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To aid surgeons in more complete and safe resection of brain tumors, adjuvant technologies have been developed to improve visualization of target tissue. Fluorescence-guided surgery relies on the use of fluorophores and specific light wavelengths to better delineate tumor tissue, inflammation, and areas of blood–brain barrier breakdown. 5-aminolevulinic acid (5-ALA), the first fluorophore developed specifically for brain tumors, accumulates within tumor cells, improving visualization of tumors both at the core, and infiltrative margin. Here, we describe the background of how 5-ALA integrated into the modern neurosurgery practice, clinical evidence for the current use of 5-ALA, and future directions for its role in neurosurgical oncology. Maximal safe resection remains the standard of care for most brain tumors. Gross total resection of high-grade gliomas (HGGs) is associated with greater overall survival and progression-free survival (PFS) in comparison to subtotal resection or adjuvant treatment therapies alone.1–3 A major challenge neurosurgeons encounter when resecting infiltrative gliomas is identification of the glioma tumor margin to perform a radical resection while avoiding and preserving eloquent regions of the brain. 5-aminolevulinic acid (5-ALA) remains the only optical-imaging agent approved by the FDA for use in glioma surgery and identification of tumor tissue.4 A multicenter randomized, controlled trial revealed that 5-ALA fluorescence-guided surgery (FGS) almost doubled the extent of tumor resection and also improved 6-month PFS.5 In this review, we will highlight the current evidence for use of 5-ALA FGS in brain tumor surgery, as well as discuss the future directions for its use.

Objectives Recent observations indicate a potential survival benefit in patients with malignant pleural effusion (MPE) who achieve successful pleurodesis in comparison to patients who experience effusion recurrence post pleurodesis. This study aimed to explore this observation using two datasets of patients with MPE undergoing talc pleurodesis. Materials and Methods Dataset 1 comprised patients who underwent talc pleurodesis at Oxford Pleural Unit for MPE. Dataset 2 comprised patients enrolled in the TIME1 clinical trial. Pleurodesis success was defined as absence of need for further therapeutic procedures for MPE in the three months following pleurodesis. Data on various clinical, laboratory and radiological parameters were collected and survival was compared according to pleurodesis outcome (success vs. failure) after adjusting for the aforementioned parameters. Results Dataset 1 comprised 60 patients with mean age 74.1±10.3 years. The most common primary malignancies were mesothelioma, breast and lung cancer. 29 patients (48.3%) achieved pleurodesis. The adjusted odds ratio (aOR) for poor survival with pleurodesis failure was 2.85 (95% CI 1.08–7.50, =p 0.034). Dataset 2 comprised 259 patients from the TIME1 trial. The mean age was 70.8±10.3 and the most common primary malignancies were mesothelioma, lung and breast cancer. Pleurodesis was successful in 205 patients (79%). aOR for poor survival was 1.62 (95% CI 1.09–2.39, p = 0.015). Conclusion Achieving pleurodesis seems to impart a survival benefit in patients with MPE. Further studies are required to explore factors that may contribute to this phenomenon and to address the difference in survival between pleurodesis and indwelling pleural catheter interventions.

Focused thoracic ultrasound (TUS) provides an increased safety profile when undertaking invasive pleural procedures. This has led to the requirement for defined curricula, high quality teaching and robust, validated assessment tools among physicians to ensure patient safety and clinical excellence. Current UK practice is based almost exclusively on expert consensus, but assessment methods employed have been shown to have low reliability and validity and are potentially open to bias. As a result, several assessment tools have been developed, although each has its own limitations.This study aimed to develop and validate an assessment tool corresponding to those skills associated with the most basic level of practice, defined recently as an emergency level operator in the British Thoracic Society Training Standards for Thoracic Ultrasound.A total of 27 candidates were enrolled by two examiners based in Belfast and Oxford over a 10-month period between February and November 2019. Mean score of the inexperienced group was 44.3 (95% CI 39.2-49.4, range 28-54) compared with 74.9 (95% CI 72.8-77, range 64-80) in the experienced group providing an estimated mean difference of 30.7 between the two groups (95% CI 24.7-36.7; p .001).This tool appears to discriminate between trainees with limited experience of TUS performance and those with no experience. It has the potential to form part of the assessment strategy for trainees in the United Kingdom and beyond, alongside well established assessment tools in postgraduate training.

Advanced malignancy is a prevalent cause of exudative pleural effusion. The management of malignant pleural effusion (MPE) has been the subject of several recent randomized controlled trials and excellent reviews. Less attention has been focused on another controversial and challenging aspect of MPE: it's diagnosis. Prior to selecting the optimal management strategy, the presence of an MPE must first be correctly identified with an emphasis on minimizing invasiveness and discomfort in a patient afflicted with late-stage cancer. The aim of the present review is to summarize the current knowledge about MPE diagnostics and to propose an algorithm for the diagnosis of MPE in established or suspected malignancy.

