Pleural Fluid Characteristics of Chylothorax Maldonado, Fabien, MD; Hawkins, Finn J., MBBCh; Daniels, Craig E., MD ...
Mayo Clinic proceedings,
02/2009, Letnik:
84, Številka:
2
Journal Article
Recenzirano
Odprti dostop
OBJECTIVE To determine the biochemical parameters of chylous pleural fluids and better inform current clinical practice in the diagnosis of chylothorax. PATIENTS AND METHODS We retrospectively ...reviewed 74 patients with chylothorax (defined by the presence of chylomicrons) who underwent evaluation during a 10-year period from January 1, 1997, through December 31, 2006. The biochemical parameters and appearance of the fluid assessed during diagnostic evaluation were analyzed. RESULTS The study consisted of 37 men (50%) and 37 women (50%), with a median age of 61.5 years (range, 20-93 years). Chylothorax was caused by surgical procedures in 51%. The chylous pleural fluid appeared milky in only 44%. Pleural effusion was exudative in 64 patients (86%) and transudative in 10 patients (14%). However, pleural fluid protein and lactate dehydrogenase levels varied widely. Transudative chylothorax was present in all 4 patients with cirrhosis but was also seen with other causes. The mean ± SD triglyceride level was 728±797 mg/dL, and the mean ± SD cholesterol value was 66±30 mg/dL. The pleural fluid triglyceride value was less than 110 mg/dL in 10 patients (14%) with chylothorax, 2 of whom had a triglyceride value lower than 50 mg/dL. CONCLUSION Chylothoraces may present with variable pleural fluid appearance and biochemical characteristics. Nonmilky appearance is common. Chylous effusions can be transudative, most commonly in patients with cirrhosis. Traditional triglyceride cutoff values used in excluding the presence of chylothorax may miss the diagnosis in fasting patients, particularly in the postoperative state.
Despite significant recent progress in precision medicine and immunotherapy, conventional chemotherapy remains the cornerstone of the treatment of most cancers. Chemotherapy-induced lung toxicity ...represents a serious diagnostic challenge for health care providers and requires careful consideration because it is a diagnosis of exclusion with significant impact on therapeutic decisions. This review aims to provide clinicians with a valuable guide in assessing their patients with possible chemotherapy-induced lung toxicity.
Summary The IASLC/ATS/ERS and 2015 WHO classifications of lung adenocarcinoma recommend designating tumors showing entirely lepidic growth as adenocarcinoma in situ (AIS), and lepidic tumors with ...invasion ≤5 mm as minimally invasive adenocarcinoma (MIA), both of which have superior outcome to conventional invasive adenocarcinoma (IA). Data on interobserver variability within this classification is limited, and further validation of the superior survival of AIS and MIA is needed. 296 surgically excised pulmonary adenocarcinomas were reviewed from 254 patients (1997-2009). Slides were independently reviewed by two pulmonary pathologists who categorized tumors as AIS, MIA, or IA. 244 of 296 nodules (82.4%) were agreed upon by both observers: 10 AIS, 61 MIA and 173 IA (kappa = 0.63, good agreement). In 6 cases (2%) there was disagreement between AIS and MIA; in 45 cases (15%) there was disagreement between MIA and IA; and in 1 case there was disagreement between AIS and IA. Overall survival was significantly different among categories as determined by both observers. Cases with disagreement between MIA and IA had similar survival to agreed MIA. Disease-specific 10-year survival (DSS) was 100% for AIS (both observers), 97.3 and 97.6% for MIA, although this did not reach statistical significance compared to IA for either observer. Good agreement was present between observers when classifying tumors as AIS, MIA and IA. Significant differences in overall survival were present between the 3 groups for both observers, and interobserver variability was evident. Patients with AIS and MIA experienced excellent DSS.
