Effectiveness and safety of outpatient pleurodesis in patients with recurrent malignant pleural effusion and low performance status

OBJECTIVES: To evaluate the effectiveness and safety of pleurodesis carried out entirely on an outpatient basis in patients with recurrent malignant pleural effusions and Karnofsky Performance Status scores <70. METHODS: This study was a prospective trial comprising patients with symptomatic recurrent malignant pleural effusion and Karnofsky Performance Status scores <70 but &gt;30. All selected patients underwent pleural catheter placement (14 Fr) in an outpatient facility. When chest radiography revealed post-drainage lung expansion of &gt;90%, pleurodesis (3 g of talc) was performed. Catheters were maintained until the daily output was ,100 mL/day. The patients were evaluated in the first month and every three months thereafter for fluid recurrence, the need for additional procedures, and complications. RESULTS: During the study period (January 2005 to July 2007), 64 patients (24 men, 40 women), with an average age of 61.4 years, underwent elective chest tube drainage. Primary sites of the underlying malignancy were breast (27), lung (22), and others (15). Sixty-six pleural catheters were placed (bilaterally in 2 patients), and 52 talc pleurodesis procedures were performed. Fourteen patients had a trapped lung and were excluded from the trial. No complications were observed during catheter placement or pleurodesis. Post-pleurodesis complications included catheter obstruction (4 patients) and empyema (1). The average drainage time was 9.9 days. The recurrence rate observed in patients that were alive 30 days after pleurodesis was 13.9% (5/36 patients). Six patients required additional procedures after the pleurodesis. The average survival time was 101 days. CONCLUSION: In this study, talc pleurodesis was safely performed in an outpatient setting with good efficacy and a reasonable complication rate, thereby avoiding hospital admission

Does the Evaluation of Coagulation Factors Contribute to Etiological Diagnosis of Pleural Effusions?

OBJECTIVE: The aim of this study was to identify the participation of the coagulation system in the differential diagnosis of pleural effusions. INTRODUCTION: Imbalance between immunologic and metabolic factors triggers a sequence of events resulting in pleural reactions and accumulation of fluid. The coagulation system, which is fundamental for the maintenance of homeostasis, contributes to the inflammatory process responsible for pleural effusions, and participates in cellular proliferation and migration as well as in the synthesis of inflammatory mediators. METHODS: We evaluated the laboratory profile of coagulation and fibrinolysis in 54 pleural fluids (15 transudates and 39 exudates). RESULTS: The coagulation system acts according to the pathophysiologic mechanisms involved in the development of pleural effusions. In inflammatory effusions (exudates), there is activation of coagulation with increased levels of fragment 1+2 and thrombin-antithrombin complex in addition to reduction of fibrinogen levels due to fibrinolysis and fibrin tissue incorporation. As a consequence, there is activation of the fibrinolytic system with increased levels of fibrin degradation products, including the D-dimer. These changes are not sufficient for differentiation of different subgroups of exudates. In transudates, these events were observed to a lesser degree. CONCLUSION: The coagulation system plays an important role in the development of pleural diseases. Coagulation tests show differences between transudates and exudates but not among exudate subgroups. Understanding the physiopathological mechanisms of pleural disorders may help to define new diagnostic and therapeutic approaches

Differentiating between tuberculosis-related and lymphoma-related lymphocytic pleural effusions by measuring clinical and laboratory variables: Is it possible?

OBJETIVO: Descrever características clínicas e laboratoriais em pacientes com derrames pleurais linfocíticos secundários a tuberculose ou linfoma, a fim de identificar as variáveis que possam contribuir no diagnóstico diferencial dessas doenças. MÉTODOS: Estudo retrospectivo com 159 pacientes adultos HIV negativos com derrame pleural linfocítico secundário a tuberculose ou linfoma (130 e 29 pacientes, respectivamente) tratados no Ambulatório da Pleura, Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo (SP), entre outubro de 2008 e março de 2010. RESULTADOS: A média de idade e de duração dos sintomas foi menor no grupo tuberculose que no grupo linfoma. Os níveis pleurais de proteínas, albumina, colesterol, amilase e adenosina desaminase (ADA), assim como os níveis séricos de proteínas, albumina e amilase, foram maiores no grupo tuberculose, enquanto os níveis séricos de colesterol e triglicérides foram maiores no grupo linfoma. As contagens de leucócitos e linfócitos no líquido pleural foram maiores no grupo tuberculose. Células malignas estavam ausentes no grupo tuberculose, entretanto, linfócitos atípicos foram observados em 4 desses pacientes. No grupo linfoma, a citologia para células neoplásicas foi positiva, suspeita e negativa em 51,8%, 24,1% e 24,1% dos pacientes, respectivamente. A imunofenotipagem do líquido pleural foi conclusiva na maioria dos pacientes com linfoma. CONCLUSÕES: Nossos resultados demonstram semelhanças clínicas e laboratoriais entre os pacientes com tuberculose ou linfoma. Embora os níveis de proteínas e ADA no líquido pleural tendam a ser mais elevados no grupo tuberculose que no grupo linfoma, mesmo essas variáveis mostraram uma sobreposição. Entretanto, nenhum paciente com tuberculose apresentou níveis de ADA no líquido pleural inferiores ao ponto de corte (40 U/L)

