Pleural Biopsy Research Articles

Uniportal VATS pleural biopsy in the diagnosis of exudative pleural effusion: awake or intubated?

BackgroundThe aim of this study is to compare the diagnostic efficacy and safety of video-assisted thoracoscopic surgery (VATS) with awake VATS (AVATS) pleural biopsy in undiagnosed exudative pleural effusions.MethodsThe diagnostic efficacy of pleural biopsy by uniportal VATS under general anesthesia or AVATS under local anesthesia and sedation performed by the same surgeon in patients with undiagnosed exudative pleural effusion between 2007 and 2020 were retrospectively evaluated. Test sensitivity, specificity, positive predictive value and negative predictive value were compared as well as age, gender, comorbidities, procedure safety, additional pleural-based interventions, duration time of operation and length of hospital stay.ResultsOf 154 patients with undiagnosed exudative pleural effusion, 113 (73.37%) underwent pleural biopsy and drainage with VATS, while 41 (26.62%) underwent AVATS pleural biopsy. Sensitivity, specificity, positive predictive value and negative predictive value were 92, 100, 100, and 85.71% for VATS, and 83.3, 100, 100, and 78.9% for AVATS, respectively. There was no significant difference in diagnostic test performance between the groups, (p = 0.219). There was no difference in the rate of complications [15 VATS (13.3) versus 4 AVATS (9.8%), p = 0.557]. Considering additional pleural-based interventions, while pleural decortication was performed in 13 (11.5%) cases in the VATS group, no pleural decortication was performed in AVATS group, (p = 0.021). AVATS group was associated with shorter duration time of operation than VATS (22.17 + 6.57 min. Versus 51.93 + 8.85 min., p < 0.001). Length of hospital stay was relatively shorter in AVATS but this was not statistically significant different (p = 0.063).ConclusionsOur study revealed that uniportal AVATS pleural biopsy has a similar diagnostic efficacy and safety profile with VATS in the diagnosis and treatment of patients with undiagnosed pleural effusion who have a high risk of general anesthesia due to advanced age and comorbidities. Accordingly, uniportal AVATS pleural biopsy may be considered in the diagnosis and treatment of all exudative undiagnosed pleural effusions.

Pleural biopsy: A useful diagnostic tool in undiagnosed pleural effusion

JCHM - J Community Health Manag- Print ISSN No:-2394-272X Online ISSN No:-2394-2738,The Journal of Community Health Management (JCHM) open access, peer-reviewed quarterly journal publishing since 2014 and is published under the auspices of the Innovative Education and Scientific Research Foundation (IESRF), aim to

Modified thoracoscopic pleural cryo-biopsy in diagnosis of exudative pleural effusion of undetermined etiology

BackgroundRigid thoracoscopy is the gold standard tool for diagnosing exudative pleural effusion, but sometimes it is difficult to obtain sufficient biopsies using the conventional forceps. This study evaluated the efficacy, safety, and diagnostic value of a modified technique using cryoprobe to obtain pleural biopsies during thoracoscopy.ResultsThis is a single-center prospective study in patients that underwent rigid thoracoscopy using conventional rigid forceps followed by a cryoprobe at the same setting after injection of subpleural mixture of adrenaline and xylocaine. Biopsies were reviewed by an independent pathologist; any complications were recorded, and all patients were followed-up post-procedure. Twenty-four patients (12 males; mean age was 56 ± 15.1years) were included. The diagnostic yield of both rigid forceps biopsy (RFB) and cryoprobe biopsy (CPB) was 100%. CPB had more surface area than RFB with no difference regarding largest diameter (p = 0.064). RFB and CPB had similar results regarding presence of fat cells. CPB had much less crushed cells than RFB with better tissue preservation (p = 0.004). No significant complications were reported.ConclusionsThe modified cryoprobe biopsy is a highly effective and safe way for obtaining pleural biopsy besides affording good quality and size of the biopsy especially in thick firmly adherent pleura.

