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Image-guided or assisted needle biopsies and the increasing use of medical thoracoscopy (MT) have increased the diagnostic accuracy of pleural diseases significantly. However, no consensus exists regarding which patients with pleural effusion should undergo MT and which patients should undergo image-guided or assisted needle biopsy as the first procedure to ensure greater diagnostic accuracy. Which biopsy method is more appropriate for which patient to provide the highest diagnostic accuracy in the diagnosis of pleural effusion? This prospective, randomized, parallel study included 228 patients with undiagnosed exudative pleural effusion. Patients were divided into two groups based on CT scan findings. Group 1 included patients with pleural effusion only. Group 2 included patients with pleural thickening or lesion in addition to pleural effusion. Patients in each group were assigned randomly to an image-assisted Abrams needle pleural biopsy (IA-ANPB) or MT arm. The diagnostic sensitivity, reliability, and safety were determined for both groups. The false-negative rate was 30.3% for the IA-ANPB arm and 3.1% for the MT arm in group 1. The same rates were 11.9% for IA-ANPB and 4.7% for MT in group 2. In group 1, the sensitivity for the IA-ANPB arm was 69.7%, and the negative likelihood ratio was 0.30. The same rates for the MT arm were 96.9% and 0.03 (P =.009). In group 2, these values were 88.1% and 0.12 for the IA-ANPB arm and 95.4% and 0.05 for the MT arm (P =.207). The rate of complications between the two biopsy methods was not different (8.5% and 15.8%, respectively; P =.107). MT showed a high diagnostic success in all patients with pleural fluid. However, IA-ANPB showed similar diagnostic success as MT in patients with pleural effusion and associated pleural thickening or lesions. Therefore, in the latter case, IA-ANPB could be preferable to MT. ClinicalTrials.gov; No.: NCT05428891 ; URL: www.clinicaltrials.gov [Display omitted] [ABSTRACT FROM AUTHOR]

Subpleural micronodules and interlobular septal thickening are common CT scan findings in TB pleural effusion. These CT scan features could help us differentiate between TB pleural effusion and nonTB empyema. Does the frequency of subpleural micronodules and interlobular septal thickening correlate with the presence of pleural effusion in patients with pulmonary TB? CT scan findings of pulmonary TB, micronodules and their distribution (peribronchovascular, septal, subpleural, centrilobular, and random), large opacity (consolidation/macronodule), cavitation, tree-in-buds, bronchovascular bundle thickening, interlobular septal thickening, lymphadenopathy, and pleural effusion were retrospectively analyzed. Patients were divided into two groups according to the presence of pleural effusion. Clinicoradiologic findings of the two groups were then analyzed. We presented Benjamini-Hochberg critical value for multiple testing correction of CT scan findings, with a false discovery rate of 0.05. Of a total of 338 consecutive patients diagnosed with pulmonary TB who underwent CT scans, 60 were excluded because of coexisting pulmonary diseases. The frequency of subpleural nodules (47/68, 69% in pulmonary TB with pleural effusion vs 30/210, 14% in pulmonary TB without effusion, P <.001, Benjamini-Hochberg [B-H] critical value = 0.0036) and interlobular septal thickening (55/68, 81% vs 134/210, 64%, P =.009, B-H critical value = 0.0107) was significantly higher in the group of patients with pulmonary TB with pleural effusion than in the group without pleural effusion. In contrast, tree-in-buds (20/68, 29% vs 101/210, 48%, P =.007, B-H critical value = 0.0071) were less frequently seen in patients with pulmonary TB with pleural effusion. Subpleural nodules and septal thickening were more common in pulmonary TB patients with pleural effusion than in those without pleural effusion. TB involvement of the lymphatics in the peripheral interstitium could be associated with the development of pleural effusion. [ABSTRACT FROM AUTHOR]

The role of cancer-directed surgery in the treatment of stage I-IIIA malignant pleural mesothelioma (MPM) by histologic subtypes remains controversial. The objective of this study was to evaluate the survival of the different histologic subtypes for stage I-IIIA MPM stratified by cancer-directed surgery and nonoperative management. How is the histologic subtype, clinical stage, and use of cancer-directed surgery for MPM associated with overall survival? Overall survival of patients with stage I-IIIA epithelioid, sarcomatoid, and biphasic MPM in the National Cancer Database from 2004 through 2017 who underwent cancer-directed surgery (ie, surgery with or without chemotherapy or radiation) or chemotherapy with or without radiation (nonoperative management) was evaluated using Kaplan-Meier analysis, multivariable Cox proportional hazards analysis, and propensity score-matched analysis. Of 2,285 patients with stage I-IIIA MPM who met inclusion criteria, histologic subtype was epithelioid in 71% of patients, sarcomatoid in 12% of patients, and biphasic in 17% of patients. Median survival was 20 months in the epithelioid group, 8 months in the sarcomatoid group, and 13 months in the biphasic group (P <.01). Among patients who underwent surgery, median survival was 25 months in the epithelioid group, 8 months in the sarcomatoid group, and 15 months in the biphasic group (P <.01). In multivariable Cox proportional hazards analyses, surgery was associated with improved survival in the epithelioid group (P <.01) but not in the sarcomatoid (P =.63) or biphasic (P =.21) groups. These findings were consistent in propensity score-matched analyses for each MPM histologic type. In this national analysis, cancer-directed surgery was found to be associated with improved survival for stage I-IIIA epithelioid MPM, but not for biphasic or sarcomatoid MPM. [ABSTRACT FROM AUTHOR]

