Pleural Effusion Specimens Research Articles

Fungal Empyema Thoracis

To analyze the clinical spectra, pathogenesis, treatment, outcome, and prognostic factors of fungal empyema thoracis. The medical records of patients with positive fungal cultures from pleural effusions were retrospectively analyzed. A university-based tertiary care hospital in Taipei, Taiwan. From January 1990 through December 1997, patients diagnosed with fungal empyema were included in this study. The criteria for diagnosis of fungal empyema thoracis were as follows: (1) isolation of a fungal species from the pleural effusion; (2) significant signs of infection, such as fever (body temperature > 38.3 degrees C) and leukocytosis (white blood cell > 10,000/microL); and (3) isolation of the same mold species from pleural effusion on more than one occasion, or from pleural effusion and other specimens such as blood, sputum, or surgical wounds that showed evidence of tissue invasion. Sixty-seven patients with fungal empyema thoracis were included. Their mean age was 54 years (range, 2 weeks to 93 years), and 64% (43 patients) were men. Fifty-seven patients (85%) had various underlying diseases, and 18 (27%) had more than one immunocompromising condition. A total of 73 fungal isolates were recovered from pleural effusion; the most commonly encountered were Candida species (47 isolates, 64%), Torulopsis glabrata (13 isolates, 18%), and Aspergillus species (9 isolates, 12%). Candida albicans (28 isolates) was the most common Candida species, followed by Candida tropicalis (13 isolates). Six patients (9%) had two fungal strains isolated, and 16 (24%) had concomitant bacterial empyema thoracis. Eighteen patients (27%) had concurrent fungemia. Most (56 patients, 84%) cases of fungal empyema thoracis were nosocomial, and many case (43 patients, 64%) were acquired in ICUs. Abdominal disease (20 patients, 30%), especially previous abdominal surgery and GI perforation (12% and 10%, respectively), was the most common cause of fungal empyema thoracis, followed by bronchopulmonary infection (15 patients, 22%) and chest surgery (12 patients, 18%). Forty-nine patients (73%) received systemic antifungal therapy, and 38 (57%) underwent closed drainage therapy. Eleven patients (16%) underwent pleural irrigation with normal saline solution, povidone-iodine solution, or antifungal agents. Six patients (9%) finally received decortication. All patients receiving surgery or pleural irrigation with antifungal agents survived. Despite the aforementioned management, the crude mortality was high (73%). Multivariate analysis showed a significantly increased risk of death in immunocompromised patients (relative risk, 1.58; p < 0.005) and those with respiratory failure (relative risk, 2.31; p < 0.001). Systemic antifungal therapy was associated with a significantly lower risk of death (relative risk, 0.69; p < 0.05). These data imply an increasing incidence of fungal empyema thoracis in recent years and the necessity for aggressive treatment of patients with this disease.

MOC-31 aids in the differentiation between adenocarcinoma and reactive mesothelial cells.

Evaluation of effusion specimens for the presence of adenocarcinoma often is complicated by the presence of reactive mesothelial cells that can mimic adenocarcinoma. Ancillary studies, in particular immunohistochemistry, can be helpful in making this distinction. MOC-31 is an antibody that recently was reported to be useful in distinguishing adenocarcinoma from mesothelioma in tissue specimens. In this study we examined the utility of this antibody in pleural effusions. Eighty-nine archival, formalin fixed, paraffin embedded cell blocks representing 59 adenocarcinomas, 12 other neoplasms (including 6 mesotheliomas), and 18 reactive effusions were retrieved. After protease digestion, recut slides were immunostained with the MOC-31 antibody utilizing a modified avidin-biotin complex technique. Only membrane-based reactivity was considered as positive. In two adenocarcinomas there was insufficient material remaining in the cell block. Among the 57 remaining cases, reactivity was observed in 54 cases. Reactivity also was observed in one of six mesotheliomas and one small cell carcinoma. The remaining cases, including all 18 reactive effusions, were nonreactive. In distinguishing adenocarcinoma from reactive mesothelial cells, the presence of MOC-31 reactivity was found to be 95% sensitive and 100% specific with a positive predictive value of 100% and a negative predictive value of 95%. MOC-31 is useful in differentiating between adenocarcinoma and reactive mesothelial cells in pleural effusion specimens. Cancer (Cancer Cytopathol)

Use of alcohol fixed cytospins protected by 10% polyethylene glycol in immunocytology external quality assurance.

AIMS: To provide cytospins as a means of external quality assurance (EQA), while maintaining antigen expression integrity and achieving uniformity of material for all participating laboratories. METHODS: Cells were collected...

Clinical significance of immunohistochemical detection of p53 protein in pleural effusion and bronchial specimen.

