ID # s080176

Bachelor in Medical Laboratory Science

Reliability of thoracentesis (pleural fluid) in detecting cancer cells at CWMH from 2008 to 2010, (literature review).

RESEARCH PROJECT 2011 MLS 700 Donald Horiratana s080176 BMLS 4 Research supervisor: Shivanjali Sharma.

A Report Submitted in partial fulfillment of the Degree of Bachelor of Medical Laboratory Science

ID # s080176

Reliability of thoracentesis (pleural fluid) in detecting cancer cells at CWMH from 2008 to 2010, (Literature review).

ID # s080176 ACKNOWLEDGEMENT I would sincerely like to thank the following people for their assistance in making this project a success: Ms. Shivanjali Sharma (project supervisor) Ms. Aruna Devi (BMLS Course coordinator)

ID # s080176 TABLE OF CONTENTS Content ACKNOWLEDGEMENT ABSTRACT 1.0 INTRODUCTION 2.0 AIM 3.0 PROBLEM STATEMENT 4.0 OBJECTIVES 5.0 METHODOLOGY 6.0 LIMITATIONS 7.0 RESULTS 8.0 RESULTS/ DISCUSSION 9.0 CONCLUSION 10.0 RECOMMENDATIONS 11.0 IMPLICATION OF RESULTS 12.0 DISSEMINATION OF RESULTS 13.0 WORKPLAN and TIME FRAME 14.0 BUDGET 15.0 REFERENCE 16.0 BIBLIOGRAPHY 17.0 APPENDIX Page Number ii iv 1-6 7 7 7 8-10 11 12 13-15 16 17 18 18 19 19 20-21 22 23

ID # s080176 ABSTRACT Background: Malignant pleural effusion is usually suspected as a complication that is related to development of tumor or infection in individuals who have diagnostic thoracentesis findings. The method of diagnosis involves multiple procedures and steps based on the assessment the clinicians done on the patients. Thoracentesis is one of these procedures that are widely used to detect malignant cells in cytopathology. Achieving a diagnosis thoracentesis is included with the multiple invasive procedures because it is a screening test to perform initially. After reviewing of published related articles, these articles demonstrated that thoracentesis for pleural fluid is a reliable procedure to diagnose malignant pleural effusion. Thoracentesis for pleural fluid is an advantage over other procedures because tumor cells are abundant in pleural fluid and also pleural metastases tend to be central and several hundred of milliters of fluid can be removed at the initial diagnostic thoracentesis. However thoracentesis is a procedure that never diagnoses the malignancy itself but need support from other procedure such as pleural biopsy and thoracoscopy for confirmation. Although the procedure is an uncomfortable invasive procedure, it benefits the patient in diagnosing a malignant pleural effusion. Aim: The aim of this research project is to determine how reliable thoracentesis (pleural fluid) in detecting cancer cell by following up with the results in pleural biopsy at CWMH (Colonial War Memorial Hospital) from 2008 to 2010. Methods: No hands on research was done due to delay and no ethical approval by CRC (College research committees). This is a literatures review based research project. Articles obtained for this research project were taken from Google scholar and EBSCO host database. Keywords used to search for the relevant articles includes: thoracentesis, pleural fluid, malignant pleural effusion, cytology evaluation, malignant cells, and pleural biopsy. Result: The original intending hands on research was not carried out due to no ethical approval by CRC (College Research Committees) for data collections, so no result is available here, however results available for the research project are from literatures review which are discussed in the present study. Conclusion: Thoracentesis or pleural fluid is also a main back bone tool of medical procedures that aid in determining the presence of malignant cells in malignant pleural effusion. Pleural fluid cytologic examination is a useful initial step in the diagnostic work up of patients suspected with malignant pleural effusions.