Background: Visceral pleural invasion (VPI) with PL1 or PL2 increases the T classification from T1 to T2 in non-small cell lung cancers (NSCLCs) ≤ 3 cm. We proposed a modified T classification based on VPI to guide adjuvant therapy.Research Question: Is it reasonable to upstage PL1-positive cases from T1 to T2 for NSCLCs ≤ 3 cm?Study Design and Methods: In total, 1,055 patients with resected NSCLC were retrospectively included. Tumor sections were restained with hematoxylin and eosin stain and Victoria blue elastic stain for the elastic layer. Disease-free survival (DFS) and overall survival (OS) were calculated by the Kaplan-Meier method. Subgroup analysis and a Cox proportional hazards model were used to further determine the impact of VPI on survival.Results: The extent of VPI was diagnosed as PL0 in 824 patients, PL1 in 133 patients, and PL2 in 98 patients. The 5-year DFS rates of patients with PL0, PL1, and PL2 were 62.6%, 60.2%, and 28.8% (P < .01), whereas the corresponding 5-year OS rates were 78.6%, 74.4%, and 50.0% (P < .01), respectively. As predicted, the DFS and OS of patients with PL2 were much worse than those of patients with PL0 (P < .01) and PL1 (P < .01). However, both the DFS and OS of patients with PL0 and PL1 were comparable (DFS: P = .198; OS: P = .150). For node-negative cases, the DFS and OS of patients with PL0 and PL1 were also comparable (DFS: P = .468; OS: P = .388), but patients with PL2 had much worse DFS and OS than patients with PL0 (P < .01) and PL1 (P < .01). Multivariable analyses suggested that PL2, together with node positivity and poor cell differentiation, was an independent adverse prognostic factor.Interpretation: In NSCLCs ≤ 3 cm, tumors with PL1 should remain defined as T1, not T2. Overtreatment by adjuvant chemotherapy in node-negative NSCLCs ≤ 3 cm might be avoided in PL1 cases. [ABSTRACT FROM AUTHOR]

Background: Both elevated pleural elastance (E-PEL) and radiographic evidence of incomplete lung expansion following thoracentesis have been used to exclude patients with a malignant pleural effusion (MPE) from undergoing pleurodesis. This article reports on a cohort of patients with MPE in whom complete drainage was attempted with pleural manometry to determine the frequency of E-PEL and its relation with postthoracentesis radiographic findings.Methods: Seventy consecutive patients with MPE who underwent therapeutic pleural drainage with pleural manometry were identified. The pressure/volume curves were constructed and analyzed to determine the frequency of E-PEL and the relation of PEL to the postthoracentesis chest radiographic findings.Results: E-PEL and incomplete lung expansion were identified in 36 of 70 (51.4%) and 38 of 70 (54%) patients, respectively. Patients with normal PEL had an OR of 6.3 of having complete lung expansion compared with those with E-PEL (P = .0006). However, 20 of 70 (29%) patients exhibited discordance between postprocedural chest radiographic findings and the pleural manometry results. Among patients who achieved complete lung expansion on the postdrainage chest radiograph, 9 of 32 (28%) had an E-PEL. In addition, PEL was normal in 11 of 38 (34%) patients who had incomplete lung expansion as detected according to the postthoracentesis chest radiograph.Conclusions: E-PEL and incomplete lung expansion postthoracentesis are frequently observed in patients with MPE. Nearly one-third of the cohort exhibited discordance between the postprocedural chest radiographic findings and pleural manometry results. These findings suggest that a prospective randomized trial should be performed to compare both modalities (chest radiograph and pleural manometry) in predicting pleurodesis outcome. [ABSTRACT FROM AUTHOR]

