• Journal of Chest Surgery
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• v.47 no.2
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• pp.124-128
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• 2014

Background: A closed pleural biopsy is commonly performed for diagnosing patients exhibiting pleural effusion if prior thoracentesis is not diagnostic. However, the diagnostic yield of such biopsies is unsatisfactory. Instead, a thoracoscopic pleural biopsy is more useful and less painful. Methods: We compared the diagnostic yield of needle thoracoscopic pleural biopsy performed under local anesthesia with that of closed pleural biopsy. Sixty-seven patients with pleural effusion were randomized into groups A and B. Group A patients were subjected to closed pleural biopsies, and group B patients were subjected to pleural biopsies performed using needle thoracoscopy under local anesthesia. Results: The diagnostic yields and complication rates of the two groups were compared. The diagnostic yield was 55.6% in group A and 93.5% in group B (p<0.05). Procedure-related complications developed in seven group A patients but not in any group B patients. Of the seven complications, five were pneumothorax and two were vasovagal syncope. Conclusion: Needle thoracoscopic pleural biopsy under local anesthesia is a simple and safe procedure that has a high diagnostic yield. This procedure is recommended as a useful diagnostic modality if prior thoracentesis is non-diagnostic.

• Tuberculosis and Respiratory Diseases
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• v.57 no.2
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• pp.138-142
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• 2004

Background : To evaluate exudative pleural fluid, thoracentesis for microbiological and cytological examination and pleural biopsy by using a Cope needle are traditionally performed. Even after these studies, about 20% of patients remain undiagnosed. We evaluated the diagnostic accuracy and complications of 2-mm minithoracoscopy instead of blind biopsy in patients with undiagnosed exudative pleural effusion. Method : Fifteen patients with exudative pleural effusion underwent thoracoscopy between April 2002 and August 2003. The indication was undiagnosed pleural effusions after having performed sputum and pleural fluid exami-nations both microbiologically and cytologically. Results : The median age of the patients was 56 years (range 21-77). Pleural effusions were lymphocyte-dominant in 11 patients (73.3%) and neutrophil-dominant in 3 (20.0%). The remaining patient (6.7%) had pleural-fluid eosinophilia. Minithoracoscopic biopsy revealed accurate diagnosis in 14 patients (93.3%), consisting of tuberculous pleurisy in 8 (66.7%), malignant effusions in 4 (33.3%), and parapneumonic effusions in 2 (13.3%). One was diagnosed as having paragonimiasis from thoracoscopic findings and clinical considerations. There was no procedure-associated mortality. There were six cases of new onset fever (40%) and one of pneumothorax (6.7 %). Conclusion : Two-millimeter minithoracoscopy, which is less invasive than conventional thoracoscopy, was an accurate and safe method for undiagnosed exudative pleural effusion.

• Tuberculosis and Respiratory Diseases
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• v.49 no.6
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• pp.733-739
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• 2000

Background : Pleural eosinophilia is rare and commonly considered to be an indicator of good prognosis. The diagnostic significance of eosinophilic pleural effusions remains controversial despite a century of observation and discussion. This study was conducted to assess the prevalence of eosinophilia in 446 consecutive samples of pleural fluid, to review the cause of eosinophilic pleural effusion and to determine whether the presence of eosinophils increases the likehood of benign conditions. Method : A retrospective analysis was performed upon patients that underwent first thoracentesis due to pleural effusion between January 1999 and December 1999. Results : Eosinophilic pleural effusions were identified in 24 of the 446 patients (5.4%). Malignancy, parapneumonic effusion and tuberculosis were determined the major causes of pleural effusion (80.6%). Malignancy was diagnosed as frequently in eosinophilic effusions as in non-eosinophilic effusions (54.2% vs 50.5%, p=0.725). No difference was found in the prevalence of eosinophilic and non-eosinophilic effusion according to the etiology. The mean blood eosinophil ratio in patients with eosinophilic pleural effusion was 5.4% and no significant correlation existed between the blood and pleural eosinophilic count. Conclusion : Pleural eosinophilia is not helpful for differentiating benign and malignant etiology and is not related with bood eosinophilia or repeated tapping.

