Mesothelioma in a developing country: a retrospective analysis of the diagnostic process / Mesotelioma em um país em desenvolvimento: análise retrospectiva do processo diagnóstico

ABSTRACT Objective: To evaluate the process of diagnosing patients with malignant pleural mesothelioma (MPM) at a tertiary care hospital. Methods: This was a retrospective study involving patients referred to a tertiary-care cancer center in Brazil between 2009 and 2020. The diagnostic process was divided into four steps: onset of symptoms, referral to a specialist visit, histopathological diagnosis, and beginning of treatment. The intervals between each phase and the factors for delays were evaluated. Data including clinical status, radiological examinations, staging, treatment modalities, and survival outcomes were collected. Results: During the study period, 66 patients (mean age = 64 years) were diagnosed with MPM and underwent treatment. Only 27 (41%) of the patients had knowledge of prior exposure to asbestos. The median number of months (IQR) between the onset of symptoms and the first specialist visit, between the specialist visit and histopathological characterization, and between definite diagnosis and beginning of treatment was, respectively, 6.5 (2.0-11.4), 1.5 (0.6-2.1), and 1.7 (1.2-3.4). The knowledge of prior asbestos exposure was associated with a shorter time to referral to a specialist (median: 214 vs. 120 days; p = 0.04). A substantial number of nondiagnostic procedures and false-negative biopsy results (the majority of which involved the use of Cope needle biopsy) were found to be decisive factors for the length of waiting time. The mean overall survival was 11.9 months. Conclusions: The unfamiliarity of health professionals with MPM and the patient's lack of knowledge of prior asbestos exposure were the major factors to cause a long time interval between the onset of symptoms and beginning of treatment. An overall survival shorter than 1 year is likely to have been due to the aforementioned delays.

RESUMO Objetivo: Avaliar o processo de diagnóstico de pacientes com mesotelioma pleural maligno (MPM) em um hospital terciário. Métodos: Estudo retrospectivo envolvendo pacientes encaminhados a um centro oncológico terciário no Brasil entre 2009 e 2020. O processo diagnóstico foi dividido em quatro etapas: início dos sintomas, encaminhamento para consulta especializada, diagnóstico histopatológico e início do tratamento. Foram avaliados os intervalos entre as etapas e os fatores de atraso. Os dados coletados incluíram estado clínico, exames radiológicos, estadiamento, modalidades de tratamento e resultados de sobrevida. Resultados: Durante o período do estudo, 66 pacientes (média de idade = 64 anos) foram diagnosticados com MPM e submetidos a tratamento. Apenas 27 (41%) dos pacientes tinham conhecimento de exposição prévia ao amianto. A mediana de meses (IIQ) entre o início dos sintomas e a primeira consulta especializada, entre a consulta especializada e a caracterização histopatológica e entre o diagnóstico definitivo e o início do tratamento foi, respectivamente, de 6,5 (2,0-11,4), 1,5 (0,6 -2,1) e 1,7 (1,2-3,4). Conhecimento de exposição prévia ao amianto associou-se a menor tempo para encaminhamento a um especialista (mediana: 214 vs. 120 dias; p = 0,04). O número substancial de procedimentos não diagnósticos e as biópsias falso-negativas (a maioria envolvendo o uso de biópsia com agulha de Cope) foram considerados fatores decisivos para o tempo de espera. A sobrevida global média foi de 11,9 meses. Conclusões: A falta de familiaridade dos profissionais de saúde com o MPM e o desconhecimento dos pacientes em relação à exposição prévia ao amianto foram os principais fatores que ocasionaram um longo intervalo de tempo entre o início dos sintomas e o início do tratamento. A sobrevida global inferior a 1 ano provavelmente se deve aos atrasos supracitados.

Efficacy observation of cisplatin sequential recombinant human vascular endostatin thoracic perfusion in treatment of malignant pleural effusion / 肿瘤研究与临床

Objective:To investigate therapeutic effect of cisplatin sequential recombinant human vascular endostatin thoracic perfusion in treatment of malignant pleural effusion.Methods:A total of 80 patients with malignant pleural effusion in Maoming People's Hospital from January 2018 to February 2021 were enrolled, and all patients were divided into 2 groups according to the random number table methods, each group with 40 cases. The control group was treated with small-bore catheter minimally invasive drainage combined with cisplatin thoracic perfusion, and the study group was treated with small-bore catheter minimally invasive drainage combined with cisplatin sequential recombinant human vascular endostatin thoracic perfusion. And then the clinical efficacy, expressions of vascular endothelial growth factor (VEGF) expression, pain degree and adverse reactions were compared of both groups.Results:The treatment efficacy rate of the study group was higher than that of the control group [90% (36/40) vs. 75% (30/40)], and the difference was statistically significant ( χ2 = 5.04, P < 0.05). After treatment, the level of VEGF in pleural fluid and serum of the study group was lower than that of the control group [(304±106) pg/ml vs. (598±159) pg/ml,(103±43) pg/ml vs. (189±49) pg/ml], and the difference was statistically significant ( t = 6.62, P < 0.001; t = 6.23, P < 0.001). After treatment, the visual analogue scale (VAS) score of the study group was lower than that of the control group [(3.7±0.3) scores vs. (4.4±0.7) scores], and the difference was statistically significant ( t = 2.10, P < 0.05). The incidence of adverse reactions including stethalgia, fever, nausea and vomiting in both groups had no statistically significant differences (all P > 0.05). Conclusions:Cisplatin sequential recombinant human vascular endostatin thoracic perfusion combined with small-bore catheter minimally invasive drainage can effectively ameliorate clinical symptoms, inhibit the expression of VEGF, and alleviate pain degree with no serious adverse reactions in patients with malignant pleural effusion.

