Muzaffer Metintas

Diagnostic value of CEA, CA 15-3, CA 19-9, CYFRA 21-1, NSE and TSA assay in pleural effusions

The aim of this study was to evaluate the individual and combined diagnostic utility of six tumor markers in patients with pleural effusion. Pleural and serum levels of carcinoembryonic antigen (CEA), carbohydrate antigen 15-3 (CA 15-3), carbohydrate antigen 19-9 (CA 19-9), cytokeratin fragment 19 (CYFRA 21-1), neuron-specific enolase (NSE) and total sialic acid (TSA) were assayed in 74 patients with pleural effusions (44 malignant and 30 benign). All tumor markers except TSA and NSE were increased in both serum and pleural fluid of patients with malignant diseases. Using the cut-off values 3 ng/ml, 14 U/ml, 5 U/ml, 8 ng/ml and 70 mg/dl for pleural fluid CEA, CA 15-3, CA 19-9, CYFRA 21-1 and TSA, respectively, the sensitivity (%) and specificity (%) of these tumor markers were as follows: CEA; 52/77, CA 15-3; 80/93, CA 19-9; 36/83, CYFRA 21-1; 91/90, TSA; 80/67, for differentiating malignant effusions from benign. When CA 15-3 and CYFRA 21-1 combined, the sensitivity and specificity were increased (100 and 83%, respectively). Classifying the malignant effusions as bronchial carcinoma and malignant pleural mesothelioma, CEA was shown to have the highest sensitivity and specificity (88 and 90%, respectively) while the combination of CEA with other tumor markers increased sensitivity but decreased specificity. According to our results, tumor markers are not suitable for the differential diagnosis of malignancy.

Medical Thoracoscopy vs CT Scan-Guided Abrams Pleural Needle Biopsy for Diagnosis of Patients With Pleural Effusions: A Randomized, Controlled Trial

BACKGROUND In cases of pleural effusion, tissue samples can be obtained through Abrams needle pleural biopsy (ANPB), thoracoscopy, or cutting-needle pleural biopsy under the guidance of CT scan (CT-CNPB) for histopathologic analysis. This study aimed to compare the diagnostic efficiency and reliability of ANPB under CT scan guidance (CT-ANPB) with that of medical thoracoscopy in patients with pleural effusion. METHODS Between January 2006 and January 2008, 124 patients with exudative pleural effusion that could not be diagnosed by cytologic analysis were included in the study. All patients were randomized after the CT scan was performed. Patients either underwent CT-ANPB or thoracoscopy. The two groups were compared in terms of diagnostic sensitivity and complications associated with the methods used. RESULTS Of the 124 patients, malignant mesothelioma was diagnosed in 33, metastatic pleural disease in 47, benign pleural disease in 42, and two were of indeterminate origin. In the CT-ANPB group, the diagnostic sensitivity was 87.5%, as compared with 94.1% in the thoracoscopy group; the difference was not statistically significant (P = .252). No difference was identified between the sensitivities of the two methods based on the cause, the CT scan findings, and the degree of pleural thickening. Complication rates were low and acceptable. CONCLUSION We recommend the use of CT-ANPB as the primary method of diagnosis in patients with pleural thickening or lesions observed by CT scan. In patients with only pleural fluid appearance on CT scan and in those who may have benign pleural pathologies other than TB, the primary method of diagnosis should be medical thoracoscopy. TRIAL REGISTRATION clinicaltrials.gov; Identifier: NCT00720954.

Malignant mesothelioma due to environmental exposure to erionite: follow-up of a Turkish emigrant cohort

The incidence of malignant mesothelioma is extremely high in some Turkish villages where there is a low-level environmental exposure to erionite, a fibrous zeolite. The best known example is the village of Karain. However, since epidemiological studies are difficult to perform in Turkey, the incidence and the dose-response curve have not been thoroughly examined. A small cohort of immigrants from Karain who have lived in Sweden for many years were studied. Exposure data, i.e. the time residing in Karain, and hospital records including pathological diagnosis, were recorded. The cohort consisted of 162 people. During the observation time, 18 deaths occurred, 14 (78%) of which were due to malignant pleural mesothelioma. In addition, there were five patients with mesothelioma who were still alive, one of whom had a peritoneal mesothelioma. Thus, the risk of mesothelioma is 135-times and 1,336-times greater in males and females, respectively, than for the same sex and age groups in Sweden. The risk increased with duration of residence.

