Nodular thickening of interlobar fissures: an early manifestation of malignant mesothelioma: a case report

Two men with occupational exposure to asbestos were admitted to our hospital with minute pleural changes on their chest CT image. Conventional computed tomography (CT) scans of the chest showed slightly thickened interlobar fissures and a small amount of pleural effusion. In addition, high-resolution CT showed small nodular opacities on interlobar fissures. There were no intrapulmonary mass shadows, pleural plaques or other extrapulmonary mass shadows. These roentgenographical findings were very similar to each other. Hyarulonic acid values obtained from their pleural fluid were extremely high. Finally, we diagnosed them as having malignant mesothelioma using an immunocytochemical technique and electronmicroscopy. We conclude that HRCT is helpful in the diagnosis of malignant mesothelioma, particularly in its early manifestation such as nodular opacities of interlobar fissures.     

恶性胸膜间皮瘤19例临床分析

目的 经病理证实的19例恶性胸膜间皮瘤的诊断经验。方法 分析19例恶性胸膜间皮瘤的临床资料,包括石棉接触史、临床表现、影像学检查、特殊检查、胸水检测和转移情况,并对比15例手术结果。结果 7例工种与石棉有关,占恶性胸膜间皮瘤36.8%(7/19),18例（94.7%)有胸痛,其中16例（84.2%)伴胸腔积液,1例出现Homer‘s综合症并影响臂丛神经,3例（15.8%)CT下穿刺找到间皮瘤细胞,2例（10.8%)胸水中找到间皮瘤细胞,1例锁髓上淋巴结穿刺找到间皮瘤细胞,15例CT发现胸膜增厚或胸膜上结节样病灶,占恶性弥漫性胸膜间皮瘤78.9%,15例手术病例中11例胸膜广泛增厚或胸壁上广泛不规则大小不等结节融合成片,侵犯肺组织或纵隔胸膜、横膈胸膜。结论 石棉接触史是恶生胸间皮瘤主要病因,胸痛、胸腔积液是胸膜间瘤的主要临床表现,CT对诊断胸膜间皮瘤有重要参考价值。CT下活检能提高诊断率。     

The location of visceral pleural invasion in stage IB patients with non-small cell lung cancer: Comparison and prognosis

ObjectivesRecently, early-stage lung cancer has been drawing more attention, especially in screening and treatment. Visceral pleural invasion in stage IB cancer is considered as risk factor for poor prognosis. Herein, we aimed to study the distinction between the different locations of visceral pleural invasion.MethodsIn this retrospective cohort study, we summarized 58,242 patient cases that underwent surgery from 2015 to 2018 at Shanghai Chest Hospital. Of those patients, 389 met the inclusion criteria. Patients with PL3 pleural invasion were excluded. The patients were dichotomized into the interlobar pleural and peripheral pleural groups. The outcomes measured were overall survival (OS) and recurrence-free survival (RFS) rates.ResultsAccording to the initial analysis, the baseline characteristics of the two groups were largely balanced. In multivariate Cox analyses, we found that the location of visceral pleural invasion was not a risk factor for prognosis in the overall population (RFS: P = 0.726, OS: P = 0.599). However, we discovered that relative to patients with peripheral pleura invasion, those with interlobar pleura invasion, PL1 invasion, lesions with greater than 3 cm solid components, and those who underwent segmentectomy had a compromised prognosis. Additionally, tumors larger than 3 cm in size with interlobar pleura invasion showed poor prognosis in patients who underwent postoperative chemotherapy.ConclusionsIn most cases, the location of tumor invasion did not worsen the postoperative prognosis of stage IB non-small cell lung cancer patients with visceral pleural invasion. However, interlobar pleural invasion still had some potential risks compared to that of peripheral pleural invasion.     

