A new electrocautery pleural biopsy technique using an insulated-tip diathermic knife during semirigid pleuroscopy.

BACKGROUND: The biopsy size obtained with standard flexible forceps (SFF) during semirigid pleuroscopy is often insufficient for pathological examination. An insulated-tip diathermic knife (IT knife) allows safe resection of a larger lesion during gastrointestinal endoscopy. We sought to validate an electrocautery pleural biopsy technique using the IT knife during semirigid pleuroscopy. We compared the diagnosis of specimens obtained using the IT knife and SFF in 20 subjects with unexplained pleural effusion, and reviewed pleuroscopic parameters such as complications, procedure time, and diameter of the specimens. METHODS: After injecting saline with lidocaine and epinephrine below the affected pleura, the lesion was incised in a circular shape with full thickness by manipulating the IT knife. RESULTS: Diagnostic yields from specimens obtained with the IT knife and SFF were 85% (17 of 20 cases) and 60% (12 of 20 cases), respectively. The IT knife biopsy was superior to SFF in 8 of 20 patients (malignant pleural mesothelioma in three, nonspecific inflammation in two, metastatic breast cancer in one, and tuberculosis in one). These pleural lesions revealed thickened, smooth abnormal appearances. The overall diagnostic yield for both IT knife and SFF was 100%. Median time of the procedure, from first pleural injection to specimen removal, was 21 min (range 12-92 min), and median diameter of specimen was 13 mm (range 6-23 mm). There were no severe complications during the procedure. CONCLUSIONS: Electrocautery biopsy using the IT knife during semirigid pleuroscopy has great potential for diagnosing smooth abnormal pleura which are difficult to biopsy with SFF.

Comparison between manual and automated total nucleated cell counts using the ADVIA 120 for pleural and peritoneal fluid samples from dogs, cats, horses, and alpacas.

BACKGROUND: Analysis of body fluids includes an estimate of total nucleated cell count (TNCC). Automated methods may enhance the accuracy and timeliness of TNCC results. OBJECTIVE: The purpose of this report was to assess the ability of the ADVIA 120 hematology analyzer to accurately count nucleated cells in pleural and peritoneal fluids from animals, compared with manual counts. METHODS: Pleural and peritoneal fluids submitted in EDTA tubes to our laboratory over a 17-month period were used in the study. TNCC/microL was determined by a manual method, using a hemocytometer, and by an automated method, using the ADVIA 120. Correlation of results was determined by Passing-Bablok regression, Bland-Altman plots, and Pearson correlation analysis. RESULTS: Samples from dogs (n=36), cats (n=36), horses (n=59), and alpacas (n=11) were analyzed. High correlation in TNCC between methods was found for peritoneal fluid (n=93, r=.959), pleural fluid (n=49, r=.966), and all fluids combined (n=142, r=.960) (P<.001). Variation between methods was greater in samples with TNCCs<1000/microL (r=.62, P<.001). The ADVIA systematically overestimated the number of cells in all fluid samples by 95 cells/microL (confidence interval=19.2-190.5/muL). CONCLUSION: The ADVIA 120 reliably determines TNCC in pleural and peritoneal effusions and can be recommended for routine veterinary laboratory analysis.

Analytical validation of the Sysmex XT-2000iV for cell counts in canine and feline effusions and concordance with cytologic diagnosis.