Background: Pleural biopsy using either video-assisted thoracoscopic surgery or medical pleuroscopy is the current diagnostic criterion standard for pleural pathology with a high, yet imperfect, diagnostic yield. Cryobiopsy may provide greater tissue, increase depth of sampled tissue, and/or reduce crush artifact. However, its impact on diagnostic yield remains uncertain, and there are potential concerns regarding its safety too. We performed a systematic review and meta-analysis to investigate the same.Methods: We performed a systematic search of MEDLINE, Embase, and Google Scholar for studies evaluating the performance of pleural cryobiopsy, assessing the quality of each study using the Quality Assessment, Data Abstraction and Synthesis-2 tool. Using inverse variance weighting, we performed a meta-analysis of diagnostic yield estimations. We also reviewed specimen characteristics and complications related to the procedure.Results: Seven observational studies involving 586 pleural biopsies (311 cryobiopsies and 275 flexible forceps biopsies) were evaluated. All but one study used a semi-rigid thoracoscope. Meta-analysis generated a diagnostic yield of 96.5% for cryobiopsy and 93.1% for forceps biopsy with an inverse variance-weighted OR of 1.61 (95% CI, 0.71-3.66) and an I2 of 16%. No instances of moderate to severe bleeding were reported with cryobiopsy. A funnel plot illustrated no major publication bias.Conclusions: Based on analysis of relatively homogenous observational data, pleural cryobiopsy is safe but does not increase diagnostic yield over flexible forceps biopsy. Adequately powered multicenter randomized trials are needed for further investigation. [ABSTRACT FROM AUTHOR]

Background: This prospective observational study reports on diaphragm excursion, velocity of diaphragm contraction, and changes in pleural pressure that occur with thoracentesis.Methods: Twenty-eight patients with pleural effusion underwent therapeutic thoracentesis. Diaphragm excursion and velocity of diaphragm contraction were measured with M-mode ultrasonography of the affected hemidiaphragm. Pleural pressure was measured at each aliquot of 250 mL of fluid removal. Fluid removal was continued until no more fluid could be withdrawn, unless there was evidence of nonexpandable lung defined as a pleural elastance greater > 14.5 cm H2O/L and/or ipsilateral anterior chest discomfort.Results: Twenty-three patients had expandable lung, and five patients had nonexpandable lung. Velocity of diaphragm contraction (mean ± SD) increased from 1.5 ± 0.4 cm/s to 2.8 ± 0.4 cm/s pre-thoracentesis and post-thoracentesis, respectively (CI, 0.93-1.61; P < .001) in subjects with expandable lung. Velocity of diaphragm contraction (mean ± SD) increased from 2.0 ± 0.4 cm/s to 2.3 ± 0.4 cm/s pre-thoracentesis and post-thoracentesis (P = .45) in subjects with nonexpandable lung. Diaphragm excursion was significantly increased in subjects with expandable lung at the end of thoracentesis; diaphragm excursion did not increase to a significant extent in patients with nonexpandable lung.Conclusions: The velocity of diaphragm contraction and diaphragm excursion increased in association with fluid removal with thoracentesis in patients with expandable lung, whereas it did not significantly change in patients with nonexpandable lung. This may derive from improvement in loading conditions of the diaphragm in patients with expandable lung related to its preload and length-tension characteristics. [ABSTRACT FROM AUTHOR]

Pressure-dependent pneumothorax is a common clinical event, often occurring after pleural drainage in patients with visceral pleural restriction, partial lung resection, or lobar atelectasis from bronchoscopic lung volume reduction or an endobronchial obstruction. This type of pneumothorax and air leak is clinically inconsequential. Failure to appreciate the benign nature of such air leaks may result in unnecessary pleural procedures or prolonged hospital stay. This review suggests that identification of pressure-dependent pneumothorax is clinically important because the air leak that results is not related to a lung injury that requires repair but rather to a physiological consequence of a pressure gradient. A pressure-dependent pneumothorax occurs during pleural drainage in patients with lung-thoracic cavity shape/size mismatch. It is caused by an air leak related to a pressure gradient between the subpleural lung parenchyma and the pleural space. Pressure-dependent pneumothorax and air leak do not need any further pleural interventions., Competing Interests: Financial/Nonfinancial Disclosures The authors have reported to CHEST the following: M. A. J. received institution grant support from Mallinckrodt Pharmaceuticals. J. T. H. reports consultant/advisory boards for IBIOS (IPF), Roche/Genentech (IPF [nintedanib]), and Boehringer Ingelheim (IPF [pirfenidone]). None declared (A. C., P. D., K. H.)., (Copyright © 2023 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Background: The presence of B lines on lung ultrasonography is a characteristic feature of both cardiogenic pulmonary edema (CPE) and noncardiogenic alveolar interstitial syndrome (NCAIS), so their presence does not allow the clinician to differentiate between the two entities. Our study used M-mode ultrasonography of the pleura to differentiate CPE from NCAIS.Methods: A total of 43 subjects were enrolled in the study, and based on history, physical examination, and chart review, the patients were divided into three groups: an NCAIS group, a CPE group, and a control group. Three distinct pleural line morphologic categories were identified: a continuous pleural line, a fragmented pleural line, and a sinusoidal pleural line. In addition, two separate subpleural patterns were independently identified by the investigators: a horizontal pattern and a vertical pattern. These pleural and subpleural patterns were correlated with subject diagnoses.Results: A fragmented pleural line and a vertical subpleural pattern on M-mode ultrasonography is associated with patients who have NCAIS. Most patients with CPE have a continuous pleural line and a vertical subpleural pattern on M-mode ultrasonography. A sinusoidal pleural line on M-mode ultrasonography is suggestive of the presence of a pleural effusion.Conclusions: Our results indicate that M-mode ultrasonography is useful to distinguish CPE from NCAIS based on the pleural and the subpleural morphologic features. [ABSTRACT FROM AUTHOR]

