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Current Opinion in Pulmonary Medicine Jul 2022The diagnosis of malignant pleural disease is important in the care of patients with cancer. However, a one-size-fits-all approach to diagnosis may lead to delays in... (Review)
Review
PURPOSE OF REVIEW
The diagnosis of malignant pleural disease is important in the care of patients with cancer. However, a one-size-fits-all approach to diagnosis may lead to delays in care as the sensitivity of each biopsy modality varies and can be dependent on the tumor type. We review current literature on pleural biopsy techniques and propose a diagnostic algorithm for suspected malignant pleural disease.
RECENT FINDINGS
Recent literature has shown that the sensitivity of pleural fluid cytology varies based on tumor type resulting in a limited value of repeated thoracenteses in many cases. Furthermore, the ability to test for molecular biomarkers on pleural fluid samples has contributed to the recommendations to send large volumes of pleural fluid for analysis. Studies have also supported the consideration of medical thoracoscopy earlier in the diagnostic work-up of malignant pleural disease.
SUMMARY
The decision to repeat a diagnostic thoracentesis when suspecting malignant pleural effusions should take into account the primary tumor type. Open pleural biopsy with medical thoracoscopy has been shown to be a relatively safe diagnostic modality with high sensitivity and should be considered in patients with a nondiagnostic thoracentesis.
Topics: Exudates and Transudates; Humans; Pleura; Pleural Effusion; Pleural Effusion, Malignant; Thoracentesis; Thoracoscopy
PubMed: 35749791
DOI: 10.1097/MCP.0000000000000877 -
Chest Jan 2022Hepatic hydrothorax can be present in 5% to 15% of patients with underlying cirrhosis and portal hypertension, often reflecting advanced liver disease. Its impact can... (Review)
Review
Hepatic hydrothorax can be present in 5% to 15% of patients with underlying cirrhosis and portal hypertension, often reflecting advanced liver disease. Its impact can be variable, because patients may have small pleural effusions and minimal pulmonary symptoms or massive pleural effusions and respiratory failure. Management of hepatic hydrothorax can be difficult because these patients often have a number of comorbidities and potential for complications. Minimal high-quality data are available for guidance specifically related to hepatic hydrothorax, potentially resulting in pulmonary or critical care physician struggling for best management options. We therefore provide a Case-based presentation with management options based on currently available data and opinion. We discuss the role of pleural interventions, including thoracentesis, tube thoracostomy, indwelling tunneled pleural catheter, pleurodesis, and surgical interventions. In general, we recommend that management be conducted within a multidisciplinary team including pulmonology, hepatology, and transplant surgery. Patients with refractory hepatic hydrothorax that are not transplant candidates should be managed with palliative intent; we suggest indwelling tunneled pleural catheter placement unless otherwise contraindicated. For patients with unclear or incomplete hepatology treatment plans or those unable to undergo more definitive procedures, we recommend serial thoracentesis. In patients who are transplant candidates, we often consider serial thoracentesis as a standard treatment, while also evaluating the role indwelling tunneled pleural catheter placement may play within the course of disease and transplant evaluation.
Topics: Catheters, Indwelling; Chest Tubes; Disease Management; Humans; Hydrothorax; Hypertension, Portal; Liver Cirrhosis; Liver Diseases; Pleural Cavity; Pleural Effusion; Pleurodesis; Thoracentesis; Thoracostomy
PubMed: 34390708
DOI: 10.1016/j.chest.2021.08.043 -
Journal of Investigative Surgery : the... Sep 2022Pancreaticopleural fistula, an abnormal communication between the pancreas and the pleural cavity, is a rare complication of pancreatic disease in children and is... (Review)
Review
Pancreaticopleural fistula, an abnormal communication between the pancreas and the pleural cavity, is a rare complication of pancreatic disease in children and is mainly associated with acute pancreatitis, chronic pancreatitis, trauma or iatrogenicinjury. The present review presents the current available data concerning the pathogenesis, clinical features, diagnosis and management of this unusual but difficult clinical problem among children, in order to shed light on its pathologic manifestation and raise clinical suspicion. The review of the literature was performed through a PubMed search of pediatric original articles and case reports, using the key words "pancreaticopleural fistula", "pancreatitis", "pleural effusion", "pseudocyst" and "children". The literature search revealed 47 cases of pediatric patients with pancreaticopleural fistula. Diagnosis is based on the patient's medical history, physical examination and imaging, while the cornerstone of diagnosis is the presence of high pleural effusion amylase levels. The management of this disorder includes conservative, endoscopic and surgical treatment options. If treated promptly and properly, this clinical entity could have a lower rate of complications. The incidence of pancreaticopleural fistula in children may be underestimated in the literature, due to a reduced degree of clinical suspicion. A more heightened awareness of this entity is needed to improve the quality of life in children that suffer from this condition, as early diagnosis is essential for effective treatment and improved outcome.
