Non-malignant Effusions Research Articles

Diagnostic value of lactoferrin analysis in pleural effusions.

Lactoferrin was analysed with an ELISA in pleural effusions from 21 patients with malignant exudative effusions (15 carcinomas and 6 mesotheliomas), 12 patients with non-malignant exudative effusions of unknown aetiology, 11 patients with transudative effusions due to congestive heart failure, 12 patients with exudative effusions secondary to infection, and 2 patients with tuberculous effusions. Median pleural fluid lactoferrin was 133 micrograms/l (range 25-435) in carcinomas, 55 micrograms/l (23-185) in mesotheliomas, 198 micrograms/l (31-530) in non-malignant exudates, 68 micrograms/l (17-205) in transudates, 1815 micrograms/l (1380-2050) in infectious exudates and 107 micrograms/l (88-125) in tuberculosis. Due to a wide overlap between the various groups pleural fluid lactoferrin appears to be of limited value in the routine diagnostic evaluation of non-infectious pleural effusions, but seems to separate infectious exudates from non-infectious exudates.

Malignant pericardial effusions: Usefulness of pericardioscopy

In cases of malignant pericardial effusion, surgical subxiphoid biopsy sometimes fails to prove malignancy. To assess the usefulness of pericardioscopy, which allows an endoscopic investigation of the pericardial cavity, this technique was systematically performed during surgical drainage procedures that were performed on 40 patients who had pericardial effusions of suspected malignant origin. Twenty-six patients had a history of neoplasm, 10 had a history of hematologic malignancy, and four had recent tumors or lymphadenopathies that were suspected to be of malignant origin. Classical tests that are usually performed during a conventional surgical drainage procedure (fluid studies and subxiphoid biopsy) were combined with direct visualization of the pericardial surfaces and guided biopsies of suspicious areas. The follow-up period after pericardioscopy was at least 12 months. Two early deaths occurred after pericardioscopy, but no death was directly related to the endoscopy. According to all of the tests that were performed, diagnoses were malignant pericardial effusion in 15 of 40 patients (group I, 37#) and nonmalignant pericardial effusion in 25 of 40 patients (group II, 73%). In 3 of 13 patients (23%) in group I, the diagnosis was obtained only by pericardioscopy (results of cytologic studies and subxiphoid biopsy were negative). In two patients in group I, pericardioscopy could not be completed, but the diagnosis of malignant pericardial effusion was obtained by pericardiocentesis. In group II, effusion was considered to be postradiation pericarditis in five cases, infectious pericarditis in three cases (bacterial in one and tuberculous in two), hemopericardium induced by coagulation disturbances in three cases, and idiopathic pericarditis in 14 cases. Mid- and long-term follow-up (mean duration, 35 months; range, 12 to 72 months) showed that in group I the median survival time was 42 days, whereas in group II it was 1 year. The difference between the two life curves was significant ( p < 0.05). Thus pericardioscopy appears to be a technique that does not increase the risk of the surgical drainage procedure. Its main benefit is a greater diagnostic sensitivity as a result of direct visualization of the pericardial surfaces and guided biopsies. It should be available at the time that the surgical drainage procedure is performed, since the diagnosis of malignant pericardial effusion has significant prognostic consequences.

Subxiphoid Pericardiotomy in the Diagnosis and Management of Large Pericardial Effusions Associated with Malignancy

To determine the safety, diagnostic value, and clinical outcome of patients with malignancy undergoing subxiphoid pericardiotomy for large pericardial effusions, we prospectively studied 25 consecutive patients with malignancy and new, large pericardial effusions diagnosed by echocardiography. Twenty-two of the 25 operations were done under local anesthesia, and no patient died at surgery. Pericardial fluid cytology revealed malignant cells in 11 patients (44 percent), while tumor was seen in only five (45 percent) of these 11 patients on pathologic examination. The remaining 14 patients showed no evidence of pericardial invasion with tumor. Evidence of intrathoracic disease by CT or MRI scanning, tamponade, a sanguineous pericardial fluid character, and an elevated serum and pericardial fluid lactate dehydrogenase level all were suggestive of malignant invasion of the pericardium. All 25 patients were followed at least 12 months postoperatively. Effusions recurred in three patients (12 percent), and one patient required reoperation. Overall mortality was 72 percent with a 91 percent (10 of 11) mortality for those with malignant effusions and a 57 percent (8 of 14) mortality for those with nonmalignant effusions. Diagnostically, subxiphoid pericardiotomy has little advantage over examination of pericardial fluid alone in this group of patients. Therapeutically, however, it is a low morbidity procedure which is safe and effective in treating patients with malignancy and large pericardial effusions.

