisciplinary approach.

Newly marketed tissue markers for malignant mesothelioma: immunoreactivity of rabbit AMAD-2 antiserum compared with monoclonal antibody HBME-1 and a review of the literature on so-called antimesothelioma antibodies.

A complementary DNA (cDNA) library was constructed from a human malignant mesothelioma (MM) cell line and a cDNA fragment encoding for a cytoplasmic mesothelial protein recognized by the polyclonal antibody AMAD-1 was then cloned and expressed in Escherichia coli. The purified recombinant protein was used to raise a novel antibody, named AMAD-2, in rabbits. This antibody reacted with normal mesothelium and most MM (15 of 17) on paraffin sections and featured a cytoplasmic labeling. Conversely, AMAD-2 immunostaining of normal and tumor tissues from body sites other than serosal membranes was limited with respect to the proportion of positive specimens and usually less conspicuous than in MM. AMAD-2 immunoreactivity was subsequently compared with staining for HBME-1, another newly marketed antimesothelial monoclonal antibody, concerning the ability to distinguish pleural MM from metastatic pleural tumors of epithelial type. A granular cytoplasmic immunoreactivity for AMAD-2 was present in 50% or more of tumor cells in all 84 MM, regardless of histological type, but also in 3 (7%) of 42 pleural metastases, albeit only focally. HBME-1 was shown in 63 of 66 epithelial MM and in the epithelial component of all 8 mixed MM, with a prevailingly membranous pattern, usually homogeneous and strong, whereas none of the 10 sarcomatous MM was positive. HBME-1 was also expressed in 6 (14%) of 42 pleural metastases in a cytoplasmic or membranous pattern. Compared with HBME-1, AMAD-2 showed a higher degree of specificity and sensitivity for MM. AMAD-2 still proved to be superior to HBME-1, also when sarcomatoid MM were excluded from the assessment. This finding supports the view that AMAD-2 is an antibody highly, although not entirely, specific for the mesothelial lineage, whereas HBME-1 is probably a cell marker more closely related to the epithelial differentiation of MM. Therefore, AMAD-2 is preferable as a positive tissue marker to be incorporated in the optimal immunohistochemical panel for the diagnosis of MM.

Clinical significance of a multiple biomarker assay in patients with lung cancer. A study with logistic regression analysis.

The relative usefulness of a combination of some tumor markers, such as CEA, AFP, ferritin and NSE for the diagnosis of lung cancer was assessed by multiple logistic analysis. Serum concentration of these markers was determined in 68 patients with lung cancer (50 with NSCLC and 18 with SCLC, in 68 patients with benign lung disease and 75 normal control subjects. Ferritin proved to be the most useful in diagnosing both NSCLC and SCLC, while NSE was found to be of some help in diagnosing SCLC only. The multiple marker panel proved to be more sensitive and specific than any single marker in discriminating lung cancer from normal control tissue, but it was of limited value in discriminating malignant from benign lung disease. The results of the present study would suggest that the panel of investigated tumor markers is not of great help for the early diagnosis of lung cancer.

[Oxygen therapy with an oxygen concentrator]. / Ossigenoterapia mediante concentratore di ossigeno.

An account is given of the employment of an O2 concentrator (De VO2 955) in chronic bronchopneumopaths with respiratory insufficiency and pulmonary hypertension. An assessment was made of the gas supply modalities, particularly with Venturi masks. In patients with normal or low ventilation, 24% and 28% FiO2 masks gave suitable results, whereas those with a higher concentration were unusable, since the present FiO2 value was not reached. This was probably due to the fact that there is a fall in O2 concentration at high low flow rates, and as a result of an insufficient Venturi effect.

[Symphyseal therapy with tetracycline in neoplastic pleurisy and spontaneous pneumothorax]. / La terapia sinfisaria con tetraciclina nelle pleuriti neoplastiche e nel pneumotorace spontaneo.

The treatment of 15 patients with neoplastic pleurisy and 25 with spontaneous pneumothorax occurring for the second time is described. All were given endopleural tetracycline therapy for symphyseal purposes. In the neoplastic pleurisy cases, the treatment reduced the number of thoracenteses required. In only 1 case did spontaneous pneumothorax recur a short time after treatment.

Erionite and asbestos differently cause transformation of human mesothelial cells.

Malignant mesothelioma (MM) is an aggressive tumor associated with environmental or occupational exposure to asbestos fibers. Erionite is a fibrous zeolite, morphologically similar to asbestos and it is assumed to be even more carcinogenic. Onset and progression of MM has been suggested as the result of the cooperation between asbestos and other cofactors, such as SV40 virus infection. Nevertheless, several cases of MM were associated with environmental exposure to erionite in Turkey, where SV40 was never isolated in MM specimens. We show here that erionite is poorly cytotoxic, induces proliferating signals and high growth rate in human mesothelial cells (HMC). Long term exposure to erionite, but not to asbestos fibers, transforms HMC in vitro, regardless of the presence of SV40 sequences, leading to foci formation in cultured monolayers. Cells derived from foci display constitutive activation of Akt, NF-kappaB and Erk1/2, show prolonged survival and a deregulated cell cycle, involving cyclin D1 and E overexpression. Our results reveal that erionite is able per se to turn HMC into transformed highly proliferating cells and disclose the carcinogenic properties of erionite, prompting for a careful evaluation of environmental exposure to these fibers. The genetic predisposition to the effect of erionite is a separate subject for investigation.

