Role of cancer ratio and other new parameters in the differential diagnosis of malignant pleural effusion

OBJECTIVES: We compared the diagnostic potential of cancer ratio (CR, serum lactate dehydrogenase [LDH]/pleural fluid adenosine deaminase [pfADA]), cancer ratio plus (CR plus, cancer ratio/pleural lymphocyte percentage), and age/pfADA ratio with pfADA in malignant pleural effusion. METHODS: Data from 100 patients with malignant pleural effusion (MPE) and 119 patients with tuberculous pleural effusion (TPE) were retrospectively collected. PfADA, age/pfADA ratio, CR, and CR plus were compared between patients with MPE and those with TPE in two age groups (≤50 and >50 years). The best cut-off value was determined, and the diagnostic performance was evaluated according to the receiver operating characteristic curve. RESULTS: PfADA was statistically significantly lower while age/pfADA ratio, CR, and CR plus were significantly higher in the MPE group than in the TPE group in both age groups (p<0.05). For patients aged ≤50 years, the differential diagnostic value of pfADA for MPE was better than those of age/pfADA ratio, CR, and CR plus. At a cut-off value of 13.0 U/L, the sensitivity, specificity, and accuracy were 88.9%, 100.0%, and 98.9%, respectively. For patients aged >50 years, the diagnostic performance of CR plus was superior to those of pfADA, age/pfADA ratio, and CR. At a cut-off value of 22.6, the sensitivity, specificity, and accuracy of CR plus for the diagnosis of MPE were 86.8%, 84.6%, and 86.2%, respectively. CONCLUSIONS: The best parameter for diagnosing MPE was different for patients aged ≤50 years and >50 years. For patients aged >50 years, CR plus was a good parameter for the differential diagnosis of MPE. For patients aged ≤50 years, pfADA was better.

Diagnóstico e tratamento dos derrames pleurais malignos / Diagnosis and treatment of malignant pleural effusions

Carcinomas brônquicos, com maior frequência os adenocarcinomas, linfomas e carcinoma de mama, constituem 75% das causas de derrame pleural maligno (DPM). Para utilização das diversas opções terapêuticas paliativas disponíveis deve ser considerada uma avaliação multidisciplinar do estado do paciente, em conjunto com a experiência do profissional médico assistente, a capacidade técnica da instituição onde o tratamento será realizado e o custo-benefício AU.

Lung cancer, more often adenocarcinomas, lymphomas and breast carcinoma, are 75.0% of the causes of malignant pleural effusion. Palliative therapeutic options should be considered a multidisciplinary assessment of the patient's condition, together with the experience of the physician assistant professional, technical capacity of the institution where the treatment will be carried out and cost-effective AU.

Aspectos diagnósticos y terapéuticos en el mesotelioma pleural maligno / Diagnostic and therapeutic aspects in malignant pleural mesothelioma

Para el diagnóstico de mesotelioma se requiere distinguir entre afectación mesotelial benigna y maligna, y entre mesotelioma maligno y carcinoma metastásico. Para ello son necesarias técnicas inmuno-histoquímicas realizadas sobre biopsias amplias. La toracoscopia es la técnica de elección, aunque la biopsia con aguja usando técnicas de imagen en tiempo real puede ser muy útil si hay marcado engrosamiento nodular. Es improbable que la cirugía radical (pleuroneumonectomía) sea realmente curativa, por lo que está ganando adeptos la reducción de masa tumoral mediante pleurectomía/decorticación, con asociación de quimioterapia y radioterapia a la cirugía (terapia multimodal). Cuando la resección no es factible se plantea quimioterapia, con pleurodesis o colocación de un catéter pleural tunelizado si se requiere el control del derrame pleural y se reserva la radioterapia para tratar la infiltración de la pared torácica. También es esencial un completo control del dolor (que adquiere particular protagonismo en esta neoplasia) en unidades especializadas.

