SFTP are rare tumours arising from mesothelial parenchymal cells. The majority follow a benign course, but these tumours do have the potential to metastasise. England et al developed a set of criteria to define which tumours are malignant including mitotic index, cellularity, pleomorphism, haemorrhage and necrosis. SFTP are heterogenous and a malignant diagnosis can be missed if limited areas are examined, although histologically benign tumours can still follow a malignant course. There is no agreed treatment or management strategy for SFTP – we therefore performed a systematic review of the available literature regarding the diagnosis of benign versus malignant SFTP.
Methods
A broad search strategy of four large databases was undertaken for any articles related to SFTP from inception of the database until November 2017. There were no randomised control trials thus large case series were the mainstay of evidence for the systematic review. Data was collected according to a pre-specified protocol and assessed by two reviewers.
Results
21 papers were suitable for data extraction for this question from an initial review of 3447 abstracts. Rates of malignancy ranged from 0% to 57%. The criteria proposed by England et al was used in 14/21 papers with another 4/21 using part of this criteria. 8/21 studies specifically assessed factors which could help differentiate between malignant and benign tumours. 6/8 studies found that large tumours were more likely to be malignant. 3/3 studies showed that the presence of a pleural effusion was associated with malignancy. Non-visceral origin and sessile attachment were not found to have any association in 3/4 studies. There was no association with age and likelihood of a malignant diagnosis. Further associations were reported in solitary papers such as PET avidity, inverted tumours, hypervascularity, lobulated margins and fibrous adherences.
Conclusion
Features such as size and the presence of a pleural effusion suggest a SFTP is likely to be histologically malignant. Previous criteria such as sessile attachment and non-visceral origin are not consistently predictive of malignancy. Whilst being able to identify which SFTP are likely to be malignant is important, benign tumours can still follow a malignant course and thus further work is needed to identify all tumours which require a more aggressive management/monitoring strategy.
Indwelling pleural catheters (IPC) offer an alternative to talc pleurodesis in recurrent effusion, especially in patients wishing to avoid hospitalization. Two randomized trials have demonstrated reduced time in hospital using IPCs versus talc pleurodesis in malignant pleural effusion (MPE). However, the impact of IPCs on hospital services and patients has not been well studied.To analyze long-term outcomes of IPCs and understand the hospital burden in terms of requirement for hospital visits and contacts with healthcare, while the IPC was in situ.IPC insertions in a tertiary pleural center were analyzed retrospectively. Reviews of patients with IPCs in situ considered "additional" to routine clinical follow-up were defined pre-hoc.A total of 202 cases were analyzed: 89.6% MPE group (n = 181) and 10.4% non-MPE group (n = 21). There were a median 3.0 (interquartile range [IQR] 3) and 2.0 (IQR 2) ipsilateral pleural procedures prior to each IPC insertion in non-MPE and MPE groups, respectively (p = 0.26), and a mean 1.3 (SD 1.7) planned IPC-related outpatient follow-up visits per patient. There were 2 (9.5%) and 14 (7.7%) IPC-related infections in non-MPE and MPE groups, respectively. Four (19.0%) and 44 (24.3%) patients required additional IPC-related reviews in non-MPE and MPE groups, respectively (p = 0.6), and these occurred within 250 days post IPC insertion.Although IPCs decrease initial length of hospital stay compared to talc pleurodesis via chest drain, IPCs are associated with significant hospital-visit burden, in addition to planned visits and regular home IPC drainages. IPC-using services need to be prepared for this additional work to run an IPC service effectively.
The severity of Obstructive Sleep Apnoea (OSA) is highly variable on night-to-night basis. Patients are commonly placed into categories based on the severity of OSA which can be used to influence management including Continuous Positive Airway Pressure (CPAP). Aims: To establish whether OSA severity category changes on CPAP withdrawal based on mean and maximum Oxygen Desaturation Index (ODI). Methods: Patients with a diagnosis of moderate to severe OSA who had been on CPAP for > 1 year were included in the study. Subjects underwent two CPAP withdrawal studies of 4 nights each. Results: 25 patients completed the study. Based on the mean ODI, 14 (56%) patients changed OSA severity categorisation, with 3 (12%) changing category to mild. Based on the maximum ODI, 9 (36%) patients changed OSA severity categorisation, with and 1 (4%) changing category to mild. Method: In the four sequential night studies, in one third to a half of patients OSA severity category differs during two periods of CPAP withdrawal. We believe the concept of patients having definable and 'real' OSA severity is flawed and that severity of OSA should be based mainly on symptoms, as these are the dominant reasons for treatment and the sleep study should be used to ascertain if the respiratory events are the cause of the symptoms.