Minimal Change Disease Associated with Malignant Epithelioid Mesothelioma: A Case Report

We report the case of a 64 year old male patient with a recent diagnose of pulmonary nodules with pleural thickening who was admitted to the nephrology department of our hospital for further evaluation of nephrotic syndrome (NS). Malignant epithelioid mesothelioma (MEM) was diagnosed after pleural biopsy while the renal biopsy showed minimal change disease (MCD) with acute tubular necrosis and interstitial lymphoplasmacytic infiltrate. MCD is the most common cause of nephrotic syndrome in children while it accounts for a smaller proportion of NS in adults. The underlying cause of MCD is unclear (Cameron, 1987). Evidence so far suggests that T-cell dysfunction results in the production of a circulating factor directly affecting the glomerular capillary wall with consequent foot process fusion. MCD as paraneoplastic syndrome is common in hematological disorder while the incidence in lung pulmonary malignancies is rare. Early recognition leads to an early diagnosis of malignancy improving the outcome and diminishing the associated co-morbidities.

Propensity-score-matching analysis to compare efficacy and safety between 16-gauge and 18-gauge needle in ultrasound-guided biopsy for peripheral pulmonary lesions

BackgroundDefinitive diagnosis of peripheral pulmonary lesions (PPLs) depends on the histological analysis of the pleural biopsy sample. Ultrasound (US)-guided sampling is now standard practice in the clinical setting. However, determining a suitable needle size and sampling times to improve the efficacy and safety of the biopsy remains challenging. Here, we compared the efficacy between 16- and 18-gauge core biopsy needles in US-guided percutaneous transthoracic biopsy for PPLs on histological diagnosis and procedure-related complications.Materials and methodsIn total, 1169 patients (767 men, 402 women; mean age, 59.4 ± 13.2 years) who received biopsy for PPLs between September 2011 and February 2019 were included. The propensity score matching (PSM) analysis was performed to adjust the baseline differences, and the rate of successful specimen assessment and complications were compared between the 16-gauge (249 patients) and 18-gauge (920 patients) groups. The number of pleural surfaces crossed (NOPSC) was defined as the number of times the visceral pleural surface was transgressed. Stratified analysis was performed based on NOPSC.ResultsThe overall success rate was 92.0% (1076/1169). The overall complication rate was 9.6%, including pneumothorax, hemorrhage, and vasovagal reaction, which occurred in 2.5% (29/1169), 6.6% (77/1169), and 0.5% (6/1169) of the patients, respectively. When NOPSC was 1 or > 2, the success and complication rates in the 16-gauge group were comparable to those of the 18-gauge group (all P > 0.05). When the NOPSC was 2, the success rate in the 16-gauge group was significantly higher than that in the 18-gauge group (P = 0.017), whereas the complication rate was comparable (P > 0.05).ConclusionHigher success rate could be achieved using a 16-gauge than an 18-gauge core biopsy needle in the US-guided percutaneous transthoracic biopsy for PPLs when the NOPSC was 2. We recommend using 16-gauge needles with 2 times of needle passes in biopsy for PPLs in clinical practice.

Interventional pulmonology during COVID-19 pandemic: current evidence and future perspectives.

COVID-19, caused by SARS-CoV-2 infection, has become increasingly prevalent worldwide, reaching a pandemic stage in March 2020. The organization of health care services had to change because of this new disease, with the need to reallocate staff and materials, besides changing management protocols. A very important challenge is not to expose patients and health care workers to the risk of infection and not to waste personal protective equipment (PPE). In the field of interventional pulmonology, various aspects related to COVID-19 must be taken into great consideration. Although bronchoscopy is not a first-line test for patients with suspected SARS-CoV-2 infection, it has a role in selected cases and it can be useful for differential diagnosis. However, bronchoscopy is an aerosol-generating procedure, that’s why its unjustified use could contribute to propagate the virus. For this reason, the utility of each procedure must be carefully evaluated, the patient has to be properly investigated before the procedure, which has to be performed with specific precautions, including adequate PPE. In this review, we summarize the knowledge and the principal statements about endoscopic activity in COVID-19 period, in both diagnosis of COVID-19 and management of patients. How to safely perform both bronchoscopic and pleural-related procedures (thoracoscopy, pleural biopsy and drainage of pleural effusions) is described with the aim to help the staff to decide when and how performing a procedure. We also highlight how interventional pulmonology could help in matter of complications related to COVID-19.