BACKGROUND: The Sysmex XT-2000iV is a hematology analyzer that combines laser and impedance technology. Its usefulness for determining cell counts in canine and feline intracavitary effusions has not yet been studied. OBJECTIVES: The objectives of this study were to evaluate the analytical performance of the Sysmex XT-2000iV for cell counts in effusions from dogs and cats, and to assess correlation with an impedance counter and concordance with diagnoses based on cytologic findings. METHODS: Effusions (43 pleural, 23 peritoneal, 6 pericardial) were analyzed from 32 dogs and 34 cats. Total nucleated cell count (TNCC), HCT, and RBC count were determined on the Sysmex and compared with those obtained on an impedance counter (Hemat 8, SEAC). Imprecision, linearity, and limit of detection were determined for the Sysmex. An algorithm was designed using quantitative and qualitative data from the Sysmex to classify the effusions and the results were compared with diagnoses based on cytologic findings. RESULTS: Intra-assay and interassay coefficients of variation on the Sysmex were variable. Linearity of TNCC was >or=0.993 for dogs and cats, with the exception of effusions from cats with feline infectious peritonitis, which had delta (Delta) TNC values >3.0. In comparison with the Hemat 8, a proportional error was found for TNCC on the Sysmex. Effusion classification based on the algorithm was concordant with that obtained by cytologic examination in 43/72 (60%) samples. Discordant results usually were due to the misclassification of cells with similar morphology (such as mesothelial and carcinoma cells) in Sysmex scattergrams. CONCLUSION: The Sysmex XT-2000iV provides a precise and accurate TNCC and has moderate concordance with cytologic findings for classifying canine and feline effusions. Although microscopic examination of effusions is necessary to achieve an accurate diagnosis, the Sysmex can provide preliminary information that may be helpful to cytopathologists.

TLR2 and TLR4 expression on the immune cells of tuberculous pleural fluid.

Toll-like receptors (TLRs) play an important role in mediating the down stream signaling of immune response in tuberculosis. The predominance of Th1 response in tuberculous pleurisy prompted us to study the expression profiles of TLR2 and TLR4 on different immune cells and on subsets of T cells obtained from the site of infection. Our results showed that TLR2 was up-regulated on the monocytes from pleural fluid indicating a prominent role for this receptor in anti-tuberculous immunity. Notably, TLR2 and TLR4 expression were also enhanced on IFN-gamma secreting CD4(+)T cells. However, their expression was down-regulated on activated and IL-4 secreting CD4(+)T cells from the site of infection indicating that TLR expression is differentially modulated on the different subsets of T cells depending on their activation status and cytokine expression. The down-regulation of both TLRs on the natural regulatory T cells despite their higher number at the site of infection might be a mechanism to maintain their suppressive activity.

The value of pleural fluid analysis.

Pleural fluid analysis in isolation may have clinical value. To have the greatest diagnostic impact, the clinician must formulate a prethoracentesis diagnosis based on the clinical presentation, blood tests, and radiographic imaging. With this approach, a definitive or confident clinical diagnosis can be expected in up to 95% of patients. The information in this report should allow the clinician to achieve this goal.

Diagnostic work-up of pleural effusions.

A wide range of diseases may be the cause of an accumulation of fluid in the pleural space. Pleural effusion is a major diagnostic problem, since the pleura is an inner cavity with no direct access. The aim of this review is to provide a practical approach to the investigation of the patient presenting with pleural effusion. This should help to accurately diagnose pleural effusion and keep time-consuming, but necessary, invasive investigations to the minimum.

[Influence of pleural fluid red blood cell count on the misidentification of transudates]. / Influencia del recuento de hematíes del líquido pleural en la identificación errónea de los trasudados.

BACKGROUND AND OBJECTIVE: Light's criteria misclassify a quarter of transudates as exudates. We assessed the influence of red blood cell counts on pleural lactate dehydrogenase (LDH) levels and, thereby, on the specificity of Light's criteria. PATIENTS AND METHOD: We retrospectively reviewed 1,312 consecutive patients with pleural effusion, of whom 1,014 were exudates and 298 transudates according to clinical criteria. The relationship between pleural erythrocytes and LDH using simple linear regression analysis, as well as the operating characteristics of Light's criteria, were assessed. Finally, a formula to correct pleural LDH levels, according to the erythrocyte count, was generated. RESULTS: There was a linear relationship between the pleural erythrocyte count and LDH levels (r = 0.44; p < 0.001). Light's criteria yielded 81% specificity in patients with pleural erythrocyte counts < or = 10.000 3 10(6)/l, as compared to 61% in a group with a higher erythrocyte counts (p < 0.01). The application of the LDH formula enabled the correct reclassification of 24 of 64 (37%) false exudates. CONCLUSIONS: A high pleural erythrocyte count, through its influence on the LDH levels, may lead to a transudate being misclassified as an exudate after applying Light's criteria.

