Abstract: BACKGROUND AND OBJECTIVE: We aimed to examine the frequency of pleural adhesions and to determine their relationship with pleural tumor burden, pleural fluid (PF) biochemistries, PF cytologic yield, and survival in patients with malignant pleural effusion (MPE). METHODS: We performed retrospective analysis of 540 consecutive patients with MPE who underwent medical thoracoscopy. Pleural lesion rating and grade of pleural adhesions based on a thoracoscopic score model were recorded. RESULTS: Sixty percent of patients with MPE were found to have adhesions in the pleural space. The sensitivity of PF cytology was 71% if there were no pleural adhesions, and 20% if the maximum adhesion score was reached (p < 0.01). The extent of pleural adhesions correlated positively with the pleural tumor burden, and inversely with PF pH. The median survival of patients with minimal or no adhesions in the pleural space was 9 months as compared with patients with the highest grade of adhesions, whose median survival was 5 months (p < 0.01). CONCLUSION: MPE are often loculated. The higher the grade of pleural adhesions, the greater the tumor burden exists, and paradoxically the lower the PF cytologic yield. The presence of pleural adhesions in MPE implies a poor prognosis.
Abstract: BACKGROUND: To determine the effects of the biochemical and cytological properties of the pleural fluid (PF) on the survival of patients with malignant pleural effusion (MPE). METHODS: A retrospective study of 284 patients with MPE was performed, which measured overall survival, survival of patients with different types of primary tumors, and survival as a function of PF biochemical variables transformed into quartiles. RESULTS: Median overall survival of MPE patients was 5.4 months following diagnosis. Survival varied significantly depending on the type of the primary tumor: 17.4 months for mesothelioma, 13.2 months for breast cancer, 7 months for lymphoma and 2.6 months for lung cancer. A multivariate analysis of PF biochemical parameters showed that survival was lower as the concentration of lactate dehydrogenase (LDH) increased (11.3 months if LDH was between 140 U/L and 358 U/L vs 2.8 months if LDH was between 1027 U/L and 10,110 U/L) or the concentration of pleural proteins decreased (9.4 months if proteins were between 4.92 g/dL and 7.94 g/dL vs 2.2 months if proteins were between 0.97 g/dL and 3.85 g/dL). We also found that when mesotheliomas were excluded from the analysis, survival was lower in patients with a PF pH lower than 7.3 (2.4 months vs 6.8 months, p=0.03). CONCLUSIONS: Tumor type as well as some biochemical features of the pleural fluid, such as pH and concentrations of proteins and LDH, influence survival in patients with MPE.
Abstract: Objective: To assess the usefulness of repeat cytological examination of pleural fluid (PF) for diagnosing malignancy as well as the influence of time length between analyses, effusion's size and pleural fluid biochemistries on the diagnostic yield of cytology. Methods: Retrospective analysis of 1,427 patients with pleural effusion (PE), including 466 patients with malignant PE. In this latter group, the time length between cytological analysis, the size of the PE, and the biochemical characteristics of PF were recorded. Results: The first cytological analysis had a sensitivity of 48.5%. If this was negative, a second PF specimen was diagnostic in 28.6% of cases, whereas submission of a third PF specimen allowed 10.3% of additional diagnosis. The incidence of positive results depended on the primary tumor (e.g. 66.5% in adenocarcinomas, 30.8% in mesotheliomas), but neither on the time length between cytological analyses nor on the effusion's size. A multivariate analysis showed that a PF to serum glucose ratio </= 0.75 was associated with a higher diagnostic yield of cytology (74 vs. 47%, p < 0.001). Conclusion: At least a second PF specimen should be submitted immediately for cytologic analyis in all PE of unknown cause, when the first analysis is not contributory. To delay this second analysis does not increase diagnostic yield. The percentage of cases in which cytologic study of the PF established the diagnosis of malignant PE depends on the tumor type and on certain PF biochemical characteristics such as the PF to serum glucose ratio.