To explore the usefulness of p53 immunohistochemical staining as a marker of malignancy in the diagnosis of lung cancer. The expression of p53 in 57 samples of pleural effusion and 69 bronchial biopsy specimens was investigated by immunohistochemical method. p53 was well preserved in the samples of pleural effusion. p53 positive rate was 0%(0/27) ,33.3 %(2/6) and 54.2%(13/24) respectively in cytologically benign , suspicious but not conclusively malignant and malignant pleural effusion. Benign pleural effusion referred as tuberculous and other inflammatory effusion. p53 poisitive rate was 0%(0/23) ,14.3 %(1/7) and 35.9 % (14/39) in histologically benign , atypical proliferating and malignant bronchial biopsy sample. The cases with p53 immunoreactivity were proved to have lung cancer after follow-up in cytologically suspicious but not conclusively malignant pleural effusion and histologically atypical proliferating bronchial biopsy sample. p53 immunostaining could be useful as a marker of malignancy in the cytologic examination of pleural effusion and bronchial biopsy sample. The presence of p53 immunoreactivity in these samples is strongly suggestive of malignancy , though its absence does not exclude neoplasms.

Molecular detection of cancer cells by competitive reverse transcription-polymerase chain reaction analysis of specific CD44 variant RNAs.

CD44 is a cell surface glycoprotein implicated in such diverse biologic processes as lymphocyte activation and homing, extracellular matrix adhesion, and cellular migration. Primary transcripts of the CD44 gene can be alternatively spliced to produce a variety of messenger RNA (mRNA) species. The standard form of CD44 mRNA contains sequences from at least 20 genomic exons; variant mRNAs contain sequences from one or more additional exons (v1-10). Predominant expression of a specific CD44 variant, i.e., CD44v8-10, in several human carcinomas has been described previously. In this study, we developed a novel molecular approach for detecting cancer cells that overexpress CD44v8-10 mRNA. After finding that CD44v8-10 was predominantly expressed in non-small-cell lung and bladder carcinomas and that CD44v10 was predominantly expressed in leukocytes, we developed a competitive reverse transcription-polymerase chain reaction assay (CC-RT-PCR) that allows quantification of the relative expression of these two mRNA species in clinical specimens (i.e., determination of a v8-10/v10 ratio). CC-RT-PCR analysis was applied to pleural effusion specimens from patients with benign or malignant lung diseases as well as to spontaneously voided urine samples from patients with benign or malignant urologic diseases. Fifty two of 54 samples from patients with benign diseases expressed CD44v10 predominantly (v8-10/v10 ratio < or = 0.65), whereas 46 of 61 samples from patients with malignant diseases expressed CD44v8-10 predominantly (v8-10/v10 ratio > 1.00) (two-sided P < .001). CC-RT-PCR detected predominant expression of CD44v8-10 in cytologically negative samples from 11 patients who were later diagnosed with malignant disease. CC-RT-PCR analysis of CD44v8-10 expression could be an important adjunct to cytologic examination in cancer diagnosis, especially in detecting exfoliated cancer cells in pleural effusions and urine.

Cancer cells isolated from malignant pleural and peritoneal effusions inhibit phospholipase A 2 activity in human polymorphonuclear leukocytes

We studied the influence of cancer cells on the LTB 4 production by human polymorphonuclear leukocytes (PMN). The cancer cells were isolated from malignant pleural effusion specimens taken from two patients or from a peritoneal effusion specimen of one patient. While human PMN produced LTB 4 following stimulation with A23187, the addition of cancer cells inhibited LTB 4, 5-HETE and 12-HETE production by PMN in a cell number-dependent manner, while the cancer cell lines also showed a similar inhibition. The addition of lysate of the breast cancer cells also inhibited in a dose-dependent manner the production of LTB 4 by PMN following stimulation with A23187. The addition of arachidonic acid completely reversed the inhibition of PMN-LTB 4 production by the addition of the breast cancer cell lysates, thus suggesting inhibition at the phospholipase A 2 level. The addition of this lysate to the partially purified human cytosolic PLA 2 also inhibited the PLA 2 activity. In contrast, the addition of lymphoma cells isolated from metastatic lymphnodes did not inhibit the LTB 4 production from PMN. Since LTB 4 is one of the important chemotactic factors for PMN and monocytes, these findings suggest that the inhibition of the PLA 2 activity by the cancer cells thus results in a reduced production of LTB 4 from PMN and contributes to a predisposition to develop severe infection in patients with advanced cancer.

