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    2 views4 pages

    Kjim 18 4 230 5

    Uploaded by

    yulia
    kjhikh

    Copyright:

    © All Rights Reserved
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    ‘The Korean Journal of ltomal Medicine: 18230-238 2003 What is the Clinical Significance of Transudative Malignant Pleural Effusion? Jeong-Seon Ryu, M.D., Seong-Tae Ryu, M.0., Young-Shin Kim, M.D., Jae-Hwa Cho, M.D. and Hong-Lyeol Lee, M.D, Department of internal Medicine, College of Medicine, Inha University. Incheon, Korea Background :A few reports of transudative malignant effusion on a small number of patients have ‘suggested the need to perform routine cytologic examination in all cases of transudative pleural effusion, whether encountered for malignancy or not, The purpose of this study was to investigate whether cytologic examination should be performed in all cases of tvansudative pleural effusion for the diagnosis of ‘malignancy. ‘Methods : We performed a retrospective study of 229 consecutive patients with malignant pleural effusion, proven either cytologically or with biopsy. In patients with transudative pleural effusion, we reviewed medical records, results of transthoracic echocardiography, fiberoptic bronchoscopy, chest X-ray, chest CT sean, and Utasonogram of the abdomen. These data were examined with particular attention to identifying whether or rot the malignancy was suggested on chest X-ray, examining the involvement of the superior vena cava, great vessels, and lymph nodes, determining the presence of pericardial effusion, and observing the ‘endobronchial obstruction. Results : Transudative malignant pleural effusion was observed in seven (3.1%) of the 229 patients, and was caused either by the malignancy itself (6 patients) or by coexisting cardiac diseases (1 patient). All the patients showed evidence suggesting the presence of malignancy at the time of intial thoracentesis, which facilitated the decision of most clinicians on whether to perform cytologic examination for the diagnosis of malignancy. Conclusion : Therefore, in ail cases of transudative pleaural effusion, no clinical implications indicating ‘malignancy were found on cytologic examination. Key Words : Transudative pieural effusion, Malignancy INTRODUCTION Aller the inal differentation between tansudates and ‘exudates in the dagrosis of pleural eusion, futher agnostic ‘evaluation was traditionally thought to be needess in cases of Wransudatve pleural effusion. Recently 2 few reports have slated thet transudatve effusion may be observed in malignant pleural etision and have suggested the need to perform routine cytologic examination in all cases of lransudative pleural effusion’, In this study, we attempted to evaluate the prevalence of ‘ransudates among masgnant pleural eftusion, proven ether cyologcaly or with biopsy, 10 ‘elucidate the etclogy causing the transudative pleural effusion, and fo determine whether the presenoe of transudative ‘malignant pleural effusion has cinical implications for its agnostic evaluaton, MATERIALS AND METHODS From January 1999 fo June 2001, 278 consecutve patents with malignant pleural effusion were admitied to the pulmonary depariment of the teaching hospital. Alter excluding 49. patients wth incomplete data, the study population ‘+ Reoeed : une 90, 2008 Aovected | August 25, 2003 + Correspondence 10: Jeong-Seon Ayu M.D, Oenatert ol nteral Meicre, ha Unversity Hosts, 7-208 Strneung-dong 3-ga, Jung-ay, fon, ‘0-711, Kores Ta 82-G2-600-97, Fax 222-880-6578, Ema: jsyudinhaacke Jeang-Seon Ryu, et ak What is the Cinical Signifcance of Transudatve Malignant Pleural Etuson? 231 consisted of 229 patients with maignant pleural effusion, proven etter cjtologcaly or via biopsies. The present study wes ited to the data ffom pleural efusion at the frst thoracentesis. In the appicaton of Lights ortea for 2'3 of the upper limits of the normal serum LDH value: 2. pleural fd LOH'serum LDH vvalue>0.6; and 3, pleural fluid protein'serum protein level-0, ‘According to the decison of the atending physician, the ler, heart, kidney and thyroid were studied in transudative pleural Table 1. Etiology of Malignant Pleural Eftusions (n=225) Nasopharyngeal carcinoma 10 Transuate No (06) Ipatent na.) Lang cancer| 204 (a0) 5 ‘Adenocarcinoma 101 212) Squamous cel carcinoma ° 13) ‘Smell c= carina % 2445) Metastasis Unknown primary 25 (19), 2 Breast cancer 9 Stomach cancer 4 Hepaiocebier carcinoma 4 Malignant mesotnetoma 3 Bladder cance: 2 Invasve thymoma ' 16 1 1 fusion, We reviewed medical records, laboratory results, ‘such as thyroid functon test, levels of blood urea nitrogen, creatinine, aspartate aminotransferase (AST), alanine amino transferase (ALT) and abumin, as well 2s the results from transthoracic echocardiography (TTE) and fiberoptic bronchos- ‘copy, in patients with tansudative pleural effusion. The results from radiologic studies were reviewed by chest X-ray, chest CCT scan, and ulrasonogram of the abdomen on the day of thoracentesis. At the beginning of the diagnostic work up of transudative pleural effusion, we evaluated whether the ‘malignancy was suggested on chest X-ray by the radiologist oF alnican, or whether the malignancy had already been «dagnosed. We also examined the involvement of the superior vena cava, great vessels, and lymph nodes, studied