Malignant lymphoma in pleural effusions: An immunocytochemical cell surface analysis

Nine malignant pleural effusions due to lymphoma were immunocytochemically analyzed with the peroxidase-antiperoxidase adhesive slide assay for detection of cell surface antigens using a broad panel of monoclonal antibodies. The study population included one case of hairy-cell leukemia; four cases of B cell non-Hodgkin's lymphoma (B-NHL), low malignant grade; two cases of B-NHL, high malignant grade; one case of Hodgkin's disease; and one case of plasmacytoma. In the cases of B cell lymphoma, high percentages of B cells with monoclonal staining for kappa were found. In hairy-cell leukemia, the hairy cells reacted with the monoclonal antibodies CD20, CD25, HLA-DR, CD45, and HLA-1. In Hodgkin's disease, the Hodgkin cells reacted with CD15, CD20, CD25, CD30, Tü9, and OKT9. The plasmacytoma case showed tumor cells negative for CD20, HLA-DR, and CD45; partially positive for CD38; positive for HLA-1; monoclonally positive for lambda; and negative for heavy-chain immunoglobulins. The analysis of nonmalignant lymphocyte subpopulations revealed CD4/CD8 ratios similar to those in effusions of other etiologies. The percentages of natural killer cells (Leu-7-positive and CD16-positive) were small and also similar to percentages in effusions of other etiologies. We conclude that immunocytochemical analysis of pleural effusions allows a clear recognition of B lymphoma cells and also of Hodgkin and hairy cells and that the distribution of nonmalignant lymphocyte subsets is indistinguishable from those found in other malignant and nonmalignant effusions.

Surgical treatment of large pericardial effusions Etiology and long-term survival

From 1977 to 1988 60 patients were treated for large pericardial effusion. The operation consisted of a small left anterior thoracotomy with formation of a pericardial window. In 28 patients (47%) the etiology was a malignant disease. Eight patients (29%) had malignant cells in the pericardial fluid and 23 patients (82%) had metastases to the pericardium. Seven patients (12%) had purulent pericarditis; in 4 cases Staphylococcus was found. Of the remaining 25 patients, the etiology remained unknown in 13. The 5-year survival rate was 60% among patients with nonmalignant effusions. In patients with malignant effusions only 20% were alive after 2 years. There were no deaths related to the operation. We conclude that large pericardial effusions of unknown etiology can be safely treated with a small left anterior thoracotomy. This access gives optimal possibilities for rapid diagnosis and treatment.

Symptomatic pericardial effusion in breast cancer patients: The role of fluid cytology

Clinical and cytologic findings in 21 breast cancer patients with symptomatic pericardial effusion are presented. The etiology of the pericardial effusion was definitely malignant, by cytology/histology in 13 patients (62%), and suspected malignant by cytology in 2 patients (9%). One patient (5%) with definitely nonmalignant pericardial effusion by cytology was found to be histologically positive at autopsy. In 5 patients (24%) there was no histological/cytological evidence of malignancy; radiation pericarditis could be the etiology in 4 of these 5 patients. The median time from the diagnosis of breast cancer to the development of symptomatic pericardial effusion was 60 months (range: 1-219 months). Ten patients developed cardiac tamponade; they were treated by either pericardiocentesis or pericardiectomy. The mean survival of patients with negative cytology/histology was 12 months; patients with suspicious cytology had a mean survival of 9 months; patients with malignant effusion, treated by pericardiectomy, had a mean survival of 22.3 months, while patients with malignant pericardial effusion, who were not subjected to surgery, had a mean survival of 4.7 months, only. It is concluded that the etiology of symptomatic pericardial effusion in breast cancer patients is not always malignant, which emphasizes the role of fluid cytology in establishing definite diagnosis. The survival probability is a function of the extent of extracardiac disease; among patients with malignant pericardial effusion those selected for pericardiectomy have a longer than average survival.