Short-term efficacy of pemetrexed combined with cisplatin in the treatment of malignant pleural effusion and its effect on serum carbohydrate antigen 199 level and circulating tumor cells / 中国基层医药

Objective:To investigate the short-term efficacy of pemetrexed combined with cisplatin in the treatment of malignant pleural effusion and its effect on serum carbohydrate antigen 199 level and circulating tumor cells.Methods:Sixty patients with advanced lung cancer complicated by malignant pleural effusion who received treatment in Healthcare Group of Cixi Third People's Hospital, China from January 2017 to January 2020 were included in this study. They were randomly assigned to receive intrapleural injection of cisplatin (cisplatin alone group, n = 30) or intrapleural injection of cisplatin combined with intravenous injection of pemetrexed (cisplatin + pemetrexed group, n = 30) after thoracic drainage. Before and 1 month after treatment, pleural effusion was measured to evaluate clinical efficacy and improvement in quality of life. Serum carcinoembryonic antigen level, serum carbohydrate antigen 199 level and circulating tumor cells were determined. Adverse reactions during the treatment were recorded. Results:Total effective rate and the rate of improvement in quality of life in the cisplatin + pemetrexed group were 66.67% (20/30) and 70.00% (21/30), respectively, which were significantly higher than those in the cisplatin alone group [40.00% (12/30) and 43.33% (13/30), χ2 = 4.286, 4.344, both P < 0.05]. After treatment, serum carcinoembryonic antigen and serum carbohydrate antigen 199 levels in each group were significantly decreased compared with before treatment (both P < 0.05). Serum carcinoembryonic antigen and serum carbohydrate antigen 199 level in the cisplatin + pemetrexed group were (22.26 ± 5.13) ng/mL and (20.12 ± 4.35) U/mL, respectively, which were significantly lower than those in the cisplatin alone group [(31.64 ± 6.46) ng/mL, (28.07 ± 5.61) U/mL, t = 6.228, 3.134, both P < 0.05). In the cisplatin alone group, there was no significant difference in the proportion of circulating tumor cells before and after treatment ( P > 0.05). In the cisplatin + pemetrexed group, the proportion of circulating tumor cells after treatment was significantly lower than that before treatment ( χ2 = 4.286, P < 0.05). After treatment, there was no significant difference in the proportion of circulating tumor cells between the two groups ( P > 0.05). During the treatment, there were no significant differences in the incidences of rash, nausea and vomiting, leukopenia, and anemia between the two groups (all P > 0.05). Conclusion:Pemetrexed combined with cisplatin in the treatment of malignant pleural effusion exhibits better short-term efficacy than cisplatin alone. The combined therapy is more conducive to relieving clinical symptoms and improving the quality of life with higher safety than monotherapy.

Clinicopathological analysis of malignant pleural effusion cell masses from 105 cases / 中国基层医药

Objective:To analyze the pathological types, tissue sources and clinical features of malignant pleural effusion.Methods:Cell masses were collected from 105 cases of malignant pleural effusion diagnosed by immunohistochemical examination after liquid-based cytology between May 2017 and October 2019 in Qidong People's Hospital, China. The pathological, morphological, immunohistochemical and clinical characteristics of the cell masses were analyzed.Results:Immunohistochemistry results showed that pleural effusion malignant cells were from lung adenocarcinoma tissue in 94 (89.52%) cases because they were positive for thyroid transcription factor-1, Napsin A and carcinoembryonic antigen, from small cell lung cancer tissue in one (0.95%) case because they were positive for neural cell adhesion molecule 1 and synaptophysin,from lung squamous cell carcinoma tissue in 2 (1.90%) cases because they were positive for cytokeratin 5/6 and P40, from ovarian adenocarcinoma tissue in 1 (0.95%) case because they were positive for CA125, from breast adenocarcinoma tissue in 4 (3.81%) cases because they were positive for estrogen receptor, progesterone receptor and gross cystic disease fluid protein 15, from the gastrointestinal tract adenocarcinoma tissue in 2 (1.90%) case because they were positive for caudal-type homeobox 2, and from the pancreatic adenocarcinoma tissue in 1 (0.95%) case because they were positive for cancer antigen 19-9 (CA199).Conclusion:Lung adenocarcinoma is the most common cause of malignant pleural effusion. Lung adenocarcinoma cells are positive for thyroid transcription factor-1, Napsin A and carcinoembryonic antigen. The combined use of the three markers can help the diagnosis of lung adenocarcinoma. In addition, lung adenocarcinoma should be differentiated from other types of lung cancer and the tumors from other regions.