Diagnosis of malignant pleural mesothelioma requires making the distinction between benign mesothelial hiperplasia and true mesothelioma, and between malignant mesothelioma and metastatic pleural adenocarcinoma. This involves immunohisto-chemical techniques applied on large biopsy specimens, and thoracoscopy is the best choice for obtaining them. Real-time image-guided needle biopsy can also be very helpful in presence of marked nodular pleural thickening. Radical surgery (ie, extrapleural pneumonectomy) is unlikely to cure completely the patient, and cyto-reduction surgery with preservation of the underlying lung (pleurectomy/decortication), with addition of chemo and radiation therapy (muiltimodal treatment) is gaining adepts in the last few years. When surgery is not feasible at all, early chemotherapy -with pleurodesis or placement of a indwelling pleural catheter (to control the effusion if necessary)- is advisable. Radiation therapy should be reserved to treat chest wall infiltration in those cases, and complete control of pain in specialized units is also essential in those patients.

Superoxide dismutase 2 as a marker to differentiate tuberculous pleural effusions from malignant pleural effusions

OBJECTIVES: Our previous study demonstrated that superoxide dismutase levels were higher in tuberculous pleural effusions than in malignant pleural effusions, but that this difference could not be used to discriminate between the two. The objective of the present study was to investigate the levels of superoxide dismutase 2 in pleural effusions and to evaluate the diagnostic significance of pleural effusion superoxide dismutase 2. METHODS: Superoxide dismutase 2 concentrations were determined in pleural effusions from 54 patients with tuberculous pleural effusion and 33 with malignant pleural effusion using an enzyme-linked immunosorbent assay (ELISA) kit. Pleural effusion interferon gamma and tumor necrosis factor alpha levels were also analyzed by ELISA. The Mann-Whitney U test was used to evaluate the significance of differences. Associations between superoxide dismutase 2 concentrations and sex, age and smoking habits were assessed using Spearman's or Pearson's correlation coefficient analysis. Receiver operator characteristic analysis was performed to evaluate the value of superoxide dismutase 2 levels in the discrimination of tuberculous pleural effusion from malignant pleural effusion. RESULTS: Superoxide dismutase 2 levels were significantly higher in patients with tuberculous pleural effusion compared with those with malignant pleural effusion ...

Diagnostic value of p16 methylation for malignant pleural effusion a meta-analysis / Valor diagnóstico de la metilación p16 en el derrame pleural maligno un meta-análisis

OBJECTIVE: To evaluate the overall diagnostic performance of the p16 methylation for diagnosing malignant pleural effusion (MPE). METHODS: All published literature in English and Chinese were reviewed. Sensitivity, specificity, likelihood ratio and diagnostic odds ratio (DOR) were pooled by using random-effects model or fixed-effects model. Summary receiver operating characteristic (SROC) curve was used to evaluate the overall diagnostic value. RESULTS: Six studies were included with a total of 378 cases. The sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR) and DOR of p16 methylation in the diagnosis of MPE were 0.41 [95% confidence interval (CI) 0.35, 0.48], 0.97 [95% CI 0.93, 0.99], 9.57 [95% CI 4.53, 20.20], 0.61 [95% CI 0.45, 0.82] and 19.82 [95% CI 8.35, 47.04], respectively. The area under the curve (AUC) was 0.864. CONCLUSION: Pleural p16 methylation test plays a useful role in the diagnosis of MPE.

OBJETIVO: Evaluar el rendimiento diagnóstico general de la metilación p16 para el diagnóstico del derrame pleural maligno (DPM). MÉTODOS: Se revisó toda la literatura publicada en inglés y chino. La sensibilidad, especificidad, razón de verosimilitud, y el odds-ratio diagnóstico (DOR) fueron agrupados mediante el modelo de efectos aleatorios o el modelo de efectos. La curva de las características operativas de resumen del receptor (SROC) fue usada para evaluar el valor diagnóstico general. RESULTADOS: Se incluyeron seis estudios con un total de 378 casos. La sensibilidad, especificidad, razón de verosimilitud positiva (PLR), razón de verosimilitud negativa (NLR) y el DOR de la metilación p16 en el diagnóstico de DPM, fueron 0.41 [95% intervalo de confianza (IC) 0.35 0.48], 0.97 [95% IC 0.93, 0.99], 9.57 [95% IC 4.53, 20.20], [95% IC 0.45, 0.82] 0.61 y 19.82 [95% IC 8.35, 47.04], respectivamente. El área bajo la curva (AUC) fue 0.864. CONCLUSIÓN: La prueba de metilación p16 pleural desempeña un papel útil en el diagnóstico del DPM.