Abstract: BACKGROUND: Talc is the most effective chemical pleurodesis agent for patients with malignant pleural effusion. However, concerns have arisen about the safety of intrapleural application of talc, after reports of development of acute respiratory distress syndrome in 1-9% of treated patients. Our aim was to establish whether use of large-particle-size talc is safe in patients with malignant pleural effusion. METHODS: We did a multicentre, open-label, prospective cohort study of 558 patients with malignant pleural effusion who underwent thoracoscopy and talc poudrage with 4 g of calibrated French large-particle talc in 13 European hospitals, and one in South Africa. The primary endpoint was the occurrence of acute respiratory distress syndrome after talc pleurodesis. FINDINGS: No patients developed acute respiratory distress syndrome (frequency 0%, one-sided 95% CI 0-0.54%). 11 (2%) patients died within 30 days. Additionally, seven patients had non-fatal post-thoracoscopy complications (1.2%), including one case of respiratory failure due to unexplained bilateral pneumothorax. INTERPRETATION: Use of large-particle talc for pleurodesis in malignant pleural effusion is safe, and not associated with the development of acute respiratory distress syndrome.
Abstract: GOALS OF WORK: The goal of the study was to evaluate the safety and efficacy of bedside pleurodesis with doxycycline using a short-term indwelling chest catheter for the palliative treatment of malignant effusions. MATERIALS AND METHODS: A prospective study of 36 rapid pleurodesis procedures in 34 patients with malignant pleural effusions was conducted over a 5-year period in a university hospital. A 12F chest catheter placement was facilitated utilizing the Seldinger percutaneous entry technique. Patients received 500 mg of intrapleural doxycycline combined in half of the cases with mepivacaine. We assessed success or failure of pleurodesis in addition to the frequency of complications and survival. MAIN RESULTS: Chest tubes were removed within 24 h in 69% and within 48 h in 94% of the patients. Complete success of pleurodesis was achieved in 17 (55%), partial success in eight (26%), and failure in six (19%) out of 31 evaluative procedures. Thus, the overall success rate of pleurodesis was 81%. Toxicity was mild and included pain (36%), fever (8%), and pneumothorax (6%). The median survival was 105 days. There was no relationship between instillation of intrapleural anesthetics and development of pain. CONCLUSIONS: Rapid pleurodesis with doxycycline, which can be accomplished within 24 to 48 h, is a valid option for the symptomatic treatment of malignant effusions. This technique can be used as a first-line procedure in the majority of cases, particularly if thoracoscopic facilities are not available.
Abstract: It was hypothesised that monitoring neutrophil and D-dimer (DD) levels into the pleural fluid, after talc instillation, could predict the outcome of pleurodesis. The current authors investigated a total of 168 patients with malignant pleural effusion, who were treated with talc poudrage. According to the outcome the patients were categorised into one of two groups, either successful or failed pleurodesis. In all cases, pleural fluid neutrophils and DDs were determined on serial measurements at 0, 3, 24 and 48 h after the procedure. The time course of these parameters was assessed in both groups and the time point at which they could better predict the outcome was further explored. Neutrophils rose rapidly after talc poudrage in both groups, reaching a plateau at 24 h, although in successful pleurodesis this response was significantly higher. DD dropped markedly at 24 h in the group with the successful outcome, but it did not show significant changes in the other group. A cut-off value of 61% for neutrophils and 61 mg.L-1 for the DD at 24 h yielded the best prognosis for successful pleurodesis. The current authors conclude that serial measurements of neutrophil and d-dimer values into the pleural fluid after talc poudrage could be used as predictors of the outcome of pleurodesis.