Papel das citocinas proliferativas TGF-&#946; e VEGF no derrame pleural p&#963;s-revascularização do miocárdio The proliferative cytokines TGF-&#946; and VEGF in pleural effusions post-coronary artery bypass graft

A cirurgia de revascularização do miocárdio envolve o acometimento, tanto do pericárdio como da pleura, conduzindo ao favorecimento de processos inflamatórios responsáveis pelo desenvolvimento de derrames nestes compartimentos. Objectivo: Estudar o comportamento das citocinas proliferativas TGF-&#946; (factor beta de transforma&#951;ão do crescimento) e VEGF (factor de crescimento do endotélio vascular) nos líquidos de 16 transudatos e de 43 derrames pleurais de doentes submetidos a cirurgias de revascularização do miocárdio provenientes do Instituto de Coração e do Serviço de Pneumologia da Universidade do São Paulo nos intervalos de 2, 24 e 48 horas de pós-operatório. Resultados: O derrame pleural pós-revascularização do miocárdio é um exsudato mobilizador de TGF-&#946; e VEGF no pós-operatório imediato. Os níveis de TGF-&#946; apresentam-se elevados nas primeiras 2 horas para caírem progressivamente até se aproximarem dos valores dos transudatos ao fim de 48 horas, enquanto o VEGF se inicia com níveis elevados já nas primeiras 2 horas com tendência a aumento pelo menos até 48 horas de pós-operatório. Conclusões: O TGF-&#946; parece comportar-se como elemento gatilho sobre a c&#953;lula mesotelial pleural para a liberação de VEGF no desenvolvimento de derrame pleural nas cirurgias de revascularização do miocárdio.Coronary artery bypass graft (CABG) surgeries canimpact on the pericardium and pleural space, leading to inflammation which can cause effusion. Aim: To study the role of the proliferative cytokines TGF-&#946; and VEGF in the fluids of 16 transudates and 43 pleural effusions of patients who underwent CABG at the Heart Unit and Pulmonology Unit of the University Hospital of São Paulo. Levels of cytokines were assessed 2, 24 and 48 hours post-surgery. Results: The pleural effusion after CABG is an exsudative mobilizer of TGF-&#946; and VEGF cytokines immediately after surgery. The TGF-&#946; concentrations were elevated 2 hours after surgery but started to fall soon after, reaching transudate levels after 48 hours. VEGF levels were high in the first 2 hours post surgery and tended to maintain the same concentrations for at least 48 hours after surgery. Conclusions: Based on the results obtained, TGF-&#946; is a cytokine that seems to work as a trigger, leading the pleural mesothelial cell to express VEGF a cause of pleural effusion in CABG surgeries

Parâmetros clínicos e laboratoriais no diagnóstico diferencial de efusões pleurais secundárias à tuberculose ou ao cancer

