Significance of p53 and VEGF expression in liver metastasis from colorectal cancer

BACKGROUND: Children with large anterior mediastinal masses frequently present with severe respiratory compromise and often pose a difficult diagnostic dilemma. A biopsy is preferred for diagnosis before treatment can begin; however, many of these children are at risk of acute clinical deterioration and cardiovascular arrest with the induction of anesthesia. The authors noted a correlation between pleural effusions and lymphoblastic lymphoma and recently diagnosed three cases of lymphoblastic lymphoma in children with a large anterior mediastinal mass and pleural effusion through cytological and flow cytometric examination of the pleural fluid. METHODS: To focus on this problem, 101 pediatric patients presenting with an anterior mediastinal mass between January 1980 and September 1994 were reviewed to determine if pleural effusions occur more frequently at initial presentation with lymphoblastic lymphoma than with Hodgkin's disease, thus offering a means of diagnosis in children with severe respiratory compromise. The patients' chest radiographs and/or computed tomograms for the 88 cases in which they were available were reviewed retrospectively in a blinded fashion to identify those children with pleural effusions at the time of presentation. RESULTS: In this study, 71% of patients with lymphoblastic lymphoma (10 of 14) had a pleural effusion at presentation, whereas only 11.7% of patients with Hodgkin's disease (7 of 60) had a pleural effusion on initial presentation. (P < .002 Fisher's Exact test). CONCLUSION: This retrospective review suggests that there is a significantly greater association of pleural effusions in patients with lymphoblastic lymphoma than with Hodgkin's disease. Our experience supports the conclusion that thoracentesis may provide a means of diagnosis in children presenting in severe respiratory compromise obviating the need for anesthesia and open biopsy.     

Comparison of computerized tomography and magnetic resonance in the assessment of benign and malignant pleural diseases

To compare the diagnostic capabilities of Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) in differentiating benign from malignant pleural disease, we examined with MRI at 0.5 T forty-five patients with pleural lesions identified on CT scans. For 34 patients, a final diagnosis of malignant (n = 18) or benign (n = 16) disease was made. T1, proton density/T2 and enhanced T1-weighted spin-echo images were acquired. CT and MR images were independently studied by two observers, who were unaware of the final diagnosis. Various morphological features suggesting benign or malignant pleural disease were evaluated. On the basis of the morphological CT features, a final diagnosis of benignity of malignancy was expressed in terms of two different levels of confidence-probable or definitive. The MR signal intensity of pleural lesions was compared with that of intercostal muscles (isohypointense or hyperintense). No significant differences were observed between CT and MR morphological findings. High signal intensity on proton density/T2-weighted images was observed in all malignant lesions and in 2 benign lesions (100% sensitivity, 87% specificity). In the absence of this sign (i.e., isointense or hypointense signal), the lesions were always benign (100% negative predictive value). All the definitive CT diagnoses were correct, while 6 of 17 probable CT diagnoses were incorrect. In the subgroup of lesions misinterpreted with CT, MR signal intensity on long-TR images always allowed the correct differentiation of benign from malignant conditions. To conclude, MR signal intensity is a valuable additional feature to differentiate benign from malignant pleural disease. We suggest the use of MRI in the pleural lesions where the level of confidence of CT diagnosis is low.     