Malignant pleural effusions (MPE) are common and associated with disabling symptoms, and large hospitalisation costs [1]. Current management of recurrent MPE is symptomatic, with chest drain and talc pleurodesis, or indwelling pleural catheter (IPC) insertion. IPCs are an increasingly attractive option in patients wishing to avoid hospitalisation as they reduce initial length of stay [2, 3], but require repeated domiciliary drainage. Other patients opt for talc pleurodesis because, if successful, it represents a one-time definitive procedure, but it has a modest failure rate (20–30%) [4]. In the case of talc pleurodesis failure, IPC insertion is usually advocated with the consequence that a subset of patients with IPC in situ will have previously received ipsilateral intrapleural talc. IPCs are also increasingly being used in patients with recurrent benign pleural effusions (non-MPE) [5, 6]., Prior talc pleurodesis does not result in worsened outcomes from subsequent indwelling pleural catheter use, and patients should not be dissuaded from choosing talc as a primary treatment for recurrent pleural effusion. http://ow.ly/qAAC30mYmr3

© 2018 Wolters Kluwer Health, Inc. Malignant pleural effusion is a common clinical problem with an increasing incidence that may be seen to complicate the management of almost all forms of cancer. It is associated with a very poor median survival leading to a palliative management approach. Several methods are available in the management of malignant pleural effusion including simple pleural aspiration, talc pleurodesis, or indwelling pleural catheters. Patient selection, however, remains difficult. The role for each management option, their indications, predictors of success, and factors influencing patient selection are all crucial considerations and are discussed here, as are the health economic impacts and future directions.

Background: Diagnostic yield (DY) and safety of computed tomography (CT)- and thoracic ultrasound (TUS)-guided biopsies in the diagnosis of pleural lesions have been investigated in a number of studies, but no synthesis of data from the literature has ever been performed. Objectives: We aimed to provide the first systematic review and meta-analysis on the DY and safety of CT- versus TUS-guided biopsy in the diagnosis of pleural lesions. Method: We searched MEDLINE and EMBASE for all studies reporting outcomes of interest published up to April 2018. Two authors reviewed all titles/abstracts and retrieved selected full text to identify studies according to predefined selection criteria. Summary estimates were derived using the random-effects model. Cumulative meta-analysis assessed the influence of increasing adoption of the procedures over time. Results: Thirty original studies were included in the present review; the number of studies on TUS-guided biopsy was almost three-fold higher than those on CT-guided biopsy. The pooled DYs of the 2 procedures were overall excellent and differed Conclusions: Data show that CT- and TUS-guided biopsies in the diagnosis of pleural lesions are both excellent procedures, without meaningful differences in DYs and safety. Considering that TUS is non-ionizing and easily performed at the bedside, it should be the preferred approach in presence of adequate skills.

These recommendations apply to adults with a newly diagnosed lesion with a suspected or histopathologically proven glioblastoma (GBM). What are the optimal imaging techniques to be used in the management of a suspected glioblastoma (GBM), specifically: which imaging sequences are critical for most accurately identifying or diagnosing a GBM and distinguishing this tumor from other tumor types? Critical Imaging for the Identification and Diagnosis of Glioblastoma Level II: In patients with a suspected GBM, it is recommended that the minimum magnetic resonance imaging (MRI) exam should be an anatomic exam with both T2 weighted, FLAIR and pre- and post-gadolinium contrast enhanced T1 weighted imaging. The addition of diffusion and perfusion weighted MR imaging can assist in the assessment of suspected GBM for the purposes of distinguishing GBM from other tumor types. Computed tomography (CT) can provide additional information regarding calcification or hemorrhage and also can be useful for subjects who are unable to undergo MR imaging. At a minimum, these anatomic sequences can help identify a lesion as well as its location, and potential for surgical intervention. Improvement of diagnostic specificity with the addition of non-anatomic (physiologic imaging) to anatomic imaging Level II: One blinded prospective study and a significant number of case series support the addition of diffusion and perfusion weighted MR imaging in the assessment of suspected GBM, for the purposes of distinguishing GBM from other tumor types (e.g., primary CNS lymphoma or metastases). Level III: It is suggested that magnetic resonance spectroscopy (MRS) and nuclear medicine imaging (PET 18F-FDG and 11C-MET) be used to provide additional support for the diagnosis of GBM.

IntroductionThe rising incidence of pleural disease is seeing an international growth of pleural services, with physicians performing an ever-increasing volume of pleural interventions. These are frequently conducted at sites without immediate access to thoracic surgery or interventional radiology and serious complications such as pleural bleeding are likely to be under-reported.AimTo assess whether intercostal vessel screening can be performed by respiratory physicians at the time of pleural intervention, as an additional step that could potentially enhance safe practice.MethodsThis was a prospective, observational study of 596 ultrasound-guided pleural procedures conducted by respiratory physicians and trainees in a tertiary centre. Operators did not have additional formal radiology training. Intercostal vessel screening was performed using a low frequency probe and the colour Doppler feature.ResultsThe intercostal vessels were screened in 95% of procedures and the intercostal artery (ICA) was successfully identified in 53% of cases. Screening resulted in an overall site alteration rate of 16% in all procedures, which increased to 30% when the ICA was successfully identified. This resulted in procedure abandonment in 2% of cases due to absence of a suitable entry site. Intercostal vessel screening was shown to be of particular value in the context of image-guided pleural biopsy.ConclusionIntercostal vessel screening is a simple and potentially important additional step that can be performed by respiratory physicians at the time of pleural intervention without advanced ultrasound expertise. Whether the widespread use of this technique can improve safety requires further evaluation in a multi-centre setting with a robust prospective study.

IntroductionCurrent guidelines recommend an initial pleural aspiration in the investigation and management of suspected malignant pleural effusions (MPEs) with the aim of establishing a diagnosis, identifying non-expansile lung (NEL) and, at times, providing a therapeutic procedure. A wealth of research has been published since the guidelines suggesting that results and outcomes from an aspiration may not always provide sufficient information to guide management. It is important to establish the validity of these findings in a ‘real world’ population.MethodsA retrospective analysis was conducted of all patients who underwent pleural fluid (PF) sampling, in a single centre, over 3 years to determine the utility of the initial aspiration.ResultsA diagnosis of MPE was confirmed in 230/998 (23%) cases, a further 95/998 (9.5%) were presumed to represent MPE. Transudative biochemistry was found in 3% of cases of confirmed MPE. Positive PF cytology was only sufficient to guide management in 45/140 (32%) cases. Evidence of pleural thickening on CT was associated with both negative cytology (χ2 1df=26.27, p2 1df=10.39, p=0.001). In NEL 44.4% of patients did not require further procedures after pleurodesis compared with 72.7% of those with expansile lung (χ2 1df=5.49, p=0.019). In patients who required a combined diagnostic and therapeutic aspiration 106/113 (93.8%) required further pleural procedures.ConclusionsAn initial pleural aspiration does not achieve either definitive diagnosis or therapy in the majority of patients. A new pathway prioritising symptom management while reducing procedures should be considered.