超声导引下经皮穿刺治疗外科术后腔内局限性积液

为了协助临床更为直接、快速处理术后并发症。对28例术后局限性感染性或化脓性积液患者行经超声导引下经皮穿刺抽吸，并以甲硝唑200～1000mL冲洗，然后注入20mL生理盐水溶解的一定剂量的广谱抗菌素。在28例患者中，胸腔感染性或化脓性积液5例，腹腔感染性或化脓性积液16例，盆腔感染性或化脓性积液7例。结果28例患者中，16例经1次介入治疗后，体温恢复正常，积液90％～100％吸收，有效率为100％；10例经2次介入治疗后，体温恢复正常，积液〉90％吸收，有效率为100％；2例经3次介入治疗后，体温恢复正常，积液〉90％吸收，有效率为100％。所有患者在治疗过程中未发生并发症和严重的不良反应。初步研究结果提示，超声导引下经皮穿刺治疗外科术后腔内局限性感染性或化脓性积液是安全有效的，且方法简便、价格低廉，应在临床推广和应用。     

磁富集法检测52例胸腹腔积液中癌细胞的结果分析

目的 探讨磁富集法对胸腹腔积液中癌细胞检测的临床价值。方法 采用磁富集法检测52例患者体腔积液（胸腔积液20例，腹腔积液32例）中癌细胞，并与常规细胞检测方法进行比较。结果 根据细胞学的检测结果进行分组，在细胞学诊断为恶性的11例患者中有10例用磁富集检测出恶性肿瘤细胞，4例细胞学诊断为不典型细胞的患者中用磁富集检测出2例恶性肿瘤细胞，38例细胞学诊断为阴性的患者中用磁富集检测出3例为恶性肿瘤细胞。共有5例在细胞学诊断为不典型细胞或阴性的患者中用磁富集检测出恶性肿瘤细胞，其中4例在别的检测方法得到证实，1例患者失访。52例病例中阳性率为38．5％，磁富集法的阳性检出率为85．0％，而常规方法的检出率仅为60．0％。结论 磁富集法检测腹腔或胸腔积液中的恶性肿瘤敏感性高于常规细胞学检测，其结果有利于更准确的肿瘤分期。     

Primary soft tissue tumours of the pelvis causing referred pain in the leg

Referred pain in the leg is occasionally due to a pelvic soft tissue tumour. Among 11 patients who presented this way, one had a lymphoma, one had a benign schwannoma, and nine had soft tissue sarcomas. Most patients had undergone a variety of procedures, including laminectomy, before the correct diagnosis was established. In five cases, an accurate diagnosis was obtained by needle biopsy. The lymphoma responded to chemotherapy, and the benign schwannoma was excised. Of the nine patients with soft tissue sarcoma, six underwent marginal/intracapsular excision, three receiving supplementary radiotherapy, and two were treated by nonsurgical means. Hindquarter amputation was technically impossible or inappropriate in these cases. All those with high-grade tumours have died or have metastases. Of four patients with low-grade tumours, three have exhibited only slow disease progression. Careful judgment and a precise histopathological diagnosis are required in planning treatment for patients with pelvic soft tissue tumours causing referred pain in the leg.     

Ultrasound in Chest Disease: 1. Pleura.

Retrospective study of 97 examinations in 60 patients with pleural problems. Seventy-six were for assessment of presence of pleural fluid and localisation of aspiration/drainage sites in 37. Mass lesions studied in eleven and 16 patients were either biopsied or drained by the radiologist under ultrasound control. Examination of two post-pneumonectomy patients revealed tumour recurrence in one and post-surgical fluid residue in another. All fluids were transonic, whereas a fibrin meshwork was found in haemothoraces and empyemas. Microbubbles were specific for pyopneumothoraces while echogenic pus mimicked tumour in one patient. Seven pleural tumours were transonic or echogenic. The tumours were either smooth (metastatic) or irregular (mesothelioma). Two benign fibrous plaques were uniformly echogenic and smooth and were indistinguishable from malignant masses.     

Gray scale echography of the lung and pleural space: current applications of oncologic interest

B mode gray scale echography is not useful in evaluation of the normal lung and pleural space. The presence of abnormal fluid collections in the chest change the acoustic properties of the thorax and pleural fluid collections may be detected and localized with precision. Lesions abutting the chest wall may be characterized as cystic or solid. Echography can be used to assess the motion and morphology of the diaphragms. Sonographic examination of the thorax is particularly useful in determining whether a large area of radiographic opacification such as an opaque hemithorax is due to fluid, tumor, or intrinsic pulmonary disease such as atelectasis or consolidation.     