Presence of high concentration of 7B2 in pleural effusion.

7B2 (a novel pituitary protein) is a secretory protein in the neuroendocrine tissues and an increase in the plasma 7B2 concentration was noted in some patients with various endocrine tumors, including small cell carcinoma of the lung and acromegaly, suggesting that 7B2 is a possible marker for these tumors. Using a radioimmunoassay, the 7B2 concentration was measured in pleural fluid samples obtained from 36 patients with lung cancer and benign pulmonary disease to assess its concentration as a marker for small cell carcinoma of the lung (SCCL) or malignant effusion. 7B2-immunoreactivity (IR) was present in pleural fluid and its concentration was much higher than in plasma. However, there was no significant difference between pleural fluid 7B2 in patients with SCCL and in other histological types of lung carcinoma or in malignant and nonmalignant patients. In the chromatographic analysis of pleural fluid on gel permeation chromatography and reverse-phase high-performance liquid chromatography, there was no molecular heterogeneity between malignant and nonmalignant effusion. These results suggest that pleural fluid 7B2-IR is not a useful marker for SCCL or malignant effusion.

Tissue Polypeptide Antigen (TPA) in Pleural Effusions

The usefulness of tumor marker assay in pleural effusions for differential diagnosis is still debated. From the observation of common antigens on tissue polypeptide antigen (TPA) and keratins 8, 18 and 19 and vimentin, all substances contained in normal and neoplastic mesothelium, we felt it opportune to evaluate the use of TPA assay in 105 pleural effusions (46 benign and 59 malignant). The values were much higher than those found in blood. In hydrothorax the median value was 454 U/l (range, 59-1923), in exudative effusions 846 U/l (range, 258-4485), in metastatic pleural effusions 1277 U/l (range, 58-32352) and in mesotheliomas 7705 (range, 759-16000). The maximum value found in nonmalignant effusions was 4485 U/l; this value was taken as a cutoff level, so only 29.9% of the tumors were positive to the test. Our results showed this assay to be not very important for a differential diagnosis of malignant and nonmalignant pleural effusions. Nevertheless, the different TPA patterns in mesotheliomas (66.6% positive) and metastatic pleural effusions (15.9%) suggest that further studies are warranted.

Diagnostic value of ferritin analysis in pleural effusions.

Ferritin was analysed with an immunoradiometric assay using anti-spleen ferritin antibodies, in pleural effusions (Pl) from 28 patients with malignant effusions (18 carcinoma, 10 mesothelioma), 15 patients with non-malignant exudative effusions of unknown aetiology, and from 12 patients with transudative effusions due to congestive cardiac failure. Geometric mean Pl-ferritin was 617 micrograms/l in carcinoma, 1301 micrograms/l in mesothelioma (p less than 0.01 against carcinoma), 931 micrograms/l in non-malignant exudates, and 178 micrograms/l in transudates (p less than 0.0001 against malignant and non-malignant exudates). There was no correlation between Pl-ferritin and Pl-protein, Pl-albumin or Pl-cell count. P1-ferritin displayed a wide overlap between the various groups, and was of no value in the discrimination between malignant and non-malignant exudates. In the differentiation between exudates and transudates, the diagnostic accuracy of Pl-ferritin was only slightly lower compared to Pl-protein and Pl-albumin. With the present method, analysis of Pl-ferritin appears to be of limited value in the routine diagnostic evaluation of pleural effusions.

Secretion of transforming growth factors by primary human tumour cells.

We examined the ability of primary human tumour cells to secrete diffusible factors capable of stimulating anchorage independent growth of normal rat kidney fibroblast (NRK) cells. Conditioned media (CM) prepared from cells derived from 31/43 patients with adenocarcinoma of the breast, colon, ovary or lung were found to induce growth of NRK cells in soft agar. The ability of the CM to induce anchorage independent growth was enhanced in 25/35 cases by the presence of epidermal growth factor (EGF). The CM did not compete with EGF for binding to the EGF receptor site. CM from cells derived from nonmalignant effusions also supported the growth of NRK cells in soft agar. There was no significant difference in the ability of the CM derived from malignant or normal cells to support NRK colony growth. The ability of primary human tumour cells to clone in soft agar was compared to the ability of these cells to produce diffusible colony stimulating factors for NRK cells. No correlation was observed between the ability of the primary human tumour cells to clone in soft agar and their ability to induce anchorage independent growth of NRK cells. The secretion of substances with TGF like activity may be a property of many types of primary human cells.