Introduction Malignant pleural effusion (MPE) signifies advanced disease and poor prognosis, with median survival ranging from 3 to 12 months. Pleural cytology is a widely used initial investigation for MPE but has a relatively low sensitivity of around 60%1. Negative pleural fluid cytology can result in a delay in diagnosis and treatment pathways. Negative CT findings alone cannot out malignancy. Pleural biopsy provides a definitive diagnosis of malignancy in the majority of cases of MPE,1 but is more invasive and may not be suitable for every patient. Objective The aim of this retrospective analysis was to assess the relationship between CT findings that are often associated with malignancy, and pleural cytology results. Methods We performed a retrospective analysis of all patients who had a pleural aspiration between 2015 and 2017 (n=219) with either positive pleural fluid cytology or a malignant pleural biopsy following negative cytology at a UK tertiary hospital. Patients were divided into two groups according to the cytology results. Chi-Square tests were used to analyse the relationship between CT findings and cytology result. Patients with negative pleural fluid cytology who did not go on to have a pleural biopsy were excluded. Results Of the 219 patients with diagnosed MPE, fluid cytology was positive in 151 (68.9%) patients. The remaining 68 (31.1%) patients had positive pleural biopsy as the initial cytology test was negative. Thoracic lymphadenopathy on CT was associated with positive pleural fluid cytology (odds ratio [OR]=1.82; p=0.042). Pleural nodularity (OR=4.76; p Conclusions This study suggests that pleural nodularity and pleural thickening on CT are associated with negative pleural fluid cytology. In patients with such features on CT and suspected MPE, a ‘straight to pleural biopsy’ approach should be considered. Reference Hooper C, Lee YCG, Maskell Investigation of a unilateral pleural effusion in adults: British Thoracic Society pleural disease guideline 2010.Thorax 2010;65:ii4-ii17.

Introduction Diagnosing pleural infection can be challenging in the clinical setting. Positive microbiology is the gold standard, but pleural fluid culture requires days to establish and can be negative in 40% of patients with pleural infection. Rapid biomarker testing showing low pH, low glucose and very high LDH in pleural fluid is used to diagnose pleural infection in the correct clinical setting. Objectives To establish the diagnostic accuracy of low pH, low glucose and very high LDH in pleural fluid for pleural infection and establish the common alternative diagnoses leading to this biochemical pattern. Methods A retrospective analysis of pleural effusion results from a UK tertiary centre over a three year period. Pleural fluid results with either pH 1000 IU/L (total 173) were assessed to establish the frequency of non-infective final diagnoses and the relative specificity of each parameter calculated for the diagnosis of pleural infection. Results Of effusions with either a low pH, low glucose or LDH>1000 (n=173), the most common causes were infective 51% (n=89), with the most frequent alternative diagnosis malignant pleural effusion (MPE) 31% (n=53). Of note 10% (n=19) had co-existing malignancy and infection. The most common causative MPEs were lung 51%, mesothelioma 32% and breast 16%. In all pleural effusions with a pH 1000 (n=129), 47% were non infective in aetiology, 30% due to MPE. Table 1 illustrates further specific diagnoses within each cohort. Conclusions Pleural effusions with a low pH, low glucose or very high LDH often have a non-infective cause. While it may be appropriate to commence antimicrobial treatment, our results suggest that malignancy should be actively investigated. Pleural fluid pH

Introduction Light’s criteria is widely utilised to differentiate pleural effusions as exudative or transudative. In a subsect of pleural effusions, there is discordance between protein and lactate dehydrogenase (protein high, LDH low or vice versa). The causes of this biochemical pattern are not well established, nor are the mechanisms well understood. Objectives To establish the incidence of discordant pleural effusions, and determine demographics and common aetiologies leading to discordance. Methods We performed a retrospective analysis of initial pleural fluid samples sent between 2015–2017 (n=995) from a UK tertiary centre. 792 of these were exudative based on Light’s criteria. These were subdivided into concordant or discordant exudates, with analysis of demographics and final diagnoses in each group. Low protein was defined as Results 29% (n= 229) of exudative effusions displayed discordance in either LDH or protein. 33% of these (n=75) had low protein with high LDH and 67% (n= 154) had low LDH with high protein. The median age was significantly higher in the discordant group (75 years vs 70 years). In the discordant group with high protein, the most common diagnoses were malignant pleural effusion (MPE) 38% (n=59), cardiac/osmotic related effusions 13% (n=19), and infection 7% (n=12). The most common diagnoses in the discordant group with high LDH were infection 37% (n=30), MPE 24% (n=18), and cardiac/osmotic related 7% (n=6). In the concordant group (n=486), frequent diagnoses were MPE 42% (n=206), Infection 37% (n=132) with cardiac/osmotic related effusions only representing Figure 1 compares the percentage occurrence of specific diagnoses in concordant and discordant groups. Conclusions A significant proportion of pleural effusions that are initially classified as exudative display discordance between LDH and protein. Discordance occurs in older patients, possibly due to increased capillary permeability with age. Within discordant groups, more effusions occurred secondary to global fluid overloaded states (11% of discordant versus

