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The role of tumour marker assays in differentiating malignant from benign pleural effusions is not yet clear. This study was designed to prospectively assess the individual and combined diagnostic utility of three tumour markers in patients with pleural effusion.Pleural and serum levels of carcinoembryonic antigen (CEA), carbohydrate antigen 15-3 (CA 15-3) and cytokeratin 19 fragment (CYFRA 21-1) were determined in 115 patients with pleural effusions (42 malignant and 73 benign). The diagnostic utility of each tumour marker was assessed using accuracy to determine the optimal cut-off point, whilst a logistic regression model was used to obtain the optimal combined test.In serum, every marker showed an individual high specificity (over 97%) for malignancy. The sensitivity of CEA, CA 15-3 and CYFRA 21-1 was 36, 48 and 31%, respectively. In patients without renal failure, the sensitivity of CYFRA 21-1 rose to 53%, while those of CEA and CA 15-3 remained almost unchanged. In pleural fluid, CYFRA 21-1 showed low sensitivity (32%) and specificity (82%), while CEA showed the highest sensitivity (57%). Excluding patients with renal failure, the combined determination in serum of CEA, CA 15-3 and CYFRA 21-1 has a high accuracy (88%), similar to that for CEA plus CA 15-3 in pleural fluid (87%).We conclude that CYFRA 21-1 is useless in pleural fluid and should not be used in serum for patients with renal failure. The combined determination of CEA, CA 15-3 and CYFRA 21-1 in serum may obviate its determination in pleural fluid.

Nontraumatic chylothorax is an uncommon condition of thoracic or abdominal origin caused by multiple disorders, of which malignancy is by far the most frequent one. Because gross appearance of pleural fluid is frequently misleading, pleural fluid and serum lipid analysis is required for its diagnosis. In addition to the presence of chylomicrons, chylothoraces are usually characterized by all three of the following: (1) a triglyceride level of more than 110 mg/dL; (2) a ratio of pleural fluid to the serum triglyceride level of more than 1.0; and (3) a ratio of the pleural fluid to serum cholesterol level of less than 1.0. In patients with lymphoma-related chylothorax refractory to chemotherapy and radiation therapy, medical thoracoscopic talc pleurodesis has an acceptable complication rate and a 100% success rate in the prevention of recurrences. Pleuroperitoneal shunting is considered a safe and effective treatment in the management of persistent chylothorax in children in the absence of chylous ascites.

In April 1992 an outbreak of severe respiratory illness occurred among aerographic textile workers in the area of Alcoi, Autonomous Community of Valencia, Spain. An epidemiological study linked this outbreak to the use of a reformulated aerosolized product, Acramin-FWN. We analyzed clinical, laboratory, and pathological data of the first 14 patients with confirmed organizing pneumonia (OP) secondary to this newly recognized occupational toxicant. The mean age of the patients was 30 yrs. The most common clinical findings were cough (86%), epistaxis (71%), dyspnoea (64%), oppressive chest pain (57%), and crackles (50%). A restrictive functional pattern was evident in 64%. Radiographic findings consisted predominantly of patchy infiltrates in 65% and a micronodular pattern in 35%. Treatment with corticosteroids did not prevent initial progression in 11 of the 14 patients and development of irreversible respiratory failure in five patients. At necropsy, besides features of OP, interstitial fibrosis and diffuse alveolar damage were evident. A low total lung capacity, the presence of crackles at admission, and increases in the alveolar-arterial oxygen difference were predictive of death. The organizing pneumonia caused by the inhalation of Acramin-FWN is characterized by a tendency to evolve into progressive interstitial fibrosis despite the use of corticosteroids. The illness is restricted to the respiratory system and once respiratory failure has developed the prognosis is poor.

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Urinothorax can be divided into two categories: (1) obstructive urinothorax, due to bilateral obstructive uropathy; and (2) traumatic urinothorax, due to unilateral traumatic injury of the urinary system, mostly iatrogenic. In patients with urinothorax, the pleural effusion usually has the biochemical characteristics of a transudate, with a pH lower than 7.30 and a pleural fluid/serum creatinine ratio higher than 1. These characteristics are not always present, however, and individually are shared by a significant number of pleural effusions of different etiology.

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