Autologous mixed lymphocyte reaction in the peripheral blood and pleural effusions of cancer patients.

T cells proliferate in response to autologous non-T cells in the autologous mixed lymphocyte reaction (AMLR). AMLR was impaired in the peripheral blood of patients with advanced lung cancer (4,159 +/- 3,878 delta cpm vs. 11,221 +/- 4,156 delta cpm for normal donors) but normal or even higher in their malignant pleural effusions (13,257 +/- 7,075 delta cpm vs. 10, 870 +/- 5,013 delta cpm for nonmalignant control effusions). Blood T cells also failed to respond to autologous effusion non-T cells, while effusion T cells strongly responded to autologous erythrocytes blood non-T cells. The presence of blood T cells did not inhibit effusion AMLR of the same patients. A subset of T cells that form rosettes with autologous erythrocytes if found to proliferate in AMLR. The number of autorosette-forming cells was lower in blood T cells of cancer patients than in blood T cells of normal donors and in effusion T cells of the patients. After enrichment of autorosette-forming cells, there was no difference in AMLR of normal blood and cancer blood and effusions. These results indicate that the loss of AMLR in the blood of cancer patients is due to a reduction of number of autoreactive T cells and not to a defect of autologous stimulator non-T cells.

Use of cytogenetic analysis of body fluids in cancer diagnosis.

Direct chromosome preparations were made from 52 malignant and 21 non-malignant effusions. An effusion was classified as malignant if 2% of the counted cells showed abnormal karyotypes. There was a significant relationship between diversified karyotypes and the pathological nature of tumours: diversity of karyotypes was much higher in undifferentiated adenocarcinoma, anaplastic carcinoma and embryonal cell carcinoma cells than in well-differentiated cancer cells. Diagnosis was positive for 38 of the 52 malignant effusions by cytological examination (73% sensitivity), and positive for 41 of the 52 by cytogenetic analysis (78% sensitivity). There were no false positive results using both cytogenetic and cytologic examinations (92% sensitivity). Particularly in patients with equivocal cytology, cytogenetic analysis appears to be a useful tool in the diagnosis of malignant effusions.

Natural killer cells in carcinomatous pleural effusions

Effector cells in carcinomatous pleural effusions of patients with primary or secondary lung cancer were examined for natural killer (NK) activity against K562 cells in a 4-h chromium release assay, and for mitogenic responses and lymphocyte subpopulation constitutions. NK activity of lymphocyte-rich mononuclear cells isolated from carcinomatous pleural effusions by centrifugation on a discontinuous gradient of Ficoll-Hypaque was markedly low in seven of 40 patients studied, and absent in the other 33 cases. NK activity of peripheral blood mononuclear cells from the patients was lower than that of cells from normal donors, but always higher than that of effusion cells from the same patients. NK cells in the peripheral blood and in pleural effusions had some characteristics in common, in that they lacked a capacity to bind sheep erythrocytes, were nonadherent to Sephadex G-10 beads and nylon wool, and belonged to large granular lymphocytes. On the other hand, nonmalignant effusions of patients with congestive heart failure had significant NK activity. The effector cells in the effusions included a higher frequency of T cells than those in the peripheral blood of the same patients. Proliferative responses to phytohemagglutinin and concanavalin A of effusion cells were comparable to those of normal blood cells and were higher than those of blood cells from the same patients. The reason for low NK activity and high mitogenic response in carcinomatous pleural effusions is as yet undefined.