Endobronchial ultrasound has become first line in the investigation of mediastinal lesions suspicious for malignancy in keeping with National Institute for Health and Care Excellence (NICE) guidelines; however, needle size and type required to maximise diagnostic sensitivity remains unclear. Previous meta-analyses have compared the use of ProCore with standard fine needle aspiration in the assessment of pancreatic masses with differences noted only in the number of passes required. We aim to assess whether a ProCore needle improves diagnostic sensitivity in EBUS-TBNA. Complete follow-up data regarding all 235 patients undergoing EBUS-TBNA in a district general hospital has been collected since the service's inception in 2012. Results were collated and retrospectively analysed allowing for calculation of test sensitivity and specificity. Comparison was then made between procedures where standard fine needle aspiration was performed and those using a ProCore needle. Overall sensitivity of EBUS-TBNA was shown to be 85% with a specificity of 100% in keeping with quoted figures from other centres. Standard fine needle aspiration produced a sensitivity of 77% (85/110) versus ProCore sensitivity of 92% (115/125) with a p value of 0.0016. Thirty percent (33/110) of patients undergoing standard fine needle aspiration required an appropriate crossover technique such as mediastinoscopy or CT-guided FNA in order to either obtain or confirm the diagnosis compared with 15% (19/125) of the ProCore group with a p value of 0.0064. Our retrospective analysis shows a statistically significant difference in the diagnostic sensitivity of sampling mediastinal lymphadenopathy using a ProCore needle compared with standard fine needle aspiration. It also shows that a significantly fewer number of patients required further procedures in order to obtain or confirm the diagnosis. This could potentially be confounded by the retrospective nature of the study design; however, due to the statistical significance demonstrated, further study is required.

Pleural disease is common with an increasing incidence and so represents a significant proportion of the workload for respiratory physicians. Chest drain insertion continues to be considered a mainstay of pleural disease management however the optimum drain size required for various pleural conditions remains unclear. Traditionally large-bore chest drains were inserted through a surgical technique of blunt dissection however smaller bore Seldinger (guidewire) drains have dramatically increased in popularity in recent times most likely due to ease of insertion and perceived increased patient tolerability. Despite British Thoracic Society Guidelines advocating a preference for small-bore chest drains, their use remains controversial. We aim to review the literature in each category of pleural disease including pneumothorax, malignant pleural effusion and pleural infection, regarding chest drain size, comparing the role, effectiveness and complications of each.

Background: The diagnostic yield for malignancy of pleural fluid (PF) cytology in patients with pleural effusion (PE) is well known but there is scarce data in the setting of patients who developed a PE and have a prior diagnosis of cancer. Aim: The aim of our study was to evaluate the negative predictive value (NPV) of cytological examination of the PF in patients who had a background of cancer and developed PE. Method: This was a retrospective, descriptive analysis of consecutive patients who developed PE, between January 2015 to December 2017, and had a background of cancer in the Oxford Pleural Unit. Follow-up was made until death or at least one year. Results: 152 patients were included (79 -51.9%- women; mean age 71±12). 75 (49.3%) patients had a malignant PE; 48.0% of these cases were diagnosed by cytology. Sensitivity of cytological diagnoses on PE was 57.3%, specificity 100%, positive predictive value 100%, and NPV 70.6%. A background of breast cancer was the most common (39 cases) and malignancy was identified in 26 patients (66.6%) whose PF cytology was positive in 22. For patients with prior breast cancer the sensitivity of the cytological samples was 84.6% and NPV was 76.4%. Conclusion: The negative predictive value of pleural effusion cytology in patients with prior diagnosis of cancer is moderate, however, this technique confirmed the diagnosis in approximately one half of the patients with malignant pleural effusion. The negative predictive value of pleural effusion cytology in the setting of patients with previous breast cancer was slightly higher but remains insufficient to make clinical decisions as a stand alone test. Acknowledgement: European Respiratory Society (CTF201804-00345)

Background: SFTP are rare tumours arising from mesothelial parenchymal cells. The majority do not follow a malignant course, but they do have the potential to metastasise, despite the majority being considered histologically benign. Treatment is often surgical resection but there are currently no management guidelines due to the paucity of evidence. We therefore conducted a systematic review of the available literature of management of SFTP. Methods: A broad search strategy of four large databases was undertaken for any articles related to SFTP from inception of the database until November 2017. There were no randomised control trials thus large case series were the mainstay of evidence for the systematic review. Data was collected according to a pre-specified protocol and assessed by two reviewers. Results: 25 papers were suitable for data extraction from an initial review of 3447 abstracts, including a total of 1424 patients. Rates of histological malignancy and tumour recurrence ranged from between 0-57% and 0-42.9% respectively. The operative mortality ranged from 0-3.6% with 11.8% morbidity in one study. The presence of a pleural effusion was reviewed in six studies and found to be predictive of malignancy and poor outcomes in all. Conclusions, regarding the significance of size, tumour origin, pleural attachment or presence of symptoms were contradictory between studies. Malignant histological did not always predict a poor clinical outcome. Conclusions: There is significant heterogeneity between studies regarding the majority of outcomes. SFTP resection has associated morbidity and mortality and if the higher risk patients could be identified, unnecessary surgery may be able to be reduced.

