Pleural Biopsy Research Articles

Performance of Xpert\xae MTB/RIF in diagnosing tuberculous pleuritis using thoracoscopic pleural biopsy

BackgroundEtiological diagnosis of tuberculous pleuritis is challenging, owing to a paucity of Mycobacterium tuberculosis (MTB) in the affected region. Moreover, currently available methods, such as the detection of acid-fast bacilli and microbiological culture, are not always conducive to timely diagnosis and treatment. In this study, we evaluated the performance of Xpert® MTB/RIF assay (hereinafter referred to as “Xpert”) in detecting MTB in difficult-to-diagnose patients using suspensions of pleural biopsy tissue specimens obtained under direct thoracoscopic guidance.MethodsOne hundred and sixty patients with an unexplained pleural effusion were included from the Shenyang Tenth People’s Hospital and Shenyang Chest Hospital, China, between 2017 and 2018. The included patients underwent thoracoscopy under local anesthesia, with an intercostal incision of approximately 1.0 cm for biopsy. The biopsy specimens were used for pathological and etiological examinations. The Xpert test was evaluated for its sensitivity and specificity, as well as positive and negative predictive values (PPV and NPV, respectively), against data obtained using standards: the BACTEC™ MGIT™ 960 liquid culture system and a composite reference standard (CRS).ResultsThe sensitivity and specificity of Xpert were 68.8 and 64.6%, respectively, against the MGIT 960 culture data. The PPV and NPV of Xpert were 56.4 and 75.6%, respectively. The sensitivity of Xpert was 69.0% against the CRS data, which was significantly higher than that of MGIT 960 culture (56.6%). The PPV and NPV of Xpert against the CRS data were 100.0 and 57.3%, respectively.ConclusionsXpert is a good rule-in test but has limited value as a rule-out test for the diagnosis of tuberculosis pleuritis.

Technique of pressurized intrathoracic aerosol chemotherapy (PITAC) for malignant pleural effusion.

ObjectivesMalignant pleural effusion (MPE) is a devastating evolution of several malignancies. Pressurized intrathoracic aerosol chemotherapy (PITAC) might be a novel therapy option in MPE.MethodsPITAC is considered for patients with MPE with a performance status <2 and without other metastatic sites. General anesthesia is administered and a double-lumen bronchial tube is inserted. The patient is placed in a lateral decubitus position, and the operation is performed after ipsilateral lung exclusion. Two 12-mm balloon trocars are inserted—one in the seventh intercostal space in the mid-axillary line and one in the fifth intercostal space in the anterior axillary line. Extent of pleural disease and volume of MPE are documented. MPE is removed and parietal pleural biopsy are performed. An intrathoracic pressure of 12 mmHg CO2 is established, and a combination of Cisplatin (10.5 mg/m2 in a total volume of 150 cc NaCl 0.9%) and Doxorubicin (2.1 mg/m2 in a total volume of 50 cc NaCl 0.9%) are aerosolized via nebulizer in the pleural cavity. Vital signs and nebulization are remote-controlled. After 30 min, the remaining toxic aerosol is exhausted using a closed surgical smoke evacuation system. A 24Fr chest tube is inserted in postero-apical position with continuous negative pressure of 20 cm H2O. When needed, PITAC may be repeated every six weeks in alternate with systemic chemotherapy.ResultsIn our hands, the technique above has shown to be feasible and safe.ConclusionsFurther studies are needed to assess the potential symptomatic and oncological benefits of PITAC in MPE.

Molecular Profiling of Malignant Pleural Effusions with Next Generation Sequencing (NGS): Evidence that Supports Its Role in Cancer Management.

Malignant pleural effusions (MPEs) often develop in advanced cancer patients and confer significant morbidity and mortality. In this review, we evaluated whether molecular profiling of MPEs with next generation sequencing (NGS) could have a role in cancer management, focusing on lung cancer. We reviewed and compared the diagnostic performance of pleural fluid liquid biopsy with other types of samples. When applied in MPEs, NGS may have comparable performance with corresponding tissue biopsies, yield higher DNA amount, and detect more genetic aberrations than blood-derived liquid biopsies. NGS in MPEs may also be preferable to plasma liquid biopsy in advanced cancer patients with a MPE and a paucicellular or difficult to obtain tissue/fine-needle aspiration biopsy. Of interest, post-centrifuge supernatant NGS may exhibit superior results compared to cell pellet, cell block or other materials. NGS in MPEs can also guide clinicians in tailoring established therapies and identifying therapy resistance. Evidence is still premature regarding the role of NGS in MPEs from patients with cancers other than lung. We concluded that MPE processing could provide useful prognostic and theranostic information, besides its diagnostic role.

Diagnostic implications of bronchial lavage in patients with pleural tuberculosis.