Abstract: OBJECTIVES: To investigate whether pleural levels of the soluble oncoprotein 185 HER-2 (sp185(HER-2)), individually or in combination with CEA and CA 15-3, were useful for the diagnosis of malignant effusions. DESIGN AND METHODS: Levels of CEA, CA 15-3, and sp185(HER-2) were measured in the pleural fluid from 135 malignant and 103 benign effusions. Thresholds of these tumor markers were chosen for a diagnostic specificity of >or=99%. RESULTS: Pleural sp185(HER-2) levels greater than 25 ng/mL were observed in 20% of breast and 10% of lung adenocarcinomas, and predicted a malignant effusion with a sensitivity of 7% and a likelihood ratio of 7.6. Combination of CEA and CA 15-3 resulted in 50% sensitivity, while adding sp185(HER-2) to this panel nonsignificantly increased sensitivity by 5% (P = 0.45). Only 1 patient with breast adenocarcinoma among 45 cytology-negative malignant effusions had sp185(HER-2) above the diagnostic cutoff point. CONCLUSION: Measurement of pleural fluid sp185(HER-2) has poor diagnostic performance in patients with malignant effusions.
Abstract: OBJECTIVE: Sarcoidosis is a multisystem granulomatous inflammatory disease of unknown etiology that mainly affects the lungs and lymph nodes. Bronchoalveolar lavage (BAL) is known to be useful in diagnosis of the disease but its value as a prognostic marker is unclear. The aim of this study was to assess whether there is a characteristic pattern in BAL cell counts according to radiographic stage and determine whether BAL offers information on disease course. PATIENTS AND METHODS: The study included 34 patients with untreated sarcoidosis. Data were collected on the following variables: age, sex, smoking habit, treatment type, radiographic stage, respiratory function, serological parameters, and BAL cell counts. The patients were classified into 3 groups according to functional and radiographic change at 12-month follow-up. RESULTS: No differences in age, sex, or smoking habit were found according to either radiographic stage or disease course. Although the proportion of lymphocytes in BAL fluid was higher in radiographic stage I than in stages II and III, the differences were not statistically significant. The differences in BAL cell counts between groups based on disease course were not statistically significant. CONCLUSIONS: No differences were found in the characteristics of BAL fluid according to radiographic stage. The differential cell count in BAL fluid does not appear to predict the course of sarcoidosis in the first 12 months.
Abstract: STUDY OBJECTIVE: The diagnostic value of tumor markers in pleural fluid is subject to debate. The aim of this study was to evaluate the diagnostic performance of several tumor markers in common use for detecting malignant pleural disease. DESIGN: Blinded comparison of four tumor markers in pleural fluid with a confirmatory diagnosis of malignancy by pleural cytology or thoracoscopic biopsy. SETTING: Two teaching hospitals in Spain. PATIENTS AND METHODS: A total of 416 patients (166 with definite malignant effusions, 77 with probable malignant effusions, and 173 with benign effusions) were enrolled. Among them, there were 42 patients recruited from one of the participant centers with thoracoscopic facilities, who had false-negative fluid cytology findings and malignancy confirmed by medical thoracoscopy. Tumor markers in pleural fluid were determined either by electrochemiluminescence immunoassay (carcinoembryonic antigen [CEA], carbohydrate antigen 15-3 [CA 15-3], cytokeratin 19 fragments [CYFRA 21-1]) or microparticle enzyme immunoassay (cancer antigen 125 [CA 125]) technologies. Cutoff points that yielded 100% specificity (ie, all patients with benign effusions had levels below this cutoff) were selected for each marker. RESULTS: Malignant pleural effusions (PEs) had higher levels of pleural fluid markers than did effusions due to benign conditions. At 100% specificity, a pleural CEA > 50 ng/mL, CA 125 > 2,800 U/mL, CA 15-3 > 75 U/mL, and CYFRA 21-1 > 175 ng/mL had 29%, 17%, 30%, and 22% overall sensitivities, respectively. The combination of the four tumor markers reached 54% sensitivity, whereas the combined use of the cytology and the tumor marker panel increased the diagnostic yield of the former by 18% (95% confidence interval, 13 to 23%). More than one third of cytology-negative malignant PEs could be identified by at least one marker of the panel. CONCLUSIONS: No single pleural fluid marker seems to be accurate enough as to be introduced in the routine workup of PE diagnosis. However, a tumor marker panel may represent a helpful adjunct to cytology in order to rule in malignancy as a probable diagnosis, thus guiding the selection of patients who might benefit from further invasive procedures.