Background and objectivesPleural infection is a major cause of morbidity and mortality among adults. Identification of the offending organism is key to appropriate antimicrobial therapy. It is not known whether the microbiological pattern of pleural infection is variable temporally or geographically. This systematic review aimed to investigate available literature to understand the worldwide pattern of microbiology and the factors that might affect such pattern.Data sources and eligibility criteriaOvid MEDLINE and Embase were searched between 2000 and 2018 for publications that reported on the microbiology of pleural infection in adults. Both observational and interventional studies were included. Studies were excluded if the main focus of the report was paediatric population, tuberculous empyema or post-operative empyema.Study appraisal and synthesis methodsStudies of ≥20 patients with clear reporting of microbial isolates were included. The numbers of isolates of each specific organism/group were collated from the included studies. Besides the overall presentation of data, subgroup analyses by geographical distribution, infection setting (community versus hospital) and time of the report were performed.ResultsFrom 20 980 reports returned by the initial search, 75 articles reporting on 10 241 patients were included in the data synthesis. The most common organism reported worldwide was Staphylococcus aureus. Geographically, pneumococci and viridans streptococci were the most commonly reported isolates from tropical and temperate regions, respectively. The microbiological pattern was considerably different between community- and hospital-acquired infections, where more Gram-negative and drug-resistant isolates were reported in the hospital-acquired infections. The main limitations of this systematic review were the heterogeneity in the method of reporting of certain bacteria and the predominance of reports from Europe and South East Asia.ConclusionsIn pleural infection, the geographical location and the setting of infection have considerable bearing on the expected causative organisms. This should be reflected in the choice of empirical antimicrobial treatment.

A 75-year-old man initially presented to the respiratory service in 2012 with severe chronic obstructive pulmonary disease (COPD) defined as Global Initiative for Chronic Obstructive Lung Disease stage 3. Forced expiratory volume in 1 s (FEV1) was 1.1 L (33% predicted) with FEV1/forced vital capacity 32%. He required long-term oxygen therapy at home at 4 L·min−1 and by 2015 nocturnal high-pressure noninvasive ventilation (NIV) was required due to progressive symptomatic hypercapnic respiratory failure including a carbon dioxide tension (PCO2) of 7.9 kPa and bicarbonate of 28.3 mmol·L−1., Pneumothorax is a well-recognised complication of end-stage COPD, but the management is often complex and may be complicated by other sequelae of advanced respiratory disease including the requirement for NIV http://ow.ly/vkoJ30mB4nZ

Introduction: Pleural infection is a condition that continues to pose a significant challenge to respiratory physicians. We hypothesize that the main barriers to progress include limited understanding of the etiopathogenesis, microbiology,and role of antibiotics in the pleural space. Areas covered: PubMed was searched for articles related to adult pleural infection using the terms ‘pleural infection’, ‘empyema’ and ‘parapneumonic’. The search focused on relevant literature within the last 10 years, with any older citations used only to display context or lack of progress. Tuberculous pleural infection was excluded. We chose to give specific attention to the etiopathogenesis of pleural infection, including recent advances in diagnostics and biomarkers. We discuss our understanding of the pleural microbiome and rationalize the current use of antibiotics in treating this condition. Expert commentary: Understanding of key events in the development of this condition remains limited. The microbiology is unique compared to the lung, and highly variable. Higher culture yields from pleural biopsy may add new insights into the etiopathogenesis. There is little evidence into achievable effective antibiotic concentration within the pleura. Research into issues including the relevance of biofilm formation and significance of pleural thickening is necessary for treatment progress.

Malignant pleural effusion (MPE) represents advanced metastatic malignancy and is associated with poor median survival. Incidence remains high and continues to rise, in part due to changing population demographics. This therefore represents a significant health care burden. Management is predominantly palliative in nature and multiple interventions are available within conventional treatment paradigms, all of which are proven to result in statistically significant patient benefit. This article further explores the methods available in the management of MPE along with the pitfalls, complications, and alternatives. Recent advances within the field are discussed with an exploration of likely future directions, including the role of ultrasound as a prospective predictor and the role of intrapleural fibrinolytic therapy.

Background Thoracic ultrasound (TUS) is widely used in the management of pleural disease due to high sensitivity in diagnosis of pleural pathology and widespread availability. Pleural sliding is a normal TUS finding, abolished by the presence of effusion, pneumothorax and impaired or absent following pleurodesis. Given the importance of lung sliding as a diagnostic test, this study aimed to assess the reliability, ease and interpretation of abnormal pleural sliding in a range of clinicians. Methods Seventeen delegates at a Pleural Diseases teaching course were given a short lecture on pleural sliding on TUS including clips of normal and abnormal sliding. Delegates then watched a series of 14 clips of B-mode TUS in patients who had undergone pleurodesis, and were asked to independently score the degree of sliding using one of three descriptors; present, absent or equivocal. Each clip ranged between 5–10 s and was looped until each candidate was satisfied. Before the session, candidates were divided into 3 groups according to self-rated TUS experience. Group A had advanced experience (6 candidates), group B basic experience (8 candidates) and group C limited or no experience (3 candidates). Two pleural fellows with level 1 Royal College of Radiologists TUS certification agreed on the ‘final’ scoring of the 14 clips on the same scheme as above. Results The ‘final’ score of the clips were: 5 clips showing sliding, 4 showing non-sliding and 5 equivocal. Overall, candidates agreed with the final description in 60% of the clips, with slight differences according to experience (64%, 53%, 59% for groups A, B and C respectively). Table 1 details the percentage of agreement in different sliding categories. Conclusion Overt pleural sliding appears to be relatively reliably identifiable regardless of the degree of experience in TUS. In situations where sliding is impaired to some degree, this can be more challenging. This has important implications on the applicability of using TUS to diagnose diseases such as pneumothorax, which mainly manifests as lack of pleural sliding.