The presence of Mycobacterium tuberculosis in a respiratory specimen is diagnostic in patients with pleural effusion. It is difficult to obtain sputum even after induction in these patients. An alternative method of acquiring respiratory specimens is via bronchial lavage. This study was undertaken to evaluate the diagnostic yield of acid-fast bacilli (AFB) smear, AFB culture, and Xpert assay of bronchial lavage fluid in the workup of pleural tuberculosis patients. All patients who met the inclusion criteria of the study underwent thoracentesis, pleural biopsy, and bronchial lavage. Specimens of pleural fluid, pleural biopsy, and bronchial lavage fluid were sent for acid fast bacilli smear, culture, and Xpert assay. Bronchial lavage AFB smear, culture, and Xpert assay was positive in 9.5%, 17.9%, and 26.2% of patients, respectively. It gave an immediate diagnosis in 22 (26.2%) patients. Bronchial lavage, though not a surrogate to pleural biopsy, offers an additional approach to the early diagnosis of pleural tuberculosis in patients not producing sputum. Besides being diagnostic, this method also has epidemiologic significance in containing the tuberculosis epidemic because detecting Mycobacterium in bronchial lavage confirms that the patient is infectious.

Metastatic Mucoepidermoid Carcinoma to the Pleura: An Unusual Presentation

Abstract Casestudy Mucoepidermoid carcinoma is the most common malignant tumor arising in salivary glands. Predictors of poor prognosis include high-grade tumors, positive surgical margins, lymph node metastasis, or distant metastasis. The most common sites for distant metastasis include skin, lung, liver, and bone. We herein present a case of salivary gland mucoepidermoid carcinoma with pleural involvement, which is an infrequent site for metastasis. A 64-year-old female presented with worsening dyspnea and cough, which showed no improvement with antibiotics. Imaging showed a right lung nodule measuring 1.2 cm along with bilateral pleural effusion and pleural based nodularities. The dominant nodules in right and left chest measured 5.8 cm and 4.8 cm in greatest dimension, respectively. The findings were suspicious for metastatic disease. Cytological examination of pleural fluid showed reactive mesothelial cells and inflammatory cells. Subsequent biopsy of the right pleural nodule showed sheets of tumor cells with abundant eosinophilic cytoplasm and few scattered clear cells. Mucocytes were absent. The tumor cells were positive for p40 and negative for TTF-1 by immunohistochemistry. A review of patient’s medical history was significant for high-grade salivary gland mucoepidermoid carcinoma, which was resected and radiated six years prior. A comparison of both lesions showed similar morphologic features. Mucicarmine stain was positive in resection specimen but negative in pleural biopsy, confirming the absence of mucocytes. Molecular studies on both specimens showed positivity for fusion of CRTC1 (19p13) and MAML2 (11q21) loci. The overall findings were consistent with metastatic mucoepidermoid carcinoma to pleura. Conclusion Pleura is an uncommon site for metastasis from primary salivary gland mucoepidermoid carcinoma but should be part of differential diagnosis. Extensive review of patient’s past medical history plays a crucial role in correctly classifying these lesions as primary or metastatic. Differential diagnoses should include primary squamous cell carcinoma, mesothelioma, and the rare primary mucoepidermoid carcinoma of pleura.

Symptomatic Cerebral Metastases In Malignant Pleural Mesothelioma: A Rare Case Report

Abstract Casestudy: Malignant mesothelioma is an aggressive tumor with dismal prognosis. Incidence in the United States is approximately 3300 cases/year, and the most common site is the pleura. Although mesothelioma is usually a locally invasive tumor, distant metastases to liver, adrenal glands, kidney and contralateral lung have been described. Brain metastases are observed in less than 3% of metastatic cases and most have been detected incidentally at autopsy. Symptomatic brain metastases are unusual. We describe a case of a 77 year old gentleman with history of occupational asbestos exposure who presented with shortness of breath and dry cough. The radiological investigations revealed left pleural thickening with pleural effusion, which on biopsy proved to be biphasic malignant mesothelioma. Despite multi-modality therapy, the patient showed local disease progression. Following 37 months of initial diagnosis, he developed progressive left-sided weakness. Brain MRI revealed a 1.7 cm enhancing mass involving right posterior frontal lobe, with extensive edema in the surrounding tissue. On biopsy, mass was composed of nests and sheets of round-to-spindled cells with scant eosinophilic cytoplasm, separated by fibrous septa. Brisk mitotic activity and necrosis were present. There was a sharp border with adjacent brain parenchyma. The tumor was positive for WT-1, calretinin, and cytokeratins and negative for Ber-Ep4 and glial fibrillary acid protein by immunohistochemistry. The histological appearance of the tumor was similar to that of the pleural biopsy. Thus a diagnosis of metastatic malignant mesothelioma was made. This solitary metastasis was treated with resection and post-operative stereotactic radiation. The 3-month follow-up brain MRI revealed nodular enhancement within the cavity with multiple supra- and infra-tentorial enhancing lesions, and leptomeningeal enhancement, most consistent with progressing metastatic disease. With the advancements in treatment options that has improved survival in malignant mesothelioma patients, the pathologist and neurosurgeon should be aware of the diagnostic possibility intra-operatively which may alter the management.

