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ERS International Congress Amsterdam
26–30 September 2015
Postgraduate Course 10
Malignant pleural effusion management
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Postgraduate Course 10 Malignant pleural effusion management
AIMS: To understand the new roles that molecular biology and histo-/cytopathology play in the diagnosis and management (treatment and prognosis) of malignant pleural effusions, and how to use these techniques (processing and data interpretation) in clinical practice. TARGET AUDIENCE: Trainees, pulmonary physicians, thoracic surgeons, pathologists, molecular biologists, and scientists.
CHAIRS: P. Astoul (Marseille, France), M. Skrzypski (Sopot, Poland)
COURSE PROGRAMME PAGE
09:30 Which material in which disease? 5 S. Fernandez Bussy (Santiago, Chile)
10:15 How to send your material to pathology 82 P. Schnabel (Homburg/Saar, Germany)
11:00 Break
11:30 Interpretation of the results in the clinic 83 A. Scherpereel (Lille, France)
12:15 Atypical mesothelial hyperplasia and other pitfalls in MPE diagnosis 102 F. Galateau-Salle (Caen, France)
Faculty disclosures 108
Faculty contact information 109
Answers to evaluation questions 110
Regular physical activity improves quality of life and fi tness in healthy individuals and people living with lung conditions.
www.healthylungsforlife.org
In partnership with:
Farbe/colour:PANTONE 288 CV
ERS/ELF ER Journal 210x280 ad_v2 AW.indd 4 29/07/2015 16:23
Malignant Pleural Effusion
Dr Sebastian Fernandez Bussy
Clinica Alemana-Universidad del Desarrollo
Interventional Pulmonology
Av Vitacura 5951
Santiago, Región Metropolitana
CHILE
SUMMARY
Metastatic disease to the pleura occur much more frequently than primary pleural neoplasms,
causing approximately 200 000 pleural effusions in the USA each year, as compared to Diffuse
Malignant Mesothelioma (DMM), which causes approximately 1500 pleural effusions each year.
This is a ratio of over 130 pleural metastases for each primary pleural DMM. Metastases to the
pleura exhibit characteristics, including pleural effusions, pleural thickening and pleural-based
masses, found with primary pleural neoplasms and reactive pleural processes. Common
metastases to the pleura include lymphoma, lung cancer and breast cancer; however,
malignancies from any primary may metastasize to the pleura.
The pleura can be invaded directly from neighboring structures (lung, chest wall -- including
breast in some cases -- diaphragm and mediastinum) but most of the pleural malignancies arise,
according to necropsy studies, from tumor emboli to the visceral pleura, with secondary seeding
to the parietal pleura. The effusion can develop as a direct consequence of neoplastic pleural
involvement, but it can also occur in cases with lymphatic blockade at the mediastinal level.
Diagnostic thoracentesis should be performed in every pleural effusion not clearly associated to
heart failure, hepathic hydrothorax or chronic renal failure, and also in patients with the above
conditions not responding to the appropriate treatment. Malignant transudative effusions can
occur in lung cancer with obstruction of the mainstem bronchus, but also in lymphoma and other
malignancies. Blockade of lymphatic drainage may be invoked as one of the possible
pathogenetic mechanisms, but an underlying cardiac failure or other conditions that are usually
associated with transudative effusions should be taken into account also.
Many studies have shown a large variation in the diagnostic sensitivity of pleural fluid cytological
analysis, ranging from 40−87%2. In particular, a cytomorphologic distinction between reactive
mesothelial cells, mesothelioma, and metastatic adenocarcinoma, as well as between lymphomas
and reactive lymphocytosis, can often be difficult because of significant overlapping cytologic
features. Therefore, other procedures, such as immunohistochemistry (IHC) using monoclonal
antibodies against tumor markers and chromosomal analysis, complement cytology in the
diagnosis of MPEs. IHC staining can be performed on conventional cytology specimens and cell
blocks. There have been many reports on the application of different IHC markers in pleural
effusion samples to diagnosis MPE and to identify the primary site of origin.
Differential cell counts in pleural fluid are never diagnostic, but can help (more than two-thirds of
lymphocytic pleural effusions are the result of malignancy or tuberculosis). Pleural fluid
eosinophilia (> 10% eosinophils in the total nucleated cell count) is virtually never diagnostic
because it can be due to idiopathic (25%), malignant (20%), infectious (20%) or miscellaneous
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benign conditions (35%) [48]. It should be stressed that the higher the percentage of pleural
eosinophils (e.g., > 40%), the lower the likelihood of malignancy and the greater the likelihood of
an unknown etiology.
A negative Adenosin deaminase (ADA) is useful to rule out tuberculous pleuritis in lymphocyte-
predominant effusions [12]. In addition, extremely high ADA (> 250 U/L) in pleural fluid should
raise suspicion of a non-tuberculous effusion, particularly lymphoma or complicated
parapneumonic effusion.
The yield from sending more than two separate pleural fluid specimens for cytology is very low
and should be discouraged: In a study of 603 patients with MPEs, cytological analysis had an
overall sensitivity of 50% (95% confidence interval (CI): 46 -- 54%) for the first specimen and
57% (95% CI: 53 -- 61%) and 58.2% (95% CI: 54.2 -- 62%) for the second and third separate
examinations, respectively. For both direct smear/cytospin and cell block preparations, 150 mL or
more were recommended, whereas 60 mL were adequate when only direct smear/cytospin was
used for the diagnosis of MPE.
To separate epithelial mesothelioma from adenocarcinoma, at least two mesothelial (e.g.,
calretinin, keratin 5/6, WT-1 protein) and two carcinoma (e.g., thyroid transcription factor-1-
TTF-1-, CEA, B72.3) markers should be used [56]. In a MPE of unknown origin, a positive TTF-
1 stain strongly suggests a primary non-small-cell lung cancer. Immunocytochemistry in pleural
fluid can also help in some therapeutic decisions, like selection of targeted therapy in lung cancer
[59], and hormonal therapy. Thus, expression of oestrogen/progestogen receptors or Her- 2-neu
may have both diagnostic (breast cancer) and therapeutic implications.
Flow cytometry has the advantage of fast and observer independent results and can be very
helpful in identifying pleural involvement of hematologic malignancies, and in distinguishing
malignant from atypical mesothelial cells.
There are an increasing number of MPE patients as the incidences of lung cancer and other
malignant cancers have increased. Although cytological or histopathologic changes act as the
“gold standard” of MPE diagnosis, these changes are not observed in the bodies of all patients
with MPE. Moreover, many patients are unwilling to undergo a biopsy examination. Many
researchers have evaluated multiple assays to find out a necessary to find a highly specific and
sensitive MPE marker to improve detection accuracy, reduce patient morbidity and
inconvenience, and decrease follow-up financial pressure.
A panel of PF tumor markers, including CEA, CA 125, CA 15-3 and CYFRA 21-1, have been
tested. Although the measure of these molecular markers can serve as a diagnostic guide, they
cannot be used exclusively to confirm a diagnosis.
Mesothelin levels have been examined in many series of serum samples; however problems of
confounding by kidney function and low sensitivity in presymptomatic individuals have limited
its acceptance as a diagnostic marker. In comparison there have been far fewer studies of the role
of mesothelin measurements in pleural effusions in a diagnostic setting. Tumor marker
measurements in effusions have the potential to be more sensitive than serum measures because
proximity of the fluid to the tumor allows continuous “sampling” of the tumor and because
effusions are derived from an already symptomatic group. Mesothelin levels greater than 20 nM
in effusions are highly suggestive of malignancy, particularly of MM. With a sensitivity of 67%
and specificity of 95% for distinguishing Malignant Mesothelioma (MM) from all other effusions
this study confirms that measurement of mesothelin level contributes to the diagnostic
6
investigation of patients with pleural effusions. As 33% of MM cases do not have an elevated
mesothelin level this test is not sufficient for diagnostic purposes as a stand-alone test. The
finding that non-MM mesothelin positive cases are primarily due to other malignancies supports
the notion that the value of this test is in differentiating malignant from nonmalignant effusions.