Background SFTP are rare tumours arising from mesothelial parenchymal cells and are often benign, although a proportion may follow a malignant course. Treatment is often surgical resection but there are currently no management guidelines due to the paucity of evidence. We therefore conducted a systematic review of the available literature of management of pleural fibromas. Methods A broad search strategy of four large databases was undertaken for any articles related to the management of SFTP from inception of the database until November 2017. There were no randomised control trials thus large case series were the mainstay of evidence for the systematic review. Data was collected according to a pre-specified protocol and assessed by two reviewers. Results 25 papers were suitable for data extraction from an initial review of 3447 abstracts, including a total of 1424 patients. 15/25 papers only included patients with SFTP who underwent a resection. The majority of papers required a histological diagnosis for the patient to be included in the study. Rates of recurrence ranged from 0% to 42.9% and tumour sizes ranged from 0.3 cm to 39 cm. The follow up interval for the studies was variable. 11/14 studies had no operative mortality, and one reported a mortality of 3.6% and morbidity of 11.8%. 5 studies evaluated whether tumour size affected outcomes, 2 showed poorer outcomes with larger size tumours but 3 did not show any association. 2/6 papers showed that the presence of malignant criteria did not significantly predict a greater likelihood of recurrence, likewise there were conflicting results regarding tumour origin and the type of attachment to the pleura affecting recurrence. Conclusion A number of factors could have affected the wide range of recurrence rates including the duration of follow up, bias due to the nature of patients referred to and operated on in each centre and size of tumour resected. Although the operative mortality is low, the risk exists and published data collected rarely includes patients who underwent conservative management. Information on patients who do not undergo surgical resection and are radiologically followed are poorly represented in the published literarture, and this now needs to be collated to allow clinicians to evaluate the pertinent risks and benefits when considering management of these patients.

Introduction Malignant pleural mesothelioma (MPM) is primarily associated with asbestos exposure. Prognosis is poor, with median survival quoted as 6–12 months. Although uncommon, incidence has been steadily increasing and is predicted to peak in 2020. The National Lung Cancer Audit report on MPM (2015), demonstrated significant variation in management and outcomes across the UK and subsequently lead to the production of the British Thoracic Society Guideline for the investigation and management of MPM (2017). This included the recommendation for regional mesothelioma MDTs. We present the findings from the first 15 months of the regional MDT in Oxford and its impact on other recommendations contained within the guidelines. Method Complete follow up data was collected prospectively from all patients with MPM treated at the Oxford Pleural Unit since 2005. Following the establishment of a mesothelioma MDT in March 2017, 39 patients have been diagnosed and discussed at this meeting. These cases were compared with the 39 preceding cases to assess the impact of the introduction of a specialist MDT. Results Demographics between both groups were similar. Average age was 77.4 in the MDT group versus 73.8. Sex showed a male predominance in both groups of 82.5%. There was some variation in the distribution of histological subtypes within the groups, however there was an improvement in the number of patients with a clinical diagnosis, no histological subtype or those requiring post-mortem, although sample size was inadequate to achieve significance (table 1). There was no difference in the number of patients being considered for enrolment in clinical trials (33% versus 36%) however there were significant increases in the number of patients who had prognostic scores calculated (54% versus 0%) and those who had formal staging documented (56% versus 21%, p=0.001). Discussion Mesothelioma MDTs appear to improve documentation and communication of disease stage and prognosis. Further improvement in this area and in the consideration of enrolment in clinical trials may be possible with the introduction of an MDT proforma. Further work is required to assess the impact on diagnostic accuracy which might be best achieved by joint MDT working to obtain required numbers.

Introduction Indwelling pleural catheters (IPC) are an increasingly attractive option for patients wishing to avoid hospitalisation as they reduce length of stay. However, non-draining IPC-related symptomatic loculation occurs in 8.4%–13.5% of patients,1 and requires further procedures to break down septations and drain fluid more freely.2 Fibrin deposition facilitates autopleurodesis but can also induce septations and loculations within pleural fluid, impairing effective fluid drainage in patients with symptoms of accumulated fluid. Given the larger pleural tumour load and larger area of pleura involved with mesothelioma than with other MPEs,3 mesothelioma may have an increased risk of fibrin deposition. Aim To assess whether mesothelioma is associated with increased rates of IPC-related non-draining symptomatic septated pleural effusion. Method IPC insertion records for MPE between 2008 and April 2017 were analysed retrospectively, and data collected from medical records, including whether prior intrapleural talc was administered or not (since talc may give rise to septated effusion). Fisher’s exact test was used to compare the frequency of complicated septated effusions between patients with mesothelioma (mesothelioma MPEs) and those with other malignancies (non-mesothelioma MPEs). Non-draining symptomatic septated effusions were defined as pleural effusions identified to be septated on ultrasound, associated with shortness of breath and/or cough, and not draining adequately via the IPC. Results 181 IPC insertion cases were analysed. Mean age at IPC insertion was 67.6 years (SD 13.9), 48% were female(n=87). 38 (21%) were mesothelioma MPEs and 143 (79%) were non-mesothelioma MPEs; 3 (7.9%) and 5 (3.5%) developed IPC-related non-draining symptomatic septated effusions respectively (p=0.4). There was no significant difference in rates of IPC-related non-draining symptomatic septated effusions between patients who had received prior ipsilateral talc pleurodesis and those who had not: in mesothelioma MPEs (p=1.0), in non-mesothelioma MPEs (p=1.0). Discussion There was no statistically significant difference in rates of IPC-related symptomatic septated pleural effusion between patients with mesothelioma and non-mesothelioma MPE, although this data is limited by the retrospective study design and by relatively small numbers of non-draining IPC-related symptomatic septated pleural effusions. References Tremblay A, et al. Chest2006;129(2):362–8. Thomas R, et al. Chest2015;148(3):746–51. Fysh ETH, et al. Thorax2013;68:594–6.