Imprint Cytology of Thoracoscopic Pleural Biopsy Tissue for Early Etiological Diagnosis of Pleural Effusion: A Pilot Study From India.

Thoracoscopic pleural biopsy provides the highest diagnostic yield in both malignant and tubercular pleural effusions. However histopathologic report takes 3 to 5 days to provide the diagnosis, resulting in a delay of further management plans like pleurodesis or chest tube removal. Imprint cytology of biopsy tissue can provide early information about the etiological diagnosis. Thus, we conducted this pilot study in 66 patients of exudative pleural effusions undergoing medical thoracoscopy. One or 2 biopsy pieces obtained during medical thoracoscopy from pleural nodules were used to prepare imprint cytology slides in the thoracoscopy suite. In comparison to thoracoscopic pleural biopsy, the diagnostic yield of imprint cytology of pleural tissue was 92% (49 of 53 cases) in cases of malignant pleural effusion and 75% (9 of 12 cases) in cases of tuberculosis pleural effusions. Imprint cytology provided a definite idea about the type of diagnosis, about 2.5 days before the histopathology results. By providing early etiological diagnosis, it may also decrease the duration of hospital stay and health care expenditure. A large prospective trial has been planned in our center to confirm this hypothesis.

Pleural effusion in sarcoidosis patients

The article presents the review of 62 publications which demonstrated that 1.1-16.7% of patients with pulmonary sarcoidosis develop plural effusion. Data from thoracoscopic examinations with pleural biopsy in sarcoidosis revealed damage to both the visceral and parietal pleura which manifested through hydrothorax, chylothorax, and hemothorax. Among patients with pleural effusions of various etiology, pleural sarcoidosis is detected in 1.5-4.0% of cases. However, pleural effusion in patients with sarcoidosis can also be caused by concomitant diseases (tuberculosis, mycosis, cardiac, renal, and hepatic failures, pulmonary embolism, pneumonia, and oncological diseases). In this regard, it is advisable to perform morphological verification for the etiological diagnosis of pleural effusion in sarcoidosis patients.

A Prospective Study for comparison of diagnostic utility of Gene XPERT MTB/RIF Assay, adenosine deaminase and cytology in Tuberculous Pleural Effusion

Introduction: Tubercular pleural effusion is the second most common extrapulmonary form of tuberculosis in India. It poses several health challenges in a developing country like India which has limited resources, for developing appropriate methods to diagnose. Aim: The objective of the study was to determine the role of cartridge-based nucleic acid amplification test (CBNAAT) in the diagnosis of tubercular pleural effusion (TPE) and compare it with the diagnostic utility of Adenosine Deaminase (ADA) and lymphocyte counts in pleural fluid. Methods: Total 100 patients were selected from July 2019 to December 2019. Pleural fluid was collected in sterile container. Gene/xpert, Adenosine deaminase, total leukocytes count and lymphocytes percentage were evaluated. Results: It was found that high leukocytes count and lymphocyte predominance was present in >80% of the patient. Mean ADA was 68.7 U/L 13.2 (SD). CBNAAT was positive in 30 patients. Acid fast bacilli stain was negative in the entire patient. Conclusion: The usefulness of Xpert MTB/RIF to diagnose pleural TB is limited by its poor sensitivity. A high ADA40 U/L in combination with Light’s criteria to define exudates, with lymphocyte predominance is sufficient evidence to diagnose tuberculous pleural effusion and initiate anti-tubercular therapy, thereby deferring the need to perform an invasive pleural biopsy. Keywords: Tuberculosis, Xpert MTB/RIF, Adenosine deaminase, Lymphocytes, Pleural fluid.

The Use of The International System for Reporting Serous Fluid Cytopathology (ISRSFC) on Patients with Pleural Effusion and Pleural Biopsy

The Use of The International System for Reporting Serous Fluid Cytopathology (ISRSFC) on Patients with Pleural Effusion and Pleural Biopsy

The "Brescia panel" (Claudin-4 and BRCA-associated protein 1) in the differential diagnosis of mesotheliomas with epithelioid features versus metastatic carcinomas.