Computed tomography evaluation of cavitary necrosis in complicated childhood pneumonia

The purpose of the present study was to retrospectively investigate the chest radiograph (CR) and CT findings of childhood pneumonia complicated by cavitary necrosis, and to evaluate the role of CT in decision‐making for surgical intervention. Chest CT was performed in 51 patients presenting with persistent or progressive pneumonia, respiratory distress and sepsis despite 7−10 days of appropriate antibiotic treatment and closed tube drainage. Chest radiograph and CT findings were retrospectively evaluated in 23 patients (45%) with cavitary necrosis. Chest radiographs showed consolidation in 19 of 23 patients, cavitation in five patients, parapneumonic effusions in 17 patients and air−fluid levels in the pleural space in one patient. The CT scans demonstrated consolidation and cavitary necrosis in all patients. There were parapneumonic effusions in all patients with concomitant loculated collections in six patients. Twenty‐two of 23 patients had pleural thickening. In seven patients there were air−fluid levels in the pleural space. In five of these patients, CT scans demonstrated bronchopleural fistulae. On the basis of the CT and clinical findings, 11 patients underwent surgical intervention. Computed tomography is superior to CR for demonstrating cavitary necrosis complicating pneumonia, and other parenchymal and pleural complications. It also has a crucial decision‐making role for surgery.     

Fine-needle aspiration biopsy of granulocytic sarcoma: a clinicopathologic study of 27 cases

BACKGROUND: Because of morphologic similarities, the differential diagnosis of granulocytic sarcoma (GS) in fine-needle aspiration (FNA) specimens includes non-Hodgkin or Hodgkin lymphoma, extramedullary hematopoiesis, poorly differentiated carcinoma, and infection. METHODS: Twenty-six FNAs and 1 pleural effusion fluid specimen of GS obtained from 23 patients were reviewed for cytomorphologic features and clinical characteristics. The cases were categorized as blastic, immature, or mature GS based on the population of the cells present on the smears. RESULTS: The patients included 18 men and 5 women (mean age, 54 years). Aspiration sites included subcutaneous or soft tissue (15 cases), lymph nodes (5 cases), bones (3 cases), testis (1 case), ileum (1 case), and liver (1 case). One sample of pleural effusion fluid also was included. Review of the patients' clinical history revealed that GS was secondary to chronic myelogenous leukemia (CML) in 17 patients, was secondary to chronic myelomonocytic leukemia (CMML) in 2 patients, and was secondary to acute myelogenous leukemia in 2 patients. GS preceded the manifestation of CML in one patient and of CMML in another patient. Based on the proportions of cells, morphologic classification was attempted and revealed blastic GS in 8 aspirates and 1 pleural effusion fluid specimen, immature GS in 13 aspirates, and mature GS in 5 aspirates. Twelve of 22 specimens from extranodal sites (55%) demonstrated lymphoglandular bodies in the background. Five aspirates showed rare eosinophilic myelocytes. Auer rods were not identified in any of the aspirates. Immunophenotypic and histochemical studies confirmed myeloid and/or myelomonocytic differentiation. CONCLUSIONS: GS especially can be confused with non-Hodgkin lymphoma because of morphologic similarities of the blasts to large cell lymphoma, the presence of lymphoglandular bodies, and the rarity of Auer rods and eosinophilic myelocytes. In conjunction with careful cytomorphologic evaluation, knowledge of the patient's clinical history and use of appropriate immunophenotypic studies should lead to a correct diagnosis.     

Microsatellite DNA analysis does not distinguish malignant from benign pleural effusions