Malignant Pleural Effusion from Metastatic Prostate Cancer: A Case Report with Unusual Cytologic Findings.

We present a case of 55-year-old man who complained of dyspnea and sputum for a month. He was an ex-smoker with a history of prostate cancer and pulmonary tuberculosis. Chest radiographs revealed bilateral pleural effusions of a small to moderate amount. Pigtail catheters were inserted for drainage. The pleural fluid consisted of large clusters and tightly cohesive groups of malignant cells, which however could not be ascribed to prostate cancer with certainty. We performed immunocytochemical panel studies to determine the origin of cancer metastasis. The immunostaining results were positive for prostate-specific antigen, alpha-methylacyl-coenzyme A racemase, and Nkx 3.1, consistent with prostate cancer. Pleural effusion associated with prostate cancer is rare. To our knowledge, this is the first case report in Korea to describe cytologic features of malignant pleural effusion associated with prostate cancer.

The clinical efficacy and safety of paclitaxel combined with avastin for NSCLC patients diagnosed with malignant pleural effusion

Summary Objective: The current study aimed to investigate the clinical efficacy of paclitaxel combined with avastin for non-small cell lung cancer (NSCLC) patients diagnosed with malignant pleural effusion (MPE). Method: Total of 33 patients diagnosed with NSCLC as well as malignant pleural effusion were included. All of them received paclitaxel (175 mg/m2) and avastin (5 mg/kg). Clinical efficacy was evaluated using the total response rate, overall survival, progression-free survival and changes in MPE volume. Adverse events and rates of toxicities were examined as well. Results: The total response rate reached 77% while the overall survival and the median progression-free survival were respectively 22.2 months and 8.4 months. Toxicities of grade 3-4 consisted of neutropenia in 57% of patients, anemia in 17% of them, febrile neutropenia in 11%, as well as anorexia in 7%. No treatment-correlated deaths were found. Conclusion: Paclitaxel combined with avastin decreased MPE volume and increased survival rate of NSCLC patients via inhibiting vascular endothelial growth factor expression.

[Evaluation of the diagnosis value of carcinoembryonic antigen in malignant pleural effusion].

Objective: To investigate the diagnostic value of serum and pleural fluid carcinoembryonic antigen (CEA) for malignant pleural effusion (MPE). Methods: The concentration of CEA in serum and pleural fluid of 286 patients with the diagnosis confirmed by pleural biopsy through medical thoracoscopy were retrospectively analyzed. MPE was confirmed in 171 cases which were divided into two groups (adenocarcinoma group with 121cases and non-adenocarcinoma group with 50 cases) and benign pleural effusion in 115 cases. The optimal cutoff for MPE and MPE caused by adenocarcinoma were determined by using the ROC curve. Results: The concentration of serum CEA 12.27(3.80, 58.45) µg/L was significantly higher in MPE caused by adenocarcinoma than that of non-adenocarcinoma 1.91(1.08, 4.55) µg/L and benign effusion 1.32(0.86, 2.27) µg/L (both P<0.001), but there was no statistically significant difference between benign and non-adenocarcinoma effusion (P=0.728). The concentration of pleural fluid CEA 160.70(30.48, 1 000.00) µg/L was significantly higher in MPE caused by adenocarcinoma than that of non-adenocarcinoma 1.77(0.51, 11.39) µg/L and benign effusion 1.09(0.60, 1.68) µg/L (both P<0.001), and higher in non-adenocarcinoma effusion than that of benign effusion (P<0.05). The cutoff value of serum and pleural fluid CEA for MPE was 3.10 and 5.83 µg/L, the sensitivity respectively was 67.3% and 74.3%, the specificity respectively was 87.8% and 98.3%, positive predictive value respectively was 89.2% and 98.5%, negative predictive value respectively was 64.3% and 72.0%. The cutoff value of serum and pleural fluid CEA for MPE caused by adenocarcinoma was 3.54 and 7.30 µg/L, the sensitivity respectively was 76.0% and 91.7%, the specificity respectively was 74.0% and 72.0%, positive predictive value respectively was 87.6% and 88.8%, negative predictive value respectively was 56.1% and 78.3%. Conclusions: The concentration of serum and pleural fluid CEA have diagnostic significance to MPE, especially MPE caused by adenocarcinoma. The diagnostic value of pleural fluid CEA is superior to serum CEA.

Malignant Pleural Effusion from Metastatic Prostate Cancer: A Case Report with Unusual Cytologic Findings

We present a case of 55-year-old man who complained of dyspnea and sputum for a month. He was an ex-smoker with a history of prostate cancer and pulmonary tuberculosis. Chest radiographs revealed bilateral pleural effusions of a small to moderate amount. Pigtail catheters were inserted for drainage. The pleural fluid consisted of large clusters and tightly cohesive groups of malignant cells, which however could not be ascribed to prostate cancer with certainty. We performed immunocytochemical panel studies to determine the origin of cancer metastasis. The immunostaining results were positive for prostate-specific antigen, alpha-methylacyl-coenzyme A racemase, and Nkx 3.1, consistent with prostate cancer. Pleural effusion associated with prostate cancer is rare. To our knowledge, this is the first case report in Korea to describe cytologic features of malignant pleural effusion associated with prostate cancer.