Background Nonspecific pleuritis (NSP) is a frequent diagnosis after parietal pleural biopsy, but the clinical significance of this finding and need for further follow-up have not been firmly ...established. Previous reports suggest that 5% to 25% of patients with NSP are subsequently diagnosed with pleural malignancy. Methods Our pathology database was queried for patients with histologic evidence of NSP from January 01, 2001, to December 31, 2012 (n = 413). Patients with less than 1 year of follow-up after biopsy, diagnosis of empyema, tuberculous pleuritis, active systemic connective tissue disease or vasculitis, or active malignancy were excluded (n = 327). The remaining patients were included and their medical records were reviewed. Results Eighty-six patients were included. Mean follow up was 1,824 ± 1,032 days (range, 409 to 4,599 days). Three of the 86 patients with NSP (3.5%) were subsequently diagnosed with pleural malignancy. All 3 patients were found to have mesothelioma with a mean time from biopsies to diagnosis of 205 ± 126 days (range, 64 to 306 days). Twenty-two of 86 patients (25.5%) had a possible identifiable cause of pleural inflammation (benign disease). After exclusion of these 22 patients, the incidence of malignancy was 3 of 64 (4.7%). Conclusions The incidence of subsequent pleural malignancy (mesothelioma) among patients found to have NSP based on pleural biopsy was 3.5%. Occult mesothelioma in patients with NSP will most likely be diagnosed within 1 year of the initial pleural biopsy; therefore, these patients should be followed for a minimum of 1 year to allow for timely detection of occult pleural malignancy.
To assess the frequency and clinical implications of positive autoimmune serologies in patients with biopsy-confirmed idiopathic pulmonary fibrosis (IPF).
We reviewed the records of patients at our ...institution with biopsy-confirmed usual interstitial pneumonia (UIP) from January 1, 1995, through December 31, 2010, for frequency and distribution of autoimmune serologies. Patients with IPF with and without positive serologies were compared.
Three hundred eighty-nine consecutive patients with biopsy-confirmed IPF underwent serologic testing, with positive serologic test results being found in 112 (29%). Of 2051 individual screening serologic tests performed, results of 163 tests were positive (8%), with antinuclear antibody being the most frequent (47%). There was no difference in age at biopsy (P=.21), gender (P=.21), or presenting radiologic features between those with or without positive serology. More frequent use of immunosuppressive treatment (P=.02) was noted in those with positive serology. No survival difference was observed (log-rank; P=.43). Median follow-up for the whole cohort was 43.5 months.
Positive autoimmune serology may occur in as much as one-third of the patients with biopsy-confirmed IPF with no associated clinical implication or survival advantage. Systematic use of autoimmune laboratory panels in patients without clinical features of connective tissue disease should be reconsidered in patients with suspected UIP on chest computed tomography scan or confirmed UIP on biopsy.
Background Esophageal self-expandable stents (SESs) effectively treat strictures and leaks but may be complicated by a stent-associated esophagorespiratory fistula (SERF). Little is known about ...SERFs. Objective To determine the incidence, morbidity, mortality, and risk factors for SERF. Design Retrospective case-control study. Setting Single referral center. Patients All adults undergoing esophageal SES placement during a 10-year period. Intervention Stent placement. Main Outcome Measurements Occurrence of SERF, morbidity, and mortality. Results A total of 16 of 397 (4.0%) patients developed SERF at a median of 5 months after stent placement (range 0.4-53 months) including 6 of 94 (6%), 10 of 71 (14%), and 0 of 232 (0%) of those with lesions in the proximal, middle, and distal esophagus, respectively (overall P < .001). SERF occurred in 10% of those with proximal and mid-esophageal lesions, including 14% with benign strictures, 9% with malignant strictures, and none with other indications for SES placement ( P = .27). The risk was highest (18%) in patients with benign anastomotic strictures. Risk factors for development of SERF included a higher Charlson comorbidity index score (odds ratio OR 1.47 for every 1-point increase; P = .04) and history of radiation therapy (OR 9.41; P = .03). Morbidity associated with SERF included need for lifelong feeding tubes in 11 of 22 (50%) and/or tracheostomy or mechanical ventilation in 5 of 22 (23%). Median survival after diagnosis was 4.5 months (range 0.35-67), and 7 patients survived less than 30 days. Limitations Retrospective design, limited statistical power. Conclusion SERF is a morbid complication of SES placement for strictures of the proximal and mid-esophagus. The dominant risk factors for development of SERF are prior radiation therapy and comorbidity score.
Chylothorax is an uncommon but serious medical condition, which arises when intestinal lymphatic fluid leaks into the pleural space. Treatment strategies depend on the daily output and underlying ...etiology, which may be due to direct injury to lymphatic vessels or a nontraumatic disorder. Chest radiographs confirm the presence of pleural fluid and lateralize the process. In the setting of direct injury, lymphangiography can often be both diagnostic and facilitate a minimally invasive attempt at therapy. CT and MRI in this setting may be appropriate for cases when lymphangiography is not diagnostic. When the etiology is nontraumatic or unknown, CT or MRI can narrow the differential diagnosis, and lymphangiography is useful if a minimally invasive approach to treatment is desired. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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