One of the early biomarkers, proposed over 30 years ago, for mesothelioma was hyaluronic acid.
However, the technically demanding nature of the hyaluronic acid assay limited follow-up
studies. Recently, two independent studies have been reported that find combining hyaluronic
acid with mesothelin or MPF improves sensitivity for mesothelioma, while maintaining
specificity when measured in effusion supernatants. Sensitivity of mesothelin for mesothelioma in
a dichotomous differential diagnostic setting has been improved by using additional ‘exclusion
markers’, such as carcinoembryonic antigen, has been reported.
Survivin has been confirmed as a novel member of the inhibitor of apoptosis protein (IAP)
family. Reportedly, survivin exerts antiapoptosis effects and regulates cell division in tumors and
normal tissues. During tumorigenesis, surviving expression is inversely correlated with apoptosis
inhibition but positively correlated with proliferation and angiogenesis. Survivin has been widely
studied as a prognostic marker in NSCLC, and it plays a crucial role in regulating cell
proliferation, apoptosis, and angiogenesis. Many studies have shown that the positive expression
of survivin is significantly related to lymph node metastasis and cancers of late clinical stage,
such as MPE. In recent years, surviving has generated much interest as a novel biomarker for
MPE diagnosis, and it appears to be a useful marker of MPE.
It has been reported that levels of plasma (not serum) fibulin-3 can distinguish healthy persons
with exposure to asbestos from patients with mesothelioma, and can further differentiate
mesothelioma effusions from other malignant and benign effusions. Although, there is still not
enough information about the routine use of fibulin-3.
For tissue sample, needle pleural biopsy (US or CT guided) or thoracoscopy, can be used.
Pleural malignant mesothelioma (MM) is an aggressive asbestos-induced malignancy. The
diagnosis of MM is often difficult and may take several weeks to months to establish. Current
guidelines recommend that a diagnosis be based on demonstration of invasion by tumor cells;
however, not all patients are able to undergo invasive procedures to obtain a biopsy, and even
when tissue is obtained diagnosismay still be difficult. In MM, patients often present with a
pleural effusion which can be used for diagnostic purposes. Although there is controversy
regarding the cytological analysis of cells from pleural effusions, with sensitivities reported in
several studies to be around 30%, the limitation of the technique relates primarily to difficulty in
distinguishing MM from benign mesothelial cells. However, a high sensitivity and specificity can
be achieved if a standardized approach to cytodiagnosis is used.
MPM grows in the pleural cavity diffusely more often than as a localized mass. According to
WHO histological classification of tumors of the pleura, diffuse MM is classified into four types;
epithelioid, sarcomatoid, desmoplastic, and biphasic mesothelioma. Epithelioid mesothelioma
(MPM of epithelial type) is most common, and better prognosis has been reported for patients
with MPM of epithelial type than those with MPM of other types. An extrapleural
pneumonectomy (EPP), considered to be a curative intent surgery for MPM, is characterized by
stripping of the affected parietal pleura from the endothoracic fascia of the chest wall and en bloc
removal of the affected parietal pleura and lung. To establish radical cure of MPM, it is therefore
indispensable to find earlystage MPM of epithelial type, in which mesothelial proliferation is
localized on the serosal surface of parietal pleura. Morphological discrimination between MPM
7
of epithelial type and reactive mesothelial hyperplasia (RMH) is difficult, and the most reliable
pathological criterion for malignancy is mesothelial proliferation invading deeply into subpleural
adipose tissues.
When a patient presents with an undiagnosed pleural effusion, thoracentesis is generally the first
intervention performed. If no definite cancer cells are apparent in the fluid and no alternative
cause for the effusion can be found then thoracoscopy with biopsy will be considered if
malignancy is a significant possibility.
However, in some patients with significant underlying comorbidities and/or frailty in whom
thoracoscopy is considered too high risk, or where thoracoscopy is not available, or declined by
the patient, measurement of serum and pleural effusion mesothelin levels is a useful step – a
positive result dramatically increases the likelihood of there being a pleural malignancy present.
Although soluble mesothelin has a useful clinical role in diagnosis because of its high specificity,
its sensitivity remains limited. That means that a positive result is informative, but a negative one
is not. A better biomarker for pleural malignant mesothelioma has yet to be identified.
REFERENCES
1. Lamia H. Shabaan et al. Value of thoracoscopic pleural brush in the diagnosis of exudative
pleural effusion. Egyptian Journal of Chest Diseases and Tuberculosis (2012) 61, 385–389
2. Georgia Karpathiou et al. Pleural neoplastic pathology. Respiratory Medicine (2015) xx,
1e13
3. Henderson DW, et al. Challenges and controversies in the diagnosis of mesothelioma: Part 1.
Cytology-only diagnosis, biopsies, immunohistochemistry, discrimination between
mesothelioma and reactive mesothelial hyperplasia, and biomarkers. J Clin Pathol
2013;66:847–853
4. Henderson DW, et al. Challenges and controversies in the diagnosis of malignant
mesothelioma: Part 2. Malignant mesothelioma subtypes, pleural synovial sarcoma,
molecular and prognostic aspects of mesothelioma, BAP1, aquaporin-1 and microRNA. J
Clin Pathol 2013;66:854–861
5. Philip T. Cagle et al. Pathology of the pleura: What the pulmonologists need to know
Respirology (2011) 16, 430–438
6. Tohru Tsujimura et al. Pathological and molecular biological approaches to early
mesothelioma. Int J Clin Oncol (2012) 17:40–47
7. Aur_elien de Reynies et al. Molecular Classification of Malignant Pleural Mesothelioma:
Identification of a Poor Prognosis Subgroup Linked to the Epithelial-to-Mesenchymal
Transition. Clin Cancer Res; 20(5) March 1, 2014
8. P. M. Cury et al. The use of histological and mmunohistochemical markers to distinguish
pleural malignant mesothelioma and in situ mesothelioma from reactive mesothelial
hyperplasia and reactive pleural fibrosis. J. Pathol. 189: 251–257 (1999)
9. Mark R. Wick et al. Immunohistochemical differential diagnosis of pleural effusions, with
emphasis on malignant mesothelioma. Current Opinion in Pulmonary Medicine 2001,
7:187–192
10. Jenette Creaney et al. Comparison of mesothelin and fibulin-3 in pleural fluid and serum as
markers in malignant Mesothelioma. Curr Opin Pulm Med 2015, 21:352–356
11. Shi Chen et al. The diagnostic value of survivin in malignant pleural effusion: A meta-
analysis. Clinica Chimica Acta 441 (2015) 142–147
12. Jenette Creaney et al. Pleural Fluid Mesothelin as an Adjunct to the Diagnosis of Pleural
Malignant Mesothelioma. Disease Markers Volume 2014
13. A.M. Egan et al. Malignant pleural effusion. Q J Med 2014; 107:179–184
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14. P. Korczynski et al. Diagnostic utility of pleural fluid and serum markers in differentiation
between malignant and non-malignant pleural effusions. Eur J Med Res (2009) 14 (Suppl.