Topics: Acute Disease; Child; Humans; Pancreatic Fistula; Pancreatitis; Pleural Diseases; Pleural Effusion; Quality of Life
PubMed: 35876104
DOI: 10.1080/08941939.2022.2103603 -
Seminars in Respiratory and Critical... Aug 2023Pleural diseases include a spectrum of disorders broadly categorized into pneumothorax and pleural effusion. They often cause pain, breathlessness, cough, and reduced...
Pleural diseases include a spectrum of disorders broadly categorized into pneumothorax and pleural effusion. They often cause pain, breathlessness, cough, and reduced quality of life. The global burden of diseases reflects regional differences in conditions and exposures associated with pleural disease, such as smoking, pneumonia, tuberculosis, asbestos, cancer, and organ failure. Disease burden in high-income countries is overrepresented given the availability of data and disease burden in lower-income countries is likely underestimated. In the United States, in 2016, there were 42,215 treat-and-discharge visits to the emergency room for pleural diseases and an additional 361,270 hospitalizations, resulting in a national cost of $10.1 billion.
Topics: Humans; Quality of Life; Cost of Illness; Pleural Effusion; Pneumothorax; Hospitalization; Pleural Diseases
PubMed: 37263289
DOI: 10.1055/s-0043-1769614 -
BMJ Case Reports Jan 2021We report a case of a 42-year-old man who presented with acute epigastric and retrosternal chest pain and exertional dyspnoea, and was subsequently diagnosed with...
We report a case of a 42-year-old man who presented with acute epigastric and retrosternal chest pain and exertional dyspnoea, and was subsequently diagnosed with polyserositis secondary to post- infection. A CT scan showed a large pericardial effusion requiring pericardiocentesis, small bilateral pleural effusions and small amount of ascites. Several serological tests were done, which were all found to be normal. Pericardial and pleural fluid aspirates revealed an exudate. Culture of the pleural fluid yielded growth of and this was deemed the cause of the polyserositis, which is rare. The patient made a spontaneous recovery. He was started on colchicine by the cardiologists to help prevent pericardial fluid recurrence and this was continued for 3 months. A dental review confirmed the presence of dental caries, the possible source of infection. On follow-up, the patient remained well with no further relapses.
Topics: Adult; Anti-Inflammatory Agents; Ascites; Colchicine; Humans; Male; Pericardial Effusion; Pericardiocentesis; Pleural Effusion; Serositis; Streptococcal Infections; Streptococcus mitis; Tomography, X-Ray Computed
PubMed: 33472801
DOI: 10.1136/bcr-2020-236704 -
Radiographics : a Review Publication of... Apr 2024The pleura is a thin, smooth, soft-tissue structure that lines the pleural cavity and separates the lungs from the chest wall, consisting of the visceral and parietal... (Review)
Review
The pleura is a thin, smooth, soft-tissue structure that lines the pleural cavity and separates the lungs from the chest wall, consisting of the visceral and parietal pleurae and physiologic pleural fluid. There is a broad spectrum of normal variations and abnormalities in the pleura, including pneumothorax, pleural effusion, and pleural thickening. Pneumothorax is associated with pulmonary diseases and is caused by iatrogenic or traumatic factors. Chest radiography and US help detect pneumothorax with various signs, and CT can also help assess the causes. Pleural effusion occurs in a wide spectrum of diseases, such as heart failure, cirrhosis, asbestos-related diseases, infections, chylothorax, and malignancies. Chest US allows detection of a small pleural effusion and evaluation of echogenicity or septa in pleural effusion. Pleural thickening may manifest as unilateral or bilateral and as focal, multifocal, or diffuse. Various diseases can demonstrate pleural thickening, such as asbestos-related diseases, neoplasms, and systemic diseases. CT, MRI, and fluorodeoxyglucose (FDG) PET/CT can help differentiate between benign and malignant lesions. Knowledge of these features can aid radiologists in suggesting diagnoses and recommending further examinations with other imaging modalities. The authors provide a comprehensive review of the clinical and multimodality imaging findings of pleural diseases and their differential diagnoses. RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.
Topics: Humans; Diagnosis, Differential; Pneumothorax; Positron Emission Tomography Computed Tomography; Pleural Diseases; Pleural Effusion; Asbestos; Pleural Neoplasms
PubMed: 38547031
DOI: 10.1148/rg.230079 -
Annals of the American Thoracic Society May 2021The evolution of pleural disease imaging modalities through the years has helped the scientific community understand and treat various disease states. Ultrasound (US)...