the presence of pericardial effusion seen on chest CT scan or TTE, and observed the cocurrence of endabronchial ‘obstruction or obstructive pneumonitis on fiberoptic bronchos~ ‘copy or chest CT scan, RESULTS In our series, primary fung cancer was the most common cause of malignant pioura effusion, diagnosed cytologicaly or with biopsies, affecting 204 (89%) of the 229 patients. Unknown primary adenocarcinoma was also common from metastases (Table 1) Table 2. Summary of Patonts with Transudtive Malignant Pleural Efusion (n=7) No. ‘Cinical Dagoss’ Location’ EF Possible Causes 1 aD Let 74 Obstructon of lobar bronchus of LUL Encasement of left main pulmonary artery 2 ue AD Fight 72 Tamponade by massive percardat etusion Exiensve mediasinal lmphadenopathies 3 Le sa Fight 45 Ischemic heart diease, Atal fbrilaton Exiensve mediastinal lmohadenopatnies + Le Lc Fight 73 Extensive mediastinal ymohadenopathies Enlargement of right nar lymph nodes s tc Le Bon 57 Tamponade by massive pericardial fusion SVC obstruction Encasement of both main pumonary artery 6 Metastatic carcinoma Bladder carcinoma Bon 78 Mediastina! mphadenopatties Diffuse ymohangtc metastasis to both lung r Modiastnal mass Medastial mass Lett 61 Mediastinal mass Encasement of lett main aulmonary artery Indicates the presence of pleural eflusion on intial chest X-ray: *) radologe and cinical agnosis at the time of inal tMoracentesis: LO, lung cancer cinically suggested: AD, adenocarcinoma pathologcaly confirmed: SQ, squamous cal carcinoma pathologicaly contirned: echocardiography ste of pleural efusion intaly presented on chest X-ray: EF, % of election fracon on transthorace 282. The Korean Journal of Intemal Mediche: Val. 18, No. 4, December, 2003, Table 3. inal Pleural Fluid Result (tom Patients with Transudatve Malignant Pleural Efusion (0=7) WSO Lyrmphooye Proton == LDHSS«Sgar—=SCCEA, ve im? % afd. uk mora — OOO 1 760 s 12 138 128 rr aypia 2 2 2 28 1a # 123 adenocarcinoma 3 90 2 25 119 2 163 no makanant cell 4 180 3 2i 134 22 247 no malignant cal 5 1360 a 29 7 12 2 mall call carcinoma 6 190 8 25 183 10 26 no malgnant ce 7 80 % ai i 1% 16 abpia Transudatve pleural effusion was obsened in 7 (3.1%) of the 229 patents with malignant disease (Table 2). Five patents had primary lung canoer: adenocarcinoma for patiants ros. 1-2, squamous cell carcinoma for no. 3, and small cat carcinoma for nos. 4 and 5. Their cinical siages were stage IB inal patents. Patient no. 6 had bladder carcinoma with Iymohangitc metastasis 1o both lungs al the time of diagnosis, while patient no. 7 had invasive thymoma, Of the 7 patients, 4 (n0s, 4-7) had pleural efusion on intial chest X-ray. In the ‘other 3 patients, pleural effusion was not observed intial, but was disclosed on follow-up chest X-ray after the dagnoss of imaignanoy. No patents had abnormal values for blood urea nitrogen, creatinine, AST, o ALT on the day of thoracentesis, ‘and none had a history of liver disease or thyroid disease, Lower levels of serum albumin were observed in one patient, ro. 1 at 27 gid (normal range: 3.1-62 g/dL) on the day of thoracentesis. Thyroid function was evaliated in one patient (60. 1) with normal results. Abdominal utrasonagram revealed fpormal findings in all patients. The level of pleural fluid carcinoembryonic antigen (CEA) was more than 10 ngiml in 5 patients (nos, 1-5) (Table 3), At inital thoracentesis, the presence of malignancy was suggested for all pationts, by chest X-ray or other clinical information, DISCUSSIONS ‘As in oer counties, lung cancer is the most common cause of cancer death in Korea, Malignant plural efusion is defined as pleural effusion assocaled wih cancer and has been a common cinical problem encountered by most inicians. However, the prevalence of transudtes has been rately reported in malignant pleural efsion. After the inal study by Light et al” stating the prevalence of malignant trarsudaive pleural effuson as 23% for 43. pationts, the prevalence has been reported to range from 1 to 106% in ‘ther studies", In the largest study to date, by Ashohi et al” the prevalence was reported as 46% among 171 makgnant peuraleftuson patin's. Our sores showed a prevalence of transudatve malignant pleural effusion of 3.1% for the 220 patents The folowing causes of vansudales in maignant plural etusion have been recomized: 1) malgnancy sot 2) cooxistng diseases and 3) combination of both causes, Transucative pleural effusion may occur in the early stage of ‘melgnant plural efusion and show a lower proein level of evra fid because of the invovement of the meciastina Iymon node. The pleural tid characorisios changed. to ‘exudates wih protein accumulation in the plewal space over period of several weeks, Endobronchal obstruction or hypoaburinemia. aso causes transudalve pleural efuson in patents win malignant disease”. This unusual condition Was also observed in patnts wih superior vena cava ssindrome ot tumor embolsm!®. Coexising diseases such 2s carian, renal, and hepatic diseases have been well known fo cause transudatve pleural efusion. in our series, of 7 patients wih transudatve ploural efiusion, 6 may have been causod Dy pericardial efusion, mediasinal involvement of the mabgrancy, and obstrcton of the bronchus and great vessels in other words, by the malignancy ise. Cardiac

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