Presence Of Malignant Pleural Effusion Research Articles

Clinical factors predicting objective response to bevacizumab-based chemotherapies in advanced and recurrent epithelial ovarian cancer.

Bevacizumab-based chemotherapies are commonly administered in the treatment of patients diagnosed with epithelial ovarian cancer (EOC). The primary aim of this study was to assess the factors that predict the objective response to bevacizumab-based therapies in cases of advanced and recurrent EOC. The retrospective data of 264 patients with EOC from the current study were collected between 2009 and 2022 at our clinic. Survival analyses were conducted utilizing the Kaplan-Meier method and the log-rank test. Binary logistic regression analysis was employed to assess the factors predicting the objective response. A predominant subset of patients (83%) presented with serous adenocarcinoma, exhibiting a high-grade differentiation at 87%. The vast majority (80%) of the cohort experienced disease recurrence. Three-fourths of the cases received bevacizumab in combination with platinum-based doublet chemotherapy. In the multivariate analysis, clinical factors such as a disease recurrence (P=0.031), upfront tumor debulking surgery before bevacizumab (P=0.009), doublet chemotherapy (P=0.003), and the presence of malignant pleural effusion (P=0.024) emerged as significant determinants influencing the Objective Response Rate (ORR) in patients undergoing bevacizumab-based therapy. The ORR was 67.5% (N.=178), comprising 15.2% complete responses (N.=40) and 52.1% partial responses (N.=138). The median Progression-Free Survival (PFS) and Overall Survival (OS) were estimated at 10.2 months (95% CI, 8.60-11.9) and 20.1 months (95% CI, 16.0-24.2), respectively. The responses to bevacizumab-based chemotherapies could be predict by the presence of malignant pleural effusion, disease recurrence, upfront tumor debulking surgery and doublet regimen of chemotherapy.

Expert consensus on diagnosis and treatment of malignant pleural effusion caused by lung cancer

Malignant pleural effusion (MPE) can occur in nearly all types of malignant tumors, with lung cancer being the most prevalent cause. The presence of MPE indicates an advanced stage or distant spread of the tumor, significantly reducing the patient's life expectancy. Particularly, a substantial amount of pleural effusion can impede heart and lung function, impair blood oxygen perfusion levels in the body, and greatly diminish patients' quality of life. Even when systemic treatment has alleviated the primary lung tumor in some patients, effective control over MPE remains challenging and impacts clinical outcomes. Therefore, it is crucial to implement measures for reducing or managing MPE while ensuring standardized treatment for lung cancer. In recent years, significant advancements have been made in diagnosing and treating lung cancer complicated by MPE through extensive basic and clinical research. Based on existing evidence and China's clinical practice experience, relevant experts from the China Association of Health Promotion and Education and Cancer Rehabilitation and Palliative Treatment Professional Committee of China Anti-Cancer Association (CRPC) have summarized key aspects related to diagnosis and treatment consensus opinions for lung cancer complicated by MPE. This aims to establish standardized procedures that will serve as a reference for doctors' clinical practice.

Comparison between different treatment regimens of vascular targeting drug to malignant pleural effusion in patients with lung cancer: A Bayesian network meta-analysis.