Clinical observation on Tingli-Dazao-Xiefei decoction combined with chemotherapy in the treatment of lung cancer with pleural effusion / 国际中医中药杂志

Objective To observe the effect of Tingli-Dazao-Xiefei decoction combined with chemotherapy in the treatment of lung cancer with pleural effusion. Methods A total of 90 patients who met the inclusion criteria from January to June 2017, were randomly divided into treatment group and control group. All patients were treated with intrapleural administration of cisplatin chemotherapy once a week, while patients in treatment group received additional treatment of taking Tingli-Dazao-Xiefei decoction daily.Changes of clinical efficacy, traditional Chinese medical (TCM) symptom score and Karnofsky score were observed 4 weeks later. Results After 4 weeks of treatment, there was no difference in the total effective rate between the two groups (χ2=1.600, P=0.659). The total effective rate was 71.1% (32/45) in treatment group, including 11 cases of complete remission and 20 cases of partial remission, while it was 64.4% (29/45) in control group including 10 of complete remission and 19 of partial remission. After treatment, the TCM symptom scores in the treatment group(20.81 ± 1.92 vs.8.93 ± 1.27;t=34.619,P<0.001)and control group(20.28 ± 1.36 vs.13.22 ± 1.63; t=22.310, P<0.001) were significantly lower than those before the treatment. After treatment, the TCM symptom scores(8.93 ± 1.27 vs. 13.22 ± 1.63,t=13.927)in the treatment group were significantly lower than that in the control group(P<0.001).The Karnofsky score(95.6% vs. 80.0%,χ2=3.728)in the treatment group was significantly higher than that in the control group (P<0.05). There was no difference in the incidence of adverse reactions. Conclusions The theray of Tingli-Dazao-Xiefei decoction combined with chemotherapy could achieved the similar clinical effect of cisplatin chemotherapy treatment, while it showed the advantage of improving TCM syndrome score and the quality of life.

Clinical observation on the effect of elemene injection maintenance treatment on the recurrence time of malignant pleural effusion / 国际肿瘤学杂志

Objective To observe the effect of elemene injection for the maintenance treatment of malignant pleural effusion.Methods A total of 90 patients with malignant pleural effusion from May 2014 to Apirl 2016 in First Affiliated Hospital of Heilongjiang University of Traditional Chinese Medicine were collected.They were divided into observation group (n =45) and control group (n =45) according to the random number table method.The patients of the two groups were treated with pleural effusion drainage through thoracocentesis,and Mannatide (Lifein) and carboplatin were poured.The observation group sequentially received maintenance treatment of elemene injection.The therapeutic effects of the two groups were compared.Results At the 12th month after treatment,the difference of relapse rate between the two groups was statistically significant(82.2％ vs.100.0％,x2 =8.780,P =0.003).The median progression-free survival (95％ CI) of the observation group and the control group were 10.00 (9.15-10.85) months and 6.00(4.74-7.26) months respectively,with a significant difference (x2 =40.475,P ＜ 0.001).The improvement rates of life quality of the observation group were 82.22％,57.78％,54.55％ respectively at one,six,twelve months after perfusion treatment,and the improvement rates of the control group were 84.44％,23.26％,0 respectively.The data differences between the two groups were statistically significant at six,twelve months (x2 =10.840,P =0.001;x2 =32.390,P ＜ 0.001).The one year survival rates of the observation group and the control group were 97.78％ and 95.56％,and the difference was statistically significant (P =1.000).Conclusion The effect of elemene injection for the maintenance treatment of malignant pleural effusion is obvious,which can prolong the progression-free survival time and can significantly improve the quality of life.

Comparison of EGFR mutation between supernatant and pellets of malignant pleural effusion from patients with advanced non-small cell lung cancer / 国际肿瘤学杂志

Objective To compare the epidermal growth factor receptor (EGFR) mutation differences between supernatant and pellets of malignant pleural effusion (MPE) in advanced non-small cell lung cancer (NSCLC) patients and provide the evidence for clinical accurate detection.Methods A total of 386 consecutive MPE specimens were collected in the study (202 in experimental group and 184 in validation group).Specimens in experimental group were divided into 4 groups depending on tumors cell concentration in the samples:zero cell (n =77),(1-5) × 104/ml cells (n =43),(6-10) × 104/ml cells (n =52) and ＞ 10 × 104/ml cells group (n =30).Amplification refractory mutation system (ARMS) was performed to detect EGFR gene mutation in supernatant and pellets of each individual case respectively,and the EGFR mutation positive rates were compared between the two groups.EGFR mutation test was carried out using either supematant or pellets in validation group to verify the established method.Results In the experimental group,the total EGFR mutation positive rate was 30.7％ (62/202).In the zero cell group,EGFR mutation positive rate was higher in supernatant than that in pellets (37.6％ vs.33.8％).In the (1-5) × 104/ml cells group and (6-10) × 104/ml cells group,EGFR mutation positive rate was equal but not concordant between supematant and pellets (25.6％ and 21.1％ respectively).In the ＞ 10 × 104/ml cells group,EGFR mutation positive rate was equal (33.3％) with 100％ concordance between supernatant and pellets.In the validation group (n =184),EGFR mutation rate was 32.7％ (36/110) in supernatant and 32.4％ (24/74) in pellets,and there was no statistical significance (x2 =0.02,P =0.97).Conclusion Tumor cell free MPE specimens from patients with advanced NSCLC are suitable for EGFR mutation test.Heterogeneity of MPE results in difference with respect to EGFR gene mutation status between cell-free supernatant and pellet.Pathological evaluation based on the quantity and quality of tumor cells in MPE patients prior to test and optional samples selection are necessary to increase EGFR mutation positive rate.