Distinguishing malignant from benign pleural effusions using routine cytology is a common diagnostic problem. Recently, genetic alterations, including microsatellite instability (MSI) and loss of heterozygosity (LOH), have been described in malignant pleural effusions and proposed as methods improving diagnostics. The purpose of this study was to evaluate a panel of molecular markers for the detection of genetic alterations of cells in pleural effusions and to determine their diagnostic value as an additional test to cytologic examination. Pleural fluid and peripheral blood from 48 patients (36 male and 12 female, median age 71 years) were analyzed. Twenty-six patients had malignant pleural effusion, including 23 lung cancer and three metastatic non-pulmonary carcinoma. The control group consisted of 22 patients with benign pleural effusions. Only 14 malignancy-associated pleural effusions were cytology-positive for malignant cells (54%), whereas all benign pleural effusions were negative. DNA was extracted from all the samples and analysed for MSI and/or LOH using the following microsatellite markers: D3S1234, D9S171, D12S363, D17S250, D5S346 and TP53Alu, located at five chromosomal regions: 3p, 9p, 12q, 17q, 5q. Microsatellite analysis of the pleural fluid pellet exhibited genetic alterations in two neoplastic pleural fluid cases and in one inflammatory case. Two out of 26 (7.6%) patients with malignant pleural effusion showed genetic alterations. One exhibited MSI in three different microsatellite markers (D17S250, D9S171, D3S134) and the other showed LOH in marker D3S134. One out of 22 (4.5%) patients with benign pleural effusion showed LOH in marker D3S134. In conclusion, genetic alterations at the level of microsatellite DNA, were detected only in very few cases of malignant pleural effusions, and in one case of benign pleural effusion. Thus, our data suggest that microsatellite DNA analysis does not facilitate the diagnosis of malignant pleural effusion.     

Importance of the Cell Block Technique in Diagnosing Patients with Non-Small Cell Carcinoma Accompanied by Pleural Effusion

Background: Cytological examination of pleural effusions is very important in the diagnosis of malignantlesions. Thoracentesis is the first investigation to be performed in a patient with pleural effusion. In this study,we aimed to compare traditional with cell block methods for diagnosis of lung disease accompanied by pleuraleffusion. Materials and Methods: A total of 194 patients with exudative pleural effusions were included. Tenmililiters of fresh pleural fluid were obtained by thoracentesis from all patients in the initial evaluation. Thesamples gathered were divided to two equal parts, one for conventional cytological analysis and the other foranalysis with the cell block technique. In cytology, using conventional diagnostic criteria cases were divided into3 categories, benign, malignant and undetermined. The cell block sections were evaluated for the presence ofsingle tumor cells, papillary or acinar patterns and staining with mucicarmine. In the cell block examination,in cases with sufficient cell counts histopathological diagnosis was performed. Results: Of the total undergoingconventional cytological analyses, 154 (79.4%)were reported as benign, 33 (17%) as malignant and 7 (3.6%) assuspicious of malignancy. With the cell block method the results were 147 (75.8%) benign, 12 (6.2%) metastatic, 4(2.1%) squamous cell carcinoma, 18 (9.3%) adenocarcinoma, 5 (2.6%) large cell carcinoma, 2 (1%) mesothelioma,3 (1.5%) small cell carcinoma, and 3 (1.5%) lymphoma. Conclusions: Our study confirmed that the cell blockmethod increases the diagnostic yield with exudative pleural effusions accompanying lung cancer.     

恶性胸水的综合诊断

对４２例恶性胸水患者进行胸水脱落细胞检查、胸膜活检、纤维支气管镜等多项检查方法诊断。结果：胸水脱落细胞检查阳性为３０／４２（７１．４％），胸膜活检阳性为２１／３２（６５．６％），两项检查其中一项或两项阳性３５例（８３．３％），并对各项检查意义进行讨论。     

Diffuse malignant mesothelioma of pleura. Diagnosis and survival in 92 cases

Clinical, radiographic, surgical, and pathologic findings and survival in 92 patients with diffuse malignant mesothelioma (DMM) of the pleura who were examined at the Mayo Clinic between 1950 and 1980, were studied retrospectively. With the use of defined criteria and ordinary tissue stains, the 92 cases were classified into the following histologic subtypes: purely epithelial, 42 cases; mixed, 29 cases; and sarcomatous, 21 cases. Eight of the sarcomatous cases were desmoplastic. Median survivals were 12, 5, and 3 months for the patients in the epithelial, mixed, and sarcomatous groups, respectively. Survival was significantly longer for patients with epithelial DMM. Women survived longer than men but more often had epithelial DMM. Early disease manifested as multiple discrete pleural nodules, predominantly on the parietal pleura. However, nine patients had a dominant mass. Radiographic signs especially suggestive of DMM were nodular pleural thickening, irregular thickening of interlobar fissures, a dominant mass, or decreased volume of the affected hemithorax.     