Taponamiento cardiaco como primera manifestación de una neoplasia de pulmón / Cardiac tamponade as first manifestation of a lung neoplasm

INTRODUCCIÓN: En el taponamiento cardiaco existe restricción del llenado del corazón debido a un incremento de la presión de la cavidad pericárdica secundario a derrame pericárdico. Este aumento puede alcanzar valores que lleguen a superar las presiones fisiológicas de las cavidades derechas, comprometiendo así el llene de éstas, afectando secundariamente la precarga del ventrículo izquierdo. PRESENTACIÓN DEL CASO: Paciente de 52 años, sexo masculino, con antecedentes de tabaquismo y diabetes mellitus tipo 2, que consultó al servicio de urgencias del centro asistencial Víctor Ríos Ruiz de Los Ángeles por cuadro caracterizado por dolor cólico epigástrico, asociado a nauseas, vómitos, distensión abdominal, coluria, oliguria, anorexia, constipación, astenia, adinamia y malestar general. Es hospitalizado en el servicio de cirugía por sospecha de colecistitis aguda, se realiza ecografía abdominal donde se pesquizó líquido libre perihepático y periesplénico, y aumento del calibre de la vena cava inferior con derrame pleural bilateral. Comenzó con hipotensión, pulso paradojal e ingurgitación yugular, por lo que es trasladado a UCI donde la ecocardiografía confirmó taponamiento cardiaco. Se realizó pericardiocentésis y estudio del líquido, que muestra células de aspecto neoplásico. Se realizó tomografía axial computarizada (TAC) encontrándose lesión sólida en lóbulo pulmonar inferior izquierdo, nódulo en lóbulo medio y múltiples adenopatías mediastínicas e hiliares bilaterales. DISCUSIÓN: El derrame pericárdico maligno suele presentarse como taponamiento cardiaco, siendo la causa más frecuente el cáncer de pulmón. El pronóstico de un derrame pericárdico en contexto de cáncer pulmonar es más bien ominoso, llegando a ser menor a los 3 meses de vida.

INTRODUCTION: In cardiac tamponade, there is a filling restriction of the heart due to increased pressure of the pericardial cavity secondary to pericardial effusion. Pressure can reach values greater than that of the right heart cavities, compromising their filling, and, secondarily, affecting the preload of the left ventricle. CASE REPORT: A 52-year old male, with type 2 diabetes mellitus, consulted to the emergency department of Víctor Ríos Ruiz Hospital of Los Angeles, Chile for epigastric colic pain, nausea, vomiting, abdominal distention, choluria, oliguria, anorexia, constipation, asthenia, adynamia and malaise. He is admitted to the surgery ward on the suspicion of acute cholecystitis. Abdominal ultrasound showed perihepatic and perisplenic free fluid and increased caliber of the inferior vena cava, associated with bilateral pleural effusion. Hypotension, paradoxical pulse and jugular engorgement developed, so he is transferred to the ICU where echocardiography confirmed cardiac tamponade. Pericardiocentesis was performed, which showed malignant cells on microscopy. A computerized tomography (CT scan) showed a solid mass in the left inferior lung lobe, a nodule in the middle lobe and multiple mediastinal and hiliar bilateral lymphoadenopaties. DISCUSSION: Malignant pericardial effusion commonly presents as cardiac tamponade, being the lung cancer its main etiology. The prognosis of pericardial effusion in lung cancer is rather ominous, with an overall survival of less than 3 months.

Diagnostic Value and Prognostic Significance of Pleural C-Reactive Protein in Lung Cancer Patients with Malignant Pleural Effusions

PURPOSE: C-reactive protein (CRP) has been implicated in various inflammatory and advanced malignant states. Increased serum CRP (s-CRP) levels have been shown to be associated with independent prognostic factors for survival in patients with advanced lung cancer. However, only few studies have focused on the role of CRP in pleural effusions. This study aimed to evaluate the diagnostic and prognostic value of pleural CRP (p-CRP) in lung cancer patients with malignant pleural effusion (MPE). MATERIALS AND METHODS: Pleural effusion (PE) samples were collected from patients with MPE (68 lung cancers; 12 extrathoracic tumors), and from 68 patients with various benign conditions (31 with pneumonia; 37 with tuberculosis). Concentrations of p- and s-CRP were measured by enzyme-linked immunosorbent assay. CRP level in pleural fluid and its association with survival were examined. RESULTS: p-CRP levels correlated with s-CRP levels (r=0.82, p<0.0001). For the differential diagnosis of MPE and benign PE, the area under the receiver operating characteristic curve was greater for p-CRP (0.86) than for s-CRP (0.77). High p-CRP expression significantly correlated with shorter overall survival (p=0.006). P-CRP was independent prognostic factor significantly associated with overall survival on multivariated analysis (p=0.0001). The relative risk of death for lung cancer patients with high p-CRP levels was 3.909 (95% confidence interval, 2.000-7.639). CONCLUSION: P-CRP is superior to s-CRP in determining pleural fluid etiology. Quantitative measurement of p-CRP might be a useful complementary diagnostic and prognostic test for lung cancer patients with MPE.