Clinical significance of expression of EGFR and the diagnostic value of cell wax block in malignant pleural effusions of lung adenocarcinoma / 中国基层医药

Objective To investigate the diagnostic value of cell wax block combined with immunohistochemistry in the diagnosis of malignant pleural effusion in lung adenocarcinoma and to analyze the expression and clinical significance of EGFR in pleural effusion.Methods From March 2013 to June 2017,50 lung cancer patients with pleural effusion specimens and corresponding histological specimens of lung adenocarcinoma in the Central Hospital of Wenzhou were selected.The intensity of EGFR expression in pleural effusion lung adenocarcinoma cells was detected.The difference of EGFR expression between pleural effusion cells and paraffin blocks was compared by ARMS method.Results The EGFR negative,weak positive,moderate positive and strong positive expression rates were 1 case (2.0％),8 cases(16.0％),20 cases(40.0％) and 21 cases(42.0％),respectively.There were no statistically significant differences in the sensitivity and specificity between the ARMS method and the immunohistochemical staining of lung cancer tissues (x2 =0.000,0.006,all P ＞ 0.05).The consistency of detection was excellent (Kappa value =0.93,P ＜ 0.001).There was no statistically significant differences in sensitivity and specificity between ARMS and pleural effusion wax immunohistochemical staining(x2 =0.014,0.027,all P ＞0.05),and the consistency was better (Kappa value =0.72,P ＜ 0.05).Conclusion Pleural effusion cells have the advantages of easy access,low cost,simple operation and good specificity,which is an easy and effective method to assess the expression of EGFR gene mutation in lung adenocarcinoma,which provides a reference for individualized treatment and prognosis of advanced lung adenocarcinoma.

Hyperthermic perfusion chemotherapy combined with bevacizumab for treatment of malignant ascites or pleural effusion: a meta-analysis of efficacy / 肿瘤研究与临床

Objective To make a meta-analysis of the effectiveness of hyperthermic perfusion chemotherapy (HPC) combined with bevacizumab for malignant ascites or malignant pleural effusion,and to provide the references for further practice and studies.Methods VIP,Wanfang data,PubMed and CNKI were searched from inception to January 2018.HPC combined with bevacizumab or HPC alone for malignant ascites or pleural effusion were collected for controlled clinical trial (CCT).According to inclusion and exclusion criteria,two reviewers checked studies,extracted data and assessed quality of the included studies.RevMan 5.3 software was used to make a meta-analysis.Results A total of 4 CCT involved 226 patients.Meta-analysis showed that compared with the HPC alone,HPC combined with bevacizumab had a higher rate in clinical efficiency (OR =4.82,95 ％ CI 2.45-9.49,P ＜ 0.000 01),malignant ascites or pleural effusion control rate (OR =4.06,95 ％ CI 1.09-15.11,P ＜ 0.05),quality of life improvement rate (OR =6.79,95 ％ CI 3.53-13.08,P ＜ 0.000 01),and the difference was statistically significant.Conclusion HPC combined with bevacizumab can improve the clinical effective rate,effusion control rate and quality of life improvement rate of the patients with malignant ascites or pleural effusion.

Accuracy of closed pleural biopsy in the diagnosis of malignant pleural effusion / Exactitud de la biopsia pleural cerrada para el diagnóstico de derrame pleural maligno

ABSTRACT Objective: Previous studies have demonstrated that closed pleural biopsy (CPB) has a sensitivity of less than 60% for diagnosing malignancy. Therefore, controversy has recently emerged regarding the value of CPB as a diagnostic test. Our objective was to assess the accuracy of CPB in diagnosing malignancy in patients with pleural effusion. Methods: This was a prospective 8-year study of individuals who underwent CPB to establish the etiology of pleural effusion. Information on each patient was obtained from anatomopathological reports and medical records. When CPB findings showed malignancy or tuberculosis, the biopsy was considered diagnostic, and that was the definitive diagnosis. In cases in which biopsy histopathological findings were nonspecific, a definitive diagnosis was established on the basis of other diagnostic procedures, such as thoracoscopy, thoracotomy, fiberoptic bronchoscopy, biochemical and cellular measurements in pleural fluid, and/or microbiological tests. The accuracy of CPB was determined with 2 × 2 contingency tables. Results: A total of 1034 biopsies from patients with pleural effusion were studied. Of those, 171 (16.54%) were excluded from the accuracy analysis either because of inadequate samples or insufficient information. The results of the accuracy analysis were as follows: sensitivity, 77%; specificity, 98%; positive predictive value, 99%; negative predictive value, 66%; positive likelihood ratio, 38.5; negative likelihood ratio, 0.23; pre-test probability, 2.13; and post-test probability, 82. Conclusions: CPB is useful in clinical practice as a diagnostic test, because there is an important change from pre-test to post-test probability.