What is your diagnosis? Pleural fluid from a neonatal Thoroughbred filly with pneumonia.

A 3-day-old filly was presented to the Cornell University Hospital for Animals with an umbilical hematoma and mild aspiration pneumonia. The foal underwent abdominal surgery for resection of the hematoma. Recovery was uneventful, but 3 days after surgery, the foal became progressively tachypneic. Imaging studies revealed bilateral pleural effusion and pleuropneumonia. Cytologic evaluation and bacterial culture of the pleural fluid from both sides of the chest revealed sterile exudates, consisting mostly of neutrophils, with fewer macrophages and lymphocytes. Pleural fluid macrophages contained variable amounts of purple-magenta globular material in their cytoplasm. A lighter colored granular precipitate was also seen throughout the background of the smears. Similar material was identified in a macrophage in a peripheral blood smear prepared 2 days after abdominal surgery. Large amounts of extracellular pink precipitate were also seen in the blood smear and persisted in the blood for 7 days after surgery. A protective lubricant, carboxymethylcellulose, had been instilled into the abdominal cavity during surgery to prevent intra-abdominal adhesions. The intracytoplasmic pigment within pleural fluid and blood macrophages and the extracellular precipitate in peripheral blood and pleural fluid smears was compatible with carboxymethylcellulose. The material was probably derived hematogenously and was considered an incidental finding. The pleuritis was attributed to exacerbation of the original aspiration pneumonia by the general anesthesia.

[Tuberculous pleurisy after tumour necrosis factor-alpha antagonist usage: case report]. / Tümör nekroz faktörü-alpha antagonisti kullanimi sonrasi gelisen tüberküloz plörezi: Olgu sunumu.

A thirty-six year old male patient presented with dyspnea, right-sided chest pain, night sweats and intermittent fever. He has a history of ankylosing spondylitis treated with tumour necrosis factor-alpha (TNF-alpha) antagonist (infliximab). Computed tomography of the chest showed mediastinal lymphadenopathy, right-sided pleural effusion, and atelectasis. The pleural fluid was exudative with lymphocyte dominance. Closed pleural biopsy was nondiagnostic. The adenosine deaminase level of the pleural fluid was 110 U/L. In light of these findings, the patient was diagnosed as tuberculous pleurisy and antituberculous treatment was given. After one month, pleural fluid was markedly reduced.

Establishment of novel human dedifferentiated chondrosarcoma cell line with osteoblastic differentiation.

Dedifferentiated chondrosarcoma is a rare, highly malignant variant of chondrosarcoma in which a high-grade sarcoma coexists with a low-grade chondroid tumor. We herein review a case of dedifferentiated chondrosarcoma with an osteosarcoma omit component that occurred in the distal femur of a 38-year-old man. We established the cell line (NDCS-1) from a pleural effusion of the metastatic lung tumor. The cell line was characterized by a the G-banded karyotype, polymerase chain reaction (PCR) single-strand conformation polymorphism analysis, spectral karyotyping, and reverse transcriptase PCR (RT-PCR). The tumor exhibited complex karyotypes and a high frequency of chromosomal amplication with p53 mutation. This tumor revealed an osteoblastic and chondroblastic character in vitro and in severe combined immunodeficiency mice. The expression and phosphorylation of platelet-derived growth factor receptor-beta, which seemed to play a major role in the malignant phenotype of chondrosarcoma, was confirmed by RT-PCR and Western blotting. To our knowledge, this is the first report of the establishment of a human dedifferentiated chondrosarcoma.

Herbal mixtures consisting of puerarin and either polyenylphosphatidylcholine or curcumin provide comprehensive protection against alcohol-related disorders in P rats receiving free choice water and 15% ethanol in pure water.