The distinction between mesothelioma with epithelioid features and metastatic carcinoma may be challenging, particularly on cytology. A novel 2-hit Claudin-4 and BRCA-associated protein 1 (BAP1) panel was investigated. The objective of this study was to determine the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the panel on cytology from pleural effusions and matched biopsies, including 49 malignant mesotheliomas on cytology with 43 matched biopsies, 49 normal/reactive mesothelial proliferations, and 49 pleural metastatic carcinomas from different primaries with 21 matched pleural biopsies. The diagnostic role of the 4 categories obtained by crossing the immunostaining results was analyzed. Claudin-4 strongly stained all metastatic carcinomas and tested completely negative in normal mesothelium, benign reactive mesothelial hyperplasia, and malignant mesothelioma. All normal and benign mesothelial proliferations and all carcinomas except 1 were immunoreactive for BAP1, whereas BAP1 loss was observed in 88% of malignant mesotheliomas. The expression of Claudin-4 alone excluded all benign and malignant mesothelial growth, consistently characterizing all metastatic carcinomas. Double negativity was evident in all malignant mesotheliomas, and double positivity was observed in all metastatic carcinomas. BAP1-positive/Claudin-4-negative status was observed only in malignant mesotheliomas and benign mesothelial proliferations. A single metastatic anal squamous cell carcinoma had BAP1-negative/Claudin-4-positive staining. Claudin-4 expression was completely specific and sensitive for metastatic carcinoma, excluding mesothelial proliferations. BAP1 staining characterized 98% of metastatic carcinomas and 100% of benign mesothelial proliferations, whereas negativity was observed almost exclusively in mesotheliomas. This 2-hit panel is probably the best compromise for differentiating malignant mesothelioma and metastatic carcinoma on either cytology or biopsy specimens.

Adenosine deaminase cutoff value when diagnosing tuberculous pleurisy in patients aged 40 years and older

Tuberculous pleurisy (TBP) is one of the most common manifestations of extra-pulmonary tuberculosis. In patients aged ≥40years, a closed needle pleural biopsy is recommended with an adenosine deaminase (ADA) level of 40-70U/L. We aim to investigate whether the cutoff value of ADA and the cancer ratio in patients with TBP aged ≥40years is different and determine the effects of both compounded biomarkers on diagnosing TBP. Between 2009 and 2016, the ADA levels were measured in pleural effusions from patients who were admitted to the Chest disease clinic. Of the 196 patients included in the study, 104 were aged ≥40years. A significant relationship was found between the serum LDH/pleural ADA (sLDH/pADA) ratio and ADA levels in patients aged >40years (OR: 0.935 and OR: 1.085, respectively). The model using an ADA value ≥30 and an sLDH/pADA ratio <16 yielded a sensitivity of 94.25% (95% CI, 87.1-98.10) in all patients and 69.23% (95% CI, 54.9-81.28) in patients aged >40years. ADA and the sLDH/pADA ratio are simple, cost-efficient, and obtain fast results and, therefore, are the preferred methods in TBP diagnosis. The diagnosis rate in the present study was 91% using ADA levels in combination with the sLDH/pADA ratio, both of which can be obtained only through thoracentesis.

PRIMARY MALIGNANT MYELOMATOUS EFFUSION IN MULTIPLE MYELOMA PATIENT

SESSION TITLE: Medical Student/Resident Disorders of the Pleura Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Malignant pleural effusion secondary to Multiple Myeloma (MM) is most commonly a consequence of end organ damage secondary to pleural infiltration with monoclonal gammopathy. It occurs in about 6% of cases of multiple myeloma; approximately 1% of those patients have Primary Malignant Myelomatous Effusion (PMMPE), which occurs due to myelomatous involvement of the pleura or surrounding structures. The diagnosis of PMMPE can be difficult to make with flow cytometry; definitive diagnosis is made with pleural biopsy. CASE PRESENTATION: 53-year-old female with a past medical history of hypertension presented with two months of worsening dyspnea, weight loss, and early satiety. Initial evaluation on admission included a chest x-ray, which showed a large left-sided pleural effusion requiring thoracentesis. Admission laboratory testing showed hypercalcemia and an acute kidney injury, which prompted further diagnostic testing to evaluate for underlying malignancy; which included protein electrophoresis demonstrating markedly elevated free lambda, bone marrow biopsy, which showed 66% plasma cell differentiation, confirming the diagnosis of lambda light chain MM. Her hospital course was complicated by recurrent, rapid re-accumulation of her left-sided pleural effusion requiring two additional thoracenteses. She ultimately had a Pleur-X chronic indwelling chest catheter placed for symptomatic relief. Pleural fluid cytopathology was inconclusive and immunophenotype showed no significant abnormalities. No pleural biopsy was done; however, the initial presentation of a large left-sided pleural effusion would indicate that this was more than likely PMMPE. She was started on outpatient chemotherapy, however her condition continued to deteriorate requiring multiple readmissions, and she unfortunately passed away within four months of initial diagnosis. DISCUSSION: MM is one of the most common forms of cancer in the United States. It represents 10% of all malignant hematological diseases, which mainly affect the bone marrow, although extramedullary tissues may be infiltrated as well. Pleural effusions may be a sign of thoracic involvement in approximately 6%, however 1% of these can be primary pleural effusions. PMMPE is seen very late in the disease process associated with light chain kappa MM, with left-sided effusions being more common. Median survival time after diagnosis is approximately 4 months. Cytological identification of malignant plasma cells within the pleural effusion has been the best test for diagnosis, however due to the limited number of malignant plasma cells and in vitro degeneration, cytological studies can be unreliable. Pleural biopsy may be the most accurate diagnostic test however this can also be inconclusive due to patchy infiltration of pleura. CONCLUSIONS: PMMPE is seen very late in the disease process, can be very difficult to diagnose. Prognosis is poor after diagnosis. Reference #1: Mangla, A., Agarwal, N., Kim, G., Catchatourian, R. Primary Malignant Myelomatous Pleural Effusion. Clinical Case Reports. 2016; 4(8): 803-806. Reference #2: Zhang LL, Li YY, Hu CP, Yang HP. Myelomatous pleural effusion as an initial sign of multiple myeloma—a case report and review of literature. J Thorac Dis 2014;6(7):E152-E159. https://doi.org/10.3978/j.issn.2072-1439.2014.06.48 Reference #3: Xu et al.: A case of bilateral pleural effusion as the first sign of multiple myeloma. European Journal of Medical Research 2013 18:7. https://doi.org/10.1186/2047-783X-18-7. DISCLOSURES: No relevant relationships by Jasmine Sekhon, source=Web Response No relevant relationships by Ximena Solis, source=Web Response No relevant relationships by Divya Vangipuram, source=Web Response