RESUMEN Objetivo: Estudios previos demuestran que la biopsia pleural cerrada (BPC) para diagnóstico de malignidad tiene una sensibilidad menor al 60%, por lo que recientemente ha despertado controversia su valor como prueba diagnóstica. Nuestro objetivo fue evaluar la exactitud de la BPC para diagnóstico de malignidad en pacientes con derrame pleural. Métodos: Estudio prospectivo de 8 años en individuos que se sometieron a la realización de BPC para establecer la etiología del derrame. La información de cada paciente se tomó de los registros de anatomopatología y del expediente clínico. Cuando el resultado de la BPC demostró malignidad o tuberculosis, esto se tomó como biopsia diagnóstica y quedó éste como diagnóstico definitivo. En los casos en que el resultado del estudio histopatológico de la biopsia resultó inespecífico, el diagnóstico definitivo se estableció en base a otros procedimientos diagnósticos, como toracoscopia, toracotomía, fibrobroncoscopia, estudio bioquímico y celular del líquido pleural y/o pruebas microbiológicas. Mediante una tabla de contingencia de 2 × 2 se midieron los indicadores para una prueba diagnóstica. Resultados: Se estudiaron 1034 biopsias de pacientes con derrame pleural, de las cuales se excluyeron 171 (16.54%) por muestra inadecuada o información insuficiente. El desempeño para malignidad fue: sensibilidad, 77%; especificidad, 98%; valores predictivos positivo y negativo, 99% y 66%, respectivamente; índices de probabilidad positivo y negativo, 38.5 y 0.23, respectivamente; probabilidad antes y después de la prueba, 2.13 y 82, respectivamente. Conclusión: La BPC es útil como prueba diagnóstica en la práctica clínica, debido a que produce un cambio importante de la probabilidad antes de la prueba a la probabilidad después de la prueba.

[The value of B7-H4 and carcinoembryonic antigen in diagnosing the benign and malignant pleural effusion].

Objective: To evaluate the value of combined detection of negative costimulatory molecule B7-H4 and carcinoembryonic antigen (CEA) in diagnosing malignant and benign pleural effusion. Methods: Ninety-seven pleural effusion specimen were collected, 55 of which were diagnosed as malignant pleural effusion and 42 were benign pleural effusion. Enzyme-linked immunosorbent assay(ELISA) was used to examine the concentration of B7-H4 and CEA in pleural effusion. Electro-chemiluminescence immunoassay was used to detect the CEA level in pleural effusion. Receiver operating characteristic (ROC) curve was established to analyze and evaluate the single or combined detection of B7-H4 and CEA in diagnosing malignant and benign pleural effusion. Results: The concentrations of B7-H4 and CEA in malignant pleural effusion (MPE) group were (60.08±35.04) ng/ml and (41.49±37.16) ng/ml, respectively, obviously higher than (27.26±9.55) ng/ml and (2.41±0.94) ng/ml of benign pleural effusion (BPE) group (both P<0.01). Area under curve (AUC) of B7-H4 was 0.884 in MPE groupand the diagnostic sensitivity and specificity were 81.8% and 90.5%, respectively, at the optimized cut off value of 37.25 ng/ml. Likewise, area under curve (AUC) of CEA was 0.954 and the sensitivity and specificity were 87.3% and 95.2%, respectively, at the cut off value of 4.18 ng/ml. When B7-H4 >37.25 ng/ml or CEA>4.18 ng/ml, the sensitivity of diagnosis as MPE was down-regulated to 90.9% and the specificity was elevated to 88.1%. When B7-H4 >37.25 ng/ml and CEA>4.18 ng/ml, the sensitivity of diagnosis as MPE was down-regulated to 78.2% and the specificity was elevated to 97.6%. The sensitivity and specificity of combined detection of B7-H4 and CEA to diagnose MPE were elevated to 90.9% and 97.6%, respectively. The level of B7-H4 in MPE and BPE were both positively correlated with CEA (r=0.670, P=0.001 in MPE and r=0.002, P=0.001 in BEP). Conclusions: B7-H4 is a potential tumor marker in diagnosing the benign and malignant pleural effusion. Although the diagnostic value of B7-H4 may not precede to CEA, the combined detection of B7-H4 and CEA can improve the diagnostic sensitivity and specificity of MPE.