The presence of malignant pleural effusion in lung cancer patients often suggests a poor prognosis. We plan to investigate which regimen of vascular targeting drug is preferable to control the malignant pleural effusion in such patients. Two investigators dependently searched and screened for randomized controlled trials in PubMed, Embase, Web of Science and China National Knowledge Infrastructure from the database inception to August 2022. R software was applied to build a network model in Bayesian method. Objective response rate of malignant pleural effusion is the primary outcome measure. Besides, the incidence of 3 adverse events were compared, including gastrointestinal reaction, leukopenia and hypertension. Due to the disconnection of network, we analysis and discuss the short-term treatment (3-4 weeks) and long-term treatment (6-12 weeks) respectively. 31 studies with 2093 patients were identified. Four targeting drugs contain bevacizumab (Bev), anlotinib, apatinib and Endostar. Two administration routes include intracavity perfusion (icp) and intravenous injection. Based on the current evidence, for short-term treatments, compared with single-agent chemotherapy (CT), Bev_icp + CT, anlotinib + CT, Bev_icp and anlotinib + endorstar_icp present better objective response, and no statistical significance was found in objective response between Bev_icp + CT, anlotinib + CT and Bev_icp. For long-term treatments, compared with doublet or triplet chemotherapy (2CT or 3CT), Bev_icp + 2CT, apatinib + 2CT, Bev_icp + 3CT, and Bev_intravenous injection + 2CT are more effective option, but no statistical significance was found in objective response between the 4 combination regimens with chemotherapy. Our findings suggest that no statistical significance between above vascular targeting regimens. Pathological type of lung cancer may affect the effect of bevacizumab intracavity infusion plus chemotherapy. The influence of different administration routes of vascular targeting drugs on efficacy remains to be investigated. There are some concerns with the quality of the studies, and some limitations should be considered when interpreting these results, which includes limited geographical region and sample size of studies. Despite these limitations, this study may inform vascular targeting therapy choice in such a patient population.

Small Cell Lung Cancer and Pleural Effusion: An Analysis from a District General Hospital.

The incidence of malignant pleural effusion (MPE) in patients with small cell lung cancer (SCLC) in an American population is approximately 11%, and overall survival in that group is 3 months (compared to 7 months without an effusion. To our knowledge, no study has been done in the United Kindgom and we thus sought to determine the characteristics of the local population. All patients coded as having small cell lung cancer from Somerset register from January 2012-September 2021 were reviewed. We excluded those with indeterminate pathology reports, carcinoid or large cell neuroendocrine cancers. Basic demographics, presence of an MPE and any interventions and outcomes were collected for descriptive analysis. Continuous variables are presented as mean (±) range, median (± IQR) when outliers were present and categorical variables as percentages where appropriate. Caldicott reference C3905. Four hundred one patients with SCLC were identified (11% of all patients, median time to death from presentation 208days, IQR 304 [many outliers); 224 (55.9%) were female, 177 male [median age 75years, IQR 13]. One hundred seven (27%) presented with an effusion: 23 were sampled, 10 had positive cytology, all were exudates, 8 required chest drainage, the mean performance status (PS) was 2 (range 1-4) and the median time to death 142days, IQR 45. Of the 294 with no initial effusions, 70 (24%) developed a pleural effusion with progressive disease (mean PS 1, median age 71.5years, IQR 14, median to death 327days, IQR 395, 1 outlier); 224 patients never had a MPE with a median time to death of 212 days, IQR 305, multiple outliers and, when compared to those with a MPE at any point, median time to death was 211days, IQR 295.5 (multiple outliers). Meaningful analysis was difficult because of the presence of multiple outliers in values collected and not correcting for stage at presentation or treatment modalities and previous studies did not correct for those either. Those presenting with an MPE had a poorer prognosis, probably signifying advanced disease and the presence of MPE in our SCLC cohort seems higher. Large prospective databases for this are required.

Malignant pleural effusion as a predictor of the efficacy of anti-PD-1 antibody in patients with non-small cell lung cancer.

BackgroundThe aim of this study was to evaluate the usefulness of the presence of malignant pleural effusion (MPE) as a negative predictor of anti‐PD‐1 antibody efficacy.MethodsA retrospective review of patients with advanced or recurrent non‐small cell lung cancer treated with an anti‐PD‐1 antibody between December 2015 and March 2018 at the National Cancer Center Hospital, Japan, was conducted. Progression‐free survival (PFS) and overall survival (OS) were compared between patients with and without MPE. Additional survival analysis according to PD‐L1 expression status was conducted. Univariate and multivariate analyses were performed.ResultsA total of 252 patients were identified before the commencement of anti‐PD‐1 antibody treatment: 33 with MPE and 219 without MPE. PFS and OS were significantly shorter in patients with MPE than in patients without MPE (median PFS 3.0 vs. 5.8 months, hazard ratio [HR] 1.7, P = 0.014; median OS 7.9 vs. 15.8 months, HR 2.1, P = 0.001). In patients with PD‐L1 expression in ≥ 1% of their tumor cells, the PFS of patients with MPE was significantly shorter than of patients without MPE (median PFS 3.1 vs. 6.5 months, HR 2.0, 95% confidence interval 1.0–3.5; P = 0.021). The presence of MPE was independently associated with a shorter PFS and OS in multivariate analysis.ConclusionThe presence of MPE in patients administered an anti‐PD‐1 antibody is associated with shorter PFS and OS, regardless of the presence of PD‐L1 expression ≥ 1% of tumor cells.