Association between Elevated Pleural Interleukin-33 Levels and Tuberculous Pleurisy

BACKGROUND: Interferon-gamma (IFN-gamma) plays a crucial role in Mycobacterium tuberculosis induced pleural responses. Interleukin (IL)-33 up-regulates the production of IFN-gamma. We aimed to identify whether an association between pleural IL-33 levels and tuberculous pleurisy exists and determine its diagnostic value. METHODS: Pleural IL-33, ST2 (a receptor of IL-33), adenosine deaminase (ADA), and IFN-gamma, as well as serum IL-33 and ST2 were measured in 220 patients with pleural effusions (PEs). Patients with malignant (MPEs), parapneumonic (PPEs), tuberculous (TPEs), and cardiogenic (CPEs) pleural effusions were included. RESULTS: Pleural and serum IL-33 levels were highest or tended to be higher in patients with TPEs than in those with other types of PEs. The median pleural fluid-to-serum IL-33 ratio was higher in TPE cases (> or = 0.91) than in other PE cases (< or = 0.56). Pleural IL-33 levels correlated with those of pleural ADA and IFN-gamma. However, the diagnostic accuracies of pleural IL-33 (0.74) and pleural fluid-to-serum IL-33 ratio (0.75) were lower than that of ADA (0.95) or IFN-gamma (0.97). Pleural ST2 levels in patients with MPEs were higher than in patients with TPEs. Serum ST2 levels did not differ among the groups. CONCLUSIONS: We identified an association between elevated pleural IL-33 levels and tuberculous pleurisy. However, we recommend conventional pleural markers (ADA or IFN-gamma) as diagnostic markers of TPE.

utility of survivin mRNA as a diagnostic biomarker in lung cancer with malignant pleural effusion

The sensitivity of conventional cytology for the detection of malignant cells in pleural effusion is insufficient. Since survivin is frequently overexpressed in lung cancer, it might play a role in oncogenesis and progression of the tumor. To evaluate diagnostic value of survivin mRNA expression in lung cancer with pleural effusion. Sixty-five pleural fluid specimens were collected from lung cancer patients [group I]. Twenty benign pleural fluid specimens were also collected [group II], considered to be control group, and this group was classified into transudate and exudate according to Light's criteria. Real time Polymerase chain reaction [RT-PCR] was performed to detect the survivin mRNA expression in the pleural fluid specimens. The sensitivity, specificity and accuracy were calculated by using receiver operating characteristic [ROC] analysis. Sixty-five pleural fluid specimens from lung cancer patients were tested by RT-PCR, only 30/65 [46%] had positive cytology. The positive rate of survivin mRNA expression in maligant pleural effusion [63/65; 95.38%] was much higher than that in the pleural effusion with benign disease [4/20; 20%, P < 0.01]. Twenty-seven cancer patients were negative for cytology and 24/27 were positive for survivin mRNA expression. The sensitivity, specificity and accuracy of survivin were 89.5%, 50%, 73.1% for diagnosing malignant pleural effusion. The detection of survivin by RT-PCR seems to be a promising assay to diagnose malignant pleural effusions, using the appropriate cut-off point, survivin mRNA has a significant role in differentiating benign from malignant pleural effusion