Background: Pleurodesis performed either by pleurectomy or pleural abrasion is recommended in the approach to primary spontaneous pneumothorax to avoid recurrence. However, the efficacy of parietal pleural abrasion in producing pleurodesis is questioned. This study aims to determine the efficacy of apical abrasion alone, abrasion plus fibrin sealant application, and pleurectomy in producing pleurodesis in rabbits.Methods: Rabbits were subjected to video-assisted thoracic surgery alone (control) or to video-assisted thoracic surgery with apical gauze abrasion, abrasion plus fibrin sealant instillation, or apical pleurectomy. Blood samples were collected preoperatively and 48 h and 28 days postoperatively to measure total leukocytes (white blood cell count), neutrophil counts, and serum interleukin (IL)-8 levels. After 28 days the animals were sacrificed for macroscopic evaluation of the degree of apical pleurodesis and microscopic evaluation of local pleural fibrosis and collagen deposition.Results: White blood cell and neutrophil counts were similar in all groups, whereas the serum IL-8 level peaked at 48 h in all groups and decreased after 28 days, except in the pleurectomy group. After 28 days the abrasion plus fibrin sealant and pleurectomy groups had significantly more pleural adhesions, pleural fibrosis, and collagen deposition than the abrasion alone group, mainly due to thick mature fibers.Conclusions: Abrasion with local fibrin sealant instillation is as effective as pleurectomy in producing pleurodesis in rabbits. Apical pleurectomy elicits a more persistent elevation of serum IL-8 levels than apical abrasion alone or abrasion plus fibrin adhesive instillation. [ABSTRACT FROM AUTHOR]

Background: Visceral pleural invasion (VPI) is considered an aggressive and invasive factor in non-small cell lung cancer (NSCLC). Recent studies found that depending on tumor size, VPI influences T stage, but there is no consensus on whether VPI is important in node-negative NSCLC. In addition, its role in stage IB NSCLC is still uncertain. In this meta-analysis, we assessed the role of VPI in node-negative NSCLC according to various tumor sizes and especially in stage IB disease.Methods: A systematic literature search of four databases (EBSCO, PubMed, Ovid, and Springer) was performed to find relevant articles. The primary end point was 5-year overall survival. Pooled ORs were calculated using control as a reference group, and significance was determined by the Z-test.Results: Thirteen relevant studies in 27,171 patients were included in this study. The number of patients with VPI was 5,821 (21%). VPI was a significant adverse prognostic factor in patients with tumor size ≤ 3 cm (OR, 0.71; 95% CI, 0.64-0.79; P < .001), > 3 but ≤ 5 cm (OR, 0.69; 95% CI, 0.56-0.86; P < .001), and > 5 but ≤ 7 cm (OR, 0.70; 95% CI, 0.54-0.91; P = .007). A further comparison was made with stage IB NSCLC. Tumor size ≤ 3 cm with VPI was associated with a better survival than tumor size > 3 but ≤ 5 cm regardless of VPI (OR, 1.31; 95% CI, 1.19-1.45; P < .001). Exploratory analysis found no survival benefit between tumor size ≤ 3 cm with VPI and tumor size > 3 but ≤ 5 cm without VPI (OR, 1.16; 95% CI, 0.95-1.43; P = .15); however, the prognosis for tumor size > 3 but ≤ 5 cm with VPI was not as good as that for tumor size ≤ 3 cm with VPI.Conclusions: VPI together with tumor size has a synergistic effect on survival in node-negative NSCLC. Patients with stage IB NSCLC and larger tumor size with VPI might be considered for adjuvant chemotherapy after surgical resection and need careful preoperative evaluation and postoperative follow-up. Further randomized clinical trials to determine the impact of adjuvant chemotherapy in patients with stage IB NSCLC with VPI are warranted. [ABSTRACT FROM AUTHOR]

The article discusses a study which aims to calculate the pulmonary lesion movement throughout the tidal volume breathing, from full inspiration to end-exhalation, during electromagnetic navigation bronchoscopy procedures. Topics discussed include the use of CT scans and inspiratory (INSP)-expiratory (EXP) CT scan pair, baseline characteristics of pulmonary lesions, and the movements by lobe, distance from pleura, and lesion size.