IV): 128-133
15. C. Aleman et al., Differentiating between malignant and idiopathic pleural effusions: the
value of diagnostic procedures. Q J Med 2007; 100:351–359
EVALUATION
1. Please mark the incorrect answer
a. Malignant transudative effusions can occur in lung cancer with obstruction of the
mainstem bronchus
b. Blockade of lymphatic drainage may be invoked as one of the possible
pathogenetic mechanisms of malignant pleural effusion
c. Most of the pleural malignancies arise from tumor emboli to the visceral pleura,
with secondary seeding to the parietal pleura
d. Pleural fluid eosinophilia (> 10% eosinophils in the total nucleated
e. cell count) is always diagnostic of malignant pleural effusion
2. Please mark the correct answer
a. The yield from sending more than two separate pleural fluid specimens for
cytology is very low
b. In a MPE of unknown origin, a positive TTF-1 stain strongly suggests a primary
non-small-cell lung cancer
c. At least two mesothelial markers (e.g., calretinin, keratin 5/6, WT-1 protein)
should be used to identified epithelial mesothelioma
d. Mesothelin levels greater than 20 nM in effusions are highly suggestive of
malignancy, particularly of malignant mesothelioma
e. All the above
3. Please mark the correct answer
a. Sensitivity of mesothelin for mesothelioma has been improved by using additional
‘exclusion markers’, such as carcinoembryonic antigen
b. Survivin has been confirmed as a novel member of the inhibitor of apoptosis
protein (IAP) family
c. During tumorigenesis, Survivin expression is inversely correlated with apoptosis
inhibition but positively correlated with proliferation and angiogenesis
d. Survivin has been widely studied as a prognostic marker in NSCLC
e. All the above
4. Please mark a true statement regarding malignant mesothelioma diagnosis
a. Mesothelin pleural level has high sensitivity and specificity
b. Low mesothelin rules out a malignant effusion
c. Mesothelin level has low sensitivity and high specificity
d. All the above
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Malignant Pleural Effusion: which material for what disease
Sebastian Fernandez-Bussy, MD
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I have no real or perceived conflicts of interest that relate to this presentation:
Affiliation/Financial Interest Commercial Company
Grants/research support:
Honoraria or consultation fees:
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Stock shareholder:
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Other support/potential conflict of interest:
This event is accredited for CME credits by EBAP and EACCME and speakers are required to disclose their potential conflict of interest. The intent of this disclosure is not to prevent a speaker with a conflict of interest (any significant financial relationship a speaker has with manufacturers or providers of any commercial products or services relevant to the talk) from making a presentation, but rather to provide listeners with information on which they can make their own judgments. It remains for audience members to determine whether the speaker’s interests, or relationships may influence the presentation. The ERS does not view the existence of these interests or commitments as necessarily implying bias or decreasing the value of the speaker’s presentation. Drug or device advertisement is forbidden.
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“Tumor markers seem to be a promising alternative and have been proposed to aid in the differentiation of the PE etiology. These include carcinoembryonic antigen (CEA), cancer antigens: CA- 125, CA 15-3, CA 19-9, CA 72-4, cytokeratin fragments (CYFRA 21-1), neuron specific enolase (NSA), and squamous cell carcinoma antigen (SCCA). However, the clinical value of these markers is still unclear.”
Eur J Med Res (2009) 14(Suppl. IV): 128-133
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“Pleural fluid (mean volume 50 ml) and blood samplesfor tumor marker measurements were collectedduring the first thoracentesis. They were centrifuged at2000 rpm for 10 min and the supernatant was frozenat -20°C until assayed. Concentrations of CEA, CA-125, CYFRA 21-1, and NSE were measured usingelectrochemiluminescence immunoassays on RocheElecsys 1010 analyzer (Roche Diagnostics; Mannheim,Germany).”
Eur J Med Res (2009) 14(Suppl. IV): 128-133
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“The diagnostic utility was calculated for: 1) singletumor marker level in the pleural fluid (P) and serum(S); 2) single marker pleural fluid/serum level ratio(R); 3) a combination of four markers in the pleuralfluid and serum. In the last case, the result was considered positive when the level of at least two markers was higher than the respective marker cut-off value.”
Eur J Med Res (2009) 14(Suppl. IV): 128-133
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Eur J Med Res (2009) 14(Suppl. IV): 128-133
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Eur J Med Res (2009) 14(Suppl. IV): 128-13317
“The median pleural fluid concentrations of the investigatedtumor markers were significantly higher in malignant exudates compared with non-malignant effusions, with the exception of CA-125 which was similar. An analysis of the serum concentrations revealed comparable values of CA-125 and NSE in both groups, while the CEA and CYFRA 21-1 levels were significantly higher in malignant effusions. The pleuralfluid/serum concentration ratios were similar for all markers in both investigated groups, with the exception of CEA which was significantly higher in the malignant group.”
Eur J Med Res (2009) 14(Suppl. IV): 128-133
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Eur J Med Res (2009) 14(Suppl. IV): 128-133
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Eur J Med Res (2009) 14(Suppl. IV): 128-133
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“CEA in PE proved to be the marker with the highest diagnosticaccuracy. The area under curve (AUC) in the ROC analysis for this parameter was 0.83. Previous studies which included this marker revealed the following AUC values: 0.97; 0.84, and 0.72 [3, 9, 10]. The diagnostic accuracy for serum measurements in our study was lower and equaled to 0.65.”
Eur J Med Res (2009) 14(Suppl. IV): 128-133
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“CYFRA 21-1 is another marker with a high diagnosticyield, but contrary to the three other markersthe serum, rather than plural fluid, level of CYFRA21-1 shows a higher overall diagnostic accuracy.CYFRA 21-1, soluble fragments of cytokeratin 19, isexpressed by all histological types of lung cancer, especially by squamous lung cancer [12]. Similarly toCEA, increased levels of CYFRA 21-1 in the pleural fluid may result from impaired lymphatic drainage orcancer involvement of the pleura. In our study, theAUC for this marker in serum was 0.78.”
Eur J Med Res (2009) 14(Suppl. IV): 128-133
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“Studies in which lung cancer was the predominantcause of PE, revealed a higher diagnostic yield of thisparameter. Serum CYFRA 21-1 has been found usefulfor the diagnosis of lung cancer, particularly of thesquamous cell type. However, Dejsomritrutai et al [14]found that CYFRA 21-1 is a good marker also in apopulation of patients with PE caused by adenocarcinoma.These authors reported CYFRA 21-1 sensitivity of 81.5% and 74.1% in serum and the pleural fluid, respectively.The specificity of this marker was also high and reached as much as 97.1% for both serum and PE.”
Eur J Med Res (2009) 14(Suppl. IV): 128-133
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“We found a high sensitivity, but low diagnostic accuracy,for NSE. NSE is a known marker of small cellcarcinoma. The sensitivity of pleural fluid NSE concentration was as high as 94.4%, while for the serummeasurements it was 80.6%. However, the specificityof this marker was relatively low, thus the AUC reached 0.65 for pleural fluid and 0.62 for serum.”
Eur J Med Res (2009) 14(Suppl. IV): 128-133
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“CA-125 is particularly useful in detecting the recurrenceof ovarian cancer [15], although the marker isalso observed in malignancies of the endometrium,lung, breast, and gastrointestinal tract. In our patients,the accuracy of CA-125 measurement in PE andserum was 0.64 and 0.60, respectively.”
Eur J Med Res (2009) 14(Suppl. IV): 128-133
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“In the present study, a combination of four markers (CEA,CA-125, CYFRA 21-1, and NSE), with a cut-off for two or more markers, gave sensitivity and specificity of 91.7% and 86.8% for pleural measurements, 86.1% and 71.1% for serum, and 100% and 60.5% for the pleural fluid/ serum ratio, respectively. The AUC calculated from the ROC analysis achieved as much as 0.89, 0.82, and 0.88 for the pleural fluid, serum, and pleural fluid/serum ratio, respectively. It seems that the pleural fluid/serum marker ratio does not add anyessential clinical information. A meta-analysis by Lianget al [16] showed similar results with the combinationsof different tumor markers, e.g., the AUC for CEA/CA-125 was 0.86 and for CEA/ CYFRA 21-1 - 0.93.”