Ultrasound-guided intrapleural positioning of pleural catheters: influence on immediate lung expansion and pleurodesis in patients with recurrent malignant pleural effusion / Posicionamento intrapleural, guiado por ultrassonografia, de cateteres pleurais: influência na expansão pulmonar imediata e na pleurodese em pacientes com derrame pleural maligno recorrente

ABSTRACT Objective: To evaluate the role of intrapleural positioning of a pleural catheter in early lung expansion and pleurodesis success in patients with recurrent malignant pleural effusion (RMPE). Methods: This was a retrospective study nested into a larger prospective cohort study including patients with RMPE recruited from a tertiary university teaching hospital between June of 2009 and September of 2014. The patients underwent pleural catheter insertion followed by bedside pleurodesis. Chest CT scans were performed twice: immediately before pleurodesis (iCT) and 30 days after pleurodesis (CT30). Catheter positioning was categorized based on iCT scans as posterolateral, anterior, fissural, and subpulmonary. We used the pleural volume on iCT scans to estimate early lung expansion and the difference between the pleural volumes on CT30 and iCT scans to evaluate radiological success of pleurodesis. Clinical pleurodesis success was defined as no need for any other pleural procedure. Results: Of the 131 eligible patients from the original study, 85 were included in this nested study (64 women; mean age: 60.74 years). Catheter tip positioning was subpulmonary in 35 patients (41%), anterior in 23 (27%), posterolateral in 17 (20%), and fissural in 10 (12%). No significant differences were found among the groups regarding early lung expansion (median residual pleural cavity = 377 mL; interquartile range: 171-722 mL; p = 0.645), radiological success of pleurodesis (median volume = 33 mL; interquartile range: −225 to 257 mL; p = 0.923), and clinical success of pleurodesis (85.8%; p = 0.676). Conclusions: Our results suggest that the position of the tip of the pleural catheter influences neither early lung expansion nor bedside pleurodesis success in patients with RMPE.

RESUMO Objetivo: Avaliar o papel do posicionamento intrapleural do cateter pleural na expansão pulmonar precoce e no sucesso da pleurodese em pacientes com derrame pleural maligno recorrente (DPMR). Métodos: Trata-se de um estudo retrospectivo aninhado em um estudo prospectivo de coorte maior com pacientes com DPMR recrutados em um hospital-escola universitário terciário entre junho de 2009 e setembro de 2014. Os pacientes foram submetidos a inserção de cateter pleural e, em seguida, pleurodese à beira do leito. A TC de tórax foi realizada duas vezes: imediatamente antes da pleurodese (TCi) e 30 dias após a pleurodese (TC30). Com base na TCi, a posição do cateter foi classificada em posterolateral, anterior, fissural e subpulmonar. Usamos o volume pleural na TCi para estimar a expansão pulmonar precoce e a diferença entre os volumes pleurais na TC30 e na TCi a fim de avaliar o sucesso radiológico da pleurodese. Considerou-se que a pleurodese teve êxito clínico quando não foi necessário realizar nenhum outro procedimento pleural. Resultados: Dos 131 pacientes elegíveis do estudo original, 85 foram incluídos neste estudo aninhado (64 mulheres; média de idade: 60,74 anos). A posição da ponta do cateter foi subpulmonar em 35 pacientes (41%), anterior em 23 (27%), posterolateral em 17 (20%) e fissural em 10 (12%). Não houve diferenças significativas entre os grupos quanto à expansão pulmonar precoce (mediana da cavidade pleural residual = 377 ml; intervalo interquartil: 171-722 ml; p = 0,645), sucesso radiológico da pleurodese (mediana do volume = 33 ml; intervalo interquartil: −225 a 257 ml; p = 0,923) e sucesso clínico da pleurodese (85,8%; p = 0,676). Conclusões: Nossos resultados sugerem que a posição da ponta do cateter pleural não influencia nem a expansão pulmonar precoce nem o sucesso da pleurodese à beira do leito em pacientes com DPMR.

Use of indwelling pleural catheters for the definitive treatment of malignant pleural effusion / Utilização de cateter pleural de longa permanência para o tratamento definitivo de derrame pleural neoplásico

ABSTRACT Objective: To evaluate the safety and feasibility of the use of indwelling pleural catheters (IPCs) in patients with malignant pleural effusion (MPE). Methods: We prospectively collected data from patients with MPE undergoing IPC placement between January of 2014 and July of 2015. All patients submitted to IPC placement had a life expectancy > 30 days, in accordance with the MPE treatment guidelines established by the British Thoracic Society. The data collected included gender, age, body mass index, primary cancer site, duration of IPC drainage, IPC-related complications, length of hospital stay, pleural effusion recurrence, and occurrence of spontaneous pleurodesis. Results: A total of 19 patients underwent IPC placement during the study period. Median overall survival after IPC insertion was 145 days. The median follow-up among the surviving patients was 125 days (range, 53-485 days), and the median time between catheter insertion and removal was 31 days (range, 2-126 days). There were IPC-related complications in 5 patients (26.2%), and spontaneous pleurodesis was achieved in 8 (42.0%). Among those 8 patients, the IPC was removed between days 30 and 126 in 4, and spontaneous pleurodesis occurred within the first 30 days in 4. Conclusions: The use of IPCs seems to be feasible and safe in patients with MPE.

