PLEURA

Research in pleural diseases has traditionally been neglected but is now growing.

This study aimed to analyze scientific research trends on pleural effusions over the last decades.

We conducted a bibliometric analysis of the Scopus database from its inception to March 2016, searching for original articles and reviews on “pleural effusion” (key word). Journal, year of publication, number of citations, authors and their affiliations, and the Hirsch (H)-index for some of these variables were recorded and analyzed.

A total of 15 982 documents were retrieved, of which half have been published in the last 18 years and a quarter during the last 8 years. Chest ranked first regarding the number of documents on pleural effusions (both absolute number and yearly rate) and their scientific relevance (H-index of 76). The United States had contributed the most to pleural research productivity (23%). American pulmonologists Dr Richard Light and Dr Steven Sahn exhibited the highest number of papers (206 and 156, respectively) and author H-indexes (44 and 38, respectively).

There is growing research activity in the field of pleural effusions, which has gained relevance and visibility in clinical respiratory journals. The United States is the leader in quantity and quality of research productivity in pleural medicine.

Inconsistent results have been reported regarding mortality predictors of malignant pleural effusion (MPE).

We aim to describe prognostic features of MPE in patients evaluated over 5 years in a referral center.

All consecutive MPEs (confirmed by pleural cytology or biopsy) from January 2009 to July 2014 were included in this retrospective cohort study. Clinical data were collected from medical registries. Overall survival (OS) rate was calculated with Kaplan-Meier method and compared by the log-rank test. Hazard ratios (HRs) were calculated by the Cox proportional regression model.

A total of 110 patients were identified. Mean OS was 8.3 months (range: 25-426 days). No difference in OS was noted based on tumor type. Patients with MPE <50% had a significant better survival than those with malignant pleural effusion ≥50% (median OS: 15.7 vs 5.7 months; HR: 1.71; 95% confidence interval [CI]: 1.06-2.78; P = .0026). After adjusting for confounding variables, MPE size was independently associated with mortality (HR: 1.78; 95% CI: 1.11-2.91; P < .001). No association between glucose or pH in pleural fluid and OS was noted.

Our study showed that MPE size, as determined by chest X-ray, is significantly associated with mortality.

Dyspnea due to pleural effusions is a common clinical scenario and has many underlying etiologies. Our case of a recurrent pleural effusion was misdiagnosed in part due to the complicated nature of the patient’s medical history. Nonetheless after a bedside thoracic ultrasound examination (TUE), the diagnosis became obvious.

A 63-year-old black female with congestive heart failure, end-stage renal disease, atrial fibrillation as well as a previously treated rare odontogenic carcinoma presented with shortness of breath. She reported having had “fluid drained” from her lungs a few months prior. During our encounter with this patient, a TUE was performed at beside and a large diaphragmatic mass was visualized. A malignant pleural effusion was suspected and an efficient and focused workup was tailored to our patient.

Apart from guiding the thoracentesis, the TUE is not part of the current recognized guidelines when evaluating a pleural effusion. The TUE may be undervalued and play an important impact on diagnosis and management of this condition. Our case demonstrates the utility of a thorough TUE in conjunction with the full clinical picture. A few studies have shown good sensitivities and specificities in the use of the TUE to determine the type and etiology of pleural effusions. This case is a further example of the utility in performing this relatively inexpensive diagnostic test in the evaluation of the patient with a pleural effusion.

Pleural effusions impact over 1.5 million people annually in the United States and cause significant morbidity. Although therapeutic thoracentesis is associated with improvement in respiratory parameters, unanswered questions remain regarding its impact.

The purpose of this study was to investigate patient-centered outcomes, the need for additional pleural interventions, and mortality in the 30 days following thoracentesis.

This prospective observational cohort study was performed in a tertiary care academic medical center between December 2010 and December 2011. Adult patients referred for thoracentesis were offered enrollment. The following characteristics were evaluated both before and at 30 days postprocedure: dyspnea using modified BORG (mBORG), physical and mental quality of life (QoL) using the short form 12, and basic activities of daily living (BADLs). The primary outcomes included changes in these parameters 30 days after thoracentesis. Secondary outcomes included the need for additional pleural procedures and mortality within 30 days of the thoracentesis. Multivariable logistic regression was used for analysis.