Advanced techniques in medical thoracoscopy.

For expert pulmonologists, advanced procedures in medical thoracoscopy are the nonroutine and more complex applications of the method. The main current indications are the treatment of infected pleural space, forceps lung biopsy and sympathectomy. In parapneumonic effusions and empyema, medical thoracoscopy is as a drainage procedure, intermediate between tube thoracostomy and video-assisted thoracoscopic surgery (VATS), which is efficient, significantly lower in cost and avoids surgical thoracoscopy under general anaesthesia. It is essential that it is performed early in the course of the disease and is particularly advisable for frail patients at high surgical risk. The efficacy of forceps lung biopsy has been demonstrated in diffuse lung diseases, whereas results in localised lung diseases and chest-wall lesions have been less positive. However, VATS is currently the preferred approach for these indications. The technique still maintains its efficacy for visceral pleura and peripheral lung biopsy, in particular in the presence of pleural effusion and lung disorders. At the present time, thoracoscopic sympathectomy is minimally invasive and is an accepted intervention for patients with a variety of autonomous nervous system disturbances. Essential hyperhidrosis patients, and well-selected patients with other disorders, can be helped with this procedure, which can also be performed by interventional pulmonologists.

[Microbiological drawings in pneumology (author's transl)]. / I prelievi microbiologici in pneumologia

Microbiological examinations of the sputum for clinical purposes is often not satisfactory or useless. Suitability, chances of oropharyngeal contamination, hazards for the patients and clinical indications of the various drawing methods for tracheobronchial secretions and exudates are different. Transcutaneous tracheal aspiration is easy, reliable and safe.

Thoracoscopy in pleural malignant mesothelioma diagnosis.

On the basis of our personal experience in 70 cases (66 pleural effusions) observed during the period January 1984- January 1996 we are here illustrating and discussing the diagnostic role of thoracoscopy in malignant pleural mesothelioma.A histological diagnosis was achieved in 94.2% of cases. The endoscopic appearance was clearly neoplastic (masses, nodules) in 53 patients (75.7%) and simply inflammatory in 17 pachypleuritis in 13 (18.6%) and of diffuse hyperemia in 3 (5.7%). In all cases fluid cytology (diagnostic yield: 18.5%) and needle biopsy (diagnostic yield 17.1%) were performed.The extension of pleural involvement (endoscopic staging according to Boutin) was also determined. In 16 patients (22.8%) a parietal and diaphragmatic involvement (stage Ia) was found. In 40 patients (57.2%) an associated visceral invasion (stage Ib). In 14 cases (20%) a diffuse parietal, visceral and mediastinal extension (stage II). The exam has always been well tolerated with few immediate complications: subcutaneous emphysema (4 cases) and some negligeable parietal bleeding (2 cases).

[Malignant mesothelioma of the pleura: correlations between thoracoscopy and radiology]. / Mesoteliomi maligni della pleura: correlazioni tra toracoscopia e radiologia.

The frequency of malignant pleural mesothelioma has increased greatly in the past three decades; it is a tumor of great clinical, epidemiologic and therapeutical interest. Therapy should not be started before the tumor has been correctly diagnosed and staged with thoracoscopy and computed tomography (CT) which have replaced plain chest radiography. To help optimize the combination of these techniques, the authors report on their experience in 37 patients examined with conventional radiology and then with thoracoscopy. In 26 patients with CT findings of malignant pleural mesothelioma, the authors compared thoracoscopy and CT findings in the assessment of neoplastic spread to the parietal (stage IA) and/or visceral (stage IB) pleura. CT appears to be the technique of choice after plain chest radiography: if the suspected malignant pleural mesothelioma is classified as stage II, III or IV, thoracoscopy should be used only for histologic confirmation. Conversely, in stages IA and IB, thoracoscopy--besides histology--should be used to confirm malignant spread to the visceral pleura.

[Clinical problems about microbiological findings in pneumology (author's transl)]. / Problematica clinica dei reperti microbiologici in pneumologia

Identification for clinical purposes of the etiological germs in individual cases of bronchopulmonary not tuberculous infections is usually very hard. Sometimes, particularly in acute cases, microbiological counts in sputum as in tracheobronchial secretions and exudates may be useful. In some chronic cases an amount of particular bacteria in tracheal (transcutaneous) secretion larger than in sputum is to consider an etiological sign.