RESUMO Objetivo: Avaliar a segurança e a viabilidade do uso de cateter pleural de longa permanência (CPLP) em pacientes com derrame pleural neoplásico (DPN). Métodos: Dados referentes a pacientes com DPN que receberam CPLP entre janeiro de 2014 e julho de 2015 foram colhidos prospectivamente. Todos os pacientes que receberam CPLP tinham expectativa de vida > 30 dias, em conformidade com as diretrizes de tratamento de DPN da Sociedade Torácica Britânica. Foram colhidos dados sobre sexo, idade, índice de massa corporal, local do câncer primário, tempo de drenagem com o CPLP, complicações relacionadas com o CPLP, tempo de internação hospitalar, recidiva do derrame pleural e ocorrência de pleurodese espontânea. Resultados: Dezenove pacientes receberam CPLP durante o período de estudo. A mediana de sobrevida global após a inserção do CPLP foi de 145 dias. A mediana de tempo de acompanhamento dos pacientes sobreviventes foi de 125 dias (variação: 53-485 dias), e a mediana de tempo decorrido entre a inserção e a remoção do cateter foi de 31 dias (variação: 2-126 dias). Houve complicações relacionadas com o CPLP em 5 pacientes (26,2%) e pleurodese espontânea em 8 (42,0%). Nesses 8 pacientes, o CPLP foi retirado entre os dias 30 e 126 em 4, e a pleurodese espontânea ocorreu nos primeiros 30 dias em 4. Conclusões: O uso de CPLP parece ser viável e seguro em pacientes com DPN.

Cost-effectiveness of indwelling pleural catheter compared with talc in malignant pleural effusion.

BACKGROUND AND OBJECTIVE: Malignant pleural effusion is associated with morbidity and mortality. A randomized controlled trial previously compared clinical outcomes and resource use with indwelling pleural catheter (IPC) and talc pleurodesis in this population. Using unpublished quality of life data, we estimate the cost-effectiveness of IPC compared with talc pleurodesis. METHODS: Healthcare utilization and costs were captured during the trial. Utility weights produced by the EuroQol Group five-dimensional three-level questionnaire and survival were used to determine quality-adjusted life-years (QALYs) gained. The incremental cost-effectiveness ratio (ICER) was calculated over the 1-year trial period. Sensitivity analysis used patient survival data and modelled additional nursing time required per week for catheter drainage. RESULTS: Utility scores, cost and QALYs gained did not differ significantly between groups. The ICER for IPC compared with talc was favorable at $US10 870 per QALY gained. IPC was less costly with a probability exceeding 95% of being cost-effective when survival was <14 weeks, and was more costly when 2-h nursing time per week was assumed for catheter drainage. CONCLUSION: IPC is cost-effective when compared with talc, although substantial uncertainty exists around this estimate. IPC appears most cost-effective in patients with limited survival. If significant nursing time is required for catheter drainage, IPC becomes less likely to be cost-effective. Either therapy may be considered as a first-line option in treating malignant pleural effusion in patients without history of prior pleurodesis, with consideration for patient survival, support and preferences.

Research progress of traditional Chinese medicine in the treatment of malignant pleural effusion of lung cancer in recent 5 years / 国际中医中药杂志

The Chinese medicine could alleviate clinical symptoms, improve the quality of life in the treatment of lung cancer with malignant pleural effusion. TCM showed its certain characteristics and advantages. This paper summarized the literatures about the treatment of lung cancer with malignant pleural effusion with Chinese medicine in recent years in the light of oral Chinese herbal medicine, external use of Chinese medicine, pleural perfusion with traditional Chinese medicine.

Efficacy and safety of injecting endostar combined with platinum complexes into pleural cavity for treatment of malignant pleural effusion: a meta-analysis review / 中国医师杂志

Objective To investigate the efficacy and safety of patients with malignant pleural effusion treated with injecting endostar combined with platinum complexes into pleural cavity.Methods Cochrane systematic review methods were used in the data selection,and data were selected from the PubMed,Embase,Cochrane Library,China National Knowledge Infrastructure (CNKI),WanFang,and VIP database to get all clinical controlled trials.The retrieval time was August 2014.The objects of these randomized controlled trials were malignant pleural effusion patients.Endostar combination with platinum complexes was used for the experimental group.Platinum complexes alone were used for the control group.The efficacy and adverse effects of two groups were compared.The quality of included trials was evaluated by two reviewers independently.The software RevMan 5.3 was used for meta-analyses.Results Nine trials with 488 patients were included according to the including criterion.All trials were randomized controlled trials,one of them had B level in quality and eight had C level.Meta analysis results were as follows:there was significant difference in overall effective rate (OR =3.52,95％ CI =2.37 ～ 5.22),Karnofsky (KPS) score changes rate (OR =2.64,95％ CI =1.67 ～ 4.19),between endostar combination with platinum complexes and platinum complexes alone group.The incidences of severe leucopenia (OR =1.0,95％ CI =0.62 ～ 1.61) and nausea and vomiting (OR =0.77,95％ CI =0.43 ～ 1.38) were similar in the endostar combination with platinum complexes group compared to those in the platinum complexes alone group.Conclusions In the treatment of malignant pleural effusion,injecting endostar in combination with platinum complexes into pleural cavity improves the effective rate without obviously raised side effects.Owing to the small sample size and poor quality of included trials,more well-designed double-blinded randomized controlled trials should be performed.