Of the 284 patients who underwent thoracentesis, 80 (28.2%) died within 30 days of the procedure. Of the 163 patients comprising the analytical cohort, 35 (21.5%) patients required an additional pleural intervention within 30 days of the index procedure. Patients who survived more than 30 days following thoracentesis had a sustained improvement in dyspnea and mental QoL, but a minority had improvement in physical QoL or BADLs. Surviving patients demonstrated no significant associations between bilateral and unilateral thoracentesis, volume of fluid removed, or the etiology of the effusion (malignant vs nonmalignant) and improvement in QoL, dyspnea, and BADLs. Relative to nonmalignant etiology, the presence of a malignant effusion was strongly associated with the need for an additional intervention, yielding an odds ratio (95% confidence interval [95% CI]) of 16.92 (5.47-52.37). Patients with hepatic hydrothorax and infectious etiologies of their effusion were also likely to require additional pleural interventions.

The majority of patients in this cohort demonstrated sustained improvement in dyspnea and the mental aspect of QoL 30 days following thoracentesis, independent of the etiology and regardless of the volume of pleural fluid removed. A minority experienced sustained improvements in the physical aspect of QoL and BADLs. Although 28.2% of patients died within 30 days, nearly 1 in 5 survivors required an additional pleural intervention. These results emphasize the significant clinical impact, morbidity, and mortality experienced by patients who undergo thoracentesis for pleural effusions.

Epidermal growth factor receptor (EGFR) mutation analysis is a standard approach for initial therapeutic decision in patients with metastatic adenocarcinoma of the lung (MAL). The feasibility of performing EGFR mutation testing using pleural fluid specimen is not well characterized.

The aim of this study is to report the percentage of patients eligible for EGFR mutation testing based on the percentage of malignant cells (PMCs) in the pleural fluid using the pyrosequencing method.

From our database, we reviewed the clinical data of 61 patients with malignant pleural effusion (MPE) secondary to MAL. The PMCs were divided into 2 categories with a cutoff point of 10% (PMC1 is defined as ≤10% and PMC2 is defined as >10%). For the pyrosequencing method, only patients in the PMC2 group were eligible for EGFR mutation testing.

Of 61 patients with MPE secondary to MAL, 38 (62.3%) were in the PMC2 group, which represents the percentage of patients eligible for EGFR mutation testing. Of these 38 patients, 15 patients had the testing done on the MPE. Quantity was not sufficient for testing only in 1 patient. Therefore, in PMC2 patients group, the rate of successful EGFR mutation testing was 93% (14 of 15). The thoracentesis volume was not significantly different between PMC1 and PMC2.

Performing EGFR mutation analysis on the MPE in patients with MAL is feasible in 62% of patients. The rate of successful testing on the eligible samples is 93%.

Pleural fibrosis and restriction are well-known complications of tuberculous pleurisy, which is often accompanied by respiratory distress and limitation of daily life activities.

Current evidence suggests that pleural drainage offers little benefit over and above antituberculous treatment in improving pulmonary function. Our study aims to define the role of additional pleural drainage in the management of tuberculous pleural effusions.

We enrolled 21 patients with tuberculous effusions and performed therapeutic drainage in 10 randomly selected cases. Pulmonary function testing, exercise capacity, chest radiography, and ultrasonography were performed at baseline, 7 to 10 days, and at 3 months.