SURVIVAL OUTCOMES OF HEMATOLOGIC MALIGNANCIES USING THE LENT SCORE

SESSION TITLE: Disorders of the Pleura Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Malignant pleural effusion (MPE) may portend limited survival in certain cancers. The LENT (pleural fluid lactate dehydrogenase, Eastern Cooperative Oncology Group (ECOG) performance score (PS), neutrophil-to-lymphocyte ratio and tumor type) scoring system was the first validated prognostic score for MPE. Based on their analysis, hematologic malignancies are considered a low risk tumor type with a LENT score between 0 to 1, but their analysis only included a small number of these tumors which were primarily lymphoma. We hypothesize significant heterogeneity in terms of disease course and survival exist among the various hematologic malignancies. Our objective was to evaluate the LENT score in various hematologic malignancies and compare outcomes. METHODS: A retrospective review of all hematologic malignancies undergoing pleural intervention from 1/2004 to 8/2018 was performed. Hematologic malignancies were categorized into lymphoma, acute leukemia, chronic leukemia and multiple myeloma. MPE was confirmed based on cytology, flow cytometry, pleural biopsy, radiographic evidence of malignancy, or clinical consensus. Pleural effusions due to other etiologies were excluded. Survival time was calculated from the date of first pleural intervention for MPE to death. Preliminary data for 584/999 patients is included. RESULTS: Of the 584 patients identified, there were 57% women, and the median age was 64 (17 to 94). Hematologic malignancies included 57.4% lymphoma, 17.6% acute leukemia, 14.2% chronic leukemia, and 10.8% multiple myeloma. 50.5% had newly diagnosed disease, and 49.5% had evidence of disease relapse. Most (72.4%) were on active treatment for their cancer. The majority (82.5%) were performed in the inpatient setting, and 87.1% had unilateral effusions. Confirmation of MPE was based on cytology in 86.8%, flow cytometry in 60.6%, radiographic imaging in 29.1%, pleural biopsy in 1.0% and clinical consensus in 16.9%. LENT score distribution was as follows: 0 in 0.7%; 1 in 15.7%; 2 in 29.8%; 3 in 32.9%; 4 in 15.7%; 5 in 5.1%. Median survival for groups were as follows: lymphoma 156 days 95% CI (106 to 217); acute leukemia 82 days 95% CI (57 to 97); chronic leukemia 198 days 95% CI (131 to 370); multiple myeloma 149 days 95% CI (70 to 215). Log –rank test for equality of survivals showed significant differences in survival between groups (p<0.001) CONCLUSIONS: For the majority of hematologic malignancies in our cohort, the LENT score was 2 or greater. Median survival differs among the various hematologic malignancies, and the current LENT score may overestimate survival for certain hematologic malignancies. CLINICAL IMPLICATIONS: The LENT prognostic scoring system is a useful tool for risk stratification and prognostication in MPE, but there may be significant differences in survival among hematologic malignancies. DISCLOSURES: No relevant relationships by Lara Bashoura, source=Web Response no disclosure on file for George Eapen; No relevant relationships by Saadia Faiz, source=Web Response No relevant relationships by Horiana Grosu, source=Web Response No relevant relationships by William Harding, source=Web Response No relevant relationships by Carlos Jimenez, source=Web Response No relevant relationships by Oriana Salamo, source=Web Response No relevant relationships by Mark Warner, source=Web Response No relevant relationships by Kathleen Zavalla, source=Web Response