EGFR mutation status in tumour-derived DNA from pleural effusion fluid is a practical basis for predicting the response to gefitinib

Epidermal growth factor receptor (EGFR) mutations are strong determinants of tumour response to EGFR tyrosine kinase inhibitors in non-small-cell lung cancer (NSCLC). Pleural effusion is a common complication of lung cancer. In this study, we assessed the feasibility of detection of EGFR mutations in samples of pleural effusion fluid. We obtained 43 samples, which was the cell-free supernatant of pleural fluid, from Japanese NSCLC patients, and examined them for EGFR mutations. The epidermal growth factor receptor mutation status was determined by a direct sequencing method (exons 18-21 in EGFR). EGFR mutations were detected in 11 cases (E746_A750del in seven cases, E746_T751del insA in one case, L747_T751del in one case, and L858R in two cases). The EGFR mutations were observed more frequently in women and non-smokers. A comparison between the EGFR mutant status and the response to gefitinib in the 27 patients who received gefitinib revealed that all seven patients with partial response and one of the seven patients with stable disease had an EGFR mutation. No EGFR mutations were detected in the patients with progressive disease. The results suggest that DNA in pleural effusion fluid can be used to detect EGFR mutations and that the EGFR mutation status may be useful as a predictor of the response to gefitinib.     

Use of magnetic enrichment for detection of carcinoma cells in fluid specimens

BACKGROUND: Ascites fluid or a pleural effusion are common events in metastatic carcinoma, but they also can be associated with several other medical conditions. The standard for determination of malignancy in these situations is cytologic evaluation of these fluids. Although this method is frequently successful, there are times when it fails, even when the patient has a malignancy, either because of insufficient cells in the fluid or for other reasons. This study addresses this problem taking advantage of the recent advances in technology for detection of rare epithelial cells in liquid specimens. METHODS: The authors examined fluid specimens from 59 patients to determine the frequency of recovery of epithelial cells compared with that achieved by conventional cytopathology. The Dynal CELLection Epithelial Enrich (Dynal AS, Oslo, Norway) method was used. This method is based on immunomagnetic selection of cells binding to EpCAM antibodies. Carcinoma cells were confirmed by morphology and, when there was sufficient material, by E-cadherin staining. RESULTS: Grouping the cases by cytologic diagnosis, the authors found malignant cells using the cell enrichment assay in 11 of 12 malignant cases, 2 of 5 atypical cases, and 3 of 42 negative cases. Further investigations were conducted on the five cases that were cytologically negative or atypical but yielded epithelial cells after immunomagnetic enrichment. Four cases ultimately were proven malignant by other methods and one had incomplete follow-up. CONCLUSIONS: The new methods available for epithelial cell enrichment in liquids may be used successfully on cytologic fluid specimens and may lead to increased sensitivity for detection of malignancy, and consequently more accurate staging.     

Aberrant promoter methylation in pleural fluid DNA for diagnosis of malignant pleural effusion

Accumulating evidence implicates epigenetic changes such as hypermethylation in carcinogenesis. We investigated whether DNA methylation of 5 tumor suppressor genes in pleural fluid samples could aid in diagnosis of malignant effusion. In samples from 47 patients with malignant pleural effusions and 34 with nonmalignant effusions, we used a methylation-specific polymerase chain reaction to detect aberrant hypermethylation of the promoters of the DNA repair gene O(6)-methylguanine-DNA methyltransferase (MGMT), p16(INK4a), ras association domain family 1A (RASSF1A), apoptosis-related genes, death-associated protein kinase (DAPK), and retinoic acid receptor beta (RARbeta). Promoter hypermethylation was associated with malignant effusion for MGMT (Odds ratio (OR) = infinity), p16(INK4a) (OR = infinity), RASSF1A (OR = 13.8; CI, 1.71-112), and RARbeta (OR = 3.17; CI, 1.10-9.11), but not for DAPK. Instead, DAPK methylation was associated with the length of smoking (p < 0.05). Patients with hypermethylation of MGMT, p16(INK4a), RASSF1A or RARbeta were 5.68 times more likely to have malignant effusions than patients without methylation (p = 0.008). Methylations per patient were more numerous for lung cancer than nonmalignant pulmonary disease (0.915 vs. 0.206, p < 0.001). Sensitivity, specificity, and positive predictive value of methylation in one or more genes for diagnosis of malignant effusion were 59.6%, 79.4%, and 80.0% respectively. In conclusion, aberrant promoter methylation of tumor suppressor genes in pleural fluid DNA could be a valuable diagnostic marker for malignant pleural effusion.     