ID # s080176 1.0 INTRODUCTION Pleural fluid is a filtrate from the parietal pleura, enters the pleural space and is then reabsorbed through the parietal pleural stomata (20). The protein content of normal pleural fluid is lower than the protein concentration in lung and peripheral lymph (20). The visceral pleura contributes little to the formation or resorbtion of pleural fluid in the normal state (20). In the normal state, the lymphatic drainage of the pleural space can accommodate a large volume of pleural fluid (20). So since the rate of entry into the pleural space is equal to the rate of exit of fluid, no net fluid accumulates (20). Intrapleural pressure, and plasma and lymphatic oncotic pressure are factors that influence the rate of pleural fluid formation and that can play a role in the development and progression of malignant pleural effusion (20). Pleural effusion develops when more fluid enters the pleural space than is removed (25). Malignant pleural effusions are a common clinical problem in patients with neoplastic disease. Pleural effusions occur between two membranes, the inner visceral layer of the pleura attached to the lungs and the outer parietal layer attached to the chest wall (26). Thoracentesis is the surgical puncture of the chest and pleural space with a needle to aspirate fluid for the diagnostic or therapeutic purposes or to remove a specimen for biopsy stated by Harris P, Nagy S, Vardaxis N (24). This procedure is usually performed using local anaesthesia, with the patient in an upright position (24). Thoracentesis may be used in the treatment of pleural effusion as may occur due in bronchogenic carcinoma (24). Fluid samples may be examined for erythrocyte, leucocyte, and also differential white cell counts as well as protein, glucose and amylase concentrations and may be cultured for studies of microorganisms that may be present (24). Thoracentesis should be performed in a patients in whom the diagnosis of the pleural effusion is not clear and in a patients who are symptomatic for both diagnosis and therapeutic purpose. ChyrYang, Tay Luh, Bing Chang, Dong Wu, and Jen Yu (27), stated that an effusion defined as malignant if cytologic examination of the fluid showed malignant cells or histologic examination of specimens obtained from pleural biopsy or transthoracic needle aspiration biopsy showed evidence of a malignant neoplasm. 1.1 Background information Clinically detectable pleural fluid accumulation is a common abnormality noted in patients. The study done by Salyer, Eggleston and Erozan (2), was a comparison made on the efficacy of pleural needle biopsy and pleural fluid cytopathology in the diagnosis of pleural tumor in a group of 271 patients. Where needle biopsy alone provide a diagnosis of tumor in 53 instances and fluid cytology preparations were diagnostic in 69 patients. Another study done by Bueno, Reblando and Glickman (3) that investigated the accuracy of open pleural biopsy for the diagnosis and subtype identification in mesothelioma concluded that open pleural biopsy is accurate and should considered the gold standard diagnostic method for mesothelioma. Through their work, Light, Maggregor and Luchsinger (1) explained that, pleural effusion is a common manifestation of both primary and secondary pleural diseases. They continue to explain that, pleural effusions are classically divided into transudates and exudates. Transudate occurs when mechanical factors influencing the formation or reabsorption of pleural fluid are changed. These factors include increased plasma osmotic pressure or elevated systemic or pulmonary hydrostatic pressure. Exudates results from inflammation or other disease of the pleural surface that occurs in tuberculosis, pneumonia, with effusion, malignancy, pancreatitis, pulmonary infarction or systemic lupus erythematosus.

ID # s080176 Pleural effusions of unknown etiology are frequent and often present difficult clinical problems. A variety of diseases may be associated with pleural effusions, and several techniques are used to determine a diagnosis. The common cause of effusion in the adult population is malignant tumour involving pleura as stated by Light, Maggregor and Luchsinger(1). The study done by Prakash (7) on results from thoracenteses and needle biopsies of the pleura that performed on 414 patients with pleural effusions between 1973 and 1982 shows that cytologic analysis has a higher sensitivity, (P < 0.001) than needle biopsies for the diagnosis of pleural effusion. Poe, Israel, Utell, Hall, Greenblatt and Kallay (8) following their study on a nonspecific pleural biopsy specimen and fluid in malignant neoplasm and tuberculosis of patients undergoing pleural effusion with 207 patients underwent biopsies and they stated that closed pleural biopsy with simultaneous fluid analysis is a valuable diagnostic procedure in community hospital patients but could be nonspecific as it does not exclude malignant disease. 1.2 Significance of the study Johnston (4) stated that the major purpose of cytopathologic diagnoses on specimens of pleural effusion is to determine whether or not neoplastic cells are present. Johnston (4) specified that, since the first published account by Bennett in 1848 of tumor cells observed in effusion fluid. More than 135 years of development have led to the current cytopathologic diagnosis of body cavity fluids as established procedure. Heffner (5) also stated that even with nondiagnostic thoracentesis, analysis of pleural fluid is useful in excluding other possible causes such as infection. The purpose of doing this study is that to have better understanding about thoracentesis. This study would help in demonstrating how significance is thoracentesis in diagnosing pleural effusion of unknown causes. It will also demonstrate how, when and where thoracentesis is supposed to be used. Thoracentesis was known to be a screening test in identifying malignant cells in pleural effusion of unknown causes, based on this fact this study would aid to explore how dependable was thoracentesis as a diagnostic procedure for malignant pleural effusion. This study would show thoracentesis can be evaluated as a specific and sensitive technique. 1.3 Literature review 1.3.1 Introduction Pleural effusion is the fluid that is collected from the pleural cavity, the space between the lungs and the inner chest wall. According to Light and Lee (12), pleural effusions are common in the clinical practice as it affects 3000 patients for every million population each year. The researchers explained that pleural effusions arise when rate of pleural fluid formation exceeds that of its drainage. Thus, accurate diagnosis often requires detailed clinical data, radiological imaging and laboratory analysis of pleural fluid (12). Light and Lee (12) stated that, pleural fluid samples should be analyzed to determine whether it is transudate or exudates because transudate usually results from cardiac failure or hepatic cirrhosis and exudates result from parapneumonic effusions, tuberculosis and malignancy. Pleural effusion arise in the thoraxas as primary (pulmonary infection or infarction) or secondary due to ascites. Right sided pleural effusions are due to cirrhosis, subdiaphragmatic or hepatic abscess and Meigs syndrome (12). Pancreatitis is associated with left sided pleural effusion, most common sources of malignant pleural effusion are lung, breast, lymphoreticular system and gastrointestinal cancers (12).