• The Korean Journal of Nuclear Medicine
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• v.35 no.4
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• pp.291-292
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• 2001

We report a case of malignant pericardial effusion originated from adenocarcinoma of the lung incidentally diagnosed by bone scintigraphy, prior to echocardiographic detection. A 76 year-old man with adenocarcinoma of the lung underwent Tc-99m MDP bone scintigraphy to evaluate skeletal metastasis. Anterior images of the chest of the bone scintigraphy unexpectedly showed diffuse increased activity in the region of the heart surrounded by an oval-shaped band of increased activity corresponding to the periphery of the cardiac silhouette (Fig. 1). There was no evidence of bony metastasis. Pericardial effusion was confirmed by echocardiography (Fig. 2) and malignant cells were revealed by subsequent microscopic examination of the pericardial fluid. Bone scintigraphy using Tc-99m phosphate compounds is commonly used to detect bony metastasis in cancer patients. Tc-99m phosphate compounds occasionally accumulate in extra-osseous sites, including $pleural^{1,2)},\;pericardial^{3,4)},\;and\;ascitic\;fluids^{5,6)}$. It has been reported that their accumulation in serous effusions should strongly suggest $malignancy^{1-6)}$. The exact mechanism for accumulation of Tc-99m phosphate compounds in serous effusions is unclear. Several investigators have proposed that the radiopharmaceuticals exuded directly from peripheral vessels to the serous cavity due to increased vascularity and vascular permeability, and bleeding by disruption of blood vessels due to cancerous $infiltration^{5,6)}$.

• Tuberculosis and Respiratory Diseases
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• v.62 no.6
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• pp.499-505
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• 2007

Background: Triggering receptor expressed on myeloid cells 1 protein (TREM-1) is a cell surface molecule expressed on neutrophils and monocytes, and it plays an important role in myeloid cell-activated inflammatory response. The aim of this study was to investigate the diagnostic efficiency of soluble (s) TREM-1 in the patients who had pleural effusion from various causes. Methods: Forty-five patients with exudative pleural effusion were included in this study. The level of sTREM-1 was measured in both the serum and pleural fluids by immunoblot assay with using human-sTREM-1 antibody. Results: The pleural fluid sTREM-1 was significantly different in the three groups of exudative pleural effusion (p=0.011). Particularly, the patients with parapneumonic effusion were found to have significantly higher pleural fluid levels of sTREM-1 than patients with tuberculous (p<0.05) and malignant effusion, respectively (p<0.05). However, the serum sTREM-1 did not show a significant difference in the three groups. In order to evaluate the diagnostic utility of pleural fluid sTREM-1, the receiver operating characteristic (ROC) curve was constructed and the area under the curve (AUC) was 0.818 (p=0.001). Using a cutoff value of 103.5 pg/mL for the pleural fluid sTREM-1, the sensitivity and specificity were 73% and 81%, respectively, for differentiating parapneumonic effusion from tuberculous or malignant effusions. Conclusion: Pleural fluid sTREM-1 can be an additional marker for making the differential diagnosis of pleural effusion.

• Tuberculosis and Respiratory Diseases
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• v.59 no.2
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• pp.186-192
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• 2005

Background : Diagnosis of tuberculous pleurisy is sometimes difficult using conventional diagnostic methods. We have investigated the utility of pleural fluid cell $IFN-{\gamma}$ production assay in the diagnosis of tuberculous pleurisy. Methods : We prospectively performed pleural fluid cell $IFN-{\gamma}$ production assay in 39 patients with tuberculous pleural effusions (TPE) and in 26 patients with nontuberculous pleural effusions (NTPE) (13 malignant pleural effusions and 13 parapneumonic effusions). Pleural fluid cells were cultured in DMEM media and stimulated with purified protein derivatives (PPD), and phytohemagglutinin (PHA) for 24 hr. The amount of $IFN-{\gamma}$ released in the culture supernatant was quantitated by $IFN-{\gamma}$ ELISA assay. We have also measured adenosine deaminase (ADA) activities and $IFN-{\gamma}$ concentrations in the pleural fluid. Results : 1) The pleural fluid levels of ADA activity and $IFN-{\gamma}$ concentrations were significantly higher in TPE than NTPE (p<0.01). 2) $IFN-{\gamma}$ production in TPE cells stimulated by PPD ($755,266{\pm}886,636pg/ml$) was significantly higher than NTPE cells ($3,509{\pm}6,980pg/ml$) (p<0.01). By considering the fact that $IFN-{\gamma}$ concentrations over 10,000 pg/ml is a criteria for the diagnosis of TBE, sensitivity and specificity of the test were 97.4 and 92.3%, respectively. 3) The ratios of $IFN-{\gamma}$ production by the stimulation with PPD and PHA (PPD/PHA) were significantly higher in TPE cells ($59{\pm}85$) than NTPE cells ($5{\pm}18$)(p<0.01). Considering the criteria for the diagnosis of TBE as PPD/PHA ratio over 5, sensitivity and specificity of the test were 76.9 and 92.3%, respectively. Conclusion : Pleural fluid cell $IFN-{\gamma}$ production assay may be useful for the diagnosis of tuberculous pleurisy.

