Pleural effusion hyaluronic acid as a prognostic marker in pleural malignant mesothelioma

Background

Malignant mesothelioma (MM), a primarily asbestos-induced tumour, has a poor prognosis, with over-all 5-year survival less than 5%. Tumour biomarkers are being intensely investigated in MM as aids to diagnosis and prognosis. Hyaluronic acid (HA) is produced in MM but its role in prognostication remains uncertain.

Materials and methods

HA concentrations were determined in matching serum and pleural effusion of 96 MM patients, 26 lung cancer patients and 42 patients with benign effusions resulting from infectious, cardiac, renal, liver and rheumatoid diseases and compared to the current ‘best practice’ biomarker, mesothelin. Liver and kidney function were determined for each patient. Diagnostic accuracy was determined by area under the receiver operator characteristic curve (AUC) analysis following logistic regression modelling. Difference in survival between groups was determined by both log-rank test and Cox proportional hazards regression modelling.

Results

For effusion HA, the AUC (IQ range) was 0.89 (0.82–0.94) and for effusion mesothelin, it was 0.85 (0.78–0.90). Serum HA was not diagnostically useful. A combined measure of effusion HA, and serum and effusion mesothelin had an AUC of 0.92 (0.86–0.96), which was significantly higher than effusion mesothelin alone. Effusion HA had a biphasic distribution in MM patients, dichotomised at a concentration of 75 mg/L. The median survival of MM patients with high effusion HA was 18.0 (13.7–22.4) months, significantly longer than those with low HA effusion levels (12.6 months (8.4–16.8), p = 0.004). Serum HA, and effusion and serum mesothelin were not significant prognostic indicators.

Conclusion

This study demonstrates that a combined biomarker panel has greater diagnostic accuracy than effusion mesothelin alone, and that significant prognostic information is provided by effusion HA.     

胸后壁胸膜腔穿刺安全区的定位

目的探究胸后壁第六至第九肋间隙肋间神经和肋间后血管的走行及位置关系,为临床在胸后壁行胸膜腔穿刺确定在肋间隙进针的安全区域。方法在32具成人尸体上,解剖胸后壁第六至第九肋间隙的肋间神经和肋间后血管,观察它们的走行及位置关系,测量肋间神经和肋间后动脉、静脉各自的分叉点及各自的下支与下位肋上缘交点距后正中线和肩胛线的距离,并进行统计学分析。结果肋间神经、血管在排列和分布上呈现一定的规律。结论根据肋间神经和肋间后血管在胸后壁的走行和位置状况可确定胸腔穿刺术的安全进针区。     

Pleural effusions

There are many diseases that cause pleural effusions. When a patient with a pleural effusion is first evaluated, one should determine if the patient has a transudate or an exudate. A diagnostic approach to the patient with an?undiagnosed pleural effusion is outlined. The most common pleural effusions including those caused by congestive heart failure, cirrhosis, pneumonia, malignancy, tuberculosis, lupus erythematosus, rheumatoid disease, and chylothorax are discussed.     

Pleural empyema secondary to nephropleural fistula in complicated pyonephrosis

Pleural empyema of extra pulmonary origin is uncommon and empyema secondary to a fistula between the urinary tract and thorax is extremely rare. We report a case of nephropleural fistula causing massive pleural empyema in a 64-year-old woman with a long history of urological problems, including nephrolitiasis and urinary tract infection. She was admitted with sepsis, fever, chills, tachypnea, productive cough and pyuria. At clinical examination, breath sounds were reduced over the left hemithorax. CT revealed a fistulous connection from the upper left calyceal group and the pleural space. Drainage of thoracic and perinephric collection was carried out, but nephrectomy and pleural decortication were required due to haemopurulent urine and decreased hemoglobin levels during the hospitalization. This case demonstrates the unusual and prolonged evolution of an obstructive hydroureteronephrosis complicated by pyonephrosis, culminating in retroperitoneal abscess that fistulized into the pleural space, leading to empyema.     

胸膜纤维板剥脱治疗慢性脓胸73例手术体会

目的探讨一种胸膜纤维板剥脱术的手术操作步骤.方法总结昆明医学院第一附属医院胸外科自2005年6月至2010年6月慢性脓胸手术73例.结果本组病例在手术时间,术中失血量,术后恢复等方面均较理想.结论胸膜纤维板剥脱术采用一些技巧可取得较好的手术效果.     

铜绿假单胞菌制剂胸腔注入治疗肝性胸水疗效观察

目的观察铜绿假单胞菌制剂胸腔注入治疗肝性胸水的疗效。方法患者行胸腔闭式引流术后彻底引流胸水,胸腔注入铜绿假单胞菌制剂5ml,3d后复查胸片或胸腔超声。效果不佳者1周后重复注药后观察。所有患者治疗同时均根据生化结果进行对症处理。结果部分患者出现不同程度的胸痛和发热,28例患者总有效率85.7%,注药1次症状改善19例。结论应用铜绿假单胞菌制剂胸腔注入治疗肝性胸水是有效的方法。     

鼓膜二孔穿刺灌药治疗分泌性中耳炎的临床探讨

目的:探讨分泌性中耳炎的治疗方法,提高其治疗水平.方法:对372例分泌性中耳炎的临床资料进行分析,改进传统的方法采用二孔鼓膜穿刺抽液、灌药治疗.结果:1周内治愈366例,占98.4%,2周后达100%.随访1-3月,无1例复发.结论:鼓膜穿刺是分泌性中耳炎常用的治疗方法之一,二孔穿刺灌药方法比单孔穿刺方法效果好.     

多层螺旋CT对叶间包裹性积液的诊断价值

目的探讨多层螺旋CT对胸腔叶间包裹性积液的诊断价值。方法回顾性分析6例经临床随访证实的胸腔叶间包裹性积液患者的多层螺旋CT扫描影像特点,每例均进行薄层重建及多平面重组（MPR）。结果多层螺旋CT及多平面重组能清晰地显示病灶的形态及与叶间裂的关系。结论螺旋CT扫描及三维重组能多方位显示病灶,使病灶定位准确,利于叶间包裹性积液的确诊。     

Intrapleural fibrinolytic therapy for pleural infection

Pneumonia with secondary pleural infection causes considerable morbidity and mortality. Intrapleural instillation of fibrinolytic agents to dissolve fibrinous adhesions is intended to improve pleural fluid drainage and prevent pleural loculations. In the last 20 years their application in the every day clinical practice has dragged much of attention and several studies have supported their use in the management of parapneumonic pleural effusions (PPE) and pleural empyema (PE). However, recent published data cast doubt on the effectiveness of intrapleural fibrinolytic agents in promoting drainage of infected pleural effusions. Pending future clinical trials, fibrinolytic therapy may be used selectively in patients who fail drainage with appropriately sized, image-guided chest tubes if reasons exist to delay or avoid definitive surgical drainage. The scope of this article is to systematically review evidence for the efficacy of intrapleural fibrinolytic therapy in the treatment of PPE and PE with emphasis on controlled trials and present some of the future perspectives.