ID # s080176 The study done by Ayman, Soubani, Marco, Michelson and Ashok (13) on pleural fluid findings in patients with the acquired immunodeficiency syndrome sought to define the spectrum of conditions associated with pleural effusion in patients with the acquired immunodeficiency syndrome who submitted to diagnostic thoracentesis. In this study, they described the pleural fluid findings in patients with acquired immunodeficiency syndrome who had diagnostic thoracentesis in a suburban public hospital as a procedure aids in diagnosing pleural effusion of unknown causes and examine the correlation between these findings and the underlying causes is pulmonary disease. Another study done by Thomas and Lynch (20) stated that, a simple thoracentesis is the most important step in diagnosing an malignant pleural effusion. A sample of fluid for cytology examination is the gold standard for diagnosing malignant pleural effusions. Grace, Gant, Cathi, Washam, Daniel and Sterman (19), specified that pleural effusions are a common and frequently disorderly complication of malignancy and the most frequent etiology of malignant pleural effusion is bronchogenic carcinoma which demonstrated that pleural effusion is complication that many patients suffers and breast cancer is next in incidence, followed by lymphoma. Other causes include mesothelioma, gastric or oesophageal cancer and ovarian carcinoma and development of malignant pleural effusion in general (19). Signify poor prognosis, which lengthened the survival of the patients with malignant pleural effusion if no correct diagnostic approaches was taken. Mohamed, Mobasher, Yousef, et al (18), verified that intrathoracic disease involving the lung and pleura remain a frequently encountered and challenging clinical problem and the cause of lung and pleura abnormalities may remain unknown despite thoracentesis, closed pleural biopsy, transthoracic needle aspiration, or bronchoscopy, which indicates that thoracentesis is one of the important procedure to diagnose malignant pleural effusion related lung cancer. 1.3.2 Significance Thomas and Lynch (20) stated that, a simple thoracentesis is the most important step in diagnosing an malignant pleural effusion. A sample of fluid for cytology examination is the gold standard for diagnosing malignant pleural effusions. In the setting of a recognized advanced malignancy, the malignant pleural effusion can be treated as malignant if an infectious cause is ruled out. An exudative effusion with a negative cytology without a known primary requires a diagnostic procedure and in the past as stated by Thomas and lynch (20) this has been pleural biopsy and thoracoscopy. However, the wisdom of repeated therapeutic thoracentesis can and should be questioned. Repeated thoracentesis increases the risks of pneumothorax, empyema and pleural fluid loculation. Johnston (4), explained that the major purpose of cytopathologic diagnoses on specimens of pleural effusion is to determine whether or not neoplastic cells are present. Awasthi, Gupta, Srinivasan, Nijhawan and Rajwanshi (6) explained that cytological examination of pleural fluid is also one of the most useful laboratory procedures in diagnosis of pleural effusions. Although tuberculosis is the commonest cause of pleural effusions in most developing countries, tumours including grade ones can present with the effusions. Metastatic adenocarcinoma was the commonest cause of malignant pleural effusions, a significant number of unusual causes of malignant pleural effusion were also encountered as explained by Nijhawan and Rajwanshi (6). Assi, Caruso, Herndon and Patz (21) conducted a study to determine the distribution of transudates versus exudates in pathologically malignant pleural effusions and also the importance for cytologic studies in patients with a transudative effusion concluded that transudate result from increased hydrostatic, oncotic or osmotic pressure and can be seen in entities including congestive heart failure,