Chronic alcohol drinking has been associated with the development of a number of abnormalities, including neuron-behavioral disorders, liver, pancreas, and heart-related diseases and inflammation and immune disorders. Because diverse mechanisms are involved in the development of these disorders, the commonly used receptor- or enzyme-specific drugs do not provide comprehensive protection against the adverse effects of alcoholism. This study describes possible therapeutic potency of puerarin (PU) from kudzu root, polyenylphosphatidylcholine from soy (SPCh), and curcumin (CU) from turmeric against alcohol's addiction-related and inflammatory-related abnormalities in alcohol-preferring P rats receiving free choice water and 15% ethanol in water. P-rats were fed once daily either the vehicle (for control) or different doses of PU, SPCh, CU, PU + SPCh, or PU + CU. The rats were divided in two groups: one received water alone, and the other free choice water and ethanol. Four rats from each group were fitted with electroencephalogram (EEG) electrodes for EEG recording. After 70 days of alcohol drinking, alcohol was withdrawn for 2 weeks, and the withdrawal symptoms were assessed. This study showed that alcohol drinking for 70 days (1) caused liver inflammation characterized by elevated tumor necrosis factor-alpha, interleukin-1beta, and matrix metalloproteinase-9 expression and (2) dysregulated lipopolysaccharide (LPS)-induced pleurisy. Alcohol withdrawal after 70 days of drinking generated severe withdrawal symptoms including seizure-type EEG activity. PU suppressed the addiction-mediated abnormalities but did not affect the inflammation-related abnormalities, while SPCh or CU suppressed only the inflammation-related abnormalities in alcohol-drinking rats subjected to LPS-induced pleurisy. A combination of PU with SPCh or CU suppressed both the addiction-related and inflammation-related abnormalities of alcohol drinking. Therefore, a mixture consisting of PU and either SPCh or CU may provide alternative therapy for alcohol-related disorders.

Primary pleural epithelioid hemangioendothelioma with rhabdoid phenotype: report and review of the literature.

Epithelioid hemangioendothelioma (EHE) is a rare malignant vascular tumor described in diverse locations including lung and liver. Relative to these sites, primary EHE of the serous cavities is uncommon. EHE in the serous cavities mimics mesothelioma and adenocarcinoma clinically, radiographically, cytologically, and histologically. EHEs have plasmacytoid epithelioid cells with cytoplasmic vacuoles. In addition to these features, we noted eccentric nuclei with abundant eosinophilic cytoplasm and nuclei displaced peripherally by globular cytoplasmic inclusions imparting a "rhabdoid" phenotype. These cells were often seen surrounding a hyaline core. Rhabdoid features are not unique to a single entity, and a comprehensive immunohistochemical panel is essential. We report the occurrence of pleural EHE with rhabdoid features presenting in a pleural effusion, and review the literature of primary serosal EHEs.

Distribution of T-lymphocytes and B-lymphocytes in peripheral blood and effusions of patients with cancer.

The relative distribution of T- and B-lymphocytes in the blood and in pleural or abdominal effusions was compared among 24 patients with fluid accumulation due to metastatic cancer and 8 patients without evidence of cancer. The data obtained indicated that the mean percentage of T-lymphocytes in malignant effusions was significantly greater than that in the peripheral blood of the same patients. At the same time, the mean eprcentage of B-lymphocytes was decreased in malignant effusions when compared with peripheral blood. Neither of these differences was observed when effusions and blood of patients with nonmalignant effusions were compared. In addition, patients with both types of effusions had fewer total lymphocytes in their blood than did normal control patients, whereas those with cancer-associated effusions had an increased proportion of active T-lymphocytes in their blood.

Rapid assays for evaluating the drug sensitivity of tumor cells.