Eur J Med Res (2009) 14(Suppl. IV): 128-133
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Tuberc Respir Dis 2014;76:211-217
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Tuberc Respir Dis 2014;76:211-217
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“First, measurement of pleural CEA is likely to be a useful diagnostic tool for confirming MPE and is useful for the differential diagnosis between malignant pleural mesothelioma and metastatic lung cancer. A high level of pleural CEA seems to rule out malignant mesothelioma. Second, CA 15-3, CA 19-9, and CYFRA 21-1 are highly specific but insufficiently sensitive to diagnose MPE, and the combination of two or more tumor markers appears to increase the diagnostic sensitivity. Therefore, the results of tumor marker assays should be interpreted in parallel with clinical findings and with the results of conventional tests.”
Tuberc Respir Dis 2014;76:211-217
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“Vascular endothelial growth factor (VEGF) as a diagnostic biomarker of MPE because of the high levels of VEGF present in MPE14. VEGF is thought to be the key mediator in the formation of MPE via increased vascular permeability and vascular leakage of fluid. A recent meta-analysis based on 1,025 patients in 10 studies concluded that VEGF might play a role in the diagnosis of MPE, while its diagnostic value is not satisfactory (Table 2)15. Mesothelin and fibulin-3 in pleural effusion have also been introduced as potential new biomarkers to detect pleural mesothelioma at an earlier stage.”
Tuberc Respir Dis 2014;76:211-217
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“Twenty-one studies with a total of 2,861 cases were included in present meta-analysis. The sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR) and DOR of CA 15-3 in the diagnosis of MPE were 0.58 [95% confidence interval (CI), 0.56-0.61], 0.91 (95% CI, 0.90-0.93), 8.93 (95% CI, 4.45-17.93), 0.46 (95% CI, 0.37-0.56) and 24.89 (95% CI, 10.39-59.63), respectively. In addition, the area under the curve (AUC) was 0.84. In conclusion, due to the significantly high specificity of pleural CA 15-3 in detecting MPE, it may play a pivotal role in screening to identify patients who may benefit from further invasive pathologic examination, particularly in those presenting clinical manifestations of MPE but with negative cytological findings of the pleural fluid. However, ruling out MPE by testing CA15-3 alone is not recommended due to its limited sensitivity.” 44
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“The present meta-analysis suggested that the diagnostic value of CA 15-3 for MPE was far from perfection. Combining CA 15-3 with other markers may be an appropriate method for improving the diagnostic accuracy. The study by Romero et al found that the sensitivity and specificity of carcinoembryonic antigen combined with CA 15-3 in pleural fluid were 71% and 96%, respectively, which was better than testing CA 15-3 alone (15). Another study reported that the combination of thymidine kinase with CA 15-3 and procalcitonin appeared to be an optimal combination, nearly enabling differential diagnosing in all types of effusion”
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“The diagnosis of malignant pleural effusion (MPE) is often challengingbecause differentiating MPE from benign effusion can be difficultusing the currently available tools derived from thoracentesis; onlyapproximately 50–70% of patients with MPE can be diagnosed bycytological examination of the pleural fluids [1]. Therefore, varioustumor markers found in pleural effusions, including carcinoembryonicantigen (CEA), Cyfra 21-1, CA125, CA19-9, neuron-specific enolase, andsquamous cell carcinoma antigen, have been investigated for their abilityto differentiate malignant from benign pleural effusions [5–7]. However,the sensitivity of these tests is relatively low, and false-positive resultshave been described in almost all series. Thus, it is necessary to identifyand evaluate more sensitive biological markers for MPE diagnosis [8].The ideal marker would be office-based, rapid, and inexpensive andwould have high sensitivity and specificity in the target population; thismight reduce the burden and expense of frequent biopsies of the pleura.”
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“Background: Survivin in pleural effusion is a promising marker for the diagnosis of malignant pleural effusion.Methods: Based on the principles and methods of Cochrane systematic reviews, PubMed, EMBASE, Web of Knowledge (ISI), the Cochrane Library, and China National Knowledge Infrastructure (CNKI) databases were searched to identify studies that assessed the diagnostic value of survivin in pleural effusion for malignant pleural effusion. Stata 12 and Meta-disc 1.4 software were used to test the heterogeneity and to perform the meta-analysis.Results: Our search returned 167 articles, ofwhich ten fulfilled the inclusion criteria. These studies included a total of 614 patients with malignant pleural effusion and 430 patients with benign pleural effusion as controls. The summary assessments revealed that the pooled sensitivity was 0.86 (95% CI: 0.82 0.88) and the pooled specificity was 0.92 (95% CI: 0.89–0.94). The positive likelihood ratio was 8.76 (95% CI: 5.41–14.20), the negative likelihood ratio was 0.16 (95% CI: 0.13–0. 20) and the diagnostic odds ratio (DOR) was 59.72 (95% CI: 39.60–90.05). The area under the curve (AUC) for the pleural effusion survivin tests was 0.9485, and the *Q index estimatefor these tests was 0.8885.Conclusions: Survivin in pleural effusion has potential diagnostic value with advanced sensitivity and specificity and it can be used as adjunct tool for non-invasive diagnosis of malignant pleural effusion.”
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“Survivin is a 12-amino acid protein (16.5 kDa) that islocated at chromosomal region 17q25. Survivin is an inhibitor of programmed cell death and mediates the suppression of apoptosis byinhibiting caspases 3 and 7, the terminal effectors in apoptotic protease cascades [10]. The survivinpromoter is highly active in human tumorcells, but not in normal cells, and is up-regulated by hypoxia in tumors [11]. It is undetectable in normal differentiated tissues but is notably expressed in patients with lung cancer, breast cancer, bladder cancer, multiple myeloma, and lymphoma.”
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Measurements. Pleural effusion samples were collected prospectively from 1331 consecutive patients. Mesothelin levels were determined by commercial ELISA in effusions and their relationship to concurrent pathology reporting and final clinical diagnosis was determined. Results. 2156 pleural effusion samples from1331 individuals were analysed.The final clinical diagnosis was 183 MM,436 non-MM malignancy, and 712 nonmalignant effusions. Effusion mesothelinhad a sensitivity of 67% forMM at 95% specificity.Mesothelin was elevated in over 47% of MM cases in effusions obtained before definitive diagnosis of MM was established. In the setting of inconclusive effusion cytology, effusion mesothelin had a positive predictive value of 79% for MM and 94% for malignancy.Conclusions. A mesothelin-positive pleural effusion, irrespective of the identification of malignant cells, indicates the likely presenceof malignancy and adds weight to the clinical rationale for further investigation to establish a malignant diagnosis.
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Purpose of reviewMalignant mesothelioma is an asbestos-induced, aggressive tumour, which frequently presents with pleural effusion. There are over 60 reported causes that can result in the development of a pleural effusion.Currently, there are no tumour biomarkers in widespread clinical use for the differential diagnosis of mesothelioma from other diseases. With the incidence of mesothelioma expected to continue to increase, it is timely to review the current status of effusion-based biomarkers for mesothelioma diagnosis.Recent findingsThe majority of recent studies have evaluated soluble mesothelin in effusions in a diagnostic setting for mesothelioma. However, at high specificity, the sensitivity of the assay is limited to approximately 60% at the time of diagnosis. There is considerable research effort directed toward the identification of new markers for mesothelioma through a variety of genomic, proteomic and immunomic based platforms. One of the few new biomarkers to be identified through a biomarker discovery pipeline and evaluated in pleural effusions is fibulin-3. Preliminary results on the diagnostic accuracy of fibulin-3 have been inconsistent.SummaryTo date, soluble mesothelin remains the best available biomarker for mesothelioma and a positive result is clinically useful in patients with pleural effusions in whom the diagnosis is uncertain.
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At a histopathologic level, there are essentially four circumstances in which immunophenotypic study plays animportant role in the recognition of mesothelioma.