ID # s080176 cirrhosis and renal failure and exudative effusions. The transudate have direct involvement with pleura which can be seen in malignant tumors, infections, connective tissue disorders and inflammatory processes such as pancreatitis. Sahn (22), specified that malignant pleural effusion can be diagnosed only by showing malignant cells in pleural fluid or pleural tissue. Renshaw, Dean, Antman, Sugarbaker and Cibas (28) stated that treatment of malignant mesothelioma at an early stage results in creased survival. Cytologic examination of pleural effusions is one of the first diagnostic techniques attempted in such patients. Thus, Renshaw, Dean, Antman, Sugarbaker and Cibas (28) demonstrated that thoracentesis for pleural fluid is an initial procedure and also a screening technique to primarily diagnose malignant pleural effusion. 1.3.3 Method The study done by Ayman, Soubani, Marco, Michelson and Ashok (13) is similar to the present study because the medical records of patients with human immunodeficiency virus infection and pleural effusion studied by thoracentesis over a 5 year period. The study also reviewed for demographics, clinical presentation, concomitant illnesses, pleural fluid analysis, management, and outcome. It is important to the present study because it is a retrospective study which follow up patients in the registers. Fartoukh, Azoulay, Galliot, et al (14), studied an intervention of routine thoracentesis in 82 patients without contraindications to thoracentesis. The 1 year prospective study on medical ICU patients with physical and radiographic evidence of pleural effusion and this study shows that thoracentesis pleural fluid is useful in detecting malignant cells. This study is important because it was an approaching study that helps the current retrospective study to develop a good follow up when looking at patients register. A study done by Porcel and Vives (17) was also a retrospective chart study that consisted of all patients undergoing thoracentesis during a 10 year period. This study is important because it is similar to the current study which is a reflective or backward looking study. A study done at Zagazig University Hospital (2000) by Mohamed, Mobasher and Yousef, et al (18) included thoracentesis, thoracoscopy, pleural biopsy and pleural lavage on fifty consecutive patients. The study findings had demonstrated that 32 patients had malignant pleural effusion, 15 patients had tuberculous pleural effusion and 3 patients had idiopathic effusion. This study is important to the present study because it include thoracentesis as one of the procedure done to diagnose malignant cells. A study done by, Assi, Caruso, Herndon and Patz (21), was a retrospective study that based on the review of all cytologically positive malignant pleural effuisons which was performed at Duke University Medical Centre over an 18 month period. The importance of this study to the present study is that it is a retrospective study which is similar to the current study and also because it was a review of malignant pleural effusions. Renshaw, Dean, Antman, Sugarbaker and Cibas (28), had reviewed medical records from a large general hospital and a cancer hospital and also cytologic slides of patients with pleural malignant mesothelioma were reviewed. This study is similar to the present study because Renshaw, Dean, Antman, Sugarbaker and Cibas (28) had look at the patients record and evaluation of pleural fluid for early diagnosis of malignant pleural effusion.