Chemical pleurodesis for malignant pleural effusion

Malignant pleural effusion is a common complication of primary and metastatic pleural malignancies. It is usually managed by drainage and pleurodesis, but there is no consensus as to the best method of pleurodesis, this study was designed to compare the effectiveness, side effects, and cost of different chemical pleurodesis agents used in patients with malignant pleural effusion. Seventy-five patients with malignant pleural effusion were assigned into five groups each of 15 patients, Talc slurry 5 gm, Tetracycline500 mg, Bleomycin1 IU/kg, Iodopovidone [2%] and patients underwent tube drainage only. Tube thoracotomy was performed in all patients and agents were administered through the chest tubes. Tetracycline, talc slurry, iodopovidone andbleomycin, resulted inan insignificantly different success rates of 80%, 80%, 66.6%.73.3%, at 30 days and, 66.6%, 73.3%, 60%, 66.6%, at 60 days respectively while tube alone was much lower, 40% and 26.7% respectively. Chest tubes were removed after an average of 7.2 +/- 1.4 days for tetracycline, 7 +/- 0.8 days for talc slurry, 7.6 +/- 0.9 days for iodopovidone and 6.4 +/- 1.5 days for bleomycin which did not differ significantly. Chest pain was more common in the tetracycline group, dyspnea was more common in the talc group, and fever was more common in the iodopovidone group. Since tetracycline, talc slurry, iodopovidone, andbleomycin achieved comparable success rates in this study, we suggest that the drug availability and cost are important factors in choosing a sclerosing agent in developing countries

Videotoracoscopía en cáncer de ovario avanzado con sospecha de compromiso torácico / Video-assisted thoracoscopy in advanced ovarian cancer with a probable thoracic involvement

Objetivo: Evaluar la experiencia con videotoracoscopía en pacientes con sospecha de cáncer de ovario avanzado con probable compromiso del tórax. Método: Se analiza las pacientes con sospecha clínica e imagenológica de cáncer de ovario avanzado que presentan derrames pleurales moderado y severo, así como procesos tumorales torácicos para evaluar la posibilidad de citorreducción óptima o completa. Todos los casos sometidos a este procedimiento entre enero de 2009 a Agosto de 2011, son analizados con énfasis en el diagnóstico y en los hallazgos a la videotoracoscopía, así como sus resultados. Resultados: 11 pacientes con clínica y tomografía axial computarizada de tórax sospechoso de compromiso pleural o pulmonar, son sometidas al procedimiento previo al intento de citorreducción abdominopélvica. La edad promedio fue de 62 años y Ca 125 promedio de 1030 U/ml. En 6 pacientes se encontró enfermedad macroscópica pleural, la biopsia fue positiva para adenocarcinoma en 5. Dos de ellas se consideraron no citorreducible en abdomen y se indicó neoadyuvancia. La tercera se citorredujo en forma óptima. En 2 pacientes se indicó neoadyudancia por tener residuo tumoral torácico mayor a 1 cm, consideradas citorreducibles en abdomen. De las 6 pacientes sin enfermedad torácica, 4 se citorredujeron óptimamente, una falleció previo a la cirugía abdominal y otra resultó un tumor ovárico benigno. Conclusión: La videotoracoscopía es útil para evaluar enfermedad torácica y tomar decisiones en relación a la citorreducción abdominal o neoadyuvancia en cáncer avanzado de ovario.

Objective: To describe the experience with video-assisted thoracic evaluation in patients with suspected advanced ovarian cancer with a probable thoracic involvement. Method: Patients with clinical and imaging suspicion of advanced ovarian cancer who have pleural effusions, and thoracic tumor processes are examined to evaluate the possibility of optimal debulking. All cases that underwent this procedure between January 2009 to August 2011, were studied with emphasis on diagnosis, results and findings at videotho-racoscopy. Results: 11 patients with a suspected thoracic commitment, with clinical and computerized axial tomography scan, undergo the procedure previous to an abdominopelvic cytoreductive surgery attempt. The average age was 62 years and CA 125 of 1030 U/ml average. Macroscopic pleural disease was found in 6 patients, but in 5 of them the biopsy gave positive for adenocarcinoma. Two of them were not considered for a cytoreductive surgery in the abdomen and neoadjuvant therapy was indicated. The third patient of the 5 previously mentioned, underwent an optimal cytoreduction. In 2 patients, neoadjuvant therapy was indicated for having residual tumor in the thorax greater than 1 cm, although they were considered for a cytoreductive surgery in the abdomen. Of the 6 patients without chest involvement, 4 underwent an optimal cytoreductive surgery, and one died before the abdominal surgery and the other had a benign ovarian tumor. Conclusion: Videothoracoscopy is useful for diagnosing thoracic metastasis and making decisions regarding cytoreduction and neoadjuvant therapy in advanced ovarian cancer.