PURPOSE: To evaluate the clinical and laboratory characteristics of pleural effusions secondary to tuberculosis (TB) or cancer (CA). METHODS: A total of 326 patients with pleural effusion due to TB (n=182) or CA (n=144) were studied. The following parameters were analyzed: patient gender, age and pleural effusion characteristics (size, location, macroscopic fluid aspect, protein concentration, lactate dehydrogenase (DHL) and adenosine deaminase activity (ADA) and nucleated cell counts). RESULTS: Young male patients predominated in the tuberculosis group. The effusions were generally moderate in size and unilateral in both groups. Yellow-citrine fluid with higher protein (p < 0.001) levels predominated in effusions from the tuberculosis group (5.3 + 0.8 g/dL) when compared to the CA group (4.2 &plusmn; 1.0 g/dL), whereas DHL levels were more elevated in CA (1,177 &plusmn; 675 x 1,030 &plusmn; 788 IU; p = 0.003) than in TB. As expected, ADA activity was higher in the TB group (107.6 &plusmn; 44.2 x 30.6 &plusmn; 57.5 U/L; p < 0.001). Both types of effusions presented with high nucleated cell counts, which were more pronounced in the malignant group (p < 0.001). TB effusion was characterized by a larger percentage of leukocytes and lymphocytes (p < 0.001) and a smaller number of mesothelial cells (p = 0.005). Lymphocytes and macrophages were the predominant nucleated cell in neoplastic effusions. CONCLUSION: Our results demonstrate that in lymphocytic pleural exudate obtained from patients with clinical and radiological evidence of tuberculosis, protein and ADA were the parameters that better characterize these effusions. In the same way, when the clinical suspicion is malignancy, serous-hemorrhagic lymphocytic fluid should be submitted to oncotic cytology once this easy and inexpensive exam reaches a high diagnostic performance (;@; 80%). In this context, we suggest thoracocentesis with fluid biochemical and cytological examination as the first diagnostic approach for these patients.OBJETIVO: Avaliar as características clínicas e laboratoriais de derrames pleurais secundários à tuberculose ou câncer. MÉTODOS: Um total de 326 pacientes com derrame pleural por tuberculose (n=182) ou câncer (n=144) foi avaliado. Os seguintes parâmetros foram analisados: sexo e idade dos pacientes e características do líquido pleural (tamanho, localização, aspecto macroscópico, concentração de proteínas, atividade da desidrogenase lática (DHL) e da adenosina deaminase (ADA) e contagem de células nucleadas). RESULTADOS: A tuberculose pleural predominou nos pacientes mais jovens e do sexo masculino. Em ambos os grupos, os derrames pleurais foram de tamanho moderado e unilaterais. Derrames com aspecto amarelo-citrino com níveis mais elevados de proteínas predominaram na tuberculose (5,3 &plusmn; 0,8 g/dL), quando comparados aos neoplásicos (4,2 &plusmn; 1,0 g/dL), enquanto que níveis mais elevados de DHL foram observados nos derrames neoplásicos (1.177 &plusmn; 675 x 1.030 &plusmn; 788 UI; p = 0,003). Conforme esperado, a atividade da ADA foi maior na tuberculose que no câncer (107,6 &plusmn; 44,2 x 30,6 &plusmn; 57,5 U/L; p < 0,001). Ambos os derrames apresentaram alta celularidade, embora mais pronunciada no grupo neoplásico (p < 0,001). Os derrames de etiologia tuberculosa se caracterizaram por apresentar uma maior percentagem de leucócitos e de linfócitos (p < 0,001) e um pequeno número de células mesoteliais (p = 0,005). Linfócitos e macrófagos foram as células nucleadas que predominaram nos derrames pleurais malignos. CONCLUSÃO: Nossos resultados demonstram que em exsudatos pleurais linfocíticos de pacientes com evidências clínicas e radiológicas de tuberculose, os níveis de proteína e de ADA foram os parâmetros que melhor caracterizaram esses derrames. Da mesma maneira, quando a suspeita clínica é câncer, um líquido serohemorrágico e linfocítico deve ser submetido à citologia oncótica, uma vez que este exame laboratorial de fácil realização e baixo custo apresenta alto desempenho diagnóstico (;@; 80%). Neste contexto, sugerimos que a toracocentese, com exames bioquímicos e citológicos do líquido pleural, seja a primeira abordagem diagnóstica do paciente

Papel das citocinas proliferativas TGF-β e VEGF no derrame pleural pós-revascularização do miocárdio