Retroviral Gene Transfer Is Inhibited by Chondroitin Sulfate Proteoglycans/Glycosaminoglycans in Malignant Pleural Effusions

Gene therapy may be an important adjuvant for treating cancer in the pleural space. The initial results of retroviral gene transfer to cancer cells in malignant pleural effusions revealed that transduction was markedly inhibited, and studies to characterize the inhibitory factor(s) were performed. The inhibition was contained within the soluble, rather than cellular, components of the effusions and was demonstrated with amphotropic, gibbon ape leukemia virus, and vesicular stomatitis virus-glycoprotein pseudotyped retroviral vectors. After excluding complement proteins, a series of studies identified chondroitin sulfates (CSs) as the inhibitory substances. First, treatment of the effusions with mammalian hyaluronidase or chondroitinases, but not Streptomyces hyaluronidase, abolished the inhibitory activity. Second, addition of exogenous CS glycosaminoglycans mimicked the inhibition observed with pleural effusions. Third, immunoassays and biochemical analyses of malignant pleural effusion specimens revealed CS in relevant concentrations within pleural fluid. Fourth, proteoglycans/glycosaminoglycans isolated from the effusions inhibited retroviral gene transfer. Analyses of the mechanism of inhibition indicate that the chondroitin sulfates interact with vector in solution rather than at the target cell surface. These results suggest that drainage of the malignant pleural effusion, and perhaps enzymatic pretreatment of the pleural cavity, will be necessary for efficient retroviral vector mediated gene delivery to pleural metastases.

Fibrinolytic and inflammatory processes in pleural effusions.

This study was designed to evaluate major fibrinolytic parameters in relation to parameters of inflammation associated with different kinds of pleural effusion. Sixty patients with pleural effusion were studied. The underlying aetiology was empyema in 10 cases, tuberculosis in 9, cancer in 31, cardiac failure in 7, and undetermined in 3. Plasminogen, plasminogen activator inhibitor 1 (PAI-1) and 2 (PAI-2), tissue type plasminogen activator (t-PA), urokinase (u-PA) and D-dimers (D-D) were quantified in plasma samples and pleural effusion specimens. These data were then correlated with inflammatory or infectious parameters, i.e. fibrinogen, von Willebrand factor (vWF), erythrocyte sedimentation rate (ESR), protein concentration, and white blood cell count. D-D levels were higher in pleural fluid than in plasma. D-D levels were not correlated with either plasminogen activator or plasminogen activator inhibitor levels, suggesting the presence of other fibrinolytic pathways. PAI levels (PAI activity, PAI-1 antigenicity, PAI-2 antigenicity) and vWF levels were significantly higher in patients with tuberculosis and empyema than in patients with cancer or cardiac failure. Regression analysis between inflammatory and fibrinolytic parameters showed that pleural PAI levels were significantly correlated with pleural neutrophil count, vWF levels, and plasma fibrinogen levels. D-D levels were correlated with blood ESR. No significant difference in pleural t-PA, u-PA and D-D levels was observed between aetiologies. The highest pleural t-PA and u-PA values were noted in patients with cancer, especially lymphoma. Plasma t-PA levels were higher inpatients with pleural effusion secondary to congestive heart failure, but this difference did not reach statistical significance.(ABSTRACT TRUNCATED AT 250 WORDS)

A Case of Hypersensitivity Syndrome Resembling Langerhans Cell Histiocytosis during Phenobarbital Prophylaxis for Convulsion

The case of a two-year-old girl with generalized histiocytosis, probably induced by phenobarbital, is reported. Symptoms, including intermittent fever, systemic lymphadenopathy, maculopapular skin eruption and hepatosplenomegaly, suggested Langerhans cell histiocytosis. Laboratory examinations revealed leukocytosis with lymphocytosis and eosinophilia and a high LDH serum level, while GOT and GPT were within normal ranges. Cytological studies of lymph node and pleural effusion specimens revealed proliferation and infiltration of Langerhans cell histiocytes with eosinophilia. No histiocyte proliferation was observed in the bone marrow or skin. The clinical manifestations shown by the patient were, however, transient, and improved spontaneously after the discontinuation of phenobarbital. The case was considered to be one of phenobarbital hypersensitivity syndrome based on clinical course and laboratory findings. The mechanism and differential diagnosis of the syndrome are discussed.

Distinction of Mesothelioma from Carcinoma in Pleural Effusions: An Immunocytochemical Study on Routinely Processed Cytoblock Preparations