Diagnosis and management of malignant pleural effusions: state of the art in 2017.

Malignant pleural effusion (MPE) is a known complication of both thoracic and extra thoracic malignancies. The presence of MPE regardless of the primary site translates into advanced stage disease. Diagnosis and management of MPE with the goals of palliation and improving quality of life poses a challenge for chest physicians. Recently, multiple studies have made attempts to answer questions regarding optimal management in various clinical scenarios. We will review the current evidence and available options for the management of MPE.

Diagnostic performance of CTLA-4, carcinoembryonic antigen and CYFRA 21-1 for malignant pleural effusion

ABSTRACTObjectives: The diagnosis of malignant pleural effusion (MPE) remains a clinical challenge. As a negative regulator of T-cell activation, cytotoxic T lymphocyte-associated antigen-4 (CTLA-4) has been associated with many malignant diseases. However, there is limited data about the relationship between CTLA-4 and MPE. The present study aims to investigate whether CTLA-4 levels may correlate with presence of MPE and to assess its potential diagnostic accuracy relative to that of the established markers carcinoembryonic antigen (CEA) and cytokeratin 19 fragment (CYFRA21–1).Methods: Pleural effusion samples were collected from 36 patients with MPE and 48 patients with benign pleural effusion (BPE). Pleural levels of CTLA-4 were measured by ELISA; levels of CEA and CYFRA 21-1, by electrochemiluminescence immunoassay. Receiver operating characteristic curves were calculated to evaluate the ability of CTLA-4, CEA and CYFRA 21-1 to differentiate MPE from BPE.Results: Pleural levels of CTLA-4 were significantly higher in MPE than in BPE patients (471.73 ± 378.86 vs. 289.22 ± 173.67 pg/ml, p = 0.004). At a cut-off value of 351.25 pg/ml, the sensitivity and specificity of CTLA-4 in diagnosing MPE were 58.30% and 83.30%, respectively, and the area under the curve was 0.72. Pleural levels of CEA and CYFRA 21-1 were also higher in MPE. Using the combination of CTLA-4, CEA and CYFRA 21-1 increased diagnostic sensitivity to 88.89% and the area under the curve to 0.92.Conclusion: The results of this preliminary study suggest that increased levels of CTLA-4 correlate with MPE, and that CTLA-4 may have some diagnostic usefulness when used in combination with conventional tumor markers such as CEA and CYFRA 21-1. These results justify larger, more rigorous studies to validate our findings.

P2.02-024 Phase I and II Trial of Intrapleural Paclitaxel Injection for Non-Small-Cell Lung Cancer Patients with Malignant Pleural Effusions