The evolution of pleural disease imaging modalities through the years has helped the scientific community understand and treat various disease states. Ultrasound (US) has been an image modality that has reigned superior to those used in the past such as chest X-ray and computed tomographic scan in terms of cost effectiveness, portability, and reduction in unwarranted radiation exposure to patients. Here we provide a succinct review of US use in pleural disease including imaging techniques, identifying safe pleural space for access, and predicting pleural fluid volume and etiology along with specificities regarding trapped lung identification and pleural mass biopsy. We believe bedside chest US is an adjunct to the physical exam adding superior diagnostic abilities. Further research is warranted in more specific aspects of sonographic use such as in fibrinolytic therapy management, evaluation for trapped lung, and the utility of specific modes like the color flow Doppler.
Topics: Humans; Lung; Pleura; Pleural Diseases; Tomography, X-Ray Computed; Ultrasonography
PubMed: 33621161
DOI: 10.1513/AnnalsATS.202008-948CME -
Thorax Apr 2023This study aimed to construct artificial intelligence models based on thoracic CT images to perform segmentation and classification of benign pleural effusion (BPE) and...
INTRODUCTION
This study aimed to construct artificial intelligence models based on thoracic CT images to perform segmentation and classification of benign pleural effusion (BPE) and malignant pleural effusion (MPE).
METHODS
A total of 918 patients with pleural effusion were initially included, with 607 randomly selected cases used as the training cohort and the other 311 as the internal testing cohort; another independent external testing cohort with 362 cases was used. We developed a pleural effusion segmentation model (M1) by combining 3D spatially weighted U-Net with 2D classical U-Net. Then, a classification model (M2) was built to identify BPE and MPE using a CT volume and its 3D pleural effusion mask as inputs.
RESULTS
The average Dice similarity coefficient, Jaccard coefficient, precision, sensitivity, Hausdorff distance 95% (HD95) and average surface distance indicators in M1 were 87.6±5.0%, 82.2±6.2%, 99.0±1.0%, 83.0±6.6%, 6.9±3.8 and 1.6±1.1, respectively, which were better than those of the 3D U-Net and 3D spatially weighted U-Net. Regarding M2, the area under the receiver operating characteristic curve, sensitivity and specificity obtained with volume concat masks as input were 0.842 (95% CI 0.801 to 0.878), 89.4% (95% CI 84.4% to 93.2%) and 65.1% (95% CI 57.3% to 72.3%) in the external testing cohort. These performance metrics were significantly improved compared with those for the other input patterns.
CONCLUSIONS
We applied a deep learning model to the segmentation of pleural effusions, and the model showed encouraging performance in the differential diagnosis of BPE and MPE.
Topics: Humans; Biomarkers, Tumor; Artificial Intelligence; Pleural Effusion; Pleural Effusion, Malignant; Sensitivity and Specificity
PubMed: 36180066
DOI: 10.1136/thorax-2021-218581 -
Respirology (Carlton, Vic.) Jul 2020
Topics: Biomarkers; Humans; Lung; Pleural Effusion, Malignant; Pleurodesis; Talc
PubMed: 31945800
DOI: 10.1111/resp.13765 -
Current Opinion in Pulmonary Medicine Jan 2022Pleural disease guidelines have not been updated in a decade. Advances have been made in the diagnosis and management of pleural diseases since, with expanding evidence... (Review)
Review
PURPOSE OF REVIEW
Pleural disease guidelines have not been updated in a decade. Advances have been made in the diagnosis and management of pleural diseases since, with expanding evidence of the utility of medical thoracoscopy (MT) as a safe and effective tool.
RECENT FINDINGS
Although thoracic ultrasound has improved early determination of pleural disease etiology, thoracentesis remains limited, and pleural tissue is necessary for the diagnosis of undifferentiated exudative pleural effusions. Medical thoracoscopy has been shown to be superior to traditional closed pleural biopsy, and recent literature is focused on which technique is best. A recent randomized controlled trial (RCT) found rigid mini-thoracoscopy was not superior to semirigid thoracoscopy. Meta-analyses have not found pleural cyrobiopsy to be superior to forceps biopsies. As a therapeutic tool, meta-analysis suggests MT as a possible first-line tool for the treatment of complicated parapneumonic effusions (CPE) and early empyema. A RCT comparing MT to intrapleural fibrinolytic therapy demonstrated that the former technique is safe, effective, and may shorten hospital length of stay in patients with CPE/empyema.
SUMMARY
The implications of the recent findings in the medical literature are that medical thoracoscopy, particularly by trained Interventional Pulmonologists, will find an expanded role in future iteration of pleural disease guidelines.
Topics: Empyema, Pleural; Humans; Pleura; Pleural Diseases; Pleural Effusion; Pulmonary Medicine; Thoracoscopy
PubMed: 34698676
DOI: 10.1097/MCP.0000000000000841