Abstract: The incidence of malignant pleural effusions has been increasing over the last few decades (mainly due to the absolute increase in several types of cancers, especially those of lung and breast origin) and they account for up to 50% of the exudates in many clinical series. Although pleural malignancies are thought to present most frequently with a pleural effusion, several autopsy series, including the current one, found a pleural effusion present in little more than half of the cases of malignant pleural involvement (55% in this series). Thus, many pleural malignancies without effusion might pass unnoticed in clinical practice, especially in metastatic disease. Primary malignancies of the pleura (mesotheliomas) are associated with asbestos exposure in about two-thirds of cases, and they frequently present with chest pain, sometimes associated with a pleural effusion. Benign pleural plaques can coexist with malignant mesothelioma, and this association should be suspected when long-standing plaques change in shape or size over the years, and especially if chest pain develops in a previously asymptomatic patient. Metastatic pleural involvement is much more frequent than mesotheliomas, and its most frequent mechanism is the vascular spreading of tumour cells from distant organs to the lungs, and on to the visceral and parietal pleura. The visceral pleura was involved in up to 87% of the current metastatic cases, whereas the parietal zone in only 47% of the autopsy series. The diagnostic work-up lies in cytology, whose average yield is approximately 50%, and a biopsy technique (either by blind needle biopsy or thoracoscopy) is recommended when the effusion persists, for > 2 weeks, and the first cytology has been negative. Thoracoscopy has the additional advantage of allowing pleurodesis with talc poudrage if clear tumour lesions are found in the pleura. In cases of malignant effusion which are not sensitive to chemotherapy, pleurodesis is the treatment of choice for palliation of symptoms, and talc is the most effective agent. It can be used either in suspension ("slurry") or in dry aerosolized form ("talc poudrage"), but it seems that this last technique achieves the best effects. However, it requires thoracoscopy for a proper application, and this is its main drawback when that technique is not readily available.
Abstract: We performed a prospective study to determine the evolution of perfusion defects 6 months after pulmonary thromboembolism (PTE), to identify associated factors and to evaluate the incidence of subclinical recurrence. Seventy patients diagnosed of PTE were enrolled. Perfusion pulmonary scintiscans were performed 6 months after the acute PTE episode and the results were compared with initial defects. We looked for significant relations between several course profiles and factors such as age, sex, anticoagulation therapy and patient history. Defects revealed by the initial scintiscan remained the same 6 months later in 15 (21%), decreased in 35 (53%) and disappeared in 16 (23%) of the 70 patients. New defects were identified in 2 patients. A significant relation was found between a favorable outcome as shown by follow-up scintiscans and compliance with anticoagulation therapy (p = 0.0024). Other statistically significant relations were observed between favorable outcome and a history of surgical intervention during the acute episode (p = 0.004) and between unfavorable outcome and a history of venous thromboembolic disease (p = 0.004).
Abstract: Pleurodesis is intended to prevent the accumulation of fluid or air in the pleural space by creating symphysis between the visceral and parietal pleura. The main indications for this procedure are malignant effusions and pneumothorax. A reexpandable lung and reasonably long expected survival are criteria that must be met before pleurodesis is attempted in a patient with malignant pleural effusion. A low pleural fluid pH (less than 7.20) is a good predictor for both the presence of a trapped lung and short expected survival. Talc appears to be the sclerosing agent of choice in cases of cancer, whereas video-assisted thoracic surgery techniques are preferable for the treatment of pneumothorax, especially in young patients. To improve results and prevent complications, application of the right technique is crucial, especially with regard to size of drainage and rate of suction. In addition, recent research suggests that prevention of a systemic activation of coagulation with prophylactic heparin should be taken into account in patients who are undergoing pleurodesis for palliative treatment of malignant effusion.