Diagnostic Accuracy of Transthoracic Ultrasound Guided Biopsy Versus Medical Thoracoscopic Pleural Biopsies in Unexplained Exudative Pleural Effusions in El-Minia University Hospital (Single Center Experience)

Background: Transthoracic ultrasound (TUS) has been established to be important in chest diseases including pleural diseases. Interventional pulmonology showed rapid growth and flex–rigid thoracoscopy development, which brought medical thoracoscopy to the forefront. Objective: To compare the diagnostic accuracy, advantages and complications of TUS pleural biopsies versus medical thoracoscopic pleural biopsies in patients with idiopathic and exudative pleural effusion (PE) in El-Minia University Hospital. Patients and methods: Seventy patients with idiopathic and exudative PE were divided randomly into two groups; group I included 45 patients underwent sonar guided pleural biopsy and group II involved 25 patients underwent thoracoscopic pleural biopsy. Results: TUS-guided biopsy was diagnostic in 40 of 45 (88.8%) compared to 24 of 25 cases (96%) were diagnosed by thoracoscopy. Forty-two patients had malignant cause of effusion; 23 patients (51%) in TUS group and 19 (76%) patients in thoracoscopy group. Twenty-two patients had nonmalignant pleural effusion; 17 in group I and 5 in group II. The diagnosis was unclear in 6 patients, 5 of them in group I. Thoracoscopic group displayed greater percentages of post-procedural complications especially pain in site of puncture. Conclusion: TUS examination has close sensitivity and specificity to medical thoracoscopy and allows better assessment of effusion with fewer complications.

Prise en charge diagnostique et thérapeutique du mésothéliome pleural malin en 2020: Diagnostic and therapeutic management of malignant pleural mesothelioma in 2020

AbstractMalignant pleural mesothelioma (MPM) is a rare tumor, usually due to previous asbestos exposure. Its glob prognosis is poor, without validated curative treatment to date. Diagnosis relies ideally on thoracoscopy with pleural biopsies, ± combined with talc pleurodesis. Surgery with curative intent, included with multimodal treatment, is restrained to highly selected patients. Radiotherapy is also of limited indication in MPM. Standard first line chemotherapy does quite poorly, improved by addition of bevacizumab. No treatment is validated as second line or further even if anti-PD-1/PD-L1 ± anti-CTLA-4 antibodies exhibited promising results in phase II trials (MAPS-2…). Thus the search of new treatments, strategies and biomarkers is a crucial goal, and recruitment of patients in clinical trials is strongly encouraged. Other immunotherapies alone or combined with standard treatments and/or targeted therapies, multimodal strategies including intrapleural therapy are currently assessed.In France, the national network of clinical expert centers for MPM, “MESOCLIN” then “NET-MESO” by its recent association with the pathologist network “MESOPATH”, aims at proposing an optimal treatment to all patients systematically discussed in regional (±national) MTB dedicated to MPM, and at stimulating clinical and translational research in close collaboration with its partners: Mesobank, IFCT… and patients associations.© 2020 SPLF. Published by Elsevier Masson SAS. All rights reserved.

PROGNOSTIC SIGNIFICANCE OF PLEURAL EFFUSION IN CHRONIC LYMPHOCYTIC LYMPHOMA: UTILITY OF EARLY FLOW CYTOMETERY IN HEMATOLOGIC PLEURAL METASTASES