Myelomatous Pleural Effusion: A Case Series in a Single Institution and Literature Review / 대한진단검사의학회지

BACKGROUND: Myelomatous pleural effusion (MPE) is rare in myeloma patients. We present a consecutive series of patients with MPE in a single institution. METHODS: We retrospectively reviewed the medical records of 19 patients diagnosed with MPE between 1989 and 2008 at the Asan Medical Center. Diagnoses were confirmed by cytologic identification of malignant plasma cells in the pleural fluid. RESULTS: Our patients showed dominance of IgA (36.8%) and IgD (31.6%) subtypes. Of 734 myeloma patients, the incidence of MPE was remarkably high for the IgD myeloma subtype (16.7%), compared to the other subtypes (1.4% for IgG and 4.6% for IgA). At the time of diagnosis of MPE, elevated serum beta2-microglobulin, anemia, elevated serum lactate dehydrogenase, and elevated creatinine levels were found in 100%, 89.5%, 83.3%, and 57.9% of the patients, respectively. Approximately one-third (31.3%) of the patients had adenosine deaminase (ADA) activities in their pleural fluid exceeding the upper limit of the reported cutoff values for tuberculous pleural effusion (55.8 U/L). Chromosome 13 abnormality was seen in 77.8% of the tested patients. The median survival period from the development of MPE was 2.8 months. CONCLUSIONS: Patients with MPE have aggressive clinical and laboratory characteristics. The preponderance of IgD myeloma in MPE patients is a noteworthy finding because IgD myeloma is a rare subtype. Elevated ADA activity in the pleural fluid is also noteworthy, and may be helpful for detecting MPE. Physicians treating myeloma patients should monitor the development of MPE and consider the possibility of a worse clinical course.

Reactive oxygen metabolites can be used to differentiate malignant and non-malignant pleural efffusions

Increase in reactive oxygen metabolites [ROM] and free radicals is an important cause of cell injury. In this study, we investigated whether determination of ROM in pleural fluids of patients with malignant and non-malignant pleural effusions can be used as a tumor marker indicating malignant effusions in the differential diagnosis. Sixty subjects with exudative pleural effusion and 25 healthy individuals as the control group were included in the study. Of the subjects with pleural effusion, 50% were malignant and 50% were non-malignant. ROM was studied in the pleural fluids and sera of the subjects with pleural effusion and in the sera of those in the control group. The ROM values of smokers and non-smokers were compared in each group. The Student's t-test and the Mann-Whitney U test were used in order to detect differences between groups for descriptive statistics in terms of pointed features. The statistical significance level was set at 5% in computations, and the computations were made using the SPSS [ver.13] statistical package program. It was determined that the difference between the ROM values of subjects with malignant and non-malignant pleural effusions and the sera of the control group was significant in the malignant group compared to both groups [P=0.0001], and the sera ROM values of patients with non-malignant pleural effusion were significant compared to the control group [P=0.0001], and the ROM values of smokers were significant compared to non-smokers in each of the three groups [P=0.0001]. These findings indicate that sera ROM levels are increased considerably in patients with exudative effusions compared to that of the control group. This condition can be instructive in terms of serum ROM value being suggestive of exudative effusion in patients with effusions. Furthermore, the detection of pleural ROM values being significantly higher in subjects with malignant pleural effusions compared to non-malignant subjects suggests that ROM can be used as a tumor marker in the differential diagnosis of pleural effusions of unknown origin

Derrame pleural incomum: metástase pleuropulmonar de tumor neuroectodérmico primitivo / Uncommon pleural effusion: pleuropulmonary metastasis from primitive neuroectodermal tumor

O tumor neuroectodérmico primitivo é uma neoplasia com diferenciação neural de comportamento invasivo que origina metástases para diversos órgãos. Relatamos um caso de tumor neuroectodérmico primitivo primário em axila com metástases para pulmão, pleura, osso, músculo ilíaco e medula óssea. Enfatizamos o achado incomum da análise citológica do líquido pleural.

Primitive neuroectodermal tumor is an invasive neoplasm with neuronal differentiation, which frequently results in metastasis in various organs. We report the case of a patient with primitive neuroectodermal tumor whose primary site was the axilla. The patient presented with metastases in the lung, pleura, bone, iliac muscle and bone marrow. We highlight the uncommon finding in the pleural fluid cytology.