Introduction: In patients with COPD, pseudomonas aeruginosa (PsA) airway infection is associated with disease severity. Management of PsA first isolate, from the non-CF bronchiectasis literature includes aggressive eradication treatment with IV antibiotics or high dose ciprofloxacin. The clinical effect of PsA eradication in patients with COPD is unknown. We investigated, for 1st isolate of PsA, the clinical outcomes in COPD patients following attempts at PsA eradication. Methods: All patients with a PsA isolated from 2011 to 2016 were identified. Patients with CF and non-CF bronchiectasis were excluded. Patients with a co-diagnosis of COPD and non-CF bronchiectasis were also excluded. Clinical data and outcomes following PsA eradication were collected. Results: Following exclusion, available data from 23 patients (16 men) with a mean (range) age of 70years (42-90). Following 1st isolate of PsA, 58% received high dose oral ciprofloxacin, 29% received Intravenous antibiotics and 13% received no treatment. After initial treatment 54% went on to re-culture pseudomonas and further long-term treatment of nebulised antibiotics or prolonged ciprofloxacin was given to 53% of these. Despite second line treatment all the patients who re-cultured pseudomonas went on to have PsA colonisation. Although not statistically significant, severe exacerbations, requiring hospitalisation, were more common in patients who went on to colonise PsA than those that eradicated (mean difference 1.0, 95%CI -1.2 to 3.2, p=0.34). Conclusion: Attempts at eradicating pseudomonas airway infection is successful in approximately 50% of patients with COPD and may have an impact on reducing severe hospitalisations.
Abstract Hyperammonemia syndrome (HS) is a life-threatening condition occurring in solid organ transplant patients, affecting primarily lung recipients, and is associated with Mycoplasma hominis and/or Ureaplasma spp infection. The organ donor was a young man who died of hypoxic brain injury and had urethral discharge antemortem. The donor and 4 solid organ transplant recipients had infection with M hominis and/or Ureaplasma spp. The lung and heart recipients both developed altered conscious state and HS associated with M hominis and Ureaplasma spp infections. Despite treatment with antibiotics and ammonia scavengers, both the lung and heart recipients died at day +102 and day +254, respectively. After diagnosis in the thoracic recipients, screening samples from the liver recipient and 1 kidney recipient were culture positive for M hominis with or without Ureaplasma spp. Neither the liver nor kidney recipients developed HS. Our case series demonstrates the unique finding of M hominis and Ureaplasma spp dissemination from an immunocompetent donor across 4 different organ recipients. Phylogenetic whole genome sequencing analysis demonstrated that M hominis samples from recipients and donor were closely related, suggesting donor-derived infection. Screening of lung donors and/or recipients for Mycoplasma and Ureaplasma spp is recommended, as well as prompt treatment with antimicrobials to prevent morbidity.
Background: SFTP are rare tumours arising from mesothelial parenchymal cells. The majority do not follow a malignant course, but they do have the potential to metastasise, despite the majority being considered histologically benign. Treatment is often surgical resection but there are currently no management guidelines due to the paucity of evidence. We therefore conducted a systematic review of the available literature of management of SFTP. Methods: A broad search strategy of four large databases was undertaken for any articles related to SFTP from inception of the database until November 2017. There were no randomised control trials thus large case series were the mainstay of evidence for the systematic review. Data was collected according to a pre-specified protocol and assessed by two reviewers. Results: 25 papers were suitable for data extraction from an initial review of 3447 abstracts, including a total of 1424 patients. Rates of histological malignancy and tumour recurrence ranged from between 0-57% and 0-42.9% respectively. The operative mortality ranged from 0-3.6% with 11.8% morbidity in one study. The presence of a pleural effusion was reviewed in six studies and found to be predictive of malignancy and poor outcomes in all. Conclusions, regarding the significance of size, tumour origin, pleural attachment or presence of symptoms were contradictory between studies. Malignant histological did not always predict a poor clinical outcome. Conclusions: There is significant heterogeneity between studies regarding the majority of outcomes. SFTP resection has associated morbidity and mortality and if the higher risk patients could be identified, unnecessary surgery may be able to be reduced.