The article highlights a study which investigated prognostic factors and recurrence of completely resected node-negative non-small cell lung cancer (NSCLC) with visceral pleural invasion (VPI). Results of the study revealed that patients with invasion to the visceral pleural surface (PL2) have worse survival, in comparison to patients with invasion beyond the elastic layer (PL1). PL2 was found to be a significant prognostic factor for recurrence of NSCLC with VPI.

This article cites a study focusing on the incidence of pleural tuberculosis (TB) in the U.S. To understand TB epidemiology, the researchers analyzed the U.S. national TB surveillance data from 1993-2003. They compared pleural TB to pulmonary TB. After analyzing this data, they reached to the conclusion that from 1993-2003, 7,549 cases of pleural TB and 156,779 cases of pulmonary TB were reported in the U.S.

The article discusses the role of interventional pulmonology (IP) in providing comprehensive care to patients with structural airway disorders and pleural diseases. IP encompasses three main areas in pulmonary medicine: malignant and nonmalignant airway disorders, pleural diseases and artificial airways. A variety of new scopes, modalities and technological innovations have energized the field.

The article discusses a study which examined the pleural fluid characteristics, pleural manometry and radiographic data of patients diagnosed with trapped lung. Trapped lung is characterized by the presence of a restrictive visceral pleural peel. The pleural fluid is paucicellular, lactate dehydrogenase is low and protein may be in the exudative range.

The article cites a study which reports on extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (EMZL/MALT--type). The study presents case report of a patient with EMZL/MALT-type with initial pleural presentation and reviews the literature. The patients was presented in the emergency department with fever and left-sided chest pain. A chest radiograph showed massive consolidation of the basal segments of the lower lobe of the left lung with an associated mild pleural effusion. The study indicates that EMZL/MALT-type can present as a primary pleural neoplasm or present initially in the pleura via extension from an adjacent pulmonary primary site.

The article provides information on a study which aims to establish a murine model of pneumothorax-associated pleural eosinophilia and to examine the role of interleukin (IL)-5 and IL-13 in the pathogenesis of this reaction. One hundred thirty-seven C57/Bl-6 mice were used in this study. Pleural inflammation was assessed by pleural lavage. The study concludes that pneumothorax induces an inflammatory reaction of the mouse pleura, mainly characterized by increased neutrophils and eosinophils. IL-5 but not IL-13 is required for pneumothorax-associated pleural eosinophilia.

The article focuses on a study which investigated whether anti-vascular endothelial growth factor (VEGF) antibody has any effect on the fluid production or the pleurodesis induced by transforming growth factor-beta. VEGF, also known as the vascular permeability factor, is an important angiogenic cytokine. VEGF also increases vascular permeability. It is likely that VEGF plays an important role in pleural fluid formation. In humans, pleural fluid VEGF levels were significantly higher in exudates than in transudates. Moreover, VEGF receptors are present at high density in both the normal and diseased pleura.

The article focuses on a study that aimed to assess the systemic response induced by low, nonpleurodesis-inducing doses of talc and silver nitrate in an experimental model in rabbits. The mechanism by which talc induces acute systemic effects is poorly understood. Talc particles have been demonstrated in several organs of animals that received doses of talc sufficient to produce a pleurodesis. There is also evidence that the risk of adverse effects after talc pleurodesis may be dose related. In fact, when a small dose of talc was injected in rabbits, talc particles were shown only in the ipsilateral lung and mediastinum.

The article reports on the efficacy of ultrasound in the diagnosis of pleurodesis in rabbits. The treatment of recurrent pleural effusion or recurrent pneumothorax frequently involves the creation of a pleurodesis. Ultrasound is being used more frequently to assess the presence of pleural fluid or pneumothorax. Pleurodesis usually results from pleural inflammation produced by an injury to the pleura. The assessment of the presence of a pleurodesis is difficult. Advances in technology have greatly improved the imaging capabilities of ultrasound. Using ultrasound, the parietal pleura and the visceral pleura are normally seen as two thin, bright echogenic lines just beneath the chest wall.

This article cites a study comparing the efficacy and the safety of talc slurry and silver nitrate (SN) in the treatment of symptomatic malignant pleural effusions (MPE). It was hypothesized that the two agents would be equally effective. Sixty patients with unilateral MPEs were enrolled into this study. The patients were recruited between January 2000 and July 2002 from the following two hospitals: AVG Cancer Institute and Perola Byington Hospital. Eleven of the patients did not return for their follow-up visit and were excluded from the analysis. For the remaining 49 patients, a diagnosis of malignancy was obtained via cytology in 35 patients, by histologic examination of pleural biopsy specimens in 14 patients, and by both in 3 patients. In all patients, a chest tube was inserted using local anesthesia and parenteral meperidine. Findings of the study suggest that SN is an effective agent for producing a pleurodesis. The side effects of 0.5% SN appeared to be minimal.