Abstract: Pleurodesis aims to achieve a symphysis between parietal and visceral pleural surfaces, in order to prevent accumulation of fluid or air in the pleural space. Its major indications are malignant effusions and pneumothorax, and a re-expandable lung is essential for the success of the technique. Moreover, expectation of a reasonably long survival is important before attempting pleurodesis. A successful lung re-expansion is unlikely if the pleural pressure falls more than 20 cmH2O x L(-1) of fluid removed, because there is a central bronchial obstruction or the lung is trapped by tumour and/or fibrin. Pleural fluid pH (<7.20) is a good indicator of the presence of trapped lung; moreover, a successful pleurodesis is less likely when pH is low, and this parameter is also a good predictor for survival of the patients. Among the many sclerosing agents that have been used for pleurodesis, talc has achieved the best results, with an average success rate of approximately 90%. The cellular and biochemical mechanisms involved in pleurodesis may be specific to the agent used, however, they may all follow a common final pathway leading to activation of the pleural coagulation cascade, the appearance of fibrin networks, and the proliferation of fibroblasts. The details of these mechanisms are still unclear and need to be further elaborated.
Abstract: Bronchoalveolar lavage (BAL) samples used to study immune or inflammatory response in interstitial lung disease must be representative of the lower respiratory tract. Thus, the selection of suitable samples must be part of routine practice. To assess the incidence of unsuitable BAL samples used for cytology and to determine the relation between parameters related to underlying disease and the quality of samples. One hundred sixty-one patients were enrolled. Seventy-two were HIV positive and had diffuse pulmonary infiltrates, 34 had idiopathic pulmonary fibrosis (IPF), 10 had sarcoidosis, 10 had hypersensitivity pneumonitis, 19 had interstitial lung disease and collagen diseases and 2 had pulmonary eosinophilia. Fourteen individuals formed the control group. The quality study was carried out by staining the BAL samples following a modified Wright-Giemsa technique and evaluating the samples by the selection criteria described by Chamberlain and colleagues (1987). We identified unsuitable samples from 53% of the HIV positive patients, from 35% of the IPF patients and from 21% of the interstitial lung disease patients with associated connective tissue disease. In the other groups, all samples were suitable for analysis. Intolerance of BAL with decreasing percentage of fluid recovered was significantly associated with sample quality, particularly in the IPF group. The cytology results that invalidated the samples differed by group. In all groups, unsuitable specimens had low cell counts. The finding or not of evidence of associated infection in HIV-infected patients, on the other hand, did not appear to determine sample quality in and of itself, although it did in samples related to other entities. We can predict that a high rate of unsuitable BAL samples will come mainly from patients with diffuse lung disease associated to HIV infection, IPF and interstitial lung disease with associated connective tissue disease. Tolerance to the technique influences quality of the specimen obtained and, therefore, should be taken into account in interpreting the findings of cytology. The criteria applied by the various teams using BAL should be unified, and it should be determined whether the exclusion of inappropriate samples affects the final composition of study groups.
Abstract: The main causes of pleural fluid drainage failure are known to be the formation of fibrin septa, increased viscosity in pleural fluid and inappropriate placement of chest tubes. Reports also tell us that such problems can be solved by using ultrasound as a guide for tube placement and by infusing intrapleural fibrinolytic agents to prevent the formation of septa and reduce the viscosity of pleural fluid. To assess our experience, the role and efficacy of administering intercavitary urokinase (UK) through a small caliber catheter (SCC) implanted with ultrasound guidance as part of the treatment for pleural effusions (PE) that are multiloculated and/or loculated. Fifty multiloculated and/or loculated PE were drained through a pig-tail type SCC between 8.2 and 10 F caliber inserted with ultrasound guidance. The criteria for prescribing the procedure were as follows: PE of any etiology with ultrasound confirmation of fibrin septa and/or multiloculation and absence of contraindication off UK administration. UK was given at a dose of 100,000 i.u. every two hours until disappearance of PE. Before and after treatment the levels of D-dimer were measured in order to monitor pleural fibrinolytic activity. The SCC was properly placed in all patients. UK administration was 366,000 i.u. and time the SCC were in place was 4.7 days. All PEs were initially drained completely. We examined the patients 30 days later, finding that PE had recurred in 2 (4%), resolution was complete and without sequelae in 8 (16%), nearly complete but with slight pleural thickening in 32 (64%) and partial with pleural opacities larger than 2 mm in 8 (16%). Use of SCC and UK (pleural fibrinolysis) is a moderately invasive procedure that is effective and well tolerated and that shortens drainage time, prevents sequelae and is relatively inexpensive for the treatment of PE with fibrin septation and/or multiloculation.