Differential Diagnosis of Pleural Effusions: Clinical Usefulness of Cell Marker Quantitation

Carcinoembryonic antigen (CEA), orosomucoid beta 2 microglobulin, and alpha fetoprotein were quantified in the pleural fluid and serum of 58 hospitalized consecutive patients in order to differentiate malignant from non-malignant effusions. Cytologic examination of the effusions was also performed. The orosomucoid assay was the most helpful in identifying malignant effusions; higher values (greater than 100 mg/100 ml) were found in 74 percent (26/35) of malignant effusions. Quantitation of carcinoembryonic antigen had a high specificity (95 percent) but a low sensitivity (36 percent) for the detection of malignant pleural effusions. The parallel quantitation of CEA and orosomucoid had a higher sensitivity (86 percent) which increased when associated with cytologic examination. The sensitivity of cytology was only 46 percent. The concentrations of orosomucoid in pleural effusions correlated well with serum concentrations. Alpha fetoprotein and beta 2 microglobulin quantitations were of no clinical value for diagnosing malignant effusions. It is suggested the cytologic examination combined with orosomucoid and CEA quantitation in pleural fluid have a considerable clinical value for the diagnosis of pleural effusions.

Isolation and electrophoretic analysis of immune complexes from patients with breast cancer

Immune complexes (IC) were isolated from sera of patients with breast cancer (BC), from effusions from patients with breast and ovarian cancer (OC) and from effusions from patients with non-malignant diseases. Isolation was carried out with the aid of tubes coated with rheumatoid factor (RF) as immunoadsorbents. The effusions were first filtered through Sephacryl S-300 columns and the large molecular weight material eluted in front of the IgG peak was used as the starting material, while most of the sera were processed without prior filtration. The IC eluted from the RF-coated tubes were radioiodinated and analyzed by electrophoresis on polyacrylamide gels, followed by autoradiography. Four putative IC-derived proteins were identified in the RF eluates and designated according to their molecular weights (in Kdalton): p94, p46, p 17 and p 13. p94 was found in 1/8 BC effusions, but in none of the other samples tested; “p46”, which was actually a complex of several closely spaced proteins, was identified in at least 3/16 BC sera, 6/8 BC effusions, 3/4 OC effusions and 1/5 non-malignant effusions, but in none of 17 normal sera. The upper band of the complex seemed to be present mainly, if not exclusively, in effusions from patients with neoplasia. p17 and p13 were found more often and in higher concentrations in the malignant effusions. All of these proteins could be precipitated by treating the RF eluates with anti human Ig serum, suggesting that they were associated with Ig, presumably as immune complexes.

In vitro assay of spontaneous cytotoxicity by human monocytes and macrophages against tumor cells

The [ 3H] proline microcytotoxicity technique has been adopted to examine the spontaneous cytotoxic property of human circulating monocytes (M) derived from the peripheral blood and resident monocytes/macrophages (Mø) derived from effusion fluids. A leukocyte fraction is obtained by centrifugation in Ficoll-Hypaque (F-H) gradient. M are then isolated as adherent cells following incubation of the leukocyte fraction in plastic flasks containing 50% fetal calf serum (FCS) in culture medium. Mø are isolated from effusion fluids after first separating the Fc receptor bearing cells (as Fc receptor-7S EA resettes) in F-H gradient and then enriching them as adherent cells. The above techniques yield a M/Mø population of some 90–98% purity. The M/Mø non-selectively lyse tumor cells and allogeneic normal fibroblasts in the 48 h [ 3H] proline assay. The fibroblasts, however, exhibit considerable resistance to lysis, particularly at lower effector to target ratios. While appreciable levels of cytotoxicity are observed with resident Mø at 6 h, followed by a further increase in the level of cytotoxicity at 24–48 h, circulating M exhibit a consistent level of cytotoxicity only at 24–48 h. When circulating M and resident Mø from the same donor are examined concurrently for cytotoxicity, resident Mø are consistently found to show significantly higher levels of cytotoxicity when compared to circulating M. This may reflect a true functional heterogeneity within this lineage of effector cells or some degree of in vivo activation of resident Mø in malignant and non-malignant effusion fluids. Further studies of spontaneous cytotoxicity by M/Mø through CMC assay techniques, such as the [ 3H] proline microtoxicity technique, will be useful in the examination of the role of M/Mø in cell mediated immunity and immunosurveillance against cancer.