ID # s080176 1.3.4 Results Ayman, Soubani, Marco, Michelson and Ashok (13) stated that thoracentesis was done in 30 patients, 24 men and 6 women with the age of 27 to 45 years. This study found that the cause of pleural effusion was infectious in 70% and noninfectious in 30%. Streptococcus pneumonia, staphylococcus aureus, Nocardia sp and mycobacterial are responsible for infections and non Hodgkins lymphoma, kaposis sarcoma and adenocarcinoma are responsible for non infection. Fartoukh, Azoulay, Galliot, et al (14), discussed that thoracentesis was useful in 46 patients. The thoracentesis based diagnosis was different from the presumptive diagnosis in 37 patients. Thus, 32 patients with certain benefit from thoracentesis and 5 patients in whom thoracentesis invalidated the presumptive diagnosis without assessing the definitive diagnosis. Of the 37 patients in whom thoracentesis was useful regarding diagnosis assessment, 27 patients received a change in treatment based on thoracentesis findings, indicating a marked improvement in thoracentesis would be useful. Patients in whom thoracentesis was useful had a significant shorter time from ICU admission to thoracentesis. The importance of this results to the present study demonstrated that thoracentesis is a reliable procedure in diagnosing malignant pleural effusion. Another study done by Miloslav, Boris, Libuse, Eva and Light (15) stated that pleural fluid cytology study was the best technique for establishing diagnosis this is because cytologic study which include the wrights stain and papanicolaou stain for malignant cells which was the most accurate procedure in 60.8% of the patients. Pleural effusions associated with malignancy accounted for 63.3% of all effusions (15). 44.6% of the effusions were due to pleural malignancy while 18.7% were paramalignancy (15).Thus this study shows that out of 32 patients with malignant pleural effusion, 20 are positive for pleural fluid (thoracentesis) cytology. Miloslav, Boris, Libuse, Eva and Light (15), specified that combination of cytologic study and histology study was most helpful in 26 cases. The importance of this study is that it shows that thoracentesis is reliable in diagnosing malignant pleural effusion and also pleural biopsy support thoracentesis in malignancy diagnosis. Porcel (16), stated that although cytological examination of pleural fluid is an easy way to diagnose a pleural malignancy, it reports false negative of about 40%. However, in an immunocytochemistry on cytological fluid from a malignant pleural effusion of unknown origin, a positive TTF-1 stain strongly suggests a primary non small cell lung cancer, approximately 80% of lung adenocarcinoma shows TTF-1 positivity as stated by Porcel (16). This result indicates that thoracentesis for pleural fluid in pleural malignancy yield a good number of malignant cells that are detected or stained by this TTF-1 stain. Porcel and Vives(17), in a study done at the university hospital Arnau de Vilanova (2003) on patients who undergo thoracentesis, had identified that most frequent cause of pleural effusion was malignancy. Mohamed, Mobasher and Yousef et al (18) stated in their study that thoracoscopic had highest yield followed by lavage cytology, thoracentesis (fluid cytology) and biopsy with Abrahams needle in detecting malignant cells. Thomas and Lynch (20) identified that, cytology is positive or suspicious in 70% to 80% of patients with malignant pleural effusions. Renshaw, Dean, Antman, Sugarbaker and Cibas (28), identified that the median time from initial symptoms to the diagnosis of malignant mesothelioma was eight weeks for all patients and for patients with a positive cytologic result, the median was four weeks. This result indicated that thoracentesis for pleural fluid to diagnose malignant mesothelioma is efficient and has good turn around time.

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1.4.5 Conclusion Ayman, Soubani, Marco, Michelson and Ashok (13) concluded that pleural effusion is a main problem in advanced HIV patients and are most frequently associated with bacterial pneumonia. They continued that Cytological and microbiological examination of pleural fluid is helpful in determining the cause of pleural effusion in this patient population. Although, infection was the main cause of pleural effusions that was detected based on physical and radiographic findings in the MICU, Fartoukh, Azoulay, Galliot, et al(14) stated that routine thoracentesis has proved to be a simple and safe means of improving the diagnosis and treatment. Miloslav, Boris, Libuse, Eva and Light (3) stated in their study that fluid cytology study is a part of the four steps in the diagnostic work up of the patient with a pleural effusion.A study on the use of an implantable pleural catheter for trapped lung syndrome in patients with malignant pleural effusion at hospital of the university of Pennsylvania (2001), by Grace, Gant, Cathi, Washam, Daniel and Sterman (19), demonstrated that thoracentesis often the initial approach to malignant pleural effusion, is not reliably effective for long term control as pleural fluid may reaccumulate rapidly in a symptomatic fashion. However this study revealed that therapeutic thoracentesis is one of the options for patient with malignant pleural effusion who are least likely to benefit from pleural drainage and chemical sclerosis, those with so called trapped lung. Heffner (5), stated that even with non diagnostic thoracentesis, analysis of pleural fluid is useful in excluding other possible causes such as infection. Assi, Caruso, Herndon and Patz (21), specified that patients with undiagnosed pleural effusions usually have a thoracentesis as the first step in determining the cause of them and initial evaluation often is direct distinguishing transudate from exudates. Sahn (22) in one article stated that, cytology is a more sensitive test for the diagnosis of malignant pleural effusion than percutaneous pleural biopsy, it is because pleural metastases tend to be central and if clinicians suspected a malignant effusion, several hundred milliliters of fluid should be removed at the initial diagnostic thoracentesis. Sahn (22) explained that this procedure will not improve the yield on the initial study but if it is negative a repeat procedure several days later may provide fluid with fewer degenerative mesothelial cells and freshly exfoliated malignant cells and pleural biopsy should be reserved for the second thoracentesis if the initial pleural fluid cytological examination is negative. Additionally, if the second cytological examination and initial pleural biopsy are negative, a third cytological examination and second pleural biopsy soon after is not usually diagnostic (22).