Pleural fluid investigations for pleural infections

: Over 1.5 million patients are admitted to hospital with pneumonia in the United States each year. Up to 50% of them can develop a parapneumonic effusion which is associated with higher mortality. The incidence of pleural infection continues to rise, particularly in the elderly and those with comorbidities. Parapneumonic effusions cover a spectrum of presentations from a free-flowing ‘simple parapneumonic effusion’ to a septated ‘complicated parapneumonic effusion’ (CPE) (usually from bacterial pleural invasion) and ‘empyema’ (presence of pleural pus). Pleural infection is defined as either CPE or empyema, and usually requires evacuation of the infected fluid. Laboratory investigations play an essential part of the diagnosis and management of pleural infection. A parapneumonic effusion is typically a neutrophil-rich exudate. Presence of bacteria from culture of the fluid defines pleural infection but conventional culture methods have a low yield. Surrogate pleural fluid markers are often employed to confirm a CPE, including low pleural fluid pH (<7.2) or glucose (<3.3 mmol/L) and elevated lactate dehydrogenase (LDH). Measurement of pleural fluid triglyceride and chylomicrons (for chylothorax) and cholesterol (for pseudochylothorax) may be needed to separate lipid pleural effusions from empyema. Tuberculous pleural effusions usually result from a hypersensitivity pleuritis and are lymphocyte predominant with elevated pleural fluid adenosine deaminase (ADA) and interferon gamma levels. Culture yield of mycobacteria is typically low. Caseating granulomas on pleural tissue biopsy is often considered diagnostic. Common organisms for community-acquired pleural infection include Streptococcus pneumoniae, Streptococcus anginosus group bacteria and Staphylococcus aureus. Hospital-acquired pleural infections have higher mortality and are often polymicrobial which can include S. aureus, Enterobacteriaceae and anaerobes. Antibiotics and evacuation of the infected fluid, usually by chest tube drainage, remain the mainstay of treatment. Intrapleural fibrinolytic and deoxyribonuclease therapy, or occasionally surgical drainage, may be required.

Treatment of intestinal tuberculosis with small bowel perforation: a case report

BackgroundDiagnosis of intestinal tuberculosis poses a dilemma to physicians due to nonspecific symptoms like abdominal pain, fever, nausea, and a change in bowel habit. In particular, the distinction between inflammatory bowel disease and intestinal tuberculosis remains challenging.Case presentationA 27-year-old man from Colombia presented with fever, night sweats, and progressive lower abdominal pain. Computed tomography revealed a thickening of the bowel wall with a mesenterial lymphadenopathy, ascites ,and a pleural tumor mass. Histology of intestinal and pleural biopsy specimens showed a granulomatous inflammation. Although microscopy and polymerase chain reaction (PCR) for Mycobacterium tuberculosis (MTB) were negative, empirical MTB treatment was initiated on suspicion. Due to a massive post-stenotic atrophied intestinal bowel, MTB medications were administered parenterally in the initial phase of treatment to guarantee adequate systemic resorption. The complicated and critical further course included an intra-abdominal abscess and bowel perforation requiring a split stoma, before the patient could be discharged in good condition after 3 months of in-hospital care.ConclusionsThis case highlights the clinical complexity and diagnostic challenges of intestinal MTB infection. A multidisciplinary team of physicians should be sensitized to a timely diagnosis of this disease, which often mimics inflammation similar to inflammatory bowel disease, other infections, or malignancies. In our case, radiological findings, histological results, and migratory background underpinned the suspected diagnosis and allowed early initiation of tuberculostatic treatment.

How can we use positron emission tomography/computed tomography more accurately for characterization of asbestos-related pleural thickening?

There is no consensus about the standardized uptake value maximum (SUVmax) cut-off value to characterize pleural thickening worldwide. Sometimes, this causes unnecessary invasive diagnostic procedures. Our first aim is to determine a cut-off value for SUVmax. Secondly, we try to answer the following question: If we use this cut-off value together with morphological parameters, can we differentiate benign thickening from malignant pleural mesothelioma (MPM) more accurately? Thirty-seven patients who underwent 2-deoxy-2-fluoro-D-glucose ([18F]FDG) positron emission tomography/computed tomography (PET/CT) before pleural biopsy were included the study. All of patients had histopathologically proven primary pleural disease. Their [18F]FDG-PET/CT imaging reports were re-assessed. If a patient's SUVmax or size of the thickening was not mentioned in the report, we calculated it with their [18F]FDG-PET/CT. Age, pleural effusion, size, and SUVmax were found to have a relationship with MPM. We found the size > 14 mm, and SUVmax > 4.0 as cut-off values for MPM. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for size > 14 mm were found to be 86.4%, 85.2%, 82.6%, 88.5%, respectively. For SUVmax > 4.0, sensitivity, specificity, PPV, NPV were 90.9%, 87.0%, 85.1%, 92.2%, respectively. If a patient has SUVmax > 4.0 and/or size > 14 mm, the risk of MPM is high. These patients should undergo biopsy. If a patient's SUVmax < 4.0, size < 14 mm and does not have pleural effusion, he/she has low risk for MPM. These patients can undergo the follow-up. If a patient's SUVmax < 4, size < 14, and has pleural effusion the MPM risk is approximately 4%. These patients can undergo biopsy/cytology/follow-up. Novel studies are needed for these patients.