Behavioral alterations in male golden hamsters exposed to chlorodibromomethane

STUDY OBJECTIVE: Carcinoembryonic antigen (CEA) is the most frequently used tumor marker in pleural fluid. Nevertheless, little is known about the causes of false-positive results. The aim of the study was to analyze the frequency, etiologies, and characteristics of the nonmalignant pleural effusions associated with elevated levels of CEA in pleural fluid. PATIENTS: Two hundred seventy-three consecutive patients with pleural effusions were evaluated, 91 (33%) associated with malignancy, and 182 (67%) due to benign diseases (51 transudates, 38 tuberculosis, 37 parapneumonic, 56 other). RESULTS: A level of CEA in pleural fluid above 10 ng/mL was found in 47% of pleural effusions associated with malignancy. Elevated levels of CEA were also found in 17 of the 182 (9%) nonmalignant pleural effusions: all five empyemas, one of the 23 typical parapneumonic (4%), two of the six borderline complicated (33%), and four of the eight complicated parapneumonic effusions (50%), one of the 38 tuberculous pleurisy (3%), one of the 11 hepatic transudates (9%), in the only patient with urinothorax, in the only patient with acute pancreatitis, and in one patient with postsurgery pleural effusion but with esophageal carcinoma and elevated CEA level in serum. CONCLUSIONS: Although an elevated level of CEA in pleural fluid is suggestive of malignancy, CEA can be elevated in 9% of pleurisy owing to benign diseases, especially in empyemas and in complicated parapneumonic effusions. Identifying the most frequent causes of false-positive results of CEA helps to correctly interpret the findings of this tumor marker.     

Primary diagnosis and follow-up after thoracic trauma and lung contusion

In 212 patients after injury of the thorax (54 males, 158 females; penetrating (15), blunt (197), multiple trauma (128)) 158 cases demonstrated rib fractures and 103 radiological proven pneumo- or hematothoraces or sometimes both, 108 of 138 had to be drained. 96.5% of the effusions and 98% of the pneumothoraces were clinical confirmed. 93.5% of 97 pulmonary contusions (79 unilateral, 18 bilateral) were detected by bronchoscopy within 10 h, 72% by x-ray. Caused by anatomical problems or for additional diagnosis 4 patients underwent thoracic CT. During ICU treatment 31 patients developed septic complications without detection in x-ray studies. In CT (n = 64) we found: 5 empyema, 13 pleural effusions, 4 pneumothoraces, 4 pneumocysts, 72 condensations of a lobe. After CT we performed: 9 resections of the lower lobe, 1 pneumectomy, 1 decortication, 7 thoracotomies with drainage, 8 drainages. To detect a septic focus under treatment the CT proved being an important diagnostic tool in chest trauma and lung contusion.     

The etiology of pleural effusions in an area with high incidence of tuberculosis

To investigate the etiology of pleural effusions in our region, we undertook a prospective study of patients with this condition in our centers. During a 5-year period, we studied 642 pleural effusion patients aged 57.1 +/- 21.1 years, of whom 401 were men aged 56.5 +/- 21 years and 241 were women aged 57.8 +/- 21.4 years; the male/female ratio was 1.6:1. The most frequent cause of pleural effusion was tuberculosis (25%), followed by neoplasia (22.9%) and congestive heart failure (17.9%). The etiology of 48 cases (7.5%) remained uncertain. In the neoplastic effusion group, the most frequent locations of the primary tumor were lung (32.6%), breast (11.5%), lymphoma (10.8%), and ovary (7.5%); in 21 cases (14.3% of the neoplastic group), it was not possible to identify the primary tumor. The 111 patients aged younger than 40 years with tuberculous effusions made up 69.4% of tuberculous effusion cases and the same percentage of patients younger than 40 years; the proportion of effusions that were tuberculous peaked in the 11- to 30-year-old age group and declined steadily thereafter. Of the patients with neoplastic effusions, 83% were older than 50 years; the proportion of effusions that were neoplastic rose steadily from zero in the 0- to 30-year-old age group to a peak among 60- to 70-year-olds. The age-wise distribution of effusions secondary to congestive heart failure was similar to that of neoplastic effusions. Of the effusions secondary to congestive heart failure, 86% (99/115) affected the right pleura or both, and 83% of effusions secondary to pulmonary thromboembolism (15/18) affected the right side. Neoplastic, tuberculous, parapneumonic, empyematous, and other exudative effusions showed no preference for either side. Of the 97 bilateral effusions, 77 (79.4%) were secondary to heart failure (59, 60.8%) or neoplasia (18, 18.6%). We conclude that in our region, the most frequent cause of pleural effusion is tuberculosis, followed by neoplasia and congestive heart failure. We suggest that all those interested in pleural disease should determine the etiologic pattern of pleural effusion in their region with a view to the adoption of regionally optimized diagnostic and therapeutic attitudes.     