The presence of malignant pleural effusion (MPE) frequently indicates locally advanced non-small cell lung cancer (NSCLC). The conventional management of MPE involves pleurodesis using a sclerosant substance. The Perng et al. reported injection into chest cavity using paclitaxel for 18 MPE cases. In this report overall response rate was 92.9%. No disease progression was noted among evaluable patients. Therefore we focused on Paclitaxel which had antitumor effect and a pleural effusion control, and planned clinical trials phase I and II for the treatment of MPE. The primary objective of this study was to evaluate the efficacy of paclitaxel pleurodesis, the side effects and systemic antitumor effect. Patients were enrolled cytologically proven malignant pleural effusion of NSCLC. Radiotherapy and systemic chemotherapy were also not allowed within 4 weeks. After adequate drainage and assurance of lung re-expansion, paclitaxel diluted in normal saline was infused through a double lumen catheter. The starting dose was 100 mg/m2 with dose escalation schedule of 125, 150, and 175mg/m2. The catheter was clamped for 24 hrs. Chest drainage was continued until daily drainage was under 200 ml, and the tube was removed. To measure paclitaxel concentration, serum and pleural fluid samples were collected 0.5, 1, 3, 6, 24, 72hrs after the end of drug instillation. The treatment response of malignant effusion was evaluated according to the following criteria: complete response (CR), no fluid reaccumulation for at least 4 weeks as determined by CT scan; partial response (PR), recurrence of effusion to less than 50% of the original effusion volume within 4 weeks after treatment; failure, recurrence of effusion greater than 50% of the original volume, patients were symptomatic and need for thoracentesis to relieve symptoms within 4 weeks. The criteria for main tumor lesion response to intrapleural paclitaxel treatment were in accordance with Response Evaluation Criteria in Solid Tumors (Revised RECIST guideline version 1.1). From April 2009 to November 2012, 12 patients were enrolled. There were minimal local and systemic toxicities. The serum level of PXL of the cases with the effect of treatment was significantly higher than these of the cases without the effect. Over all response rate was 67%. No disease progression was noted among evaluable patients. We decided to plan a late phase II study of the therapy with 175 mg/m2, because it was not dosage-dependent even if it was a low dose and serum level-dependent.

Itraconazole can inhibit malignant pleural effusion by suppressing lymphangiogenesis in mice.

The presence of malignant pleural effusion (MPE) indicates a poor prognosis in patients with non-small cell lung cancer (NSCLC). Itraconazole has been identified as a potent inhibitor of endothelial cell proliferation that suppresses angiogenesis; however, its role in the suppression of lymphangiogenesis is still unclear. The aim of this study was to investigate the efficacy of itraconazole for MPE and the mechanism of lymphangiogenesis suppression. Lewis lung carcinoma (LLC) cells were injected into the mouse pleural cavity to establish the MPE mouse model, followed by randomization of the mice into three groups. Each mice was injected with either a high dose of itraconazole (25 mg/kg, H-ITCZ), a low dose of itraconazole (8 mg/kg, L-ITCZ), or 50 μL of hydroxypropyl-β-cyclodextrin (130 mg/mL, H-β-C) into the pleural cavity four times every 3 days. The MPE of the mice was collected and measured with a 1 mL syringe. The vascular endothelial growth factor-C (VEGF-C) expression level in the MPE was detected by enzyme-linked immunosorbent assay (ELISA), while the VEGF-C expression and lymphatic micro vessel density (LMVD) in the tumor tissue was observed by immunohistochemistry (IHC) staining. The number of pleural tumor foci, the volume of pleural effusion, the LMVD and the VEGF-C expression levels in the tumor tissue were significantly reduced in the H-ITCZ-treated group. Our results revealed that itraconazole may play an important role in the MPE mice by suppressing lymphangiogenesis, which demonstrated the usefulness of itraconazole in the treatment of MPE.

Clinico- pathological profile and course of malignant pleural effusion in a tertiary care teaching hospital in western U.P. with special reference to lung cancer.

Background:Malignant pleural effusion is a major clinical problem associated with primary and metastatic pleural malignancies. Pleural effusions from an unknown primary are responsible for 7-15% of all malignant pleural effusions. Presence of malignant pleural effusion puts the patient in advanced stage and renders the prognosis as poor.Aim:In this study we intend to find out the incidence of malignant pleural effusion, its aetiology and clinical course in patients attending a tertiary care teaching hospital.Results:A total of 308 patients were included in this study. A majority of the patients were in age group 50- 70 years (median age = 58.8 years; range 32- 85 yrs). Male to female ratio was 2.5:1. The major primary cancers were lung cancer (135), lymphoma (40), breast cancer (36), female genital tract (30) gastrointestinal (21), and others (8). In 38 cases primary remained unknown. The yields of pleural fluid cytology, blind pleural biopsy, CT/USG guided pleural biopsy and thoracoscopy were 60%, 49%, 76% and 91% respectively. Chemical pleurodesis yielded complete response in 80%, incomplete response in another 13% patients. Only 136 (44%) cases could be followed up for minimum of 6 months. A majority of them (95, 69.85%) died.Conclusion:We conclude that malignant pleural effusion is a commonly misdiagnosed medical entity. Lung cancer is the commonest cause. Despite all efforts, in about 15% of the cases, primary remains undiagnosed. Thoracoscopy/pleuroscopy is a cost effective measure for diagnosis. Chemical pleurodesis provides expected results but mortality remains high.