Mycobacteria Tales Post Lung Transplantation: An Indian Experience

Purpose Post-lung transplant infection is one of the leading causes of morbidity and mortality. The diagnosis of pulmonary tuberculosis can be even more challenging in the setting of lung transplantation where other pulmonary complications can make diagnosis difficult. Infection may be caused by reactivation of a primary infection in the recipient, reactivation of a lesion from the donor lung, or primary infection. We present a retrospective study from India to define the incidence, clinical presentation, and course of Mycobacterial infections in a cohort of lung transplant recipients. Methods Between 1 April 2017 and 1 September 2020, 140 lung transplants were performed. Serial bronchoscopies with transbronchial biopsies and bronchioalveolar lavages were performed during follow-up. Explant Histopathological findings were taken into consideration. Pleural based interventions in the form of Tapping or CT guided Pleural biopsy were noted. Similarly, NTM infections were documented with species identification on cultures. Results 12 (8.57%) Recipients had Mycobacterial Infections post lung transplant. Mycobacterium Tuberculosis species was diagnosed in 9 patients (75%). Rest 3 recipients (25%) had Non-Tuberculosis Mycobacterium species (2 Mycobacterium abscessus and 1 Mycobacterium fortuitum). In 4 MTB patients, diagnosis was determined from the explanted lungs histopathology. The remainder were diagnosed during postoperative period. Median time to diagnosis was 40.5 days . Radiographic findings (HRCT scan) were Consolidations (n=3), Pleural Effusion (n=3), Tree in Bud (n=1), Cavity (n=1), no typical radiographical presentations (n=4) All patients responded well to anti-mycobacterial therapy. 3 recipients with NTM received individualised treatment for the same. Among these 12 recipients, 3 recipients expired with death attributable to Mycobacterial disease in only 1 recipient. Conclusion Mycobacterial Infection is not rare in lung transplant recipients and can be managed successfully with individualised antimycobacterial therapy. Non-Rifampicin based AntiMycobacterial treatment strategy is preferred to avoid drug interactions with immunosuppressants. Explant Lung Histopathology is an important tool to diagnose Tuberculosis specifically in Indian settings. NTM infection is not uncommon post lung transplantation & should have low threshold for diagnosis.

Diagnostic Accuracy of Pleural Effusion Mononuclear Cells/Leukocyte Ratio in Tuberculous Pleurisy.

Background: Tuberculous pleurisy (TBP) is a common clinical type of tuberculosis (TB) in China. TBP is difficult to diagnose. Whether the mononuclear cell/leukocyte (MNC/LEU) ratio in pleural effusion can contribute to accurate TBP diagnosis remains yet unclear.Objective: To explore the diagnostic value of MNC/LEU ratio in pleural effusion for TBP in China.Methods: This study was a retrospective case-control study involving 406 patients with pleural effusion of unknown cause who were hospitalized at the Henan Provincial People's Hospital. Using histopathological examination of thoracoscopic pleural biopsy as the gold standard for TBP diagnosis, a final total of 215 subjects were included in this study including 91 cases of TBP and 124 cases of non-TBP. The receiver operating characteristic (ROC) curve of pleural effusion MNC/LEU ratio for TBP diagnosis was plotted and the area under curve (AUC) and the optimal cutoff value were determined. In addition, the sensitivity, specificity and accuracy of the MNC/LEU ratio at the optimal cutoff value for TBP diagnosis were also evaluated.Results: The MNC/LEU ratio was significantly higher in TB pleural effusion [95.9% (89.7–98.0%)] than in non-TB pleural effusion [77.8% (39.3–93.2%)] (P < 0.001). The AUC was 0.776 (95% CI, 0.714–0.830), and the sensitivity, specificity and accuracy for TBP diagnosis at the 93.7% cutoff value were 64.83%, 79.03%, and 0.730, respectively.Conclusion: The pleural effusion MNC/LEU ratio may be a new and valuable laboratory indicator for the diagnosis of tuberculous pleurisy in China.

