Primary pulmonary monophasic synovial sarcoma initially presenting with bloody pleural effusion: A case report and literature review.

Key Clinical Message: Primary pulmonary synovial sarcoma (PPSS) can originate from blood vessels of the bronchial wall, lung interstitium, and interstitial components, and accounts for 0.1%-0.5% of all primary lung malignancies, the most common symptoms are chest pain, cough, dyspnea, and hemoptysis. Abstract: Synovial sarcoma (SS) is a rare malignant tumor of stromal origin, which accounts for approximately 8%-10% of all soft tissue sarcomas. Primary pulmonary synovial sarcoma (PPSS) can originate from blood vessels of the bronchial wall, lung interstitium, and interstitial components, and accounts for 0.1%-0.5% of all primary lung malignancies. Patient concerns: We report the first case of a 57-year-old man with bloody pleural effusion as an initial manifestation of PPSS in the middle lobe of the right lung diagnosed after surgery. Diagnosis: Chest computed tomography (CT) revealed a mass in the middle lobe of the right lung, which was pathologically diagnosed as a monophasic SS after surgical resection. Interventions: Ten days after preoperative closed chest drainage, a right thoracotomy was performed to remove the right middle lobe of the lung. Outcomes: The patient recovered smoothly and was discharged from the hospital without any other postoperative treatment. A follow-up chest CT scan 7 months postoperatively revealed intrapulmonary recurrence with multiple metastases. Lessons: Monophasic PPSS of the lung may present with bloody pleural effusion as its first manifestation.

Sudden extensive bloody pleural and pericardial effusion in a subject with untreated known hypothyroidism after total thyroidectomy, triggered by pneumonia.

BACKGROUND: In subjects with hypothyroidism, edema is often observed, and pleural effusion and pericardial fluid could be also observed. The color of such fluid retention is usually yellow. Here we show a very rare case with hypothyroidism who had bloody pleural effusion and bloody pericardial fluid. CASE PRESENTATION: A 42-year-old male noticed chest pain and the aggravation of exertional dyspnea, and he was transported to our institution by emergency. He had Graves' disease and underwent total thyroidectomy about 4 years before. After then, he had been treated with 200 µg/day of levothyroxine sodium for the maintenance of thyroid function. However, he self-interrupted such medication about 2 years before. Thyroid function on admission was reduced as follows: free triiodothyronine, 1.60 pg/mL; free thyroxine < 0.40 ng/dL; thyroid-stimulating hormone 25.50 µU/mL. Inflammation markers were increased: white blood cells 25,280 /µL; C-reactive protein 18.66 mg/dL. A large amount of pericardial fluid and pleural effusion were observed in chest and abdominal computer tomography and echocardiography. In addition, we performed pleural effusion and pericardial fluid collection. Pleural effusion in this subject showed bloody color, but not yellow. In cell block specimen of pleural effusion and pericardial fluid, red blood cells, neutrophils and lymphocyte component were observed. In this subject, however, we were unable to find any obvious background disease causing bloody pericardial effusion. Finally, we concluded that bloody pleural effusion and bloody pericardial fluid were brought about in a subject with untreated known hypothyroidism after total thyroidectomy, triggered by pneumonia. CONCLUSIONS: In subjects with hypothyroidism, fluid and mucopolysaccharide are stored in interstitial space and protein osmolality is increased, thus leading to edema and fluid retention. It is noted here that pleural effusion and pericardial fluid in this subject showed bloody color and included red blood cells. There are no reports of bloody pericardial fluid with hypothyroidism. Therefore, it is important to keep in mind that a subject with some trigger, such as infection, may have a hematologic fluid retention that is not seen when hypothyroidism is present alone, as observed in this subject.

A Case of Pneumonia Masking Pleural Malignancy.

The invasion of the pleural membrane by a malignant pleural tumor can lead to the production of malignant pleural effusion (MPE), resulting in the symptoms of dyspnea, and some patients have cough, sputum and other symptoms, which are easily confused with pneumonia. In this case, the initial diagnosis of the patient is pneumonia, and the final diagnosis is pneumonia combined with pleural malignancy. Therefore, if the patient has unexplained symptoms of bloody pleural effusion, it is necessary to examine for malignant tumors and should actively perform thoracentesis and drainage, look for malignant cells in the pleural effusion cell precipitation, evaluate the nature of pleural effusion, conduct pleural biopsy tissue examination, and determine the type and source of lung malignancy by the combined application of cell block technology and immunohistochemistry. Take the cytological examination results in pleural effusion seriously, and finally, surgical or immunotherapy can be performed.

Acquired resistance to immunotherapy characterized by bloody pleural effusion and biomarker exploration: a report of 2 cases.