Assays that assess the ability of cells to incorporate labeled precursors into acid-precipitable material in the presence of adriamycin, daunorubicin, puromycin, vinblastine, melphalan, or methotrexate were investigated as an approach to the detection of resistant cells in human tumor samples. Each assay was evaluated with suitable drug-resistant Chinese hamster ovary cell lines and normal human fibroblasts to determine whether the assays reflected the drug sensitivity of these lines. Moreover, the ability to detect the presence of drug-resistance cells in a mixed population was evaluated. Validated assays were then used to measure the drug sensitivity of cell samples from pleural and peritoneal effusions of patients, mainly with carcinoma of the breast or ovary. Though the responsiveness of the majority of the samples in these assays was similar to that of a human fetal lung fibroblast line, 37 of 142 samples displayed responses consistent with the presence of a significant proportion of drug-resistant cells. Of these 37 nonresponsive samples, 12 displayed nonresponsiveness to three drugs.

Differential isolation of normal luminal mammary epithelial cells and breast cancer cells from primary and metastatic sites using selective media.

The present studies were aimed at determining if the use of a cell culture medium that supports proliferation of human mammary epithelial cells of the luminal lineage would allow routine isolation of breast cancer cells from primary and metastatic tumor specimens. Results obtained with mammary epithelial cells derived from reduction mammoplasty specimens and primary breast carcinomas indicated that growth of cells on type I collagen-coated dishes in Ham's F-12 medium supplemented with insulin, hydrocortisone, epidermal growth factor, cholera toxin, and 5% fetal bovine serum resulted in the growth and serial passage of cells that stained positively for the luminal cell marker cytokeratin 19. By contrast, growth of mammary epithelial cells in a growth factor-supplemented serum-free medium resulted in the emergence of mammary epithelial cell colonies that were uniformly negative for keratin 19. Filter isolation methods were used to isolate individual keratin-19-positive colonies from primary cultures derived from breast cancer specimens. All of the luminal mammary epithelial cells isolated from breast cancer tissues expressed characteristics of normal cells. Keratin-19-positive colonies isolated from several different tumors all grew rapidly for 30 to 60 days in culture and then senesced. Cells were isolated from one tumor that was known to have undergone a loss of heterozygosity at a specific locus in the p53 gene. All colonies isolated from this specimen contained both p53 alleles, which was consistent with their origin from normal luminal cells. Cells were also isolated from one tumor in which the c-erbB2 protein was drastically overexpressed in the neoplastic cells. Once again, keratin-19-positive colonies isolated from this tumor did not overexpress the c-erbB-2 protein. Experiments were then performed with cells derived from pleural effusions and metastatic lymph nodes. Results obtained with these specimens indicated that the growth conditions that support the growth of normal luminal mammary epithelial cells do not support the growth of neoplastic cells. However, the omission of cholera toxin, epidermal growth factor, and type I collagen substratum resulted in the isolation of two long-term cell lines. Both cell lines have population doubling times of approximately 100 h, are hyperdiploid, and stain positively for cytokeratin 19. Thus, culture conditions that support the growth of normal luminal mammary epithelial cells do not, in general, support the growth of breast cancer cells.

Multicellular tumor spheroid formation by breast cancer cells isolated from different sites.

Fourteen breast cancer lines (8 human, 5 rat, and 1 mouse) have been studied in terms of their ability to form multicellular tumor spheroids (MTS) with the agar-base method. Only 8 of the lines formed MTS in contrast to a 100% efficiency in a series of 11 varied tumors reported in the initial studies with this method. We have compared the lines that do and do not form MTS in terms of a variety of characteristics (e.g., estrogen receptors, time in serial passage, growth in nude mice, etc.), and only one characteristic, the source of the original tumor cells, was predictive of MTS-forming ability. All 8 of the breast cancer lines (and the original 11 lines) that formed MTS had been obtained from solid growths (primaries or metastases), while the 6 breast cancer lines that did not form MTS were all derived from pleural effusions. Similarly, artificial selection for an ascites variant of the MTS-forming rat 13762 adenocarcinoma line produced the 13762-A line, which could no longer form MTS. These results suggest that breast cancer cells derived from pleural effusions are genetically different from the bulk of the tumor cells in solid breast cancer samples, that they are unable to grow in true solid form, and that these differences persist in spite of prolonged propagation in tissue culture.