Clinicopathological profile and course of malignant pleural effusion in a tertiary care teaching hospital in western Uttar Pradesh with special reference to lung cancer.

Background: Malignant pleural effusion is a major clinical problem associated with primary and metastatic pleural malignancies. Pleural effusions from an unknown primary are responsible for 7-15% of all malignant pleural effusions. Presence of malignant pleural effusion puts the patient in advanced stage and renders the prognosis as poor. Aim: In this study we intend to find out the incidence of malignant pleural effusion, its aetiology and clinical course in patients attending a tertiary care teaching hospital. Results: A total of 308 patients were included in this study. A majority of the patients were in age group 50- 70 years (median age = 58.8 years; range 32- 85 yrs). Male to female ratio was 2.5:1. The major primary cancers were lung cancer (135), lymphoma (40), breast cancer (36), female genital tract (30) gastrointestinal (21), and others (8). In 38 cases primary remained unknown. The yields of pleural fluid cytology, blind pleural biopsy, CT/USG guided pleural biopsy and thoracoscopy were 60%, 49%, 76% and 91% respectively. Chemical pleurodesis yielded complete response in 80%, incomplete response in another 13% patients. Only 136 (44%) cases could be followed up for minimum of 6 months. A majority of them (95, 69.85%) died. Conclusion: We conclude that malignant pleural effusion is a commonly misdiagnosed medical entity. Lung cancer is the commonest cause. Despite all efforts, in about 15% of the cases, primary remains undiagnosed. Thoracoscopy/pleuroscopy is a cost effective measure for diagnosis. Chemical pleurodesis provides expected results but mortality remains high.

Staging of lung cancer CT and PET

Lung cancer is the leading cause of cancer related deaths in the United States with a 5 year survival of only 15%. [1] The International Association for the Study of Lung Cancer (IASLC) issued a 7th edition of the TNM staging system for lung cancer in 2007. [2] It includes several revisions which better align TNM staging with prognosis and in some cases with treatment. There have been revisions in the TNM descriptors. In the T or tumor category, the T1 and T2 categories include now subcategorization of size with new T1a, T1b, T2a and T2b subdescriptors. One of the important changes is that tumors larger than 7 cm are now considered Stage T3 tumors. Stage IV tumors include separate tumor nodules in the same lung but not in the same lobe as the primary lesion which were previously considered metastatic (M1). Stage T4 disease is now downgraded to Stage III when satellite nodules are present in the same lobe as the primary lesion. The presence of malignant pleural effusion, pleural dissemination or pericardial disease is now considered metastatic disease, specifically stage M1a for local intrathoracic disease rather than Stage IV disease [3-5]. Although the IASLC has proposed a new lymph node map there are no changes to the end descriptors in the 7th edition of the TNM staging system [3-5]. Nearly one half of newly diagnosed lung cancers already demonstrate metastases within the lung, brain, liver, and bony structures. Any metastatic disease is automatically designated Stage IV disease and with few exceptions is considered surgically unresectable. The M category is now subcategorized into intra-thoracic metastasis M1a and extra-thoracic metastatic M1b with the former having a better prognosis [4]. Contrast enhanced CT remains the mainstay for staging of lung cancer. However, PET has particular value in nodal staging of lung cancer and also in determining the presence of distant metastatic disease. In a study by Gould et al, the sensitivity of PET CT for metastasis was 85% and the specificity was 95% as compared with a CT sensitivity of 61% and specificity of 79% [6]. PET CT does have a high false positive rate so it cannot replace invasive sampling, but it may be used to direct invasive staging. PET scanning is particularly useful in M staging of non-small cell lung cancer. PET can replace the use of bone scintigraphy and it is now widely used for determination of distant metastasis throughout the body. However, it is limited in the assessment of brain metastases. In the PLUS Trial, 188 patients with potentially resectable non-small cell lung cancer were randomized to either conventional work up or PET CT. Addition of the PET CT to the conventional work up prevented future surgery in 1 out of 5 patients [7].