Abstract: Lung cancer presenting with ipsilateral pleural effusion is considered to have a poor prognosis. Thoracoscopy has been invoked as a useful tool for staging those cases before proceeding to thoracotomy, especially in patients with large pleural effusions. In cases where there is only a small effusion or no effusion at all, direct thoracotomy would be the choice, with pleural lavage during the operation and immediate cytology investigation. We performed thoracoscopy in 76 patients with lung cancer and ipsilateral pleural effusion (55 cytologically positive and the remaining negative), and we found only five cases with potentially resectable tumor. They were submitted to thoracotomy and resection could be accomplished in none of them, due to direct mediastinal tumor invasion. On the other hand, we found visceral pleura involvement without effusion in 31 out of 167 patients submitted to thoracotomy for lung cancer in our Institution. The tumor could be resected in all but one of these cases. Talc pleurodesis was performed in all patients who were found to have pleural effusion and non-resectable tumor at thoracoscopy, and we obtained a 68% success rate in cases with no trapped lung, as opposed to 56% in patients with trapped lung (massively covered by fibrin and/or tumor). Pleural fluid glucose and pH are good predictors of the outcome of pleurodesis.
Abstract: Diffuse pleural inflammation and fibrin deposition following the instillation of the sclerosing agent is considered necessary for a successful pleural symphysis. We hypothesized that an impairment in fibrin formation or an increased endopleural fibrinolysis would lead to failure of pleurodesis. To investigate changes in the pleural coagulation/fibrinolysis balance, we studied 75 consecutive patients who underwent thoracoscopy. Fifty-four of these patients with malignant pleural effusions and four with a benign recurrent effusion underwent thoracoscopic talc pleurodesis. Another four patients with malignancy and 13 with benign effusions had no talc poudrage performed and were included as a control group. Serial determinations of thrombin-antithrombin III complex (TAT), plasminogen activator inhibitor (PAI), and D-dimer were made in pleural fluid samples taken at the beginning of thoracoscopy (baseline), immediately after thoracoscopic biopsies had been done (postbiopsy), 3 h after thoracoscopy--either with talc poudrage or without--and 24 and 48 h after the procedure, as well as in cases of recurrence of effusions (farline). Successful pleurodesis was obtained in 42 of 52 patients who could be evaluated (81%), and failure was seen in 10. Strong activation of coagulation and production of PAI was observed in all groups, including the control (no talc) group. Fibrinolytic activity (as expressed by D-dimer levels) showed a clear decline 24 h after talc poudrage in patients with a good outcome of pleurodesis, as oppossed to those with bad results and to the control group, and returned to the baseline by 15 d. We conclude that increased pleural fibrinolytic activity is associated with failure of pleurodesis, despite significant inhibitory activity of PAI in all groups.
Abstract: We studied 104 patients with pleural effusion. All underwent thoracoscopic exploration to allow direct examination of any pleural lesions present. At the same time pleural biopsies for histopathologic study and samples of pleural fluid for cytopathologic and cytogenetic study were taken. The volume of fluid in pleural cavity was also measured. The aims of the study were: a) to evaluate the sensitivity of cytogenetic analysis and cytopathology, both separately and together, and b) to look for a correlation between the sensitivity of these cell studies and the following thoracoscopic findings: tissue biopsy of pleural neoplasms, volume of pleural effusion and extension of neoplastic lesions in the pleural cavity. Seventeen of the pleural liquids studied were benign and 87 were neoplastic. Cytopathology was sensitive in 55% of the neoplastic cases and cytogenetic study was sensitive in 49%. Sensitivity rose to 74% when both techniques were applied. Cytogenetic study yielded a higher percentage of correct diagnoses in the group with hematologic neoplasia, whereas cytopathology was correct more often in cases of solid tumors, though these differences were not statistically significant. Use of both techniques resulted in correct diagnosis in 92% of patients with mesotheliomas. The number or correct diagnoses achieved with cytopathology tended to increase with size of macroscopic pleural lesion whereas cytogenetic study was more sensitive in patients with minimal or incipient pleural involvement. There were no statistically significant differences in sensitivity of cytopathology and cytogenetic analysis with regard to volume of pleural effusion.