Examines the association between pleural fluid (PF) eosinophilia, and the PF and serum levels of interleukin-5 (IL-5), eotaxin-2, eotaxin-3 and vascular cell adhesion molecule-1 (VCAM-1) in patients with post-coronary artery bypass grafting pleural effusions. Measurement of cytokines and VCAM-1 using enzyme-linked immunosorbent assay; Correlation between PF eosinophils and blood eosinophils; Preferential production of IL-5 and eotaxin-3 in the pleural cavity.

Examines the hydrodynamic performance of pleural drainage systems. Determination of ambient air flow; Models of pleural drainage systems connected to wall suction; Stability of negative pressure.

Study objectives: Although the sentinel lymph node (SLN) concept has traditionally been applied to solid organs, we hypothesized that the pleural space might drain into a specific SLN group. The identification of such a nodal group could assist in the staging and treatment of pleural-based diseases, such as mesothelioma, or other lung cancers with visceral pleural invasion. The purpose of this study was to determine whether the pleural space has an SLN group. Design: Sixteen rats underwent tight or left pleural space injection of a novel lymph tracer, quantum dots (QDs), which have a hydrodynamic diameter of 15 nm and fluoresce in the near-infrared (NIR) spectrum. Nodal uptake of the entire thorax was imaged with a custom system that simultaneously acquired color video, NIR fluorescence of the QDs, and a merged picture of the two in real-time. Six pigs underwent right or left pleural space injection of QDs and similar imaging. Measurements and results: In the rat, the QDs drained solely to the highest superior mediastinal lymph node group, corresponding to lymph node station 1, according the regional lymph node classification for lung of the American joint Committee on Cancer. In one rat, the injection of QDs in the left pleural space resulted in migration to the contralateral station 1 lymph node group. The injection of QDs in the right or left pleural space of the pig resulted in migration solely to the ipsilateral highest superior mediastinal lymph node group. Conclusions: NIR fluorescence imaging in two species demonstrated that the highest superior mediastinal lymph nodes of station 1 are the SLNs of the pleural space. This study also provides intraoperative feasibility and proof of the concept for identifying lymph nodes communicating with the pleural space on a patient-specific basis, in real-time, and with high sensitivity. [ABSTRACT FROM AUTHOR]

The diagnosis and management of malignant pleural mesothelioma are major challenges that often frustrate both patient and clinician alike. Occupational asbestos exposure to crocidolite or amosite forms of the fiber is the most important known risk factor in North America and Western Europe. Other mineral fibers such as erionite, a naturally occurring fibrous zeolite crystal, are associated with mesothelioma in volcanic tuffs of the Cappadocia region of central Anatolia in Turkey. In addition, other possible factors such as the presence of simian virus 40 and genetic susceptibility have been associated recently with the development of mesothelioma in animal models. These latter findings are increasing our understanding of this disease. In addition, the discovery of elevated levels of various markers such as folic acid receptor a, cyclooxygenase 2, and multidrug resistance proteins 1 and 2 in mesothelioma tissue have opened up new areas of potential diagnostic and therapeutic importance. However, traditional treatment modalities- surgery, radiotherapy, and chemotherapy-have evolved slowly, and few gains in therapeutic efficacy have occurred. Recently, however, continuing research efforts have led to novel treatment strategies that are changing the way clinicians view a disease that has traditionally been managed with almost universal therapeutic nihilism. This review explores our current knowledge of this disease and presents current and novel therapeutic strategies. [ABSTRACT FROM AUTHOR]

The objective of this study was to describe the clinical course and response to treatment of five patients who developed loculated pleural effusions as complications of pulmonary thromboembolism (PTE). The clinical charts of five patients who had loculated pleural effusions in the course of their PTE were reviewed, with special attention paid to the duration of symptoms before diagnosis, the pleural fluid analysis findings, and the response of the loculations to anticoagulant therapy. In a tertiary care academic medical center, the five patients described in the present study had multiple locules of pleural fluid seen on chest radiographs and thoracic CT scans. In all cases, the diagnosis of PTE had been delayed for at least 2 weeks after symptoms developed. The loculated pleural fluid had led to the mistaken diagnosis of empyema in three cases. The pleural fluid in all cases was exudative, with a pre- dominance of lymphocytes. With anticoagulant therapy, the loculations largely disappeared within the first few days of therapy. Although most pleural effusions secondary to PTE are relatively small and free-flowing, this study demonstrates that PTE can lead to loculated pleural effusions. The loculations occurred in patients who had been symptomatic from their PTE for > 2 weeks. In each instance, the pleural fluid was a lymphocytic exudate. The effusions rapidly resolved with the institution of anticoagulant therapy. PTE should be included in the differential diagnosis of a loculated pleural effusion, particularly if the pleural fluid contains predominantly lymphocytes. [ABSTRACT FROM AUTHOR]