Resumo: A cirurgia de revascularização do miocárdio envolve o acometimento, tanto do pericárdio como da pleura, conduzindo ao favorecimento de processos inflamatórios responsáveis pelo desenvolvimento de derrames nestes compartimentos.Objectivo: Estudar o comportamento das citocinas proliferativas TGF-β (factor beta de transformação do crescimento) e VEGF (factor de crescimento do endotélio vascular) nos líquidos de 16 transudatos e de 43 derrames pleurais de doentes submetidos a cirurgias de revascularização do miocárdio provenientes do Instituto de Coração e do Serviço de Pneumologia da Universidade do São Paulo nos intervalos de 2, 24 e 48 horas de pós-operatório.Resultados: O derrame pleural pós-revascularização do miocárdio é um exsudato mobilizador de TGF-β e VEGF no pós-operatório imediato. Os níveis de TGF-β apresentam-se elevados nas primeiras 2 horas para caírem progressivamente até se aproximarem dos valores dos transudatos ao fim de 48 horas, enquanto o VEGF se inicia com níveis elevados já nas primeiras 2 horas com tendência a aumento pelo menos até 48 horas de pós-operatório.Conclusões: O TGF-β parece comportar-se como elemento gatilho sobre a célula mesotelial pleural para a liberação de VEGF no desenvolvimento de derrame pleural nas cirurgias de revascularização do miocárdio.Rev Port Pneumol 2006; XII (4): 359-367 Abstract: Coronary artery bypass graft (CABG) surgeries can impact on the pericardium and pleural space, leading to inflammation which can cause effusion.Aim: To study the role of the proliferative cytokines TGF-β and VEGF in the fluids of 16 transudates and 43 pleural effusions of patients who underwent CABG at the Heart Unit and Pulmonology Unit of the University Hospital of São Paulo. Levels of cytokines were assessed 2, 24 and 48 hours post-surgery.Results: The pleural effusion after CABG is an exsudative mobilizer of TGF-β and VEGF cytokines immediately after surgery. The TGF-β concentrations were elevated 2 hours after surgery but started to fall soon after, reaching transudate levels after 48 hours. VEGF levels were high in the first 2 hours post surgery and tended to maintain the same concentrations for at least 48 hours after surgery.Conclusions: Based on the results obtained, TGF-β is a cytokine that seems to work as a trigger, leading the pleural mesothelial cell to express VEGF a cause of pleural effusion in CABG surgeries.Rev Port Pneumol 2006; XII (4): 359-367 Palavras-chave: Inflamação, citocinas, derrame pleural, revascularização do miocárdio, Key-words: Inflammation, cytokines, pleural effusions, coronary artery bypass graftin

Clinical and laboratory parameters in the differential diagnosis of pleural effusion secondary to tuberculosis or cancer

PURPOSE: To evaluate the clinical and laboratory characteristics of pleural effusions secondary to tuberculosis (TB) or cancer (CA). METHODS: A total of 326 patients with pleural effusion due to TB (n=182) or CA (n=144) were studied. The following parameters were analyzed: patient gender, age and pleural effusion characteristics (size, location, macroscopic fluid aspect, protein concentration, lactate dehydrogenase (DHL) and adenosine deaminase activity (ADA) and nucleated cell counts). RESULTS: Young male patients predominated in the tuberculosis group. The effusions were generally moderate in size and unilateral in both groups. Yellow-citrine fluid with higher protein (p @ 80%). In this context, we suggest thoracocentesis with fluid biochemical and cytological examination as the first diagnostic approach for these patients.OBJETIVO: Avaliar as características clínicas e laboratoriais de derrames pleurais secundários à tuberculose ou câncer. MÉTODOS: Um total de 326 pacientes com derrame pleural por tuberculose (n=182) ou câncer (n=144) foi avaliado. Os seguintes parâmetros foram analisados: sexo e idade dos pacientes e características do líquido pleural (tamanho, localização, aspecto macroscópico, concentração de proteínas, atividade da desidrogenase lática (DHL) e da adenosina deaminase (ADA) e contagem de células nucleadas). RESULTADOS: A tuberculose pleural predominou nos pacientes mais jovens e do sexo masculino. Em ambos os grupos, os derrames pleurais foram de tamanho moderado e unilaterais. Derrames com aspecto amarelo-citrino com níveis mais elevados de proteínas predominaram na tuberculose (5,3 &plusmn; 0,8 g/dL), quando comparados aos neoplásicos (4,2 &plusmn; 1,0 g/dL), enquanto que níveis mais elevados de DHL foram observados nos derrames neoplásicos (1.177 &plusmn; 675 x 1.030 &plusmn; 788 UI; p = 0,003). Conforme esperado, a atividade da ADA foi maior na tuberculose que no câncer (107,6 &plusmn; 44,2 x 30,6 &plusmn; 57,5 U/L; p @ 80%). Neste contexto, sugerimos que a toracocentese, com exames bioquímicos e citológicos do líquido pleural, seja a primeira abordagem diagnóstica do paciente