Accuracy of pleural biopsy for the diagnosis of histologic subtype of malignant pleural mesothelioma: Necropsy-based study of 134 cases.

Definition of histologic subtype of malignant pleural mesothelioma (MPM) is important for management of patients, because surgical treatment improves prognosis for patients with epithelioid but not biphasic or sarcomatoid MPM. In a series of necropsies performed in a hospital specialized for MPM diagnosis, we retrospectively investigated the accuracy of histologic diagnosis performed on pathologic specimens collected through pleural biopsies obtained at video-assisted thoracoscopic surgery (VATS) or surgery. We reviewed histologic records of an unselected series of autopsies performed in patients with MPM employed in the Monfalcone shipyards (Northeast Italy) or living with shipyard workers from 1999 through 2017. Using necropsy results as a gold standard, we calculated sensitivity, specificity, and positive and negative predictive values of histology from VATS or surgery after combining nonepithelioid subtypes. We retrieved necropsy records for 134 patients: 62 (46.3%) with epithelioid, 51 (38.1%) with biphasic, and 21 (15.7%) with sarcomatoid MPM. We observed good sensitivity of VATS (0.94) and surgery (0.89) in diagnosing epithelioid MPM. Conversely, specificity was low (VATS: 0.46; surgery: 0.32). Therefore, positive predictive values were also low (VATS: 0.58; surgery: 0.60). Misclassification was particularly high for biphasic MPM (three-fourths of biphasic MPM at necropsy had been classified as epithelioid at VATS or surgery). We observed a substantial degree of misclassification between epithelioid and biphasic MPM for pleural biopsies performed during VATS. Our results suggest caution should be taken in using histologic subtype obtained from VATS in selecting patients with MPM for surgical treatment. We also observed substantial misclassification of biospecimens collected during MPM surgery.

Diagnostic Yield of Closed Pleural Biopsy in Undiagnosed Exudative Pleural Effusions

Diagnostic Yield of Closed Pleural Biopsy in Undiagnosed Exudative Pleural Effusions

Diagnostic value of Xpert MTB/RIF assay on pleural tissue obtained via closed pleural biopsy among persons with presumptive tuberculous pleuritis.

Background Tuberculous pleuritis (TBP) is a common extrapulmonary tuberculosis that contributes to the tuberculosis burden. Xpert MTB/RIF assay is a promising method for rapid diagnosis of TBP. The diagnostic value of Xpert MTB/RIF assay in pleural tissue obtained via closed pleural biopsy among sputum acid-fast bacilli (AFB) smear-negative persons is not well studied. Objectives To evaluate the diagnostic value of Xpert MTB/RIF assay on diagnosis of TB in pleural tissue obtained via blind closed pleural biopsy. Methods Closed pleural biopsy using Cope needle was performed on adult patients who presented with lymphocyte predominant exudative pleural effusion. Xpert MTB/RIF assay was performed in parallel to pathology and mycobacterial culture of the pleural tissue specimen to determine its sensitivity and specificity. Final clinical diagnosis of TBP was determined by improvement in 2-months follow-up of anti-tuberculous treatment. Results A total of 33 patients were included in the study. The median (interquartile range (IQR)) age was 27 (25 - 42) years. The sensitivity and specificity of Xpert MTB/RIF assay was 30% and 100% compared with Mycobacterium tuberculosis culture as the gold standard, and 20% and 95.7% compared with histopathology as the gold standard. Conclusion Xpert MTB/RIF assay in pleural tissue obtained by closed pleural biopsy did not increase diagnostic yield, but it shortens time for diagnosis compared with conventional methods.