Background SFTP are rare tumours arising from mesothelial parenchymal cells. The majority follow a benign course, but these tumours do have the potential to metastasise. England et al developed a set of criteria to define which tumours are malignant including mitotic index, cellularity, pleomorphism, haemorrhage and necrosis. SFTP are heterogenous and a malignant diagnosis can be missed if limited areas are examined, although histologically benign tumours can still follow a malignant course. There is no agreed treatment or management strategy for SFTP – we therefore performed a systematic review of the available literature regarding the diagnosis of benign versus malignant SFTP. Methods A broad search strategy of four large databases was undertaken for any articles related to SFTP from inception of the database until November 2017. There were no randomised control trials thus large case series were the mainstay of evidence for the systematic review. Data was collected according to a pre-specified protocol and assessed by two reviewers. Results 21 papers were suitable for data extraction for this question from an initial review of 3447 abstracts. Rates of malignancy ranged from 0% to 57%. The criteria proposed by England et al was used in 14/21 papers with another 4/21 using part of this criteria. 8/21 studies specifically assessed factors which could help differentiate between malignant and benign tumours. 6/8 studies found that large tumours were more likely to be malignant. 3/3 studies showed that the presence of a pleural effusion was associated with malignancy. Non-visceral origin and sessile attachment were not found to have any association in 3/4 studies. There was no association with age and likelihood of a malignant diagnosis. Further associations were reported in solitary papers such as PET avidity, inverted tumours, hypervascularity, lobulated margins and fibrous adherences. Conclusion Features such as size and the presence of a pleural effusion suggest a SFTP is likely to be histologically malignant. Previous criteria such as sessile attachment and non-visceral origin are not consistently predictive of malignancy. Whilst being able to identify which SFTP are likely to be malignant is important, benign tumours can still follow a malignant course and thus further work is needed to identify all tumours which require a more aggressive management/monitoring strategy.

Background Talc pleurodesis is one of the main treatment lines for malignant pleural effusion (MPE). There is data to suggest that survival is better in MPE patients who receive talc pleurodesis in comparison to patients who do not choose to have this treatment.1 It has been suggested that successful pleurodesis is accompanied by an acute inflammatory response, and this may suggest a possible mechanism of improved survival.2 This is a post-hoc analysis from the TIME1 trial dataset investigating whether there is difference in survival according to the outcome (i.e. success or not) of pleurodesis. Methods Data from the TIME 1 RCT was analysed assessing pleurodesis success and survival. Success was defined as no further pleural procedures for up to 3 months post pleurodesis. Patients had undergone either thoracoscopic talc poudrage or talc slurry via chest drain. Results Data was available for 266 patients, of whom 208 patients (78%) had a successful pleurodesis. The mean age of patients was 72±9 years. The most common malignancies were mesothelioma, lung cancer and breast cancer (25, 22% and 13% respectively). The mean survival time for those with successful pleurodesis was 12 months (95% CI 10.2 to 14 months) months and in those with failed pleurodesis was 7.3 months (95% CI 6–8.6 months). Figure 1 shows the Kaplan-Meier survival curve for the study patients split by pleurodesis outcome (Log rank test: p 0.004). Conclusion Survival appears to be worse in MPE patients who fail pleurodesis. This might suggest a deleterious biological effect of persistent malignant pleural effusion, differences in stage of disease or an intrapleural inflammatory response leading to enhanced immune response to malignant cells. These findings require further exploration. References Korsic M, et al. Talc pleurodesis improves survival of patients with malignant pleural effusions: Case-control study. Wien Klin Wochenschr2015;127(23–24):963–969. Mercer R, et al. Does inflammation predict successful pleurodesis? A post hoc analysis from the TIME 1 trial. Thorax2017;72(Suppl 3):A77.2–A78.

Introduction It is well established that when associated with infection, pleural effusions carry a significant morbidity and mortality. Sonographic septations are assumed to be associated with poor fluid drainage and some clinicians use this radiological parameter as an indication to proceed directly to surgical drainage, but the evidence for this was unclear. We therefore undertook a literature review to assess the relationship between septations and pleural infection outcome. Methods A systematic literature search was conducted using Medline (1946 to present), Embase (1974 to present), Cochrane database of systematic reviews, Cochrane Central Register of Controlled Trials, Scopus and Web of Science Core Collection. The search did not restrict on language and included all age groups. Septated effusions were captured using the following MeSH terms; [septations, septae, locules, loculations, septated pleural effusions, pleural infection, empyema and parapneumonic effusion]. The outcomes assessed included length of hospital stay, mortality, sepsis, surgery, VATS, decortication, intensive care, death and a number of patient centred outcomes. Results The search resulted in a total of 267 publications. After de-duplication, two researchers independently reviewed the remaining 136 papers for inclusion criteria. Only 6 papers examined baseline sonographic appearances and related these to outcomes, and these were further evaluated. Apart from one, these were all retrospective studies (see table 1). Only 2 similar papers from the same group (Chen et al) addressed our question directly and concluded that patients with a complex septated sonographic pattern have a poorer prognosis. Lai et al specifically addressed septations as a predictor of residual pleural thickening in tuberculous pleurisy. Whilst some papers suggested that the presence of loculations carries a prognostic value and possibly indicate need for early surgery (Cheng et al, Bongiolatti et al), others (Kearney et al) concluded that no sonographic findings reliably influence outcomes. Conclusion This systematic review demonstrates that there is a paucity of evidence linking septations and outcome in pleural infection. Previous large pleural infection trials (MIST1 and MIST2) were conducted prior to the era of common ultrasound. The oft-held belief that a septated effusion requires upfront surgical treatment is not currently evidence based and necessitates urgent further prospective studies.