Valor de la videotoracoscopia en el derrame pleural maligno / Value of video-assisted throracoscopy in the malignant pleural effusion

La videotoracoscopia es una herramienta útil para el tratamiento de múltiples enfermedades torácicas, entre ellas, del derrame pleural maligno cuando otras modalidades de tratamiento han fallado en el control del derrame. Fue objetivo del presente estudio evaluar en nuestro servicio la utilidad de la videotoracoscopia para el tratamiento, mediante pleurodesis con talco, de pacientes con derrame pleural maligno. Se realizó un estudio retrospectivo, sobre una base de datos prospectiva, que comprendió a 45 pacientes consecutivos a quienes se practicó videotoracoscopia para diagnóstico o tratamiento de un derrame pleural maligno. Los pacientes fueron tratados entre enero de 1995 y julio de 2005. Las variables estudiadas fueron sexo, edad, origen del tumor primario, complicaciones y mortalidad, y el interés fundamental fue determinar el porcentaje de recaídas a los 30 días después de aplicado el procedimiento. Al sexo masculino correspondieron 24 pacientes (53,3 por ciento) y 21 (46,7 por ciento) al femenino. Las enfermedades primarias que predominaron fueron el cáncer pulmonar (48,9 por ciento) y el mamario (31,1 por ciento). La mayoría de los pacientes tenía entre 51 y 70 años de edad. En todos los casos excepto uno, el método se consideró útil, pues se logró retirar la sonda de drenaje torácico sin que reapareciera el derrame al mes de la intervención. Las complicaciones más frecuentes fueron fiebre posoperatoria (7) y empiema (2). Un paciente falleció a causa de insuficiencia respiratoria. La videotoracoscopia fue una herramienta útil para el tratamiento, mediante pleurodesis con talco, de los pacientes con derrame pleural maligno. No hubo recidiva del derrame a los 30 días de la intervención.

Video-assisted thoracoscopy is a useful tool to treat multiple thoracic diseases, such as the malignant pleural effusion when the other treatment modalities have failed in the control of the effusion. It was the objective of this study to evaluate the usefulness of the video-assisted thoracoscopy by talc pleurodesis among patients with malignant pleural effusion. in our service. A retrospective prospective study that included 45 consecutive patients who underwent video-assisted thoracoscopy for the diagnosis or treatment of a malignant pleural effusion. was carried out. The patients were treated between January 1995 and July 2005. The studied variables were sex, age, origin of the primary tumor, complications, mortality and the fundamental interest to determine the percentage of relapses 30 days after the application of the procedure. 24 patients were males (53.3 percent) and 21 were females (46.7 percent). The predominating diseases were lung (48.9 percent) and breast cancer (31.1 percent). Most of the patients were 51-70. In all the cases, excepting one, the method was considered useful, since the thoracic drainage stent was removed, and a month after surgery the effusion did not reappear. The most frequent complications were postoperative fever (7) and empyema (2). A patient died due to respiratory failure. Video-assisted thoracoscopy was a useful tool for treating patients with malignant pleural effusion by talc pleurodesis. No relapse of the effusion was observed 30 days after surgery.

Avaliação dos valores sérico e pleural dos marcadores tumorais CEA, CYFRA21-1 e CA 15-3 em portadores de derrame pleural / Evaluation of serum and pleural levels of the tumor markers CEA, CYFRA21-1 and CA 15-3 in patients with pleural effusion