Thoracoscopic practices in India-a survey by Indian chest society

BackgroundDiagnostic thoracentesis is the initial diagnostic investigation in the workup of an undiagnosed Pleural effusion. However, a significant percentage of pleural effusions remain undiagnosed after this step and after closed pleural biopsy. Medical thoracoscopy (MT) has a high diagnostic yield in these patients. MT is now widely practised in India. This survey endeavours to study the practice of this technique by respiratory physicians in India. MethodsAn electronic survey called ‘Indian Thoracoscopy survey’ was prepared and conducted under the aegis of Indian Chest Society. In all there were 63 Questions in English prepared and disseminated as a “Google Form” to conduct this survey. The subjects were recruited from the e-mail lists of the three major professional surgeries that serve the interests of the respiratory physicians. The participation in the survey was voluntary and no incentive of any sort was offered to the participants. The survey link was kept open for a 3-month period. ResultsThere were total 659 respondents, whose mean age was 41.5 years and majority of them were males (n = 564, 85.6%). The largest group of respondents practiced in corporate/private hospitals (n = 315, 47.8%). Only 311 (47.2%) respondents performed MT. Of these, 190 (61.1%) used flex-rigid/semi rigid thoracoscopes. Undiagnosed pleural effusions (N = 194; 62.4%) and recurrent pleural effusions (N = 117; 37.6%) were the most common indications for performing MT. Majority of the thoracoscopists (222, 71.4%) used conscious sedation and a combination of Midazolam and Fentanyl was the most preferred combination (n = 238; 76.5%). Most follow the manufacturer's recommendation for thoracoscope cleaning and disinfection and had safety check lists in place. ConclusionOur survey captures the practice of MT in India. MT seems to be increasing in popularity with significant numbers of respiratory physicians performing the procedure. Respondents felt that MT was a valuable investigation that was underused and more of them wanted to learn. It is safe to perform MT under conscious sedation and local anaesthesia and a boon to patients who required surgical procedures for evaluation of difficult to diagnose pleural diseases. The setup cost is significant and would not justify installation in all centres. The lack of opportunities for training is something that needs to be looked in to.

Study protocol of a phase 1 clinical trial establishing the safety of intrapleural administration of liposomal curcumin: curcumin as a palliative treatment for malignant pleural effusion (IPAL-MPE)

IntroductionThis is a phase 1, open-label, single-centre, uncontrolled, dose-escalation study to evaluate the feasibility, tolerability and pharmacokinetic profiles of a single dose of liposomal curcumin, administered via an existing tunnelled...

UTILITY OF VIDEO ASSISTED THORACOSCOPIC SURGERY (VATS) IN RESPIRATORY DISEASES

Background: VATS has diverse application from diagnostic usage to therapeutic measures. Hence the present study was undertaken to study the utility of VATS in respiratory diseases in our tertiary care centre. Methods: A total of 30 patients underwent VATS. Demographic data and peri operative details were noted. Surgical outcome, conversion rate, length of hospital stay and complications were noted. Results: Majority of study subject's age range was from (20 -40) years. (63.3%). The male: female ratio was 1.5:1. Commonest indication was Empyema( TB/Parapneumonic ) (53.33%) followed by Post thoracis trauma (6.6%) , Cystic Disease /Bulle/Pneumothorax (6.6%), Fungal Aspergilloma (6.6% ), Pleural Biopsy (6.6%) , Pulmonary Hydatid Disease (6.6%), Lung Abscess ( 6.6%) , Ca Oesophagus for VATS Esophagectomy (3.3%) and Suspicious malignant Pleural Effusion ( 3.3%).Therapeutic indication was (76.6%), diagnostic indications were (6.6%) and both were (16.6%). Diagnostic accuracy was (93.3 %). Conversion rate was (20 %). Complications were seen in (30%). Average hospital was found to be 12.59 +/- 5. 41 days (7-34 day) and chest tube drainage was 8.7 days +/- 3.0 days. Conclusions: VATS enables diagnostic accuracy for better therapeutic management. Our experience suggests that VATS is an alternative means of treatment and an excellent initial approach to various respiratory diseases.

Diagnostic utility of pleural fluid carcinoembryonic antigen in patients with exudative pleural effusion.

Background:Pleural effusion (PE) is presenting symptoms of many different diseases and is often a diagnostic challenge. Negative cytology in the malignant PE requires more complicated diagnostic procedures, such as closed pleural biopsy or thoracoscopic pleural biopsy. Not all the patients will be fit for such invasive procedures due to high risk. Tumor markers seem to be a promising alternative and have been proposed to aid in the differentiation of the PE etiology.Objective:The objective of the study was to evaluate the diagnostic value of pleural fluid carcinoembryonic antigen (CEA) in differentiation between malignant and nonmalignant PEs and to compare adenosine deaminase (ADA) levels with respect to malignant and nonmalignant PE.Methodology:It was a prospective observational study. Patients who presented with undiagnosed exudative PE during the time period 2016–2018 were studied. Pleural fluid was subjected to all routine investigations such as sugar, protein, lactate dehydrogenase, ADA, and CEA.Results:A total of 100 patients were included in the study. Fifty-one patients had malignancy. Univariate analysis showed that smoker, previous history of cancer, ADA <20, and CEA of >2.15 were variables associated with malignancy. Multivariate analysis showed pleural fluid CEA >2.15 as only independent risk factor associated with malignancy. The sensitivity of 91.5% and 65% and specificity of 92.5% and 81.4%, respectively, were found for CEA 2.15 ng/dl and ADA <16.5 U/L as plotted from receiver operating characteristic curve. The combined CEA and ADA (2.39 ng/ml and 16.5 U/L) values in pleural fluid had higher sensitivity of 100%.Conclusion:Our study demonstrated that pleural fluid CEA levels have a sensitivity of 93.5% and specificity of 73% in diagnosing of malignant PE. ADA levels lesser than 16.5 U/L were seen in patients with malignant PE, but less sensitive and specific compared to CEA. Combined ADA and CEA levels had higher sensitivity than CEA alone.