• Journal of Chest Surgery
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• v.26 no.6
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• pp.475-482
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• 1993

90 patients[75 men and 15 women] with the thoracic disease underwent video-assisted thoracic surgery[VATS] during the period March 1992 to February 1993. The thoracic diseases were classified into two groups of spontaneous pneumothorax and general thoracic patients and they were 66 and 24, respectively.The mean size of the tumor resected was 4.3 $\pm$ 2.0 cm x 3.3 $\pm$ 1.1 cm x 2.7 $\pm$ 1.0 cm. The mean time of anesthesia and operation were 90.0 $\pm$ 19.9 min and 43.7 $\pm$ 13.1 min in spontaneous pneumothorax group and 123.3 $\pm$ 40.3 min and 62.8 $\pm$ 32.2 min in general thoracic group. The mean period of postoperative chest tube drainage and hospital stay were 5.0$\pm$ 5.5 days and 6.6 $\pm$ 7.4 days in spontaneous pneumothorax group and 3.5$\pm$ 1.6 days and 9.5 $\pm$ 6.1 days in general thoracic group. The indications of VATS were 71 pleural disease[78.9%: 66 spontaneous pneumothorax; 3 pleural effusions ; 1 pleural paragonimus westermanii cyst; 1 malignant pleural tumor with metastasis to the lung], 9 mediastinal disease[10.0%: 5 benign neurogenic tumor; 2 pericardial cyst; 1 benign cystic teratoma; 1 undifferentiated carcinoma], 8 pulmonary parenchymal disease[8.9%: 3 infectious disease ; 3 interstitial disease ; 2 malignant tumor ], and 2 traumatic cases of exploration and removal of hematoma[2.2%]. The applicated objectives of VATS were diagnostic[ 7 ], therapeutic[ 67 ] and both[ 16 ] and the performed procedures were pleurodesis[ 66 ], wedge resection of lung[ 59 ], parietal pleurectomy[ 11 ], removal of benign tumor[ 9 ], excision and/or biopsy of tumor[ 4 ], pleural biopsy and aspiration of pleural fluid[ 3 ] and exploration of hemothorax and removal of hematoma in traumatic 2 patients. The complication rate was 24.2%[ 16/66 ] in the spontaneous pneumothorax group and 8.3%[ 2/24 ] in the general thoracic group and so overally 20.0%[ 18/90 ]. The mortality within postoperative 30 days was 2.2%[ 2/90 ], including 1 acute renal failure and 1 respiratory failure due to rapid progression of pneumonia. The conversion rate to open thoracotomy during VATS was 5.6%[ 5/90 ], including 2 immediate postoperative massive air leakage, 1 giant bullae, 1 malignant pleural tumor with metastasis to lung and 1 pulmonary malignancy. The successful cure rate of VATS was 75.8%[ 50/66 ] in the spontaneous pneumothorax group and 76.5%[ 13/17 ] in the general thoracic group and the successful diagnostic rate was 100%[ 7/7 ]. In conclusion, although prospective trials should be progressed to define the precise role of VATS, the VATS carries a low morbidity and mortality and high diagnostic and therapeutic success rate and now can be effectively applicated to the surgical treatment of the extensive thoracic disease.

• Tuberculosis and Respiratory Diseases
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• v.41 no.2
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• pp.135-143
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• 1994