The study was designed to find out whether the commercially available antibodies BMA 130 c, BMA 120, V 9, KL 1, B 72.3 TAG, HEA 125 and Ber-EP 4 would be of help in distinguishing carcinomas from a mesothelial process (mesothelioma/pleuritis) in pleural effusion specimens routinely processed by the cytoblock method. All of the 20 carcinomas included in the study but also 19 of the 20 mesotheliomas expressed cytokeratin (KL 1), whereas vimentin expression was found in 7 of the 20 carcinomas and 19 of the 20 mesotheliomas. 19 of the 20 carcinomas reacted with the epithelial markers B 72.3 and HEA 125, and 18 of them with Ber-EP 4. In contrast, only a few of the 20 mesotheliomas showed a weak reaction to these markers (1 with HEA 125, 2 with B 72.3, and 3 with Ber-EP 4). BMA-130 c was detected in 10/20 carcinomas but in none of the mesotheliomas. BMA-120 was observed in the effusions from 17/20 mesotheliomas and in cover cells which had undergone reactive changes, but also in 2 cases of ovarian carcinoma. The results show that reaction to the "epithelial markers" B 72.3, HEA 125 and Ber-EP 4 is strongly indicative of carcinoma and not of mesothelioma, whereas a positive reaction with the antibody BMA-120 in the absence of reaction to the epithelial markers makes a mesothelial process very likely. However, immunocytochemical distinction cannot be made as yet between mesothelioma cells and pleuritic cells. If simultaneous positivity for BMA-120 and an "epithelial marker" in a pleural effusion is observed the primary tumor could be an ovarian carcinoma.

Value of immunocytochemistry in the study of malignant effusions.

Recognition of malignant effusion relies heavily on cytologic examination despite the difficulty of distinguishing atypical mesothelial hyperplasia from metastatic carcinoma. The combination of CEA, EMA, vimentin, keratin, high-molecular-weight cytokeratin (HMWK), low-molecular-weight cytokeratin (LMWK), and Alcian blue was tested in 51 cytologic specimens of pleural, peritoneal, and pericardial effusions. These showed metastatic carcinoma in 38 cases (ovary, 14; lung, 8; breast, 7; GI, 4; endometrium, 4; bladder, 1) and mesothelial processes in 13 (hyperplasia, 9; mesothelioma, 4). Strong positivity for EMA (92%), CEA (90%), and Alcian blue (71%) was noted in metastatic carcinoma but not in the mesothelial processes. Keratin was positive in all cases of mesothelioma but occurred also in mesothelial hyperplasias (44%) and metastatic carcinomas (47%). In mesothelial cells, HMWK was consistently stronger than LMWK, whereas in adenocarcinoma the reverse was true. There was no difference in the degree or distribution of positivity of any of the markers among the various primary sites of the neoplasms. Our findings are consistent with the view that immunocytochemistry with a battery of antibodies is useful in the recognition of malignant effusions but cannot, as yet, determine the site of origin of metastatic neoplasms.

Cytologic detection of malignancy in pleural effusion: a review of 5,255 samples from 3,811 patients.

A retrospective analysis of 5,255 pleural effusion specimens from 3,811 patients was undertaken to determine the accuracy of cytopathologic correlation with pleural biopsy, the detection rate of malignancy by cytology, and the frequency distribution of malignant effusions according to age group. The cytopathologic correlation was 96.5% accurate, with 0.1% false-positive results and 0.18% false-negative results by cytology. The sensitivity of cytologic detections was 6.7% higher than that of pleural biopsy. Frequency analysis showed that the incidence of carcinoma of the lung, the most common cause of malignant effusion, is not sex based. Adenocarcinoma of the lung was the most frequent type of malignancy found in pleural effusions. It represented 79% of lung carcinomas that metastasized to pleura, accounting for 40% of all malignant pleural effusions. In young adults, lymphoreticular malignancies were the most common cause of malignant effusions.

The malignant pleural effusion. A review of cytopathologic diagnoses of 584 specimens from 472 consecutive patients.

This study reports the cytopathologic diagnoses rendered on all malignant pleural effusions received and processed over a period of 14 years. Specimens of fluid from various body sites (25,464) were examined. Of these, 5888 (23%) were specimens of pleural effusions. Five hundred eighty-four specimens (9.9% of total pleural fluid specimens) taken from 472 patients were diagnosed as containing cancer cells. Of the malignant pleural effusions, 75.7% were classified as carcinomatous in type. Adenocarcinomas comprised 47.4% of the 584 specimens. The groups of large cell undifferentiated carcinoma and lymphoma/leukemia approximated one another in being the second most common cancer groups (14.3% and 15.0%, respectively). For both males and females, the frequency of organ site or primary tumor type was lung (35.6%), lymphoma/leukemia (15.9%), breast (14.8%), female genital tract (8.1%), and gastrointestinal tract (5.9%). Among male patients, the order of frequency was lung (49.1%), lymphoma/leukemia (21.1%), gastrointestinal tract (7.0%), genitourinary tract (6.0%), and malignant melanoma (1.4%). In female patients, the order of frequency was breast (37.4%), female genital tract (usually ovary) (20.3%), lung (15.0%), lymphoma/leukemia (8.0%), and gastrointestinal tract (4.3%). In 48 patients (10.2%) the primary site of neoplasm was never determined. In 90.5% of patients a cytopathologic diagnosis conclusive for cancer was obtained on the first specimen of fluid. There were no false positive diagnoses.