Pleural biomarkers in diagnostics of malignant pleural effusion: a narrative review.

Although cytology and pleural biopsy of pleural effusion (PE) are the gold standards for diagnosing malignant pleural effusion (MPE), these tools’ diagnostic accuracy is plagued by some limitations such as low sensitivity, considerable inter-observer variation and invasiveness. The assessment of PE biomarkers may hence be seen as an objective and non-invasive diagnostic alternative in MPE diagnostics. In this review, we summarize the characteristics and diagnostic accuracy of available PE biomarkers, including carcinoembryonic antigen (CEA), neuron-specific enolase (NSE), carbohydrate antigens 125 (CA125), carbohydrate antigen 19-9 (CA19-9), carbohydrate antigen 15-3 (CA15-3), a fragment of cytokeratin 19 (CYFRA 21-1), chitinase-like proteins (CLPs), vascular endothelial growth factor (VEGF) and its soluble receptor, endostatin, calprotectin, cancer ratio, homocysteine, apolipoprotein E (Apo-E), B7 family members, matrix metalloproteinase (MMPs) and tissue-specific inhibitors of metalloproteinases (TIMPs), reactive oxygen species modulator 1 (Romo1), tumor-associated macrophages (TAMs) and monocytes, epigenetic markers (e.g., cell-free microRNA and mRNA). We summarized the evidence from systematic review and meta-analysis for traditional tumor markers’ diagnostic accuracy. According to the currently available evidence, we conclude that the traditional tumor markers have high specificity (around 0.90) but low sensitivity (around 0.50). The diagnostic accuracy of novel tumor markers needs to be validated by further studies. None of these tumor biomarkers would have sufficient diagnostic accuracy to confirm or exclude MPE when used alone. A multi-biomarker strategy, also encompassing the use of artificial intelligence algorithms, may be a valuable perspective for improving the diagnostic accuracy of MPE.

Validity of lung ultrasound to rule out iatrogenic pneumothorax performed by pulmonologists without experience in this procedure

IntroductionUltrasonography has been shown to be a useful tool for diagnosing pneumothorax in the hands of experts. After performing bronchopleural procedures, the recommendation is to perform chest radiography to rule out complications. Our objective was to determine the validity of lung ultrasound, conducted by pulmonologists without experience in this procedure, to tule out pneumothorax after invasive procedures. Material and MethodsOur prospective observational study consecutively included patients who underwent transbronchial lung biopsy (TBLB), therapeutic thoracentesis (TT) and/or transparietal pleural biopsies (PB) for whom subsequent chest radiography to rule out complications was indicated. In all cases, the same pulmonologist who performed the technique performed an ultrasound immediately after the procedure. A diagnosis of pneumothorax was considered in the presence of a lung point or the combination of the following signs: absence of pleural sliding, absence of B-lines and presence of the “barcode” sign. ResultsWe included 275 procedures (149 TBLBs, 36 BPs, 90 TTs), which resulted in 14 (5.1%) iatrogenic pneumothoraxes. Ultrasonography presented a sensitivity of 78.5%, a specificity of 85% and positive and negative predictive value of 22% and 98.6%, respectively. Ultrasonography did not help detect the presence of 3 pneumothoraxes, one of which required chest drainage, but adequately diagnosed 2 pneumothoraxes that were not identified in the initial radiography. ConclusionsLung ultrasound performed by pulmonologists at the start of their training helps rule out pneumothorax with a negative predictive value of 98.6%, thereby avoiding unnecessary radiographic control studies in a considerable number of cases.