Bevacizumab plus chemotherapy for advanced non-squamous non-small-cell lung cancer with malignant pleural effusion

The presence of malignant pleural effusion (MPE) indicates a poorer prognosis for patients with non-small-cell lung cancer (NSCLC) and impairs their quality of life. Because vascular endothelial growth factor (VEGF) is the key mediator MPE production, we evaluated the efficacy and safety of chemotherapy plus bevacizumab, an anti-VEGF antibody, in non-squamous NSCLC patients with MPE, especially regarding the control of pleural effusions. From November 1, 2009 to September 30, 2011, medical charts of 13 consecutive patients with MPE who received bevacizumab plus chemotherapy as the initial or secondary treatment were retrospectively analyzed. Of the 13 patients, 6 did not undergo pleurodesis, 3 were unsuccessfully treated by pleurodesis, 2 had encapsulated pleural effusion, and 2 had no re-expansion of the lung. Twelve patients (92.3 %) achieved MPE control lasting >8 weeks following bevacizumab plus chemotherapy. Five of 10 patients with measurable lesions had confirmed partial responses. Of 3 patients without measurable lesions, one had confirmed CR. Median progression-free survival time without re-accumulation of MPE was 312 days. Grade 3 or 4 neutropenia, thrombocytopenia, hypertension, or proteinuria was observed in 2, 2, 1, or 1 patient, respectively. This is the first study to report that bevacizumab plus chemotherapy is highly effective for the management of MPE in non-squamous NSCLC patients. Prospective clinical trials are warranted to investigate the efficacy of bevacizumab for MPE.

Forced Expiratory Volume in One Second as a Prognostic Factor in Advanced Non-small Cell Lung Cancer

Reduced lung function is an important risk factor for lung cancer and increases surgical risk in patients with operable stages of lung cancer. Nevertheless, there have been few studies to reveal association of lung function with mortality in patients with advanced lung cancer. The aim of this study was to investigate whether low forced expiratory volume in 1 second (FEV1) is an independent predictor of mortality in patients with advanced lung cancer. Data were retrospectively collected from patients with non-small cell lung cancer of stage IIIB or IV and available spirometry at diagnosis of lung cancer. They had the last follow-up consecutively between April 2003 and July 2009 in a tertiary referral hospital. Among a total of 156 patients, 118 died as of July 2009. Their mean age was 65 years; 115 (74%) were men. Mean FEV1 was 1.91 liters (79% of predicted). Seventy-one patients (46%) had adenocarcinoma, and 48 (31%) had squamous cell carcinoma. In a multivariate analysis using Cox regression model, independent prognostic factors were FEV1 less than 50% of predicted (hazard ratio [HR] = 2.704, 95% confidence interval [CI]: 1.516-4.823, p = 0.001), chemotherapy (HR = 0.311, 95% CI: 0.192-0.503, p < 0.001), adenocarcinoma (HR = 0.459, 95% CI: 0.300-0.701, p < 0.001), body mass index (HR = 0.921, 95% CI: 0.870-0.975, p = 0.005), and the presence of malignant pleural effusion (HR = 1.673, 95% CI: 1.102-2.540, p = 0.016). Reduced FEV1 is strongly associated with mortality in advanced non-small cell lung cancer.

Prognostic impact of malignant pleural effusion in patients with stage M1b non-small cell lung cancer.