(1) Mesothelioma versus adenocarcinoma
(2) Sarcomatoid mesothelioma versus primary or metastaticpleural sarcoma versus metastatic sarcomatoidCarcinoma
(3) Mesothelioma versus reactive mesothelial hyperplasia
(4) Desmoplastic sarcomatoid mesothelioma versus fibrouspleuritis
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Each of the above-cited diagnostic questions requires a different panel of immunohistochemical reagents. In cases of suspected spindle-cell or desmoplastic mesothelioma, these should include antibodies to keratin and calretinin; other markers are necessary only to subtypetruly mesenchymal keratin-negative neoplasms.
Recently, antibodies to cytokeratins 5/6 have beenadvocated as contextually specific markers for mesothelioma. Ordoñezfound that 40 cases of mesothelioma were positive for keratins 5/6, whereas adenocarcinomas of the lung were negative. Nevertheless, the selected analyses have also found that 11 to 14% of nonpulmonary adenocarcinomas show focal reactivity for cytokeratins 5/6.
Cytokeratins 7, 8, 18, and 19 are seen in all mesotheliomas and adenocarcinomas, whereas cytokeratins 5, 6, 14, and 17 are observed in some mesotheliomas but not adenocarcinomas. Unfortunately, the latter markers are absent in sarcomatoid tumors.
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Carcinoembryonic antigen: Virtually all pleural mesotheliomas lack CEA, whereas the vast majority of pulmonary adenocarcinomas expressthat marker.
CD15 has a high level of specificity for adenocarcinomaamong all epithelial tumors. Nevertheless, occasional mesotheliomas (usually primary peritoneal lesions) may show focal staining for this marker.
B72.3This antibody recognizes a widely distributed epithelial determinant (tumor-associated glycoprotein-72), which is a cell-membrane glycoprotein. Irrespective of their sites of origin, a majority of adenocarcinomas show reactivity with B72.3.
Ber-EP4 is another generic epithelial marker that was originally thought to be specific for adenocarcinomas. It is now apparent that roughly 20%of mesotheliomas demonstrate Ber-EP4 reactivity as well.
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Calretinin is a cytoplasmic and nuclear calcium-binding protein. In contrast to most antibodies used for the evaluation of possible mesotheliomas, labeling for calretinin represents positive support for that diagnosis. This marker is present in more than 85% of mesotheliomas of the epithelial type.
The authors’ own experience is that the majority of sarcomatoid lesions are, in fact, positive for calretinin.
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Aquaporin-1 (AQP1) is a molecule involved in the growth of MM cells, and yetis a factor reported to correlate with improved survival rates for MM with an epithelioid component, in comparison to AQP1-poor MM, as assessed from AQP1 expression by epithelioid MM cells only (apart from co-expression by stromal endothelial cells in addition to the tumour cells).
Prognostic factors for MM include not only the histological subtypes, butother independent variables that include (among others), AQP1 expression by mesothelioma cells, the clinical status of the patient, the serum neutrophil:lymphocyte ratio and blood thrombocytosis
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Mesothelial Hyperplasia VsEpitheliod Mesothelioma
Husain A., et al., Arch Pathol Lab Med 2013;137:647-66777
Epitheliod Mesothelioma VsLung AdenoCa
Husain A., et al., Arch Pathol Lab Med 2013;137:647-66778
Sarcomatoid Mesothelioma VsSCC and TCC
Scherpereel A, et al. Eur Respir J 2010;35:479-95
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Fibrous Pleurisy vs SarcomatoidMesothelioma
Husain A., et al., Arch Pathol Lab Med 2013;137:647-667
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Benign Vs Malignant
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How to send your material to pathology
Prof. Dr Philipp A. Schnabel
Instit. Alllgemeine&Spezielle Pathologie
University of Saarlandes
66421 Homburg/Saar
GERMANY
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Interpretation of the results in the clinic
Prof. Arnaud Scherpereel
Pulmonary and Thoracic Oncology Department
Hôpital Calmette – University Hospital of Lille (France)
INSERM Unit 1019 – Pasteur Institute of Lille
2 Avenue Oscar Lambret
59037 Lille
FRANCE
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MALIGNANT PLEURAL EFFUSION
MANAGEMENT
Pr Arnaud SCHERPEREEL
Pulmonary and Thoracic Oncology Department
Hôpital Calmette – University Hospital of Lille (France)
INSERM Unit 1019 – Pasteur Institute of Lille
ERS 2015 Congress – Amsterdam (Netherlands)PG 10 Session : Malignant pleural effusion
management : From standard cytopathologyto molecular biology
Saturday, 26 September 2015
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Financial disclosures
I have no conflict of interest for this
lecture
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Let’s talk about…
Pathogenesis, Diagnosis and Management of:
Malignant pleural effusions (MPE), pleural
metastases and malignant pleural
mesothelioma (MPM)
*Ref: chapter “Pleural and chest wall tumours”A Scherpereel. ERS Handbook 2012
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Pleural Malignancies
Clinical presentation = usually pleural effusion
Malignant pleural effusion (MPE) found in 6% of cancers
history; reveals the cancer in half cases
But in necropsy series: pleural effusion is only found in
half of pleural tumors
Dyspnea: most frequent symptom; other NON specific
signs: cough, chest pain, asthenia and weight loss…,
more rarely fever, pneumothorax
Light RW & Lee YCG. Textbook of Pleural Disease, 2nd ed 200887
Malignant pleural effusion (MPE)
200 000 patients / year in the USA; incidence:
- Breast Cancer: 1 /3
- Lung Cancer: 1 /4 (most common etiology
>40% of cases)
- MPM: 95% (unilateral+++)
Lung, breast, ovary and gut cancers and
lymphoma = 80% of MPE
Primitive malignancy: not found in 10% of
cases
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Pathogenesis of malignant pleura
Still partly unknown…
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Pleural tumor involvement may result from
different mechanisms:
1. A blood dissemination or more often from tumor emboli
to the visceral pleura with secondary seeding to the parietal
pleura (main mechanism for lung cancer)
2. direct invasion from adjacent structures (lung, chest wall...)
by the tumor (lung or breast cancer)
3. Blood metastases to the parietal pleura from tumors other
than lung cancer
4. lymph vessels spreading
5. Effusion may be due to the pleural tumor lesions or to a
lymphatic blockade at the mediastinal level
Sahn SA. Malignant pleural effusions. Pleural diseases. Philadelphia : WB Saunders, 2004 : 411-38
Pathogenesis of malignant pleura
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Pathogenesis of malignant pleura (2)
MPE depend also on interactions between tumor cells
and mesothelial cells through growth factors such as
VEGF that increase vascular permeability and
angiogenesis.
Finally, MPE need several pathogenic factors such as:
Increase of capillaries permeability
Lesions of the lymphatic system draining the pleural
space (pores of Wang at the postero-basal parietal
pleura) or at the level of the thoracic channel
Pericardial involvement
Sahn SA. Malignant pleural effusions. Pleural diseases. Philadelphia : WB Saunders, 2004 : 411-38 91
Pathogenesis of malignant pleura (3)
CAUTION : a pleural effusion is NOT systematically
synonym of MPE in the context of tumor because it may
be induced by other mechanisms :
pneumonia and/or atelectasia due to bronchial obstruction
transudate induced by severe denutrition or cardiac failure
or even a drug (MTX, CPM…) or radiotherapy-induced
effusion (breast cancer+++) www.pneumotox.com
Therefore the strategy (diagnosis/ttt) may differ whether
the patient has a cancer background or not, but should
always rely on cytology or better on histology+++
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Prognosis of MPE and pleural metastases
Poor prognosis (one year MS = 13%)
However survival may greatly vary according to the
primary cancer: lung cancer << breast cancer or
lymphoma
New 2009 TNM staging of NSCLC: MPE (or pericardial
effusion) or pleural metastases = stage T4 (TNM 1997)
NOW STAGE M1a (IV)
Survival at 5 years of tumors cT4N0M0 by pleural
involvement =2% (similar to M1 patients) vs by other cause
= 25% (p = 0,0001)
Journal of Thoracic Oncology 2007; 2 : 593-71493
Malignant (Pleural) Mesothelioma
Very agressive tumor issued
from mesothelial cells mostly
of the pleura (MPM : 80% of the
cases)
Bad prognosis : median survival
= 9-12 months
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Diagnostic issues in malignant pleural diseases: a specific clinical profile ?