Study Objective: s: To determine whether talc (TL) and silver nitrate (SN), two effective pleurodesis agents, induce a systemic inflammatory response in the acute phase of experimental pleurodesis in rabbits.Design: Samples of blood and pleural fluid were collected after 6, 24, and 48 h from rabbits injected intrapleurally with 3 mL saline solution, TL (400 mg/kg), or 0.5% SN, and were assayed for WBC count, percentage of neutrophils, and levels of lactate dehydrogenase (LDH), interleukin (IL)-8, and vascular endothelial growth factor (VEGF). The pleural liquid production was compared in the three different groups. A sample of blood collected from animals preinjection was used as the control.Results: At 6 h after pleural injection, the mean blood WBC count and percentage of neutrophils were significantly elevated in the TL group, whereas the mean LDH and IL-8 levels were significantly increased in the SN group. VEGF was undetectable in the preinjection serum and saline solution-injected animals, but was increased in the serum after the pleural injection of both TL and SN to a comparable degree. SN elicited a more intense acute pleural inflammation reaction than did TL, with higher WBC count and IL-8 levels found in the pleural fluid, mainly within the first 6 h. LDH and VEGF levels, and pleural liquid production were also higher for SN, and they increased with time.Conclusions: In the acute phase of pleural injection, TL induced a transient increase in blood WBC count and percentage of neutrophils, while SN induced increases in blood LDH and IL-8 levels. Both TL and SN induced significant increases in blood VEGF levels. SN induced an earlier and more intense acute pleural inflammation than TL. Pleural liquid VEGF levels were higher after SN injection and increased, as did pleural liquid production. These findings suggest that the intrapleural injection of TL and SN produce a systemic inflammatory response that may have a role in the pathogenesis of fever and ARDS, which occur with pleurodesis. [ABSTRACT FROM AUTHOR]

Discusses historical information, clinical findings, illustrations of salient radiologic findings and pathogenic mechanisms of asbestos exposure. Types of exposure; Features of asbestos-related diseases; Results of chest radiographs; Pleural thickening unrelated to asbestos exposure; Effect of asbestos fibers on airway wall; Policy implications of asbestos exposure.

Study objectives: Solitary fibrous tumors of the pleura (SFTPs) are slow-growing neoplasms. Approximately 800 cases have been reported in the literature to date. The aim of this study was to address our experience with the management of SFTPs and to evaluate the advantage of video-assisted thoracoscopic surgery (VATS) in SFTP treatment. Design: Retrospective analysis of our experience. Setting: Department of Thoracic and Cardiovascular Surgery, Nara Medical University. Patients: From January 1992 to August 2002, 13 patients with a SFTP were referred to us for surgical resection after VATS was adopted in our hospital. The study group consisted of seven men and six women with a mean age of 49.8 years (age range, 37 to 72 years). Results: Surgical excision was performed with VATS only in nine patients, with VATS plus a small thoracotomy in three patients, and by a posterolateral thoracotomy without VATS in one patient. The mean chest-drain duration was 1.3 days (range, 1 to 3 days), and the mean duration of hospital stay was 8.6 days (range, 3 to 30 days). Eleven tumors, originating from the visceral pleura, were pedunculate, and 2 tumors from the parietal pleura were not pedunculate. Two cases were focally characterized by a mitotic count in excess of four mitoses per 10 high-power fields and by cellular pleomorphism. Follow-up periods ranged from 6 to 120 months, with a mean of 49.7 months and a median of 42 months. All patients have remained well with no recurrence or metastasis. Conclusions: Complete surgical resection is the treatment of choice for SFYPs. For the pedunculate tumors, therefore, VATS is a powerful and useful approach. Even when it is necessary to perform a small thoracotomy in addition to VATS for the removal of a large tumor, VATS may play an important role in reducing the size of the thoracotomy incision, which results in less invasive surgery. To minimize postoperative morbidity, VATS may be the most promising surgical approach for the resection of SFTPs. [ABSTRACT FROM AUTHOR]