7636 Background: The presence of malignant pleural effusion (MPE) is associated with worse outcomes in patients with non-metastatic non-small cell lung cancer (NSCLC). As a result, the AJCC 7th edition reclassified these tumors from stage IIIB to stage IV (M1a). The effect of MPE in patients with distant metastases (stage M1b) however, remains unknown. We evaluated the prevalence, risk factors, and prognostic impact of MPE at presentation in patients with NSCLC. Methods: The Surveillance Epidemiology and End Results (SEER) registry was queried for patients with NSCLC, aged 21 or older, and diagnosed between 2004 and 2005. Demographic variables included age, gender, race, histology, and N stage. Odds ratio estimates were calculated using logistic regression, the Kaplan-Meier method was used to estimate the overall survival (OS), and the Cox proportional hazard model to evaluate whether MPE (CS extension code 72) was an independent risk for outcome. Results: A total of 57,685 patients with NSCLC were identified, with MPE present in 9,170 patients (15.9%). There were 3,944 cases of MPE among the 31,506 patients without distant metastases (12.5%) and 5,226 cases among the 26,179 with distant metastases (20%). Independent risk factors for MPE were age over 60 years (p < 0.0001), male gender (p = 0.0002), non-white race, (p < 0.0001), mediastinal lymph node involvement (p < 0.0001), and adenocarcinoma (p < 0.0001), large cell (p < 0.0001) or carcinoma NOS (p < 0.0001) histologies. In patients with NSCLC and distant metastases, the median survival was 5 months without MPE and 3 months with MPE. In these patients with stage M1b, the 1-year and 2-year survival rates were 24.8% and 11.3% respectively for patients without MPE and 13.5% and 5.4% respectively in those with MPE (HR 1.49; 95% CI 1.44-1.54; p < 0.001). MPE was also an independent factor for worse outcomes when adjusted for demographic variables (HR 1.38; 95% CI 1.33-1.44; p < 0.001). Conclusions: MPE at presentation is commonly observed in NSCLC and its presence represents an independent risk factor for worse survival in patients with distant metastases. No significant financial relationships to disclose.

Accuracy of EUS in staging of T4 lung cancer

Background Increasingly, EUS is being used to stage lung cancer. Direct mediastinal invasion (T4) by lung cancer is stage IIIb disease. Patients in this stage have a 5-year survival of less than 5% and generally are offered chemotherapy without surgery. This study evaluated the accuracy of EUS in detecting T4 lung cancer. Methods The study included all patients with lung cancer who had EUS staging and subsequent staging at surgery, or for whom there was unequivocal confirmation of unresectability (T4) by thoracoscopy, thoracotomy or presence of malignant pleural effusion, or definite invasion of great vessels/adjacent organs on CT. Results A total of 175 of 308 patients with lung cancer who underwent EUS over a 5-year period (1997-2002) had subsequent confirmatory tumor staging. Ten patients were found by EUS to have stage T4 tumors; 7 were confirmed to be T4 by either surgical exploration (2), CT demonstration of aortic invasion (3), or documentation of malignant pleural effusion (2). Three of the 10 (30%) patients found to have stage T4 tumors by EUS had T2 disease at surgery and underwent curative resection. Of the remaining 165 patients without evidence of T4 disease at EUS, only one was found to have aortic invasion (T4) at surgery. EUS had a sensitivity of 87.5%, specificity of 98%, positive predictive value of 70%, and a negative predictive value of 99% for detecting T4 disease. Conclusions Caution is warranted when unresectability of lung cancer is based solely on tumor invasion into mediastinal soft tissue at EUS. Overstaging occurs when a tumor appears to invade the pleural layer without mediastinal organ invasion. Confirmation of unresectability by other diagnostic modalities is warranted in such instances.