Complete therapeutic drainage was achieved in 4 of 10 patients randomized to undergo drainage. Immediate benefit in total lung capacity (TLC) was achieved in the 10 patients assigned to intervention. Intervention group showed significant changes compared to the non-intervention group in several functional parameters at 3 months: change in forced vital capacity (ΔFVC 1.40 L, 95% confidence interval [CI] 1.08-1.71 vs Δ0.34 L, 95% CI 0.01-0.67, P < .000), change in forced expiratory volume in 1 second (ΔFEV₁ 1.08 L, 95% CI 0.79-1.37 vs Δ0.38 L, 95% CI 0.08-0.68, P = .001), change in TLC (ΔTLC 1.45 L, 95% CI 1.05-1.85 vs Δ0.56 L, 95% CI 0.00-1.12, P = .009), and change in diffusion capacity for carbon monoxide (ΔDLCO 6.43 mL/min/mm Hg, 95% CI 3.73-9.12 vs Δ0.57 mL/min/mm Hg, 95% CI 2.31-3.34, P = .005). Significant improvement after 3 months was not observed in the 6-minute walking distance as well as oxygen saturation before and after walking.

Therapeutic drainage may offer additional short-term functional benefits to patients with pleural tuberculosis.

Malignant pleural mesothelioma (MPM) is a rapidly fatal tumor of increasing worldwide incidence. Diagnosis of MPM may be difficult and is an area of academic and clinical interest. Diagnosis by effusion cytology is controversial, and the clinical utility of soluble biomarkers, particularly mesothelin, remains unexplored in the difficult to diagnose patient.

We studied the diagnostic value of measuring mesothelin in patients with cytology-negative pleural effusion undergoing medical thoracoscopy.

Patients were enrolled prospectively and underwent medical thoracoscopy. Biopsy samples were reviewed following standard care guidelines. Soluble mesothelin was quantitated by commercial enzyme-linked immunosorbent assay in effusion and serum samples collected at the time of thoracoscopy. Patients were followed up until death or for a median of 28 (interquartile range 18-43) months.

Biopsy for thoracoscopy was definitive for malignancy in 17 of the 36 cases (16 MPM and 1 lung adenocarcinoma) and suspicious of malignancy in 6 cases. A final diagnosis of malignancy was made for 27 cases (24 MPM, 2 lung adenocarcinoma, and 1 primary pleural T-cell lymphoma). At thoracoscopy, soluble mesothelin was elevated in the effusion of 13 cases all of which were MPM. Serum mesothelin was elevated in 6 cases with MPM. One case with elevated mesothelin on whom thoracoscopic biopsy demonstrated a pleural plaque was diagnosed with metastatic MPM 9 months later.

Elevated effusion mesothelin had a positive predictive value of 100% for a final diagnosis of MPM. Elevated mesothelin, in effusion or serum, should raise the index of suspicion of malignancy and warrants continued clinical follow-up.

Malignant pleural mesothelioma is a rare but complicated disease associated with very poor prognosis, despite all forms of treatment and almost 100% mortality after diagnosis.

The use of extrapleural pneumonectomy (EPP) in the management of malignant mesothelioma has become controversial recently and appears to be a dying modality. This retrospective study aimed to review and compare our results with available literature.

Consecutive patients were reviewed from March 1999 to April 2011 who underwent EPP for malignant mesothelioma. Short- and long-term outcomes were analyzed retrospectively until February 2013.

There were 30 consecutive patients who underwent EPP in 13 years. The majority of them were male (29 patients) with a mean age of 61 years (34-71 years). There was no in-hospital or 30-day mortality in this cohort, although Thoracoscore predicted 7.9% risk of in-hospital mortality. The overall median survival was 20 ± 24 months, which prolonged to 47.5 ± 24 months in patients who received trimodality treatment. Thirty-one percent of patients survived ≥4 years and 2 patients are still alive at 6 and 7 years postoperatively. Survival was significantly longer in epitheloid versus biphasic mesothelioma, right versus left pneumonectomy, age below 65 years, and with no N2 disease. Survival at 6, 12, and 18 months was 80%, 65%, and 55% in comparison with 65%, 52%, and 34%, respectively, in the Mesothelioma and Radical Surgery trial.

Epitheloid mesothelioma, right pneumonectomy, negative extrapleural lymph nodes, and age below 65 years are associated with prolonged survival. Extrapleural pneumonectomy has a role in the management of malignant mesothelioma in selected patients by experienced surgeons.