SESSION TITLE: Fellows Lung Cancer Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pleural effusion in patients with chronic lymphocytic leukemia / small lymphocytic lymphoma (CLL/SLL) is multifactorial in origin (1). Pleural and lung parenchymal involvement by leukemic cells is very rare, but can be a sign of advanced disease, especially, in previously indolent disease (2). High index of suspicion can expedite the workup and potentially can improve clinical outcome in these patients. CASE PRESENTATION: 76-year-old Caucasian male with previous diagnosis of B-cell (CLL/SLL) lymphoma presented with dyspnea and large right sided pleural effusion (Figure 1). CLL was diagnosed two years ago and was treated with Ibrutinib which was recently discontinued due to intolerability. He had not received radiotherapy. Imaging revealed hyper metabolic mediastinal lymphadenopathy without thoracic duct obstruction (Figure 2). Patient had also undergone two prior thoracenteses in which analysis was consistent with an exudative process and cytology was negative (Table 1). Third thoracentesis was done with flow cytometry (FC) which showed monotypic B-cell population consistent with B-cell (CLL/SLL) and was identical to previous lymph node biopsy (Table 2). Indwelling pleural catheter was placed and his symptoms improved with re-expansion of the lung (Figure 1 B). Patient opted for palliative care and died two months later. DISCUSSION: Pleural and lung involvement is rarely seen as initial manifestation of CLL. It can be sign of disease progression in established and indolent CLL (1). Pleural effusion in CLL can be reactive, tuberculous or chylothorax. Radiation or chemotherapy induced serositis causes bilateral pleural and pericardial effusions (1). Very, rarely leukemic cells infiltration produces hemorrhagic effusions (1). However, it can be exudative and non-hemorrhagic, as in this case. Early diagnosis can be challenging in such cases due to coexistent etiologies such as congestive heart failure. Pleural fluid cytology is often inconclusive with mixed B-cell population (2). Identification of monoclonal malignant lymphocyte population identical to primary site is essential. Pleural fluid FC can be helpful in case of in-determinant cytology for confirmation of diagnosis, and is less invasive than pleural biopsy (3). Moreover, it can help to exclude reactive or infectious etiologies, which are T-cell predominant (1). Provider should be aware of limitations of FC in large B-Cell lymphoma (false negative) and T-Cell lymphoma (no specific FC T cell marker) (2). FC should be considered when likelihood of malignancy is high, in-determinant cytology or with previous established diagnosis of CLL. CONCLUSIONS: Refractory pleural effusion in patients with indolent CLL is concerning for disease progression. Pleural fluid cytology is often inconclusive. Early flow cytometry in carefully selected patient population can expedite the diagnosis and thus can minimize the morbidity and mortality. Reference #1: 1-Pleural Effusions in Hematologic Malignancies. Michael G. Alexandrakis, MD; Freda H. Passam, MD; Despina S. Kyriakou, MD; and Demosthenes Bouros, MD, FCCP. (CHEST 2004; 125:1546-1555 Reference #2: 2-Flow Cytometry and Effusions in Lymphoproliferative Processes and Other Hematologic Neoplasias. Beata Bode-Lesniewska. Acta Cytologica 2016; 60:354–364 DOI: 10.1159/000448325 Reference #3: 3-Czader M, Ali SZ: Flow cytometry as an adjunct to cytomorphologic analysis of serous effusions. Diagn Cytopathol 2003;29: 74–78. DISCLOSURES: No relevant relationships by Heather Boakye, source=Web Response No relevant relationships by Hafiz Mahboob, source=Web Response no disclosure on file for Cameron McLaughlin

Splenic Laceration: A Rare Complication of Abdominal Paracentesis

Abdominal paracentesis is a commonly performed diagnostic and therapeutic procedure with a low complication rate. Previously described complications include injury to the abdominal wall, small bowel perforation, and abdominal hemorrhage. Splenic injury has also been described as a complication from bedside procedures including colonoscopy, upper gastrointestinal endoscopy, thoracentesis, and pleural biopsy. This case highlights a previously unreported complication from an abdominal paracentesis, splenic laceration.

ASPERGILLUS FUMIGATUS EMPYEMA IN AN IMMUNOCOMPROMISED PATIENT WITH RHEUMATOID ARTHRITIS

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Fungal empyema is a rare entity (less than 1 percent of all cases) with Candida spp. being the most common etiological agents and only a few cases due to Aspergillus spp (1). CASE PRESENTATION: A 74-year-old male with history of rheumatoid arthritis on maintenance prednisone and methotrexate presented with progressive exertional shortness of breath and productive cough for 3 months. Chest X-ray showed a large left pleural collection with air-fluid level and thick wall. Computed tomography (CT) of the chest showed a large pleural loculation with an air fluid level surrounded by thickened wall, consolidation of the left lower lobe, and scattered tree-in-bud opacities bilaterally. A small right pleural effusion with multiple benign appearing pulmonary nodules was also noted. Video-assisted thoracoscopic surgery (VATS) with decortication was done. Pleural biopsy showed a dense mat of branching, septated fungal hyphae involving necrotic pleura. Pleural fluid cultures grew Aspergillus fumigatus. IV liposomal amphotericin was started, caused hypotension, was changed to IV voriconazole which led to acute liver injury and was eventually treated with micafungin. Repeat cultures from thoracostomy drainage grew Streptococcus viridans and Neisseria flava. They were suspected to have seeded from a bronchopleural fistula and IV piperacillin-tazobactam was given for coverage. The hospital course was complicated by left sided pneumothorax post-VATS requiring reinsertion of chest tube, atrial fibrillation with rapid ventricular rate, dysphagia and right sided pleural effusion requiring diagnostic thoracentesis (exudative fluid with negative culture). Patient requested discontinuation of medical therapy and transition to comfort measures due to his extended hospital stay. He was eventually transferred to hospice. DISCUSSION: Among the Aspergillus empyema cases, A. fumigatus is isolated most often, though other spp., such as A. flavus and A. terreus, have also been implicated (2). Fifty percent of such cases are polymicrobial. Risk factors include immunocompromised state and conditions predisposing to bronchopleural fistula (tuberculosis, sarcoidosis, cavitary pneumonia, thoracic surgery, pneumonectomy and lung transplantation). Diagnosis is made from pleural fluid culture or pleural biopsy stains showing characteristic hyphae. Pleural fluid is generally turbid with high protein, low glucose, increased neutrophils and galactomannan. Treatment is combined surgical (drainage of the pleural cavity, necrotic tissue resection and closure of bronchopleural fistula) and prolonged systemic antifungal therapy with triazoles (first line) or echinocandins (salvage therapy for treatment failure or tolerability concerns) (3). CONCLUSIONS: Aspergillus empyema is a rare but highly morbid entity that should be considered in immunocompromised hosts and requires surgical and prolonged medical management. Reference #1: Ko SC, Chen KY, Hsueh PR, Luh KT, Yang PC. Fungal empyema thoracis: an emerging clinical entity. Chest. 2000;117(6):1672. Reference #2: Albelda SM, Gefter WB, Epstein DM, Miller WT. Bronchopleural fistula complicating invasive pulmonary aspergillosis. Am Rev Respir Dis. 1982 Jul;126(1):163-5 Reference #3: Bonatti H, Lass-Floerl C, Angerer K, Singh N, Lechner M, Stelzmueller I, Singh R, Schmid T, Geltner C. Successful Management of Post pneumonectomy Aspergillus pleural empyema by combined surgical and antifungal treatment with voriconazole and caspofungin. Mycoses. 2010 Sept; 53(5) 448-54 DISCLOSURES: No relevant relationships by Amit Rout, source=Web Response No relevant relationships by Adrian Sarzynski, source=Web Response No relevant relationships by Sahib Singh, source=Web Response