Pleural effusion +++
Pleural thickening
Pneumothorax (MPM,
underlying pulmonary disease…)
Non-specific signs: dyspnea, cough,
chest pain, asthenia and weight loss…
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Management of MPE and MPM
MPE: please refer to ERS Handbook
MPM: refer to ERS/ESTS Guidelines
Scherpereel et al, ERJ 2010(ongoing update by European Taskforce)
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Clinical and/or
radiological diagnosis of unilateral
Pleural Effusion: MPE?
Chest CT scanmandatory if no contralateral mediastinal shift on chest
Xray bronchoscopy if main bronchus stenosis is suspected: trapped lung?
Previous asbestos exposure? Clinical and/or radiological
suspicion of MPM
Proceed to MPM algorythm
Thoracocentesis for diagnosis and drainage
Small effusion, hemostasis disturbancies…
= relative contra-indications for
ultra-sound (US)-guided procedure
by trained physicians
Transudate: seak and treat cause oftransudate
Exsudate
Cytology: tumor cells ?
Previous diagnosis of
malignancy (lung, breast…)?
Light‘s
Criteria
NOYES
NO YES
If no argument
for tuberculosis,
infection…
Is pleural histology needed for diagnostic clarity ?Otherwise start treatment
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Chest CT scanmandatory if no contralateral mediastinal shift on chest Xray bronchoscopy if main bronchus stenosis is suspected:
trapped lung?
CT scan or US -guided transthoracic biopsies
Thoracoscopy
Mini-thoracotomyfor pleural biopsies
Histological proof
of pleural metastases
Contra-indicationsThoracoscopy
Pleural symphysisSurgery at risk
Treatment of the primary cancer(chemotherapy and/or hormone therapy
and best supportive care (BSC)...)
Pleurodesis (Talc poudrage…)also if reccurent pleural effusion;
alternatives: talc slurry, undwelled catheter…
In the sametime if largeeffusion ANDbulky tumor lesions of thepleura
Blind pleural biopies if
suspicion of tuberculosis?!
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Medical Thoracoscopy or VATS: Gold standard diagnostic procedure
Sensitivity : 95%
Specificity : 100%
Complications (non lethal) : < 10%
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MPE aspect in thoracoscopy
(Source : Pr A. Scherpereel and Dr Ph. Ramon)
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Thank youfor your attention
Welcome to join the European Respiratory
Society group on Pleural and Mediastinal
malignancies (11.2) of the Thoracic
Oncology Assembly (N°11) +++ !
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Atypical mesothelial hyperplasia and other pitfalls in MPE diagnosis
Prof. Françoise Galateau-Salle
Centre Leon Bérard Lyon
University Hospital Caen
Avenue de la Côte de Nacre
Cedex 05, 14033 Caen
FRANCE
SUMMARY
Atypical mesothelial hyperplasia happens in response to a great variety of benign or malignant processes
including infectious pleuritis, pneumothorax, underlying pneumonia, connective tissue diseases
(rheumatoid arthritis and systemic lupus erythematosus), pulmonary embolism, drug reactions, and asbestos
associated effusions or in association with underlying bronchopulmonary carcinoma. Moreover, exudative
pleural effusion in most cases is the initial symptom revealing a mesothelioma or a metastasis as the
presenting site of another cancer. According to the literature 50% of patients with a metastatic disease
develop pleural effusion and 75% of them are symptomatic. In the majority of the case the primary site is
found with in order of frequency from Antunes et al (1, 2): lung, breast, ovarian, lymphoma, GI, GU tract,
mesothelioma. In 10% of the cases the primary site remains unknown (2). It also may represent a
precancerous step or the early phase of a malignant mesothelioma. Consequently, the separation between
benign mesothelial superficial proliferation and a malignant mesothelioma in a patient with a unilateral
pleural effusion is crucial for the patient care and is extremely challenging for both clinician and pathologist.
On the pathologist side, a first look on cell morphology, raise several questions; is the sample significant
enough for an accurate diagnosis???, Is the process malignant??? Then when the process looks malignant,
the followed questions; is the lesion a malignant mesothelioma or another tumor mimicking a
mesothelioma. Carcinoma may superficially metastases to the surface of the pleura closely mimicking a
malignant mesothelioma. It is well known that sarcomatoid mesothelioma and other spindle cell tumors
located to the pleura do not peel in the pleural cavity. This course will focus on epithelioid mesothelioma.
Indeed, the diagnostic approach in these situations is dependent on the clinical presentation and on the
material sent to the pathology lab.
1. The separation between benign mesothelial proliferations on routine biopsies has been largely
described by Churg et al(3-6), and new updates were described in the 2015 WHO classification. Two
major scenarios can arise for the pathologist:
a. The lesion appears on cytology or tissue biopsy specimens of epithelial/epithelioid type the
question is this?
i. A reactive mesothelial hyperplasia mimicking a malignant process.
ii. If malignant; is the lesion a malignant mesothelioma, a metastasis of a carcinoma/ or of a
melanoma.
iii. Or a so-called well differentiated superficial papillary mesothelioma (rare mésothéliale
tumor of uncertain behavior).
b. The lesion is morphologically a spindle cells/fibroblastic proliferation (spindle cells do not peel
in the serosal cavity) on tissue biopsy is this?
i. A reactive cellular diffuse proliferation (chronic fibrous pleuritis)
ii. A rare fibromatois desmoid invading the pleura
iii. If malignant; is the lesion a sarcomatoid/desmoplastic mesothelioma versus a metastasis of
a sarcomatoid carcinoma or a sarcoma?
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2. The lesion looks malignant the issue to reach a diagnosis;iscytology orcore tissue biopsy or open
surgical biopsy the best approach??
3. Facing these situations,
1. the clinical presentation can help the pathologist in separating a metastasis versus a
mesothelioma
2. What are the important elements brought by every practitioner for a quality and safe diagnosis?
3. What is the role in 2015 of ancillary techniques to solve the problem of the separation benign
from malignant?
4. How can we avoid pitfalls??
Nowadays, even if pathologists better know how to recognize a malignant mesothelioma on morphology
or a metastasis in many casesto separate benign versus malignant mesothelial proliferation in a significant
proportion of cases may be extremely challenging. The role of this course is to consider the management
of pleural effusion from standard cytopathology to molecular biology and to evaluate if the transition, in
2015, is real in routine practice.
The diagnostic approach
Pathologist side: When confronted with a pleural process for cytological or histological diagnosis it is
essential for the pathologist to know as much as possible of the clinical and radiologic information when
they are available. For example it is important for the pathologist to know if it is a free floating pleural
effusion without thickening and nodularity (could be a WDPM) or if it is a diffuse process (diffuse pleural
thickening with or without nodularity) could be a connective tissue disease or a malignant mesothelioma
desmoplastic type, or a mass located in the lung or in the thoracic wall (Sarcomatoid carcinoma versus
localized sarcomatoid mesothelioma). It is also important to know the age and the sex of the patient, the
context of previous history of cancer, due to secondary tumors affecting the serosal cavities that can be
great mimickers of mesothelioma and force to check the expression of organ specific markers for the
differential diagnosis (ie ER receptors in women to detect breast metastasis).
Clinician side: The technique of the pleural effusion aspiration is crucial and determines the quality of the
pre-analytical phase, but is mainly dependent on the clinical presentation, the comorbidities, the experience
of the clinician. In the majority of the cases pleural aspiration is the initial step to relieve the patient from
dyspnea. The sample should be sent as soon as possible to the pathology lab to avoid autolysis.