Study objectives: Sialomucin complex (SMC) is a heterodimeric glycoprotein, and is found on the surfaces of the mesothelia of the pleura, pericardium, and peritoneum. Sialomueins play a significant role in adhesion as well as in defense. In this study, we hypothesized that pleural mesothelial cells (PMCs) express SMC and thus prevent the adherence of ovarian cancer cells (HTB-77) to the pleura. Methods: PMCs were plated, and the adherence of HTB-77 cells was observed using a cytofluor. The PMC monolayer was pretreated with sialidase, and HTB-77 adherence was observed using cytofluor. In another set of HTB-77 cells, adherence was observed when the PMC monolayer was pretreated with supernatants of HTB-77 cells. Last, supernatants of HTB-77 cells were assayed for sialidase activity. Results: The removal of SMC by sialidase greatly increased the adherence of HTB-77 cells to the PMC monolayer, which was statistically significant (p < 0.05). Similar results were obtained when the PMC monolayer was pretreated with the supernatants of HTB-77 cells. Supernatants of HTB-77 cells showed the presence of sialidase. Conclusions: The presence of SMC on the PMC acts as a defense layer, and its removal by sialidase increases the susceptibility of the PMC layer to the adherence of malignant cells and to increased metastasis. HTB-77 cells also express sialidase, which by its action on the monolayer aids in the adherence of tumor cells to the pleural surface. [ABSTRACT FROM AUTHOR]

We describe a case of a 30-year-old man who developed a recurrent pleural effusion after sustaining a gunshot wound to the left side of his chest with subsequent complete paralysis at the T2 level. Subarachnoid-pleural fistulas have rarely been reported as complications of penetrating and blunt trauma, thoracic surgery, as well as spinal surgery. Concomitant injuries may overshadow or complicate the diagnosis of subarachnoid-pleural fistulas. The diagnosis should be considered in any patient with a pleural effusion that is associated with severe neurologic injury, as the fistula rarely heals without surgical intervention and may lead to CNS infection or pneumocephalus. [ABSTRACT FROM AUTHOR]

Study Objective: Streptococcus pneumoniae is the most frequent causative agent of community-acquired pneumonia (CAP); however, an etiologic diagnosis by traditional techniques can be accomplished in only a small percentage of patients with CAP. Pleural fluid is present in approximately 40% of patients with CAP; therefore, we hypothesized that detection of S pneumoniae DNA in pleural fluid by polymerase chain reaction (PCR) may help to increase the rate of diagnosis of pneumococcal pneumonia.Design: A prospective study of cases.Setting: A university hospital in Lleida, Spain.Patients and Methods: One hundred two samples of pleural fluid (51 samples from consecutive adult patients with pneumonia and 51 samples from unselected control subjects) were tested by the nested-PCR method to detect selected pneumolysin gene of S pneumoniae, and the results were compared with those provided by alternative diagnostic methods.Results: PCR in pleural fluid had a diagnostic sensitivity of 78% in patients with pneumococcal pneumonia, with positive results in 2 of 2 patients (100%) and 5 of 7 patients (71%) who had positive or negative pleural fluid culture findings, respectively. PCR results were also positive in 3 of 24 patients (12%) with pneumonia of unknown etiology and negative in all patients with pneumonia due to microorganisms other than S pneumoniae. Thus, the calculated specificity was 93%. Among control subjects, PCR gave positive results in two cases (4%).Conclusion: The nested-PCR test, applied to pleural fluid samples from patients with CAP, showed a sensitivity of 78% and a specificity of 93% in the diagnosis of pneumococcal pneumonia. [ABSTRACT FROM AUTHOR]

Study Objectives: Unlike thoracocentesis and closed pleural biopsy (CPB), medical thoracoscopy permits biopsy with direct visualization. In a 6-year retrospective study of patients having undergone at least one medical thoracoscopy, we analyzed the diagnostic yield of thoracoscopy and its value in the management of pleural disease.Setting/patients: From January 1, 1989, to December 31, 1994, 168 medical thoracoscopies were performed on 154 patients (123 men; mean age +/- SE, 61 +/- 1 years), of which 149 were diagnostic and 19 were indicated for therapeutic assessment in malignant mesothelioma (MM). Prior to thoracoscopy, at least one CPB had been performed in 120 of 149 cases, yielding a diagnosis in 96 cases.Results: Thoracoscopy challenged the CPB-based diagnosis in 43 of 96 cases. In 66 cases of nonspecific inflammation diagnosed by CPB, thoracoscopy revealed MM in 16 cases, adenocarcinoma in 10 cases, undetermined carcinoma in 3 cases, and pleural tuberculosis in 3 cases. In 18 cases in which the CPB diagnosis was MM, thoracoscopy, performed for precise staging, challenged the diagnosis in 4 cases. In 12 cases of carcinoma diagnosed by CPB, thoracoscopy specified the histologic type in 7 cases. Thoracoscopic diagnoses were found to be erroneous in 10 of 149 cases, mainly owing to pleural adhesions that limited access to the pleural cavity. There was one thoracoscopy-related death, one case of sepsis, and six cases of empyema.Conclusions: Medical thoracoscopy appears to be efficient and relatively safe in the management of pleural disease. Pleural adhesions can lower its diagnostic value. [ABSTRACT FROM AUTHOR]