ID # s080176 2.0 AIM The aim of this research is to determine how reliable thoracentesis (pleural fluid) in detecting cancer cell by following up with the results in pleural biopsy at CWMH from 2008 to 2010. 3.0 STATEMENT OF THE PROBLEM Pleural fluid (thoracentesis) and pleural biopsy are two tests in detecting cancer cells and are performed in cytopathology and histopathology respectively. However, thoracentesis has been regarded as a screening test. According to Heffner (5), pleural fluid analysis is the main method of determining causes of pleural effusion which uses simple procedure called thorancentesis. This allows fluid to be sampled, visualized, examined microscopically and quantified. Pleural biopsy is a confirmatory test that has been said to be sensitive and specific in detecting cancer cells. Attanoos and Gibbs (9) stated that all subtypes of malignant mesothelioma, open pleural biopsy produced the highest diagnostic accuracy which is of percent sensitivity and 95 percent specificity. Thoracentesis is a problem when it failed to diagnose a malignant pleural effusion when pleural biopsy was able to diagnose a pleural effusion suspected to be malignant, which is some instance that cytologic evaluation of pleural fluid of thoracentesis gives false positives and false negatives. Therefore by carrying out this research, one would like to find out whether thoracentesis is reliable in detecting cancer cells during the period from 2008 to 2010 in CWMH. 4.0 OBJECTIVES. 1. To find out the number of true positive for cancer in pleural fluid (thoracentesis) from 2008 to 2010. 2. To find out false positive for cancer in pleural fluid (thoracentesis) from 2008 to 2010. 3. To find out the number of true negative in pleural fluid (thoracentesis) from 2008 to 2010. 4. To find out the number of false negatives in pleural fluid (thoracentesis) from 2008 to 2010. 5. To make a conclusion, whether thoracentesis is also reliable in detecting cancer cells from 2008 to 2010.

ID # s080176 5.0 METHODOLOGY (Original hands on methodology). 5.1 Study design. The study design used in this research is retrospective, cross sectional study. The data will be collected from 2008 to 2010 using the cytology register for all positive results for pleural fluid, and then will be following up the positive pleural fluid results in the histology register to obtain results for pleural biopsy for these patients. Both negative and positive results will be recorded for pleural biopsy. 5.2 Study setting. This study will be conducted in CWMH cytology and histology laboratory in Fiji, Suva. 5.3 Study population. The study population will include all patients who were diagnosed with pleural cancer from pleural fluid and pleural biopsy in 2008 to 2010 at CWMH. Thus the study subject would include individual patients that are diagnosed with cancer from pleural fluid and pleural biopsy. The study base would include all existing data available for patients from 2008 to 2010. 5.4 Sampling. Data collected will be based upon the following criteria: 5.4.1 Inclusion criteria. 1. Potential data will be identified from available data from 2008 to 2010 data record from cytology and histology system (PATIS and registered book) on those patients results for biopsy and thoracentesis. 2. Data result from all thoracentesis and pleural biopsy only. 3. Sampling technique would involve selecting patients positive for pleural fluid (thoracentesis) in cytology and follow up their NHN in histology (pleural biopsy). The data for 3 years data for 2008 to 2010 of any age group, any gender, and any race. 4. Patients will be identified by codes 5.4.2 Exclusion criteria. 1. All those without pleural cancer will be excluded. 5.5 Data collection materials The following materials are to be used in carrying out this study: 1. 2. 3. 4. 5. 6. Cytology register Histology register NHN (National Hospital number) PATIS Microsoft Excel Epi- info.