High-Resolution Computed Tomography Findings Are Correlated with Disease Severity in Asthma

Background: The structural changes in the airways of asthmatics are also referred to as remodeling and can be identified using high-resolution computerized tomography (HRCT).Objectives: To find out whether there are any abnormal HRCT features which can be attributed to asthma and their clinical correlates, and any differences of abnormal HRCT features between asthmatics and patients with chronic obstructive pulmonary disease (COPD). Methods: We performed (HRCT) scans to assess airway remodeling in 160 nonsmoker asthmatics compared with 27 patients with COPD. Results: Bronchial wall thickening, hyperlucency, centrilobular prominence, bronchiectasis, thick linear opacities and mucoid impaction were all correlated with disease severity in asthma. FEV1 values were inversely correlated with bronchial wall thickening, hyperlucency, mucoid impaction, linear shadows, centrilobular prominence and bronchiectasis. In adddition, thick linear opacities, mucoid impaction and bronchiectasis were more prominent in those patients with a long duration of asthma. Bronchial wall thickening, thick linear opacities, mucoid impaction, bronchiectasis and emphysema were more prominent in COPD patients compared with asthmatics. There was no difference with regard to age, mean values of FEV1 and the duration of asthma between allergic and nonallergic asthmatics as well as abnormal HRCT findings. Conclusions: COPD patients have more prominent HRCT findings as compared with asthmatics. In the asthmatics, abnormal HRCT findings are more prominent with increased severity, decreased FEV1 values and the duration of asthma. The remodelling of airways in allergic asthmatics did not differ from that in their nonallergic counterparts as determined by HRCT.

CT-guided pleural needle biopsy in the diagnosis of malignant mesothelioma.

Objective Our goal was to determine the sensitivity of CT-guided closed pleural needle biopsy (CPNB) for the histopathologic diagnosis of diffuse malignant pleural mesothelioma (DMPM). Materials and Methods Thirty patients with DMPM were studied with CT-guided CPNB. Tumor specimens were classified according to their cell types. Results In 25 (83.3%) patients, the diagnosis was made by CT-guided CPNB. The remaining five patients were diagnosed by thoracoscopy, thoracotomy, or excisional biopsy of the chest wall mass. Pneumothorax was observed in 9.5% of patients and local seeding of tumor in 21.7% of patients who underwent CPNB. Conclusion Properly performed CPNB under CT guidance may yield an increased sensitivity for the diagnosis of diffuse malignant pleural mesothelioma..

Trimodality Treatment of Malignant Pleural Mesothelioma

Introduction: Multimodality treatment has achieved significant success in local control and treatment of early-stage malignant pleural mesothelioma patients. However, its favorable effect on survival is questionable. Methods: We have instituted a trimodality treatment protocol consisting of extrapleural pneumonectomy, adjuvant high-dose (54 Gy) hemithoracic irradiation, and platin-based chemotherapy in a multi-institutional setting. Preoperative pulmonary function tests, echocardiogram, chest computed tomography, and magnetic resonance imaging scans were performed in all patients. Twenty patients have been treated with this protocol during 2003–2007. Seventeen had a history of environmental asbestos/erionite exposure. Clinical stages were T1-3N0-2. Results: Median age was 56 (41–70, 8 female). There was one postoperative mortality (% 5) due to ARDS. Morbidity occurred in 11 patients (% 55). Histology was epithelial in 17, mixed in 2, and sarcomatoid in 1. Sixteen patients underwent extrapleural pneumonectomy. Microscopic margin positivity was present in 14 patients with macroscopic complete resection. Twelve patients completed all three treatments. Median follow-up was 16 months (1–43). Overall median survival was 17 months (24% at 2 years). Eight patients had extrapleural lymph node involvement (internal mammary [n = 3], subcarinal [n = 2], pulmonary ligament [n = 1], diaphragmatic [n = 1], subaortic [n = 1]). There was better survival in patients without lymph node metastasis (24 versus 13 months median survival, p = 0.052). Currently, 7 patients are alive, 6 without recurrence, and 2 patients at 40 and 45 months. Conclusions: Trimodality treatment in malignant pleural mesothelioma seems to prolong survival in patients without lymph node metastasis. Novel techniques are needed for preoperative assessment of extrapleural lymph nodes.

Environmental asbestos exposure and malignant pleural mesothelioma.

Asbestos-related benign and malignant pleural diseases are endemic in some rural parts of central Turkey because of environmental exposure to asbestos fibres. We report here epidemiological data on 113 patients with diffuse malignant pleural mesothelioma (DMPM) diagnosed in our clinic in Eskişehir, located in central Turkey. Of the 113 patients, 59 were men and 54 women (male:female ratio = 1). Ninety-seven patients (86%) had non-occupational asbestos exposure; all were living in villages. Their mean age was 56 years. As the patients had been exposed to asbestos from birth, the latency period was equivalent to the age of the patients. Twenty-eight patients (29%) had lived in villages their entire lives. The other 69 (71%) had been born in a village but migrated to the city or had given up white-soil usage for various reasons. The mean exposure time was 55 years for those with a long exposure period and 25 years for those with a short exposure period, but there was no significant difference between the age of the disease appearance for both groups (55 and 56 years, respectively). Thus, the latency time of mesothelioma due to environmental exposure to asbestos was longer than that due to occupational exposure, but independent of the length of exposure. Soil samples from 67 villages were analysed, comprising a population of 10,120 villagers. Tremolite and some other types of asbestos were found. In conclusion, DMPM in our region is due to mainly to environmental exposure to asbestos. The risk is substantial as a large proportion of the villagers are exposed. After smoking, asbestos exposure is one of the most serious health hazards in our rural population.