Rounded atelectasis: another pulmonary pseudotumor

Rounded atelectasis or Blesovsky's syndrome (also called pleuroma, folded lung or shrinking pleuritis with atelectasis) is the association of plaque-like pleural fibrosis with a folding visceral pleura and nodular atelectasis of the underlying lung. It can mimic a peripheral lung tumor or a mesothelioma. Radiography and computed tomography (CT) show a characteristic opacity with a comet-tail sign. The pathogenesis in some of the cases is considered to be secondary to pleural effusions and in others to a contraction of a focus of pleural fibrosis, not associated with effusion. In many cases, there was a history of asbestos exposure. We report the case of a 44-year-old, man who had smoked and worked with materials containing asbestos. He referred thoracic pain of 6 months duration and dyspnea. An X-ray of the chest (Fig. 1, 2) and a CT scan (Fig. 3) revealed a round peripheral mass in the left lower lobe. A fine needle aspiration biopsy of the lung was performed revealing clusters of large atypical cells with abundant cytoplasm. A thoracotomy was decided upon and no frozen section was requested. Gross examination of the resected lobe (Fig. 4) demonstrated a 2.5 cm white, irregular, firm and retracting pleural plaque. On sectioning, a peculiar folding of the visceral pleura delimited by anthracotic pigmentation was noted below the fibrotic plaque. The folding extended perpendicularly deep into the parenchyma. It was possible to separate the folding and liberate the underlying parenchyma, which was firm, fibrotic and atelectatic. No tumor was found anywhere within the lobe.(ABSTRACT TRUNCATED AT 250 WORDS)     

Pleural exudates and transudates: diagnosis with contrast-enhanced CT

PURPOSE: To determine the accuracy of computed tomography (CT) in enabling differentiation of pleural exudates from transudates. MATERIALS AND METHODS: Eighty consecutive patients (86 effusions) underwent contrast-enhanced CT. Thoracentesis was performed to measure pleural and serum total protein and lactate dehydrogenase (LDH) values. Effusions were classified as exudates with accepted criteria. CT scans were evaluated for the presence and appearance of parietal pleural and extrapleural fat thickening. RESULTS: Fifty-nine effusions were exudates and 27 were transudates. Thirty-six of the 59 exudates (61%) were associated with parietal pleural thickening. All cases of empyema and 56% of the parapneumonic exudative effusions had pleural thickening. The specificity of this finding in diagnosing the presence of an exudate is 96%. CONCLUSION: Parietal pleural thickening at contrast-enhanced CT almost always indicates the presence of a pleural exudate. A pleural exudate in the absence of pleural thickening occurs most frequently in patients with malignancy or uncomplicated parapneumonic effusion.     

Diagnosis of pleural effusions. Experience with clinical studies, 1986 to 1990

OBJECTIVES: To identify in patients with pleural effusion which procedures are most useful in separating malignant from nonmalignant pleural effusions and to identify which procedures most commonly lead to a definitive diagnosis. DESIGN: Prospective consecutive case series. SETTING: Pulmonary referral hospital in Prague, Czech Republic. PATIENTS: One hundred seventy-one adults between ages 18 and 70 years with a pleural effusion and a Karnofsky score of 70 or above. INTERVENTIONS: All patients underwent history, physical, pleural fluid cytologic study, laboratory evaluation of serum and pleural fluid, pleural biopsy, bronchoscopy, and lung scan and/or pulmonary arteriogram. RESULTS: In this series in which 45% of the patients had malignant effusions, 19% had paramalignant effusions, and 36% had benign diseases, the pleural fluid cytologic study was the best for establishing a diagnosis. The pleural fluid carcinoembryonic antigen (CEA) levels above 10 had a high specificity (90%) for malignancy but had low sensitivity (37%). The pleural fluid CEA level was increased only in 19% of patients with paramalignant effusions. Although there were statistically significant differences in the mean results on several biochemical tests of pleural fluid, none were very accurate in separating malignant from benign disease. CONCLUSION: From this study, we conclude that patients with an undiagnosed pleural effusion should be evaluated in an individualized stepwise manner. If malignancy is strongly considered, the initial three steps should be relatively noninvasive and include clinical evaluation and cytologic study.     