Distribution of T-Lymphocytes and B-Lymphocytes in Peripheral Blood and Effusions of Patients With Cancer&lt;xref ref-type="fn" rid="FN2"&gt;2&lt;/xref&gt;

The relative distribution of T- and B-lymphocytes in the blood and in pleural or abdominal effusions was compared among 24 patients with fluid accumulation due to metastatic cancer and 8 patients without evidence of cancer. The data obtained indicated that the mean percentage of T-lymphocytes in malignant effusions was significantly greater than that in the peripheral blood of the same patients. At the same time, the mean eprcentage of B-lymphocytes was decreased in malignant effusions when compared with peripheral blood. Neither of these differences was observed when effusions and blood of patients with nonmalignant effusions were compared. In addition, patients with both types of effusions had fewer total lymphocytes in their blood than did normal control patients, whereas those with cancer-associated effusions had an increased proportion of active T-lymphocytes in their blood.

Immunoglobulins and complement in pleural effusions associated with bronchogenic carcinoma.

Levels of IgG, IgA, IgM, the total haemolytic complement (CH50), and the individual components C1q, C3, C4, C6, and C7 were measured in 29 pleural effusions. Of these, 18 were associated with carcinoma of the bronchus and 11 were non-malignant effusions including empyemas. The level of IgG was significantly lower in the malignant group when compared with non-malignant effusions. The usefulness of measurements of IgG with respect to malignant effusions associated with carcinoma of the bronchus requires an expanded study to show whether it has any real diagnostic value. There were no significant differences in other immunoglobulins, the CH50, and individual complement components between the two groups. The identification of total haemolytic activity in the majority of effusions in both groups indicates that all nine components of the classical pathway of complement, including macromolecules such as C1, can be present in pleural fluids.

Karyotype Analysis of Cells in Malignant and Non-Malignant Effusions

SUMMARYBoth numerical and structural chromosome abnormalities were found in carcinomatous effusions. Large dispersion of the chromosome numbers around the mode, small percentage of modal cells, and karyotype instability, were characteristics of the malignant cells. In every tumor, however, the variations were made around a basic pattern (stemline karyotype), consistent with a clonal origin for all cells of the tumor. Both ordinary polyploidy and endoreduplication represented mechanisms responsible for the cell gigantism found in tumors. The absence of chromosomal abnormalities in benign effusions makes the cytogenetic analysis of sediments a valuable tool for the differential diagnosis of malignancy in cavitary effusions.

Orosomucoid content of pleural and peritoneal effusions.

22 nonneoplastic, noninflammatory effusions (cirrhosis and congestive heart failure), 12 non-neoplastic inflammatory effusions (tuberculosis, lupus erythematosus, rheumatoid arthritis, and idiopathic pleuropericarditis), and 58 neoplastic effusions (cancer of lung, breast, ovary, and pancreas, and lymphoma) were analyzed by radial immunodiffusion for orosomucoid concentration. The average concentration +/-SE was 35+/-4, 65+/-17, and 130+/-13 mg/100 ml in the three types of effusion, respectively. By gel filtration and ion exchange chromatography, orosomucoid was isolated from 12 nonmalignant and 14 malignant fluids. The orosomucoid preparations reacted as single components in acrylamide gel electrophoresis at pH 9.0, and in immunodiffusion and immunoelectrophoresis against antisera to human serum and to human plasma orosomucoid. In radial immunodiffusion, the slope of the line relating concentration to the square of the diameter of the precipitate area was identical for orosomucoid isolated from normal human plasma and from nonneoplastic effusions, but was subnormal for orosomucoid isolated from neoplastic fluids. All orosomucoid preparations had normal amino acid composition. Orosomucoid from the nonmalignant effusions had normal carbohydrate content. 11 of 14 samples of orosomucoid isolated from neoplastic fluids had abnormalities in carbohydrate composition, consisting of subnormal content of sialic acid (11 of 14), hexose (10 of 14), and hexosamine (3 of 14), and abnormally high content of hexosamine (4 of 14). Discriminant analysis showed that concentration of orosomucoid distinguished between neoplastic and nonneoplastic noninflammatory effusions more effectively than concentration of total protein, albumin, alpha(1), alpha(2), beta, or gamma-globulin.