Clinical value of fluorodeoxyglucose-positron emission tomography/computed tomography in differentiation of malignant mesothelioma from asbestos-related benign pleural disease: an observational pilot study.

Background: Several studies have already addressed the potential role of an increased fluorine 18 fluorodeoxyglucose (18F FDG) uptake in identification of pleural malignancy. In this pilot study, we investigate the role of 18F-FDG positron emission tomography/computed tomography (PET/CT) for differentiating asbestos-related benign pleural disease from malignant mesothelioma. Materials and Methods: The study population comprised 31 consecutive patients (17 malignant mesotheliomas, nine benign asbestos pleurisies, and five diffuse pleural fibrosis) with a mean age of 61 years between January 2006 and December 2008. Thoracoscopy or image-guided pleural needle biopsy were systematically performed to reveal pathologic diagnosis and/or clinical follow-up for at least 3 years for presence or absence of malignant pleural effusion. ROCs analyses for standardized uptake value (SUV) adjusted to body weight were calculated between benign and malignant pleural diseases. Results: 18F-FDG PET/CT imaging correctly detected the presence of malignancies in 15 of 17 patients with malignant mesothelioma for sensitivity, specificity, and overall accuracy of 88.2%, 92.9%, and 90.3%, respectively. 18F-FDG PET/CT imaging correctly identified 13 of 14 cases of benign pleural disease. The mean SUV values were 6.5 ± 3.4 for malignant mesothelioma cases and 0.8 ± 0.6 for benign pleural diseases (p < 0.001). When we compared the two groups of pleural disease, a cut-off value of 2.2 for SUV gave the best accuracy with 94.1%, 100%, 100%, and 93.3% for sensitivity, specificity, positive predictive value, and negative predictive value, respectively. Conclusion: Preliminary results of this trial provide evidence that 18F-FDG PET/CT imaging is a highly accurate and reliable noninvasive test to decide for further investigation of differentiating malignant mesothelioma from benign pleural disease.

Comparative analysis of biochemical parameters for differentiation of pleural exudates from transudates: Light's criteria, cholesterol, bilirubin, albumin gradient, alkaline phosphatase, creatine kinase, and uric acid

The differentiation of pleural effusions as being either transudate or exudate is the first step in the diagnosis of pleural effusions. The aim of this study was to compare the efficiency of the various biochemical parameters to the traditional criteria of Light et al., for differentiating exudates from transudates. Ninety-three pleural fluid and sera specimens were obtained and classified as transudates or exudates on the basis of their diagnosis. Of the 93 pleural fluids, 21 were transudates, 72 were exudates. The efficiencies of different parameters for detection of exudates were as follows: The criteria of Light 96%; effusion cholesterol concentration 77%; serum-fluid albumin gradient 67%, pleural/serum alkaline phosphatase ratio 83%; effusion creatine kinase levels 91%; pleural/serum creatine kinase ratio 83%, and effusion uric acid 71%. Pleural/serum uric acid ratio was insignificant for the purpose of this study.

Nonmalignant pleural lesions due to environmental exposure to asbestos: a field-based, cross-sectional study

The aim of the present study was to investigate the frequencies of asbestos-related benign pleural diseases in villagers environmentally exposed to asbestos and the factors affecting these frequencies. A field-based, cross-sectional study was designed. In total, 991 villagers from 10 villages, randomly chosen from 67 villages with known use of asbestos-containing white soil in central Anatolia (Turkey), were investigated. The type of asbestos in the white soil was determined for each village, as well as air-borne fibre concentrations. The villagers were investigated with small-size chest roentgenograms and epidemiological features were recorded. The air-borne fibre levels were generally low. Despite this, pleural plaques were found in 14.4% of the villagers, 10.4% had diffuse pleural fibrosis and 0.4% asbestosis. The significant variables for plaques were age, sex, type of asbestos fibre, e.g. actinolite and tremolite, and exposure duration, while there was a negative relationship with cumulative exposure. The variables affecting diffuse pleural fibrosis were age, exposure duration and cumulative exposure. In conclusion, villagers exposed to environmental asbestos have high frequencies of pleural plaques and diffuse pleural fibrosis, similar to occupationally exposed asbestos cohorts. Different types of asbestos appear to result in different frequencies of pleural lesions.