RECURRENT SPONTANEOUS PNEUMOTHORAX IN A YOUNG FEMALE PATIENT

SESSION TITLE: Medical Student/Resident Disorders of the Pleura Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Spontaneous pneumothorax (PTX) has an incidence of 1.2 to 6 cases per 100,000 females. Catamenial PTX is a rare type of secondary spontaneous PTX concomitant with menstruation, with an incidence of 3-6% among women initially diagnosed with primary spontaneous PTX. The pathophysiology of catamenial PTX involves the presence of endometrial tissue within the thoracic cavity, involving the pleura, diaphragm, or tracheobronchial tree, also known as thoracic endometriosis. These symptoms occur within 72 hours before or after menstruation. Due to the rarity of catamenial PTX, this condition represents a diagnostic & therapeutic challenge. CASE PRESENTATION: A 30 year old African American female presents with chief complaint of right (Rt) sided chest pain & dyspnea. The patient had experienced bilateral chest pain one day after beginning menstruation, with the left-sided chest pain resolving & progression of Rt-sided chest pain over the following days. She also had a cough for one week that had resolved at the time of presentation. Past medical history was remarkable for a previous episode of PTX on the left side 2 yrs prior, treated initially with chest tube drainage & subsequently requiring Video-Assisted Thoracoscopic Surgery (VATS) pleurodesis for recurrence. Pleural biopsy at that time showed acute & chronic pleuritis with inflammatory cells and fibrin. Chest Computed Tomography (CT) showed no other significant pulmonary parenchymal abnormality or cystic disease. Other co-morbidities included obesity, hay fever and acid reflux disease. Besides occasional marijuana use, no cigarette smoking or alcohol use reported. Family history was negative for pulmonary disease, endometriosis or PTX. Physical exam upon admission showed normal vital signs & diminished breath sounds on the Rt side suspicious for PTX. Chest x-ray (CXR) showed large Rt PTX with 7 cm pleuropulmonary separation without mediastinal shift. Small bore pigtail chest tube was placed with resolution of PTX. Right-sided VATS with pleurodesis was performed for definitive treatment. Post-operative course was unremarkable & the patient was discharged 2 days later. Follow-up CXR a week later showed complete resolution of small right apical PTX. DISCUSSION: Catamenial PTX should be suspected in the differential for young women with recurrent PTX coinciding with menstrual periods & in the absence of other common etiologies. Early identification, acute management with chest tube insertion, & definitive treatment with VATS pleurodesis is usually needed. Other preventative treatment may include hormonal therapy. CONCLUSIONS: This case illustrates an example of diagnosis & management of catamenial PTX, a rare type of spontaneous PTX in women associated with menstruation & caused by thoracic endometriosis. Reference #1: Noppen, M. (2010). Spontaneous pneumothorax: Epidemiology, pathophysiology and cause. European Respiratory Review, 19(117), 217–219. DISCLOSURES: No relevant relationships by Asok Dasgupta, source=Web Response No relevant relationships by Reed Geisler, source=Web Response No relevant relationships by Ty Gilkey, source=Web Response No relevant relationships by Chelsea Leipold, source=Web Response No relevant relationships by Paresh Timbadia, source=Web Response