ID # s080176 5.6 Data collection procedure. Firstly, approval and ethical approval will be sought from respective authorities. Identify pleural fluid records for patients in cytology register for 2008 to 2010. Find the records for patients diagnosed positive and negative for malignant cells. Follow up of NHN (national hospital number), Identify and collect all positive and negative results in pleural biopsy from histology. Tally all true positive results against all false positive for thoracentesis and all true negative results against all false negatives. Data collected will keep in password protected folders and own private folder. NHN will be given initials or code.

5.7 Data analysis. 1. The data collected will then be summarized in tables and charts. Also will be using the computer software such as Epi-Info for further analyzing of data collected. 2. Data entering, processing and analyzing will be done using Windows Microsoft Excel 2007. 5.8 Expected limitations. All studies have their own limitations. Thus, the expected limitation for this proposed study is as follow; 1. Waiting for the ethics approval, delays the data collection. 2. Follow up of data result according to NHN samples from pleural fluid or thoracentesis in cytology to histology takes time.

ID # s080176 3. Tallying data results for positive and negative results for each year from 2008 to 2010 takes time. 5.9 Ethical Issues 1. To obtain approval from FNU College Research Committee, NHRC, Lab Superitendent and the Consultant Pathologist, CWMH, to use the Histology and Cytology registers 2. The college research and Ministry of health, Fiji must approve my research project before obtaining secondary data from CWM hospital histology and cytology laboratory department. 3. This research project would only use available secondary data and it would not involve procedures. There will be no sample collection and tests carried out. 4. Records obtained will be only accessible to the principle investigator (Donald Horiratana), research supervisor (Shivanjali Sharma). 5. Data storage - No usage of Names. Codes will be used instead of names and this raw data will be kept in a locked drawer and soft copies in password protected PCs which will be shredded after three years. 6. Confidentiality/ Data storage - No usage of Names. Codes will be used instead of names and this raw data will be kept in a locked drawer and soft copies in password protected PCs which will be shredded after three years. All follow up cases or cancer patients will be given initials instead of using names or NHN, example ES (effusion sample) ES1, ES2, ES3 etc and BS (biopsy sample) BS1, BS2, BS3 etc to avoid repeated cases and to maintain patient confidentiality

ID # s080176 6.0 LIMITATIONS The limitation of this research project is that no data collection had been done due to delay of the CRC (College Research Committee) approval for data collections from the histology and cytology departments. This is an incomplete research project due to no ethical approval. Therefore, no data is available to analyze. As a result there is no data available for the results. However, this research project is mainly on literature reviews based on related articles to the present study. Most of the articles reviewed did not have the exact objectives this project supposed to cover, although these articles are not exactly the same as this project, they do demonstrated how reliable thoracentesis in global settings where the studies were done. 6.1 literature review methodology All the articles obtained for this research project were taken from Google scholar and EBSCO host database and the keywords used to search for the relevant articles includes: thoracentesis, pleural fluid, malignant pleural effusion, cytology evaluation, malignant cells, pleural biopsy. Articles are reviewed in the following format; INTRODUCTION, SIGNIFICANCE, METHOD, and RESULT. All the articles are global and no regional and local articles identified. There was no similar articles identified in Fiji and the pacific so all the articles used in this present study are from other countries.

ID # s080176 7.0 RESULTS The original intending hands on research was not carried out due to delay and no ethical approval by CRC (Community Research Committee). Therefore, no data was analyzed and no hands on result was available here. However, most of the results included in this research project were from relevant articles which were related to the present study. These results were included in the literature reviews and were discussed in the discussions of the present study.