Additional information from percutaneous cutting needle biopsy following fine-needle aspiration in the diagnosis of chest lesions

OBJECTIVE: To determine the contribution of percutaneous cutting needle biopsy (PNB) subsequent to fine-needle aspiration (FNA) in the diagnosis of chest lesions. DESIGN: A retrospective review of 220 patients who underwent CT-guided FNA followed immediately by PNB performed at our center between 1988 and 1995 was undertaken. Thirty-eight patients were excluded because FNA and/or PNB specimens were nondiagnostic, yielding a study group of 182 patients. RESULTS: A diagnosis of malignancy was made in 141 (77.5%) and nonmalignancy in 41 (22.5%) cases. The yield of histospecific diagnosis due to FNA was marginally higher than PNB in malignant lesions (86.5% vs 78%, respectively). In contrast, PNB was superior to FNA for the histospecific diagnosis of benign lesions (87.8% for PNB vs 31.7% for FNA, p<0.00001) and lymphomas (88% for PNB vs 56% for FNA, p<0.05). In 58.8% of the patients with benign lesions and in 37.5% of the patients with lymphoma, PNB performances altered clinical management, either by avoiding further surgery or allowing specific medical treatment. Pneumothorax occurred in 24.7% of the cases but only five patients (2.7%) required hospitalization. CONCLUSION: PNB is extremely effective for making a specific diagnosis in benign lesions compared with FNA. PNB does not increase the yield of histospecific diagnosis for malignant lesions except for the subset of lymphoma, where it seems to provide important additional information in many instances. We recommend that FNA be performed as the initial procedure, followed by PNB in cases of equivocal diagnosis of carcinoma, for lymphoma and for suspected benign lesions.     

Experience with closed needle biopsy and pleural fluid cytology in the diagnosis of malignant pleural effusions in Yaounde, Cameroon

To determine and compare the efficacy of pleural fluid cytology and closed needle biopsy of the pleura in establishing the diagnosis of malignant pleural effusions in Yaounde, we reviewed the medical records of all consecutive patients with a pleural effusion admitted in unit B of the Chest Clinic of the Jamot Hospital between January 1990 and December 1994. Fifty four cases of malignant pleural effusion were diagnosed over this period. Closed needle biopsy of the pleura alone permitted a diagnosis of malignancy involving the pleura in 32 instances while cytological studies of pleural fluid provided a diagnosis in thirty six cases. A combination of both techniques was diagnostic in 48 (88.9%) patients. We recommend that both pleural fluid cytology and closed needle biopsy of the pleura be used concomitantly in the evaluation of pleural effusion for which malignancy is suspected.     

Analysis of renal water excretion in full-term newborn infants

The clinicopathologic characteristics of two patients with Gorham's disease and bilateral recidivant pleural effusions are reported. The first case corresponded to a nine year-old girl with osteolysis in her right clavicle and ribs. The second case was a 55 year-old male with osteolytic lesions in ribs, cranium, pelvis and femurs; a thymic cyst was also documented. In both patients, biopsies were performed from ribs, which showed proliferating, benign, thin walled small vessels that extensively replaced the intertrabecular spaces. Thoracocentesis, instillation of talcum and radiation therapy were used in the former patient and no recidivant pleural effusions have developed after one year. The second patient was not treated with radiation therapy, persisted with pleural effusions and finally died two years after the diagnosis. Because Gorham's disease is rare, it was not immediately suspected in the cases described here. Its association with pleural effusion is even rarer and has been mentioned only occasionally in the literature. The utility of radiation therapy in Gorham's disease is commented.     