Clinical Role of F-18 Fluorodeoxyglucose Positron Emission Tomography Imaging in Patients with Lung Cancer and Suspected Malignant Pleural Effusion

The goals of this study were to determine the sensitivity, specificity, and predictive accuracy of F-18 fluorodeoxyglucose positron emission tomography (PET-FDG) imaging in detecting metastatic disease involvement of pleura and/or presence of malignant pleural effusion in patients with proven lung cancer. We wanted to compare efficacy of PET-FDG imaging to CT scanning in differentiating benign pleural effusion from malignant effusion and/or pleural involvement in patients with lung cancer. We studied 35 patients with biopsy-proven lung cancer and abnormal findings on CT scanning for presence of pleural effusion (n = 34) and/or pleural thickening or nodular involvement (n = 4). The results of positron emission tomography and CT scanning were compared to pleural cytology (n = 31), histologic findings of pleural biopsy (n = 3), and/or clinical follow-up (n = 3) for at least 1 year for presence or absence of malignant pleural effusion. PET-FDG imaging correctly detected the presence of malignant pleural effusion and malignant pleural involvement in 16 of 18 patients and excluded malignant effusion or pleural metastatic involvement in 16 of 17 patients (sensitivity, specificity, and accuracy of 88.8%, 94.1%, and 91.4% respectively). PET-FDG imaging is a highly accurate and reliable noninvasive test to differentiate malignant from benign pleural effusion and/or pleural involvement in patients with lung cancer and findings of suspected malignant pleural effusion on CT scanning.

Management of limited small-cell lung cancer

An important prognostic factor of SCLC is stage (limited vs extensive). Limited disease is confined to the hemithorax, although the presence of malignant pleural effusion will affect the outcome adversely. Whether negative cytology of the pleural effusion affects the outcome is controversial in SCLC. Extensive disease is disease beyond the hemithorax, such as disease in bilateral lungs or extension beyond the chest, often to the brain, bone, bone marrow, or upper abdomen. Patient factors influencing outcome are performance status and sex. Age is not a significant prognostic variable in patients with limited SCLC. Continuation of smoking will adversely affect the outcome. Other prognostic factors are elevated lactic dehydrogenase (LDH), and alkaline phosphatase, low sodium, and, possibly,

Pre- and postresection thoracic washings in non-small cell carcinoma of the lung: A cytological study of 44 patients without pleural effusion

The presence of malignant pleural effusion in patients with non-small cell bronchogenic cancer has a poor prognostic significance and is indicative of advanced disease (T4, IIIB). The present study will investigate the role of cytology and identify the various cellular components seen in thoracic washings, in the absence of an effusion, and will identify the potential pitfalls in diagnosing these specimens. The sensitivity, specificity, and positive and negative predictive values will be determined, as well as the associated predictive factors. From November 1996 to July 1997, 96 thoracic washings were performed on 44 patients with non-small cell carcinoma of the lung prior to and following resection. The specimens were processed routinely. To assess the false-negative or false-positive cases, all cases were rescreened and then correlated with the surgical pathology. Seven (15.9%) patients had positive findings detected on the pre- and/or postresection thoracic washings. One (2.3%) patient had a negative preresection, but cytologically atypical cells were found on the postresection. Thirty-six (81.8%) patients had negative pre- and postresection thoracic washings. There were no false-positive diagnoses in the study; however, two false-negative diagnoses were made. The finding of positive cytology in 7 of 44 (15.9%) patients appears significant. Thoracic washings may provide evidence of cancer beyond the pleura in patients without pleural effusion which may be indicative of advanced disease.

Serum cytokeratin 19 fragment levels in non-small cell lung cancer patients according to T factor in the TNM classification

We examined changes in cytokeratin 19 fragment (CYFRA 21-1) levels in relation to the T factor in 64 non-small cell N2M0 lung cancer patients. Although a correlation between the levels and T factor was found (ρ=0.627, p<0.0001), there was no difference between the levels in T3 and T4. Serum CYFRA 21-1 levels increased in the order of the following groups: the limited tumor group (T1+T2: n=28), the group with tumor extending to the pleura or chest wall (T3: n=13), and the group with tumor invading into the mediastinum (T4: n=12). The level was lower in the group with malignant pleural effusion (T4: n=11) than in the group with tumor invading into the mediastinum (6.7±4.7 ng/ml vs. 12.2±8.1 ng/ml, p=0.0046). We suspect that the presence of malignant pleural effusion is not directly related to the three-dimensional expansion of the tumor and this is a reason why CYFRA 21-1 levels in T4 are not higher than those in T3.