Mammary hamartoma

Introduction Mammary hamartomas are rare benign breast lumps. They are usually painless, wellcircumscribed, mobile and with no adherence to skin or muscle, composed of varying amounts of fat, glandular and fibrous tissue. Mammary hamartoma has been classically considered as an underdiagnosed pathology, but with the increasing use of diagnostic procedures in breast tumours, the number of hamartomas has increased in the last years. Because there is no distinct pathological feature, a correlation with the clinical findings and image techniques is necessary in order to achieve a correct diagnosis of the pathology. Materials and methods The clinicopathological features of 8 mammary hamartomas are reported here. Results The patients are ranged in age from 34 to 67 years. The initial manifestation was in all cases a well-circumscribed, soft, palpable breast lump. Mammography was performed in all patients. Other diagnostic procedures used in the diagnosis were Ultrasound, Fine Needle Aspiration Cytology and Needle Core Biopsy. Treatment was tumourectomy. We describe a case of recurrence after excision of the lump in a more aggressive histological form and one patient who presented the coexistence of a mammary hamartoma and an invasive ductal carcinoma. Conclusion Mammary hamartoma is an uncommon breast tumour. It is necessary the correlation between pathology and clinical and radiological findings. We express our management plan for these lesions.     

The evolving role of interventional pulmonary in the interdisciplinary approach to the staging and management of lung cancer. Part III: diagnosis and management of malignant pleural effusions

The diagnosis and management of a malignant pleural effusion can be one of the most vexing problems faced by physicians and their patients. Lung cancer is the most common primary tumor of origin with a prognosis that is limited, but variable and correlated with performance status (PS). Therefore, with a poor PS and known advanced lung cancer, establishing whether or not an effusion is malignant might not be necessary. Conversely, identifiable subsets of patients will have a much better survival, and establishing a definitive diagnosis could be of critical importance. In the great majority of cases, a diagnosis can be determined by serial thoracenteses with or without closed pleural biopsy. However, thoracoscopy is increasingly being utilized and can expedite the workup by obviating the need for repeated thoracenteses and/or closed pleural biopsy, while in the same setting providing definitive palliative treatment. Although studies comparing diagnostic and treatment strategies are limited, we will present the available data with the intention of providing the practicing oncologist with a practical strategy for the diagnosis and management of malignant pleural effusions due to lung cancer. The interventional pulmonologist can play an important role from diagnosis to palliation, greatly facilitating the care of patients with malignant pleural effusions.     

局麻下电视胸腔镜手术诊治恶性胸腔积液的探讨

目的：探讨局麻下电视胸腔镜手术（video-thoracoscopic surgery,VTS)诊治恶性胸腔积液的安全性和效果。方法：自2000年1月到2001年1月,探索性地在局麻下对8例恶性胸腔积液患者和7例疑患恶性胸腔积液者实施了VTS。其中3例为无法耐受全麻的高危患者。结果：对8例恶性胸腔积液患者分别进行了VTS－肺纤维膜剥脱、滑石粉洒胸膜固定术（2例）和VTS－滑石粉喷洒胸膜固定术（6例）。对7例疑患恶性胸腔积液者首先进行了VTS－胸膜腔探查,发现积液由胸膜病变引起者5例,胸膜活检均诊为转移腺癌,随后进行了VTS－滑石粉喷洒胸膜固定术;另2例脏壁层胸膜均正常,证实积液为纵隔淋巴结广泛肿大造成胸膜淋巴液引流障碍所致。以上操作在局麻下顺利完成。手术时间30－120min。期间病人的心率、血压及血氧饱和度均无明显变化。术后无严重并发症和死亡。术后住院时间7－10天。随访1－8个月,平均5个月,胸腔积液均得到控制,未见复发。与控制积液有关的花费平均为3000元。结论：局麻下进行VTS诊治恶性胸腔积液是安全、有效的。该方法经济、创伤少,值得推广应用。