Eotaxin-3 and interleukin-5 pleural fluid levels are associated with pleural fluid eosinophilia in post-coronary artery bypass grafting pleural effusions.

OBJECTIVES: The primary aim of this study was to examine the association between pleural fluid (PF) eosinophilia, and the PF and serum levels of interleukin (IL)-5, eotaxin-2, eotaxin-3, and vascular cell adhesion molecule (VCAM)-1 in patients with post-coronary artery bypass grafting (CABG) pleural effusions. DESIGN: A prospective observational study. SETTING: A tertiary teaching hospital. PATIENTS AND METHODS: Thirty-eight patients with post-CABG pleural effusions were recruited into the study. An effusion that contained at least 10% eosinophils was called "eosinophilic." The PF and serum levels of the cytokines and VCAM-1 were measured using an enzyme-linked immunosorbent assay. RESULTS: (1) The number of PF eosinophils significantly correlated with the number of blood eosinophils. (2) PF IL-5 levels were significantly higher than the corresponding serum levels, and there was a significant correlation between the PF and serum IL-5 levels. PF IL-5 levels significantly correlated with the PF eosinophil count, and serum IL-5 levels significantly correlated with the number of blood eosinophils. (3) PF eotaxin-3 levels were significantly higher than serum levels, and PF eotaxin-3 levels significantly correlated with the PF eosinophil count. (4) PF VCAM-1 levels were significantly lower than the corresponding serum levels, and PF VCAM-1 levels were significantly higher in eosinophilic pleural effusions (EPEs) than in non-EPEs. CONCLUSION: In patients with post-CABG pleural effusions, IL-5 and eotaxin-3 are produced preferentially in the pleural cavity, and they are strongly associated with PF eosinophilia.

Comparative analysis of expert and machine-learning methods for classification of body cavity effusions in companion animals.

A rule-based expert system using CLIPS programming language was created to classify body cavity effusions as transudates, modified transudates, exudates, chylous, and hemorrhagic effusions. The diagnostic accuracy of the rule-based system was compared with that produced by 2 machine-learning methods: Rosetta, a rough sets algorithm and RIPPER, a rule-induction method. Results of 508 body cavity fluid analyses (canine, feline, equine) obtained from the University of California-Davis Veterinary Medical Teaching Hospital computerized patient database were used to test CLIPS and to test and train RIPPER and Rosetta. The CLIPS system, using 17 rules, achieved an accuracy of 93.5% compared with pathologist consensus diagnoses. Rosetta accurately classified 91% of effusions by using 5,479 rules. RIPPER achieved the greatest accuracy (95.5%) using only 10 rules. When the original rules of the CLIPS application were replaced with those of RIPPER, the accuracy rates were identical. These results suggest that both rule-based expert systems and machine-learning methods hold promise for the preliminary classification of body fluids in the clinical laboratory.

Characteristics of pleural effusions associated with pulmonary embolism.

Pleural fluid characteristics were analyzed in 26 patients with pulmonary embolism. All determinations were highly variable. A bloody effusion occurred in 65%, while clear fluid was found in 35%. White blood cell counts had a wide distribution of values; polymorphonuclear leukocytes predominated in 61% and lymphocytes in 39%. Less than two thirds of tested specimens were exudates by standard criteria. Only 27% of effusions had the "typical" pattern of bloody appearance, polymorphonuclear predominance, and characteristics of an exudate. Roentgenographically evident infiltrates occurred in 62% and were correlated with bloody pleural fluid (P less than .01), which suggests that infarction is not necessary for effusion to occur, but may account for a bloody appearance. The variability of these results indicates that there are no typical or diagnostic pleural fluid findings in pulmonary embolism.

Early pleural effusion in histiocytosis X.

Two cases of histiocytosis X, one of the disseminated form and the other localized to the lung, are reported, in which pleural effusion, probably due to pleural involvement as assessed by biopsy, was one of the initial manifestations of the disease.