Muscular lengthening of the triceps by successive casts in children with cerebral palsy

ThinPrep processing, an automated cytopreparatory method, has been reported to show good correlation with conventional preparations and to reduce the rate of false-negative diagnoses. In a retrospective review of 230 consecutive nongynecologic cytology cases, we compare the ThinPrep (TP) method with conventional preparations (CP). There were 129 fine-needle aspiration (FNA) specimens from various sites, including 51 breasts, 40 thyroids, 14 lungs, 8 livers, and 16 miscellaneous sites. The sources of 101 body cavity fluids included 68 pleural/peritoneal effusions, 25 peritoneal/pelvic washings, and 8 miscellaneous sites. Each case was evaluated for cellularity, morphologic, details, and obscuring background material. Diagnoses of the TP slides were classified as insufficient, normal, benign, suspicious, or malignant. Each case was then correlated with the tissue diagnosis when available. In TP slides, cellular arrangements, nuclear details, and nuclear cytoplasmic ratio were preserved, while blood and diathesis were eliminated. There was no statistically significant difference between TP and CP in the diagnostic categories. However, in six cases of "insufficient for diagnosis" on FNA by CP, TP yielded sufficient cells and tissue fragments for diagnosis. One case each of FNA and body fluid with a diagnosis of "suspicious for malignancy" by CP was considered "positive" on TP slides. The overall sensitivity of TP was 97.6%, and the specificity was 92.9%. The positive predictive value was 93.0%. We conclude that the ThinPrep method shows good correlation with conventional preparations in both FNA and body fluids.     

Usefulness of chromosome examination in the diagnosis of malignant pleural effusions

To determine whether chromosome analysis could facilitate the diagnosis of malignant pleural effusions, we examined chromosomes in effusions from 104 unselected patients. An effusion was regarded as malignant if at least three of 30 metaphase cells were hyperdiploid or contained a marker chromosome. Results were compared with standard cytologic diagnoses. All 22 benign effusions were diagnosed correctly by cytologic examination, but one nosed correctly by cytologic examination, but one (acute rheumatoid lung disease) was misclassified as positive by chromosome criteria. Of the 82 malignant effusions, 53 (65 per cent) were diagnosed correctly by cytologic tests, as compared with 58 (71 per cent) by chromosome analysis (P greater than 0.2). Among patients with malignant neoplasms, 13 had leukemia or lymphoma; only four of these (31 per cent) were diagnosed by cytologic tests as compared with 11 (85 per cent) by chromosome analysis (P less than 0.01). The combination of standard cytologic and chromosome analyses correctly identified 83 per cent of the neoplasms, a result significantly better than that with either technic alone (P less than 0.01).     

Diagnostic value of ferritin, haptoglobin, alpha 1-antitrypsin, lactate dehydrogenase and complement factors C3 and C4 in pleural effusion differentiation

Searching to define diagnostic criteria for malignant and non-malignant pleural effusions, the differential diagnostic value of ferritin (FRT), haptoglobin (Hp), alpha 1-antitrypsin (alpha 1-AT), lactate dehydrogenase (LDH) and complement factors C3 and C4 were investigated prospectively in 100 consecutive patients with pleural effusions of various aetiologies. Pleural effusion FRT, C3 and C4 concentrations were found to be useful in differentiating exudates from transudates, so that transudates practically could be excluded in pleural effusion: serum FRT ratio lower than 0.5 and/or in pleural effusion values for C3 and C4 higher than 300 mg dl-1 and 70 mg dl-1, respectively. A pleural effusion: serum C3 ratio greater than 2 is seen only in malignant effusions. No discriminative pleural: serum ratio could be found in FRT and C4 values capable of differentiating malignant from non-malignant effusions. Pleural effusion alpha 1-AT and LDH values were elevated in exudates, as compared with transudates, and had an excellent sensitivity and predictive value, but low specificity, in differentiating malignant from non-malignant effusions. Finally, the sensitivity, specificity and positive predictive value of pleural effusion Hp concentrations were lower than those of FRT and complement factors C3 and C4, respectively.     