Background: Pleural effusions are common in intensive care patients. Without strong evidence to guide management, clinicians variably undertake either intervention with drainage procedures, or expectant management, that is, observation, whilst treating the underlying cause. Early drainage may be associated with improved diagnostic accuracy and oxygenation, without increased complications. However, randomized evidence is needed to confirm these observations. Hypotheses: In patients diagnosed with a safely drainable pleural effusion while admitted to the intensive care units (ICU) and in whom there is no absolute indication for immediate drainage, intervention with early pleural drainage compared with initial expectant management: improves oxygenation and is safe. Aims: To undertake a phase II multicenter randomized controlled trial evaluating the safety and efficacy of early pleural effusion drainage compared with expectant management in the intensive care setting. Methods: Population – patients admitted in intensive care units and diagnosed with a safely drainable pleural effusion in whom there is no absolute indication for immediate drainage. Co-primary endpoints – ratio of arterial oxygen partial pressure to fraction of inspired oxygen ratio at 48 hours after randomization and number of Pleural Effusion Related Serious Adverse Events at 90 days. Inclusion criteria – admitted to intensive care, age > 18 years, pleural effusion safely drainable, and no absolute indication for immediate drainage. Exclusion criteria – in the opinion of treating clinician trial not in patient’s best interests, inability to gain consent from patient or responsible decision-maker, and patient requiring extracorporeal membrane oxygenation. Randomization – open-label, 1:1 patient ratio using permuted block randomization. Intervention and comparator – drainage of pleural effusion as opposed to expectant management. Outcomes – physiological data including ratio of arterial oxygen partial pressure to fraction of inspired oxygen and/or ratio of oxygen saturation measured by pulse oximetry to fraction of inspired oxygen ratio will be collected at randomization and 6 hourly until 72 hours or ICU discharge (whichever sooner). Adverse event and clinical data will be recorded daily to ICU discharge, hospital discharge and death up to 90 days after randomization.
The severity of obstructive sleep apnoea (OSA) is highly variable on a night-to-night basis. Patients are commonly categorised based on the severity of their OSA, and this is then used to influence management and reimbursement, including continuous positive airway pressure (CPAP). We aimed to establish to what extent the OSA severity category changes during two periods of OSA, based on mean and maximum oxygen desaturation index (ODI).Patients with a diagnosis of moderate to severe OSA who had been on CPAP for greater than 1 year were included in this study. Subjects underwent two periods of CPAP withdrawal for four nights each.Twenty-five patients completed the study. Based on the mean ODI of the four nights, 14 (56%) patients changed OSA severity categorisation, with three (12%) changing category to mild. Based on the maximum ODI of the four nights, nine (36%) patients changed OSA severity categorisation, with one (4%) changing category to mild. One third to a half of patients' OSA severity category changed between the two periods of four night's CPAP withdrawal.OSA is highly variable on a period-to-period basis as well as on a night-to-night basis. We believe the concept of patients having a definable and 'real' level of OSA severity is therefore flawed. OSA severity should be based mainly on symptoms, as these are the dominant reasons for treatment, and the sleep study should be used qualitatively to ascertain whether respiratory events are the likely cause of the symptoms.ISRCTN17987510.
Solitary fibrous tumours of the pleura (SFTP), or pleural fibromas, are rare tumours that generally, but not universally, follow a benign course. Surgical resection is the standard treatment, but there are no evidence-based guidelines regarding the management of these tumours.Five databases were searched from inception to April 1, 2019 for studies reporting on SFTP management.Twenty-seven studies met the inclusion criteria (1542 patients, all non-comparative case series); 98% of these patients underwent resection and all SFTP included were pathologically diagnosed. 394 out of 1299 cases (30.5%, 95% CI 27.8-32.8%) were malignant with recurrence rates of between 0% and 42.9%. A pleural effusion was always associated with a negative outcome, but no other features were consistently reported to have negative associations. Preoperative biopsies incorrectly reported malignant histology in two studies. Over 25% of cases of recurrence occurred when a complete (R0) resection had been achieved. The first recurrence occurred >5 years after the initial resection in at least 23% of cases.There is strong evidence to support long-term surveillance after surgical resection of SFTP, even where a complete (R0) resection has been achieved; however, there is no clear evidence to inform clinicians regarding the selection of patients who should undergo resection. The rates of malignant SFTP and SFTP recurrence are higher than previously reported. Only those that were pathologically diagnosed or resected were included, which may bias the data towards more aggressive tumours. Data collection on radiologically diagnosed SFTP is required to draw conclusions regarding the timing and need for intervention.
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