Abstract: Posterior mediastinal tumors in young people are most often neurogenic. The presence of a meningocele has occasionally been described as causing mass in the region and cases reported have mainly been in patients with neurofibromatosis. We describe a patient with type I neurofibromatosis and intrathoracic meningocele.
Abstract: STUDY OBJECTIVE: To find out whether patients with different types of metastatic pleural carcinomas have significant differences in survival, as related to pleural fluid glucose and pH. A second objective was to evaluate the outcome of talc poudrage for pleurodesis. DESIGN: Cohort analytic prospective study; follow-up of patients from thoracoscopic diagnosis and evaluation to death. SETTING: Pulmonary department at a referral medical center. PATIENTS: One hundred twenty-five patients with metastatic pleural carcinoma diagnosed by thoracoscopy were evaluated prospectively. One patient was lost to follow-up. INTERVENTIONS: Thoracoscopy was performed in every patient, with talc pleurodesis performed at the end of each procedure. MEASUREMENTS AND RESULTS: On the same day as thoracoscopy or the previous day, glucose levels and pH of both the blood and pleural fluid were determined. The outcome of talc poudrage was that pleural effusions were controlled in 104 out of 119 patients (87 percent). Pleurodesis failed in 43 percent (6/14) of the patients with a pleural fluid pH lower than 7.20, as opposed to 9 percent (8/92) of failures in patients with a pH above this limit (p < 0.01). Average survival was as follows: nonsmall cell lung cancer (n = 40), 4.3 months (range, 1 to 15 months); small cell lung cancer (n = 8), 3.7 months (1 to 12 months); breast carcinoma (n = 30), 7.4 months (1 to 29 months); and ovarian carcinoma (n = 8), 9.4 months (1 to 29 months). There was a significant difference in survival between patients with breast carcinoma and patients with cancer not sensitive to chemotherapy (7.4 vs 4.7 months; p < 0.02), although the pleural tumor lesion rating was even greater in the first group. We found no significant differences between lung carcinomas and those from other origins. Patients with a low pleural fluid glucose level and low pH had significantly shorter survival than the group with high glucose and high pH levels (1.9 vs 5.7 months, respectively; p < 0.005). CONCLUSIONS: We confirmed our previous data demonstrating poor survival in patients with pleural effusions with low glucose and pH levels. The outcome of talc pleurodesis correlated to these same parameters. These results apply to all kinds of metastatic pleural carcinomas.
Abstract: To assess the validity of enlarged mediastinal nodes as markers of involvement for staging in non-small cell lung cancer, we studied the records of 167 consecutive patients who underwent thoracotomy for this disease in the last 4 yr in our center. Careful search for both hilar (N1) and ipsilateral mediastinal nodes (N2) was done in every case. All nodes found at thoracotomy (regardless of their size) were either removed or sampled and then sent to the pathology department for examination. We found enlarged nodes (larger than 10 mm) in 131 of the 167 patients included in the study (72%). Of these patients, 58 had enlarged nodes at the hilar level (presumably N1 disease, 38%), and 73 were considered as presumably N2 at thoracotomy, before pathologic examination (62%). Only 12 of 58 patients with presumably N1 disease had true neoplastic involvement at this level (21%), whereas there was true N2 disease in only 18 of 73 patients with enlarged mediastinal nodes (25%). The positive predictive value for N2 in epidermoid carcinoma was 23%, and it was even lower with adenocarcinoma (18%). We conclude that open surgery with careful sampling is the method of choice for evaluation of mediastinal nodes in non-small cell lung cancer if evidence of malignant involvement cannot be proven histologically before thoracotomy.