BACKGROUND: With the current wide use of checkpoint inhibitors in the treatment of solid tumors, some patients who initially respond to immunotherapy have been shown to develop acquired resistance. However, the manifestation and underlying mechanisms are currently poorly understood. This is the first reported case of acquired resistance and pleural metastasis with uncontrolled massive bloody pleural effusion after immunotherapy. CASE DESCRIPTION: Case 1, a 54-year-old man, was treated with erlotinib for advanced lung adenocarcinoma due to deletion mutations in exon 19 of epidermal growth factor receptor (EGFR). After disease progression, he received pembrolizumab. The best efficacy evaluation during the period was partial response (PR). After 12 cycles of treatment, the patient exhibited rapid disease progression characterized by bloody pleural effusion. Pembrolizumab treatment was discontinued and an attempt was made to inject bevacizumab into the chest cavity; however, the bloody pleural effusion remained difficult to control. The patient experienced a rapid disease progression and died. Case 2, a 71-year-old man, with advanced hepatocellular carcinoma who had previously undergone right hepatectomy, and subsequently received pembrolizumab treatment after disease progression. During the treatment period, his best efficacy evaluation also reached PR. After 23 cycles of treatment, he developed a massive bloody pleural effusion in the chest cavity. He continued to use pembrolizumab for 2 cycles, and anti-angiogenic drugs were injected into the chest cavity, while taking lenvatinib orally; however, the bloody pleural effusion remained difficult to control. The patient eventually died of tumor progression. After the emergence of resistance, we subjected the pleural effusion of the 2 patients to next-generation sequencing (NGS), and preliminarily analyzed the relevant biomarkers. CONCLUSIONS: We found fibroblast growth factor (FGF) family gene mutations in pleural fluid obtained from two patients after immunotherapy resistance. It may suggest that the FGF family may be involved in the development of pembrolizumab resistance. And the combination of fibroblast growth factor receptor (FGFR) inhibitors and immune checkpoint inhibitors (ICIs) may be a promising option for cancer patients.

Using Disposable Membrane Cell Collector to Enrich Lung Adenocarcinoma Cells in Bloody Pleural Effusion for Anaplastic Lymphoma Kinase Fusion Gene Detection.

PURPOSE: For anaplastic lymphoma kinase (ALK) gene detection, the centrifugal sedimentation method (CSM) and cell block method (CBM) are commonly used to process samples of bloody pleural effusions (BPEs). However, in practice, the impurity content in the processed samples often affects the results and even leads to the detection failure. The purpose of this study was to establish a cell enrichment method (CEM) by using a disposable membrane cell collector to remove blood and inflammatory cells and enrich lung adenocarcinoma cells in BPE for more efficient RNA extraction and ALK gene detection. MATERIALS AND METHODS: CEM proposed in this study and the traditional CSM and CBM were used to treat BPE samples collected from 37 lung adenocarcinoma patients. A DeNovix DS-11 ultraviolet spectrophotometer was used to measure the concentration and purity of extracted RNA. Amplification refractory mutation systems (ARMS) and ABI 7500 fluorescence qPCR were used to detect ALK gene. Through statistical analysis, the CEM was compared with the CSM and CBM in RNA concentration, purity, and ALK gene detection results. RESULTS: The concentration of RNA extracted by using the CEM was significantly higher than that extracted by using the CBM and CSM (p < 0.001). The purity of RNA extracted by using the CEM was significantly higher than that by the other 2 methods (p = 0.011, p = 0.005). ALK gene testing with PCR was successful in all the samples using the CEM, but 2 cases by the CSM and 1 case by the CBM failed. CONCLUSIONS: Using the disposable membrane cell collector to process BPE of lung adenocarcinoma patients for RNA extraction and ALK gene detection is more effective and successful compared with the traditional methods, and it is suggested to be further applied and popularized in clinical practice.

Application of removing red blood cell block technique in diagnosis of lung adenocarcinoma in bloody pleural effusion / 肿瘤研究与临床

Objective:To investigate the value of paraffin-embedded section of cell block in the diagnosis of lung adenocarcinoma in bloody pleural effusion.Methods:The data of 60 patients with lung adenocarcinoma diagnosed by bloody pleural effusion and confirmed by pathological biopsy in the First Affiliated Hospital of Xi'an Jiaotong University from June 2018 to June 2019 were retrospectively analyzed. Cell smears and paraffin-embedded sections of cell blocks using removed red blood cells sedim entation method were used to make cytological examination in bloody pleural effusion. The expressions of carcinoembryonic antigen (CEA), cytokeratin 7 (CK7), NapsinA, thyroid transcription factor 1 (TTF-1), cytokeratin 5/6 (CK5/6), calretinin, P63 and P40 in the specimens were detected by using immunohistochemistry. The results of histopathological examination were used as the gold standard, and the diagnostic values of cell block paraffin-embedded sections and cell smears for lung adenocarcinoma in bloody pleural effusion were evaluated and compared.Results:The cell block sections had a clear background, clear and easy to distinguish cell morphology, and can be made into permanent specimens. The bloody pleural effusion cell smears results of 60 cases of lung adenocarcinoma showed that 21 cases were diagnosed as atypical cells, 39 cases were diagnosed as adenocarcinoma, and the coincidence rate with the diagnosis of adenocarcinoma by histopathological examination results was 65% (39/60); the immunohistochemistry results of cell block paraffin-embedded sections of bloody pleural effusion showed that CK7, NapsinA, TTF-1 and CEA were positive, and P40, P63, CK5/6 and calretinin were negative, all 60 cases were diagnosed as adenocarcinoma according to the results, and the coincidence rate with the diagnosis of adenocarcinoma by histopathological examination results was 100% (60/60), which was significantly higher than that of cytological smears ( χ2 = 23.088, P < 0.01). Conclusions:The technique of paraffin-embedded section of cell block using removed red blood cells sedim entation method has a high diagnostic rate for lung adenocarcinoma in bloody pleural effusion, and it has a high coincidence rate with histopathological diagnosis. It can improve the accuracy of diagnosis of lung adenocarcinoma in bloody pleural effusion, and it also has a good reference value for cytological typing.