Asbestos: current knowledge and perspectives

Diseases due to asbestos inhalation are not only a concern for occupational physicians, but also for general practicioners and pneumologists. The real or supposed risk has extended beyond the factories employing "primary asbestos workers" to thousands of people exposed to this material or simply working in buildings insulated with asbestos. The spectrum of asbestos-related diseases has changed: asbestosis (parenchymal fibrosis due to asbestos) tends to disappear, whereas the incidence of pleural lesions, which can be associated with lower cumulative exposures, increases. Patients with asbestos related diseases do not die any more from respiratory failure but from late neoplastic complications, such as mesothelioma and lung cancer. The lack of interest and of training in occupational medicine leads to an underrecognition and an underestimation of cancers due to asbestos by the physicians. Recent progresses in CT imaging and evaluations of exposure to fibers through mineralogical analysis of lung samples have led to improve the diagnostic approach of fiber-related diseases.     

Extramedullary hematopoietic effusions

OBJECTIVE: To investigate the frequency and diagnostic implications of extramedullary hematopoietic effusions. STUDY DESIGN: Smears of the effusions diagnosed cytologically as myeloid metaplasia or extramedullary hematopoiesis and their clinical records were reviewed and compared with the histologic diagnoses. RESULTS: There were 7 pleural and 1 peritoneal effusion from 5 patients out of 20,793 pericardial, peritoneal and pleural effusions studied during a period of 21 years. CONCLUSION: When compensatory responses can be ruled out, the diagnosis of extramedullary hematopoietic effusion points toward replacement of the bone marrow by a metastatic process. The first primary to consider in males is lung carcinoma.     

High-resolution computed tomographic appearance of MALToma of the lung

MALToma of the lung is rare and advances in molecular techniques have only recently allowed accurate diagnostic classification of the previously termed "pseudolymphomas" by demonstrating that many are monoclonal B-cell proliferations of MALT tissue and therefore true low-grade lymphomas. No significant previous contribution was found in the literature regarding the high-resolution CT appearance (HRCT) of these tumours. We describe the high-resolution CT appearances in five cases presenting to our institution from 1994 to 1997. The HRCT scans (1-mm sections at 10- to 15-mm intervals) were performed as the opacities seen radiographically were thought to be part of a diffuse lung process. In one patient a spiral sequence was performed through the main airway. Multifocal, ill-defined nodules containing air bronchograms were seen in four cases and focal lobar consolidation in one case. Interlobular septal thickening, centrilobular micronodules and bronchial wall thickening were seen in two cases. Mediastinal lymphadenopathy and pleural reaction do not appear to be characteristic features. The appearance of multifocal consolidation is similar to that seen in bronchoalveolar cell carcinoma and cryptogenic organising pneumonia.     

Elevated sialyl Lewis X-i antigen levels in pleural effusions in patients with carcinomatous pleuritis

The levels of sialyl Lewis X-i antigen (SLX), which is one of the cancer-associated carbohydrate antigens, were evaluated in 83 malignant and 46 benign pleural effusions. SLX levels in pleural effusion due to lung adenocarcinoma were significantly higher than those due to benign diseases (p < 0.0001), lung cancer other than adenocarcinoma (p = 0.0052), and adenocarcinoma originating from other organs (p = 0.0492). According to receiver operating characteristic (ROC) curve analysis, the optimal cut-off level in the discrimination between malignant and benign pleural effusions was 92 U/ml, which gave a sensitivity of 57.1% and a specificity of 77.8%. The cut-off level of pleural effusion in patients with carcinomatous pleuritis might be higher than that of serum (38 U/ml).     

Plasma-cell granuloma of the mediastinum]

Elastofibroma dorsi is a benign soft-tissue tumor. Its sub- and pre-scapular location and its appearance on CT and MRI generally lead to the diagnosis. We have analyzed with sonography 6 elastofibromas in 4 patients; the diagnosis was confirmed with CT scan or MRI. Some sonography imaging features supported the diagnosis of elastofibroma dorsi. In all the cases, (1) the tumor occurred typically in a sub- and pre-scapular location, and (2) showed a streaky echostructure (3). A similar symptomatic or asymptomatic mass in the opposite subscapular location is highly suggestive.