Abstract: STUDY OBJECTIVE: To determine the survival time of patients with pleural metastatic carcinoma diagnosed by thoracoscopy, as related to the pleural glucose and pH levels, and to the extension of pleural neoplastic lesions. DESIGN: Cohort analytic prospective study. Follow-up of the patients from diagnostic thoracoscopy to death (range: one to 29 months). SETTING: Referral Pneumology Service at a Tertiary Care Center. PATIENTS: Consecutive sample of 50 patients with pleural metastatic carcinoma diagnosed by thoracoscopy. Three patients were lost in the follow-up. INTERVENTIONS: Talc pleurodesis was performed after diagnosis and with the same technique in every case. MEASUREMENTS AND RESULTS: In all the cases, the extension of the tumorous lesions was determined by thoracoscopy (classified on a scale from 0 to 9) and the survival time was studied from the time that thoracoscopic diagnosis was made. On the same or the previous day as the exploration, blood and pleural fluid glucose levels as well as arterial and pleural pH and gas tensions were determined.
Abstract: In order to determine the diagnostic and prognostic significance of low pleural glucose and pH levels, we executed a prospective study of these parameters and cytologic yield in 77 cases of malignant pleural effusions diagnosed from 116 consecutive thoracoscopies. The extension of the neoplasms detected by thoracoscopy as well as the results of our attempts to carry out pleurodesis by talc were also studied. Pleural glucose levels were less than 60 mg/dl in 16 cases, and the cytologic yield was positive in 14 of these cases (87%). The glucose value rose above this level in 61 cases, and the cytology was positive in 30 cases (49%; p less than 0.006). A pH less than 7.30 was encountered in 18 cases and there were positive cytologic findings in 14 of these cases (78%). The pH was above 7.30 in 46 cases, and cytologic studies were positive in 22 cases (48%; p less than 0.03). There were ten cases in which both the glucose and pH levels were low, and the cytology was positive in 9 cases (90%), while there were 40 cases in which both the glucose and pH levels were high and cytologic yields of 20 of these cases were positive (50%; p less than 0.03). The extension of the lesions observed during thoracoscopy showed important differences as far as this related to the glucose levels (p less than 0.005), but this relationship as it concerned pH levels was even more significant (p less than 0.0002). The differences were also highly significant (p less than 0.003) when the glucose and pH were jointly considered.(ABSTRACT TRUNCATED AT 250 WORDS)
Abstract: Eight patients with obstructive sleep apnea syndrome were treated with continuous positive airways pressure by nasal route. The treatment was carried out in the hospital during the initial days. If the procedure was effective and the tolerance was good, the patients were discharged to continue with treatment at home. Polygraphic sleep recordings carried out 2-4 months after the beginning of therapy showed normalization of the structure and the phases of sleep, apnea and desaturation being virtually absent. After a mean follow up of 18 months the patients are asymptomatic. The treatment has been well tolerated and significant side effects have not developed.
Abstract: We examined the post-mortem records of 191 patients who had one or more malignant tumours (196 neoplasms in total). We found 55 cases with pleural metastases (28%) and 30 of these presented pleural effusions (15% of the total number of neoplasms). The visceral pleural was involved in all 24 cases of lung cancer with pleural metastasis and in 27 out of 31 of those of other origins. The parietal pleura was affected in 16 out of 24 cases of the lung tumours and in 15 out of 31 of those of other origins. There were no cases in which only the parietal layer of the pleura was involved, with the only exception of neighbouring tumours. We found neoplastic vascular invasion in 43 out of 55 cases, retrograde lymphatic spread from the mediastinum in two cases, and direct pleural involvement from a neighbouring tumour in the remaining. We conclude that malignant pleural implantation fundamentally arises from the spread of tumour emboli to the lungs and the visceral pleura, with secondary seedings to the parietal pleura. Therefore, this phenomenon leads to the usual finding of lower involvement of parietal pleura as compared to the visceral pleura in our series.