Unfortunately due to undiagnosed exudative pleural effusion pleuralbiopsy is necessary. In 2015,
thoracoscopy and CT-guided core biopsy have a quite similar diagnostic yield for the diagnosis of a
malignant diseases including mesothelioma with a reported sensitivity of 76-88% and up to 100%
specificity depending of the authors’ series (1, 2). In order to help, the quality of cytopathological
examination, if a biopsy is taken or cell blocks made, the sample should be fixed immediately and preserve
in formalin 5%. It is also important to avoid acid fixative (AFA and others new fixatives) as it is responsible
of absence of signal by FISH analysis. Even though, an open surgical biopsy is a better material for the
accurate diagnosis of subtyping mesothelioma 83% versus 74% on VATS and 44 % with CT-guided biopsy
(8, 9).
On the pathologist side
Cytology samples are the initial and major step to approach the diagnosis of a pleural effusion. The
cytologist, without major difficulties, recognizes malignant effusions and many studies have shown that
malignant effusions are diagnosed in nearly 60 % by cytological examination alone, but drop down to 30%
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for a diagnosis of mesothelioma. Recently some authors showed high specificity for the diagnosis of
mesothelioma, but with the limitation depending on the experience of the cytologist. Paintal et al, and
Henderson et al (8-10), have reported the update sensitivity of pleural effusion cytology, which is reported
from 16% to 75%, and reported lower when lesions are suspicious for malignancy.
The major reason to not use cytology alone is even if it is workable in highly cellular pleural effusion for
epithelioid type, the deceptively bland appearance of malignant mesothelioma is a cause of misdiagnosis,
while reactive mesothelial proliferation may show severe atypia and invasion of adipose tissue on biopsy
remains the definitive criteria for malignancy. In 2015 the criteria for distinguishing diffuse malignant
mesothelioma from reactive mesothelial proliferations have been further redefined by Churg, and Galateau
Salle et al (3-6).
From standard cytopathology to molecular biology. Can we improve the diagnosis of
malignancy on cytology and tissue biopsy samples?
Updates on ancillary techniques have been extensively described in the new 2015 WHO classification. Up
to now a great variety of immunohistochemical markers have shown various level of sensitivity and
specificity. Among them the most famous are EMA (epithelial membrane antigen, desmin, p53 the well-
known tumor suppressor gene, but largely not mutated in mesotheliomas, IMP3 (the Insulin – like growth
factor 2 messenger RNA-binding protein 3), GLUT1 (Glucose transporter 1), ki67(3,5). For all of them, the
authors claimed that positive staining were not observed on benign reactive mesothelial cells compared to
malignant mesothelioma with statistically significant results. From our experience in a large cohort of 18
000 cases. The studies were statistically valuable but individually not reliable due to staining observed in
benign reactions.
Two new molecular makers have recently emerged and have demonstrated their usefulness in the separation
of benign mesothelial hyperplasia versus diffuse malignant mesothelioma (4-6).
1. p16 is a tumor suppressor gene. p 16 INK4A (p16) have been reported to be deleted in 60 to 80% of
diffuse epithelioid malignant mesothelioma (7) and in nearly 100% of sarcomatoid and desmoplastic
malignant mesothelioma. Moreover, p16 deletion has been shown to be correlated with a more
aggressive clinical course. p16 homozygous deletion is detected by fluorescence in situ hybridization
both on cytological and paraffin embedded tissue biopsy samples and has been considered as a robust
marker in separating benign from malignant mesothelial proliferation) (5,6,7). p16 homologous
deletion by FISH in more than 200 reported benign atypical mesothelial proliferations reported in the
literature have never been observed. p16 immunohistochemical stain does not give the same results
and are notup to now reliable. From our MESOPATH experience 20 % of AMH suspicious for
malignancy with a p16 homozygous deletion by FISH have turn up in a malignant mesothelioma after
5 to 9 years.
2. BAP-1, the BRCA associated protein 1 is a nuclear ubiquitin hydrolase that is expected to function as
a tumor suppressor gene. BAP 1 controls DNA repair and cell cycle proliferation. Bott et al, were the
first authors to describe the presence of somatic mutations in malignant mesothelioma followed by
Testa et al, who showed the presence of germ line mutations in several families. The concept of BAP1
associated cancer syndrome has emerged soon after showing an increased number of mesothelioma
with ocular and cutaneous melanoma, renal cell and breast carcinoma and others.BAP1 loss is
evaluated by immunohistochemistry and is now routinely used on FFPE tissue biopsy samples, and
more recently has been reported to be useful on cell-block sections by immunohistochemistry (9).
BAP1 somatic mutations are observed in around 30% of mesothelioma, more often in epithelioid type
than in biphasic and sarcomatoid mesothelioma. From our MESOPATH and Churg et al (3, 5, 6),
experience BAP1 loss has never been reported in reactive mesothelial proliferation.
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Examples of routine practice situations
The challenging separation of benign versus malignant lesions.
Taking into account the constraints of technical approaches, there are nowadays major advances in the
characterization of atypical mesothelial hyperplasia and mimickers of mesothelioma.
A- Superficial mesothelial proliferation benign reactive process versus epithelioid malignant mesothelioma
.
1. The sample on cytology (highly cellular atypical mesothelial hyperplasia) or on tissue biopsy shows
an atypicalmesothelialproliferation, loss of BAP1 by immunohistochemistryand or/a deletion of
p16present in the definitive clinical, radiological and thoracoscopic context of a tumor some authors
consider that this is a definitive malignant mesothelioma and represents either 1) the superficial pleural
extension of a definitive invasive mesothelioma or 2) an early mesothelioma.
2. The atypical mesothelial hyperplasia is associated with a deletion of p16 but there is no definitive
clinical, radiological, thoracoscopic context of tumor, a diagnosis of mesothelioma could not be
validated. This can represent sampling error and it is recommended if possible to rebiopsy, or it also
can represent a ‘’precancerous state’’ the mesothelioma can develop 1 to 9 years later. In this situation
a close clinical follow up is recommended and if a context of asbestos exposure is present a CT -scan
follow up is considered. If the PET scan shows a hyperfixation a new biopsy if possible for the patient
is considered and the pathologist should blocked in totality the samples.
3. The samples shows an atypical mesothelial proliferation and no deletion of p16 is observed in the
clinical, radiological context of uncertain tumor. A clinical follow up is only recommended.
4. On the other hand, a strong clinical, and radiological context of mesothelioma is present; the absence
of p16 deletion did not eliminate a diagnosis of mesothelioma. p16 deletion is present in 60 to 80% of
epithelioid malignant mesothelioma and in 80 to 100% of sarcomatoid mesothelioma. In this situation
it is recommended to rebiopsy.
5. Up to now loss of BAP1 has not been observed in reactive mesothelial superficial proliferation and
benign processes. Loss of BAP1 is a very promising marker with a high specificity (from our
experience 0/23) to detect malignancy.
6. The nuclear staining of BAP1 is present this result did not means the lesion is a benign process. BAP1
loss on tissue biopsy is observed according to series in around 30 to 40% of malignant mesothelioma
when all histological type are considered.
7. Recommended scheme from Churg et al
B- The other challenging situations are the separation between well differentiated papillary mesothelioma
and a reactive superficial mesothelial proliferation or with a more challenging conventional papillary
mesothelioma with areas of WPM. WDPMis now well-defined and represents a distinct mesothelial tumor
of uncertain behavior (ICD-0 9052/1) (3, 11). Clinically the presentation is a free floating pleural effusions
without pleural thickening or nodularity. The tumor is usually not related to asbestos exposure. It may affect
all serosal cavities with a predilection for peritoneum more frequently in women. Histologically it is
characterized by a superficial spreading of papillary structures with myxoid vascular cores lined by bland
mesothelial cells. These lesions have an indolent clinical outcome and when a minimal invasion is observed,
in rare patient, they may recur but no fatal outcomes have been observed. p16 deletion and BAP1 have not
been extensively studied on this specific entity and they are no guidelines up to now published. Adequate
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sampling of the lesion, and clinical correlation are required to avoid the diagnosis of an undersampled
malignant mesothelioma mimicking a WDPM (3, 11).