Background Indwelling pleural catheters (IPCs) are used to manage recurring effusions in patients with symptomatic malignant pleural effusion (MPE). A subset of these patients will have had previous failed talc pleurodesis. This study aims to look at the rate of autopleurodesis (and the time to achieve this) in IPC patients who had received previous talc compared to those who had not. Methods All IPC insertion records for MPE between 2008 and April 2017 were analysed retrospectively. Data on previous ipsilateral pleural procedures, including attempted talc pleurodesis performed prior to the IPC insertion, and details about IPC insertion outcomes were collected from the medical records. Autopleurodesis was defined as minimal or no output via IPC, with subsequent IPC removal. Results 181 IPC insertions for MPEs were recorded, but 2 insertions were excluded due to insufficient data about IPC removal date and reason for removal (n=179 analysed further). 68 patients (38%) had received prior talc (60 received talc once; 8 received talc twice); while 111 (62%) had not received prior talc. IPC was subsequently removed due to autopleurodesis in 23 of the 68 (33.8%) who had received prior talc after a median 105 days (IQR 91) (an additional IPC was removed because of pain 4 days after insertion). IPC was subsequently removed due to autopleurodesis in 37 of the 111 (33.3%) who had not received prior talc after a median 104 days (IQR 83.5) (3 more IPCs removed in this group for other reasons). There was no difference in rates of autopleurodesis between patients who had received prior talc and those who had not (X2 0.0045, p=0.946). When comparing time to autopleurodesis, there was no statistically significant difference between the 2 groups (2 tailed Mann Whitney test, p=0.29). Conclusion There does not seem to be a difference in the rate of autopleurodesis between patients who had previous failed talc pleurodesis and those who chose IPC in the first instance. Further studies are needed to investigate whether the pleural space in certain patients is inherently resistant to different forms of pleurodesis.

Introduction: Pleural fluid (PF) cytology was previously sufficient to guide oncological treatment. In the current field of personalised medicine, this may not be the case and it is frequently necessary to obtain a tissue sample even when the PF cytology demonstrates malignant cells. This raises the question of the role of PF cytology in the diagnostic pathway of patients with malignant pleural effusion. Aims & Method: All patients who had a procedure performed by the pleural service between 2015 - 2017 were included. Those with PF demonstrating malignant cells were reviewed to determine whether further tissue was required. Those with concurrent pleural histological samples were excluded. Results: 107 patients had positive PF cytology. No further testing was needed in 49 patients; 33 already had a pathological diagnosis and 16 were too unwell for treatment or followed up elsewhere. PF was sufficient to test for receptor or mutation status in 33/58 (57%) patients, 19 (33%) required further pleural biopsies and 6 (10%) underwent alterative procedures to obtain tissue. 52/58 patients had adenocarcinoma cells in the PF. Conclusions: PF cytology was sufficient for definitive oncological treatment in 57% of patients. Further work is needed to determine characteristics which would highlight which patients are likely to need further tests to guide treatments and in which patients PF will be sufficient.

A patient with severe emphysema, post pulmonary rehabilitation and on full inhaled treatment underwent elective placement of eight endobronchial coils (RePneu Lung Volume Reduction Coils) in the right lung to attempt endoscopic lung volume reduction, targeted at the upper and lower lobes. The patient was not suitable for surgical open lung volume reduction and was unable to undergo valve treatment due to homogenous disease and an incomplete fissure on thoracic CT. Twelve hours post …

Introduction: The need for therapeutic dual antiplatelet therapy in patients with cerebral aneurysms treated with flow-diverting stents increases the risk of thromboembolic and hemorrhagic complications. To balance these risks, we assessed patients for their responsiveness to dual antiplatelet therapy using a modified platelet aggregation study (PIPA). We hypothesized that double doses of clopidogrel or aspirin in patients with antiplatelet non-responsiveness would reduce the incidence of thromboembolic complications without increasing the incidence of hemorrhage or decreasing the rate of aneurysm occlusion. Methods: 79 patients with 98 cerebral aneurysms were treated with the pipeline embolization device. All patients with a suboptimal PIPA received double doses of clopidogrel or aspirin prior to treatment. Aneurysm occlusion was categorized using the Roy-Raymond Occlusion Classification (RROC). Chi-square or Fisher’s exact tests were used for univariate analyses, and logistic regression was used to identify potential predictors of complications and aneurysm occlusion. Results: Seven patients had a major complication and 7 had a minor complication (8.9%). There were 3 cerebral ischemic strokes (3.8%) and 5 cerebral hemorrhages (6.3%). Thirty-eight patients had angiographic follow-up at 6 months. Of these, 18 patients were resistant to clopidogrel or aspirin, and 19 received double dose therapy prior to treatment. Double dose clopidogrel or aspirin was not associated with major, minor, cerebral ischemic or hemorrhagic complications. Twenty-one patients (55.3%) had complete occlusion of their aneurysms (RROC type 1), and 17 patients were categorized as RROC type 2 or 3 at 6 months. Treatment with double dose clopidogrel or aspirin was not associated with reduced occlusion (RROC type 2 or 3) in a univariate and multivariate analysis. Conclusions: In patients treated with flow-diverting stents, the risk of ischemia must be balanced with the risk of hemorrhage. We found that the use of double dose clopidogrel and aspirin in the setting of antiplatelet non-responsiveness is safe. It is not associated with increased hemorrhagic complications. Patients treated with double dose therapy did not exhibit a reduced aneurysm occlusion rate.