Accumulating evidence implicates epigenetic changes such as hypermethylation in carcinogenesis. We investigated whether DNA methylation of 5 tumor suppressor genes in pleural fluid samples could aid in diagnosis of malignant effusion. In samples from 47 patients with malignant pleural effusions and 34 with nonmalignant effusions, we used a methylation-specific polymerase chain reaction to detect aberrant hypermethylation of the promoters of the DNA repair gene O 6 -methylguanine-DNA methyltransferase (MGMT), p16 INK4a , ras association domain family 1A (RASSF1A), apoptosis-related genes, death-associated protein kinase (DAPK), and retinoic acid receptor b (RARb). Promoter hypermethylation was associated with malignant effusion for MGMT (Odds ratio (OR) 5 '), p16 INK4a (OR 5 '), RASSF1A (OR 5 13.8; CI, 1.71-112), and RARb (OR 5 3.17; CI, 1.10-9.11), but not for DAPK. Instead, DAPK methylation was associated with the length of smoking (p < 0.05). Patients with hypermethylation of MGMT, p16 INK4a , RASSF1A or RARb were 5.68 times more likely to have malignant effusions than patients without methylation (p 5 0.008). Methylations per patient were more numerous for lung cancer than nonmalignant pulmonary disease (0.915 vs. 0.206, p < 0.001). Sensitivity, specificity, and positive predictive value of methylation in one or more genes for diagnosis of malignant effusion were 59.6%, 79.4%, and 80.0% respectively. In conclusion, aberrant promoter methylation of tumor suppressor genes in pleural fluid DNA could be a valuable diagnostic marker for malignant pleural effusion. ' 2007 Wiley-Liss, Inc.Key words: MGMT; p16 INK4a ; RASSF1A; DAPK; RARb; malignant pleural effusion Epigenetic changes such as hypermethylation increasingly appear to play a role in carcinogenesis. DNA methylation is one form of epigenetic variability in mammalian cells. [1][2][3] As aberrant hypermethylation in CpG-rich promoter regions of many tumor suppressor genes interferes with gene transcription, hypermethylation can contribute to development and progression of various cancers by abolishing tumor suppressor gene function. 1-3 Aberrant hypermethylation of many tumor suppressor genes has been observed in various specimens from lung cancer patients, including serum, plasma, sputum, lavage fluid, and epithelial brushing. 4,5 Recent studies have demonstrated the presence of promoter hypermethylation of various genes in fluids including bronchoalveolar lavage fluid (BALF), pleural fluid, 6 and peritoneal fluid. 7 These findings raise the possibility that methylation analysis in such materials may be a useful diagnostic tool for cancer detection.A number of studies have demonstrated frequent methylation in lung cancer cells of several tumor suppressor genes including the DNA repair gene O 6 -methylguanine-DNA methyltransferase (MGMT), 8,9 p16 INK4a , 10,11 ras association domain family 1A (RASSF1A), 12,13 apoptosis-associated genes such as death-associated protein kinase (DAPK), 14 and retinoic acid receptor b (RARb) 15 ; in contrast, methylation of thes...