OBJETIVO: Dosar os marcadores tumorais antígeno carcinoembrionário (CEA), fragmento da citoqueratina 19 (CYFRA21-1) e antígeno glicosídico associado a tumor 15-3 (CA 15-3) em sangue e líquido pleural de portadores de derrames pleurais benignos e malignos, avaliando a sensibilidade de cada um deles nesses fluidos. MÉTODOS: Avaliamos prospectivamente 85 pacientes com derrame pleural. O estudo do líquido pleural obedeceu a critérios determinados pela literatura. A dosagem dos marcadores foi realizada por eletroquimioluminescência. A sensibilidade foi determinada sob a condição de que a especificidade fosse > 90 por cento. RESULTADOS: Foram diagnosticados 36 casos malignos (42,4 por cento), 30 benignos (35,3 por cento); em 19 pacientes (22,3 por cento), o diagnóstico foi inconclusivo. Nos casos malignos, os valores de CEA e CYFRA21-1 foram maiores no líquido pleural do que no sangue, fato não observado para o CA 15-3. Nos casos benignos, os valores do CYFRA21-1 foram maiores no líquido pleural do que no soro, enquanto que para o CEA e o CA 15-3, ocorreu o oposto. Todos os marcadores apresentaram diferença significativa entre os casos malignos e benignos, em líquido pleural e soro. Foi encontrada sensibilidade para CEA, CYFRA21-1 e CA 15-3 no líquido pleural de 69,4 por cento, 69,4 por cento e 66,7 por cento, respectivamente e quando associados, foi 80,6 por cento. No soro, a sensibilidade foi 57,1, 71,4 e 48,6 por cento para CEA, CYFRA21-1 e CA 15-3, respectivamente, e quando associados, foi 77 por cento. CONCLUSÃO: Os resultados sugerem que a utilização desses marcadores pode ser útil na diferenciação entre derrames pleurais malignos e benignos.

OBJECTIVE: To determine the levels of the tumor markers carcinoembryonic antigen (CEA), cytokeratin 19 fragment (CYFRA21-1) and carbohydrate antigen 15-3 (CA 15-3) in the blood and pleural fluid of patients with benign or malignant pleural effusion, evaluating the sensitivity of each marker in these fluids. METHODS: We prospectively evaluated 85 patients with pleural effusion. The study of the pleural fluid observed the criteria established in the literature. Levels of the markers were determined using electrochemiluminescence. The sensitivity was determined on the condition that the specificity was > 90 percent. RESULTS: Of the 85 cases, 36 (42.4 percent) were malignant, 30 (35.3 percent) were benign, and the results were inconclusive in 19 (22.3 percent). In the malignant cases, the CEA and CYFRA21-1 levels were higher in the pleural fluid than in the blood, which was not observed for CA 15-3. In the benign cases, the CYFRA21-1 levels were higher in the pleural fluid than in the blood, whereas the opposite was found for CEA and CA 15-3. There were significant differences between malignant and benign cases for all markers, in pleural fluid and blood. In the pleural fluid, the sensitivity of CEA, CYFRA21-1 and CA 15-3 was 69.4, 69.4 and 66.7 percent, respectively, and the combined sensitivity was 80.6 percent. In the blood, the sensitivity was 57.1 percent, 71.4 percent and 48.6 percent for CEA, CYFRA21-1 and CA 15-3, respectively, and the combined sensitivity was 77 percent. CONCLUSION: The results suggest that these markers might be useful in the differentiation between malignant and benign pleural effusion.

Derrame pleural maligno: abordagem individualizada conforme apresentação clínica / Malignant pleural effusion: individual management according to clinical presentation

Os pacientes com derrame pleural maligno (DPM) têm neoplasias em fase avançada com mau prognóstico e baixa resposta a tratamento sistêmico. Devido à curta expectativa de vida e ao controle muitas vezes ineficaz pela quimioterapia, quando se apresentam muito sintomáticos alguma terapêutica paliativa efetiva é necessária para oferecer conforto e qualidadede vida a estes pacientes. Porém, visto a grande variedade de apresentações clínicas, a terapêutica ideal não deve ser generalizada para todos os pacientes com DPM, como é pode ser observado em muitos ensaios clínicos sobre o assunto. Esta deve ser individualizada considerando principalmente a performance status e as condições clínicas do paciente. Revisamos as várias opções terapêuticas descritas na literatura para o tratamento de pacientescom DPM, propondo uma abordagem individualizada destes pacientes, de acordo com a suas...

Malignant pleural effusion (MPE) patients have advanced neoplasms with bad prognosis and low response of systemic therapy. When symptomatic, a palliative treatment is mandatory in order to offer comfort and quality of life to these patients. Several options areavailable, as ambulatory procedures and video assisted thoracic surgery. The clinical efficacy of these methods is a matter of debate and subject of many papers. Because of the high varietyof clinical presentations, no single method should be considered as a gold standard procedure, rather the management should be individualized considering the performance status and clinical condition of the patient. We reviewed the options described in the literature for the treatment ofMPE and proposed an individualized management strategy for these patients according to their clinical presentation...