C- The last challenging situation is the separation between metastatic carcinoma and mesothelioma. A huge
number of immunohistochemical markers have been published since the last 2004 WHO classification and
the 2015 classification has particularly covered this topic giving recommendations for the management of
the patient samples. Nevertheless some situations may be challenging due to metastatic adenocarcinoma
that are clinically and pathologically great mimickers of mesothelioma. Breast and lung carcinoma the
major causes of pleural metastasis are among them. Calretinin the more sensitive and specific marker for
mesothelioma may be positive in both tumors. 38% of triple negative breast carcinoma expresses calretinin
with a nuclear staining (12). p40 nuclear expression is a marker of squamous differentiation and has never
been observed positive in sarcomatoid/pleomorphic mesothelioma (MESOPATH unpublished data).
Moreover, TTF1 positivity is a highly specific marker in favor of a lung origin (30% of the cases of
pleomorphic/sarcomatoid carcinoma), andmay avoida misdiagnosis of malignant mesothelioma (3).
Conclusion
On the past decades and more recently in 2015, many advances have been made for the management of
atypical mesothelial hyperplasia versus malignant mesothelioma and other pitfalls in MPE that have
promising hopes in clinical practice. These include morphological criteria, the use of BAP1
immunohistochemical stains and p16 homozygous deletion by FISH both on cellblocks and FFPE tissue
samples. These are important step forwards in the future role of cytopathological diagnosis in effusions of
malignant mesothelioma. However, BAP1 and p16 deletion can be observed in metastatic tumor from other
organs and are not, on their own diagnostic, of mesothelioma.
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Management of a malignant pleural effusion: British ThoracicSociety Pleural Disease Guideline 2010.
Thorax. 2010 Aug; 65 Suppl 2:ii32-40.
3. Galateau-Salle F, Churg A, Roggli V, et al. Epithelioid mesothelioma. In Travis WD, Brambilla E,
Burke AP, Marx A, Nicholson AG eds. WHO Classification of Tumours of the Lung, Pleura, Thymus
and Heart. 4 th ed Lyon, France. IARC Press. 2015:156-164.
4. Churg A, Galateau-Salle F. The separation of benign and malignant mesothelial proliferations. Arch
Pathol Lab Med. 2012:136 (10):1217-1226.
5. Churg A, Sheffield BS, Galateau-Salle F. New Markers for Separating BenignFrom Malignant
Mesothelial Proliferations: Are We There Yet? Arch Pathol Lab Med.2015 Aug 19.
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immunohistochemistry and p16 FISH to separate benign from malignantmesothelial proliferations.
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development for the detection of p16/CDKN2A deletion in malignant pleural mesothelioma. J Clin
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EVALUATION
1. Mesothelioma can accurately be diagnosed on cytology specimens alone without ancillary techniques
a. yes
b. no
2. The sensitivity of cytological diagnosis on pleural aspiration in mesothelioma is upgraded with
immunohistochemistry
a. yes
b. no
3. BAP1 loss by immunohistochemistry on FFPE cell blocks and tissue biopsy samples is a robust marker
of malignant mesothelioma versus benign reactive mesothelial proliferation
a. yes
b. no
4. p16 homozygous deletion in pleural effusion observed by FISH assay may be encountered in benign
reactive superficial mesothelial proliferation
a. yes
b. no
5. P16 loss by immunohistochemistry on cell blocks and FFPE biopsy tissue samples is a robust marker
of malignancy for the diagnosis of mesothelioma
a. yes
b. no
6. Calretinin positivity by immunohistochemistry on pleural cytoblocks or FFPE tissue biopsy samples
can be observed in mesothelioma and other metastatic carcinoma such as metastatic breast carcinoma.
a. yes
b. no
107
Faculty disclosures
Prof. Philippe Astoul was leading courses for which the materials or equipment was provided by:
Novatech (Material for thoracoscopy course), Wolf (telescope for hands-on session during
thoracoscopy course) and Sebac (IPC for practical sessions during course). He is also a Scientific
Board Adviser for Sequana.
108
Faculty contact information
Prof. Philippe Astoul
Department of Thoracic Oncology,
Pleural Diseases, and Interventional Pulmonology
Hôpital Nord
Chemin des Bourrely, cedex 20
13326 Marseille
FRANCE
Dr Sebastian Fernandez Bussy
Clinica Alemana-Universidad del Desarrollo
Interventional Pulmonology
Av Vitacura 5951
Santiago, Región Metropolitana
CHILE
Prof. Françoise Galateau-Salle
Centre Leon Bérard Lyon
University Hospital Caen
Avenue de la Côte de Nacre
Cedex 05, 14033 Caen
FRANCE
Prof. Arnaud Scherpereel
Pulmonary and Thoracic Oncology
Department
Hôpital Calmette – University Hospital of
Lille (France)
INSERM Unit 1019 – Pasteur Institute of Lille
2 Avenue Oscar Lambret
59037 Lille
FRANCE
Prof. Dr Philipp A. Schnabel
Instit. Alllgemeine&Spezielle Pathologie
University of Saarlandes
66421 Homburg/Saar
GERMANY
Dr Marcin Skrzypski
Department of Oncology and Radiotherapy
Medical University of Gdansk
ul. Debinki 7
80-211 Gdansk
POLAND
109
Answers to evaluation questions
Please find all correct answers in bold below
Malignant Pleural Effusion - Dr Sebastian Fernandez Bussy
1. Please mark the incorrect answer
a. Malignant transudative effusions can occur in lung cancer with obstruction of the mainstem
bronchus
b. Blockade of lymphatic drainage may be invoked as one of the possible pathogenetic
mechanisms of malignant pleural effusion
c. Most of the pleural malignancies arise from tumor emboli to the visceral pleura, with
secondary seeding to the parietal pleura
d. Pleural fluid eosinophilia (> 10% eosinophils in the total nucleated
e. cell count) is always diagnostic of malignant pleural effusion
2. Please mark the correct answer
a. The yield from sending more than two separate pleural fluid specimens for cytology is very
low
b. In a MPE of unknown origin, a positive TTF-1 stain strongly suggests a primary non-small-
cell lung cancer
c. At least two mesothelial markers (e.g., calretinin, keratin 5/6, WT-1 protein) should be used to
identified epithelial mesothelioma
d. Mesothelin levels greater than 20 nM in effusions are highly suggestive of malignancy,
particularly of malignant mesothelioma
e. All the above
3. Please mark the correct answer
a. Sensitivity of mesothelin for mesothelioma has been improved by using additional ‘exclusion
markers’, such as carcinoembryonic antigen
b. Survivin has been confirmed as a novel member of the inhibitor of apoptosis protein (IAP)
family
c. During tumorigenesis, Survivin expression is inversely correlated with apoptosis inhibition but
positively correlated with proliferation and angiogenesis
d. Survivin has been widely studied as a prognostic marker in NSCLC
e. All the above
4. Please mark a true statement regarding malignant mesothelioma diagnosis
a. Mesothelin pleural level has high sensitivity and specificity
b. Low mesothelin rules out a malignant effusion
c. Mesothelin level has low sensitivity and high specificity
d. All the above
![Management of Malignant Pleural Effusion...Asymptomatic patients with either a malignant or a paramalignant effusion need not be treated initially [9]. Malignant pleural effusion will](https://img.pdfslide.net/doc/110x75/5f8bc67cd3c5026bc44819fe/management-of-malignant-pleural-effusion-asymptomatic-patients-with-either-a.jpg)