Background: The cell mediated immunity has an important role in the pathogenesis of tuberculosis. sIL-2R has been known as a sensitive marker of T lymphocyte activation Elevated serum levels of sIL-2R have been found in patients with lymphoproliferative disorders, organ transplantation, autoimmune diseases, and various granulomatous diseases. Elevated levels of sIL-2R have been also found in the serum and pleural fluid of the patients with tuberculosis. To evaluate the diagnostic value of sIL-2R in the differentiation of tuberculous pleurisy and nontuberculous pleurisy. We measured the level of sIL-2R in the sera and pleural fluids of 12 patients with tuberculous pleurisy and 32 patients with nontuberculous pleurisy. Method: Samples of pleural fluid and serum were centrifuged at 2500 rpm for 10 min to remove cell pellets. Soluble IL-2R was measured with a sandwitch enzyme immunoassay using the Cellfree(r) Interleukin-2 Receptor Test kit(T-cell science,Inc. Cambridge, MA). Results: The results obtained were as follows: 1) The sIL-2R level in pleural fluid of the patients with tuberculous pleurisy was higher than that of patients with nontuberculous pleurisy(P<0.005). 2) When the sIL-2R level above 5,000 u/ml in pleural fluid was used as the cut-off value to diagnose tuberculous pleurisy, it had a sensitivity of 84.6% and a specificity of 90.9%. 3) The sIL-2R level in the sera of the patients with tuberculous pleurisy was higher than that of patients with bacterial pleural effusions and normal control group(P<0.05) and there was no difference of levels compared with malignant pleural effusions and transudative pleural effusions(P>0.05). 4) In patients with tuberculous pleurisy, the mean concentration of sIL-2R in pleural fluid was higher than that in serum(P<0.005). Conclusion: These findings suggest that the measurement of elevated levels of pleural fluid sIL-2R in tuberculous pleurisy may be useful in the differential diagnosis between patients with tuberculous pleurisy and nontuberculous pleurisy.

• Tuberculosis and Respiratory Diseases
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• v.45 no.6
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• pp.1214-1222
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• 1998

Background : The intrapleural hypofibrinolysis is caused by mainly excessive concentration of pleural plasminogen activator inhibitor-1 antigen(PAI-1 Ag), which binds tissue type plasminogen activator. In pleural inflammation induced by sclerosing agents for pleurodesis, levels of pleural PAI-1 antigen increase in relation to decreasing D-dimer levels. It has been known that the pleural mesothelial cells have the capability of secreting PAI-1 Ag in response to inflammation in vivo. Therefore, we estimated whether pleural inflammation changes the balance between fibrinolytic and coagulative properties in exudative pleural effusions. Method : The thirty cases was included in our study. We determined the pleural levels of glucose, lactic dehydrogenase(LDH), pH and the counts of white blood cell(WBC), polymorpho leukocyte(PMN), lymphocyte as the parameters of pleural inflammation and cellular components of pleural fluid. The plasma level of fibrinogen in fluid and the neutrophil count in blood were determined. The levels of D-dimer, PAI-1 Ag and thrombinantithrombin III complex(TAT) were determined by ELISA(Behring, Marburg, Germany). Result : The causes of pleural effusion were as following : tuberculous in 14 cases, malignant in 10 cases and parapneumonic in 6 cases. The levels of pleural D-dimer, PAI-1 Ag and TAT was significantly higher than that of plasma(p<0..001). The severity of pleural inflammation did not correlated with pleural D-dimer, PAI-1 Ag, TAT and their plasma levels. But the level of pleural TAT correlated with pleural WBC and lymphocyte count. Conclusion : We found that the severity of pleural inflammations did not correlated with pleural D-dimer, PAI-1 Ag, TAT and the possibility of local production of PAI-1 antigen is present.

• Tuberculosis and Respiratory Diseases
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• v.38 no.2
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• pp.135-142
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• 1991

We reviewed 15 cases of mesothelioma of the pleura, of which three cases were localized benign form and 12 cases were malignant diffuse form. The tumors were distributed equally in both sexes, and occured most commonly in fifth to seventh decades. The history of exposure to asbestos was present in only one case. The chief complaints were mainly chest pain and dyspnea. Associated symptoms were cough, sputum, hemoptysis, weight loss, anorexia, chill. On physical examination, unilateral, decreased breathing sound was main feature. The simple chest radiograph showed masses in all localized mesotheliomas (100%) and in 2 diffuse mesotheliomas (17%). 8 cases of diffuse mesotheliomas (67%) showed unilateral pleural effusions. Pleural effusions were mainly bloody (67%), and almost all were exudates. In all localized mesotheliomas, final diagnosis was made by open thoracotomy. In diffuse mesotheliomas, final diagnosis was made by open thoracotomy in 7 cases, chest wall mass biopsy in 2 cases, thoracoscopic biopsy in 1 case, pleural biopsy in 1 case, and pleural biopsy combined with axillary lymph node biopsy in 1 case. Localized mesotheliomas were treated by simple excision with good prognosis. In diffuse mesotheliomas, surgical treatment (pleuropneumonectomy, pleurectomy), chemotherapy, or radiotherapy, alone or in combination, were used with dismal prognosis. The prognostic factors were not found due to the small number of cases, incomplete follow up, and early drop out.