ID # s080176 8.0 RESULTS/ DISCUSSION 8.1 pleural fluids Pleural fluids are fluids obtained from the pleural space and this space normally contains between 7 and 14 ml of fluid as defined by Bartter, Akers and Pratter (23). Bartter, Akers, Pratter (23) and Light and Lee (12), stated that an increased amount of fluid or an effusion will accumulate in the pleural space whenever the rate of fluid formation exceeds the rate of fluid removal. Thus, Bartter, Akers and Pratter (23) specified that, increase formation occurs either because of an elevated net hydrostatic pressure gradient known as transudation or because of increased permeability of the pleural vessels also known as exudation. 8.2 Causes of abnormalities to pleural effusion. There are many causes of abnormalities to pleural effusion as Grace, Gant, Cathi, Washam, Daniel and Sterman (19), specified that pleural effusions are a common and frequently disorderly complication of advanced malignancy and the most frequent etiology of malignant pleural effusion is bronchogenic carcinoma. Additionally, breast cancer is most in occurence, followed by lymphoma. The other causes as mentioned by these authors include mesothelioma, gastric or oesophageal cancer and ovarian carcinoma and development of malignant pleural effusion in general, signify poor prognosis, and the mean length of survival of the patients with malignant pleural effusion was estimated at 6 months. Metastatic adenocarcinoma was the commonest cause of malignant pleural effusions, a significant number of unusual causes of malignant pleural effusion were also encountered as explained by Nijhawan and Rajwanshi (6). 8.3 Thoracentesis There are several approaches that are medically involved to diagnose a pleural effusion and most of the approaches includes procedures like chest radiography, CT study of the thorax, thoracentesis, microbiologic studies on the pleural fluid, pleuroscopy, bronchoscopy, needle biopsy of the pleura and open pleural biopsy. However the purpose of this study is to look at one of the procedure known as thoracentesis on how dependable in diagnosing a malignant pleural effusion. Most of the articles obtained for review in this literature review study are also retrospective study. For instance a study done by, Assi, Caruso, Herndon and Patz (21), was a retrospective study that was based on the review of all cytologically positive malignant pleural effuisons which was performed at Duke University Medical Centre over an 18 month period. A study done by Porcel and Vives (17) was a retrospective chart study that was a review of all patients undergoing thoracentesis during a 10 year period. Although these researches look at the patients cytological reviews and retrospective studies, they didnt meet the exact procedure or methodology of this current study should undertaken. Therefore the results obtained for their studies are not really exactly as the result this current study hope to accomplish. Porcel (16), stated that although cytological examination of pleural fluid is an easy way to diagnose a pleural malignancy, false negative of about 40% has been reported. In Porcels article false negative tend to be low so this means that thoracentesis still gives good positive diagnosis on pleural malignancy. Fartoukh, Azoulay, Galliot, et al (14), discussed the usefulness of thoracentesis that indicated thoracentesis yield a good turnaround time for diagnosing of malignant cells in pleural fluid where patients have shorter time from ICU admission. Another study done by Miloslav, Boris, Libuse, Eva and Light (15) stated that the pleural fluid cytology study was the best for establishing a diagnosis this is because cytologic study which included the wrights satin and papanicolaou stain for malignant

ID # s080176 cells was the most definitive procedure in 60.8% of the patients including 60 with malignancy and 18 with inflammatory type effusions. Thus this study shows that out of 32 patients with malignant pleural effusion, 62.5% are positive for pleural fluid (thoracentesis) cytology. This results demonstrated that thoracentesis for pleural fluid is still reliable in detecting malignant cells.A lot of the articles related to thoracentesis or pleural fluid did not have the same objectives as this proposed research objectives, the articles objectives always look at different direction. However, the retrospective study articles provide additional evidence that thoracentesis when performed by pulmonology and interventional radiology attending physicians is a safe procedure. Thus a lot of these articles discussed that thoracentesis is not a procedure on its own, thoracentesis is a part of the whole steps in diagnosing a malignancy, for instance there are instances where thoracentesis failed to detect a malignant cell that pleural biopsy is able to detect or vice versa. Additionally thoracentesis is a procedure that is reliable in quick screening of patients with suspected unknown malignant pleural effusion. 8.4 Pleural biopsy Pleural biopsy is a technique used as a diagnostic method to confirm if pleural effusion is suspected to be malignancy. It is useful when thoracentesis has not able to verify a specific diagnosis of malignant pleural effusion. Klein and Heffner (29) stated that when malignant pleural effusion is still suspected after thoracentesis and pleural fluid analysis but cytology has not established a specific diagnosis, pleural biopsy might be indicated. Attanoos and Gibbs (9), done a study on evaluation of the diagnostic accuracy of closed and open pleural biopsies in diagnosing the malignant pleural mesothelioma. Attanoos and Gibbs (9) explained that biopsy specimen size was important in obtaining a positive absolute diagnosis. Attanoos and Gibbs (9) concluded that eventhough, all procedures had efficacy, the best diagnostic accuracy for blind closed pleural biopsy was low and depended on size of biopsy specimen and tumour subtype. Paulose, Shee, and Abdelhadi (10) in their 3 yearlong study specified that, imprint cytology can be used to provide a rapid, preliminary diagnosis of lung cancer and found that imprint cytology gave a 100% accuracy in the diagnosis of small cell lung carcinoma (SCLC) and 91% accuracy in the diagnosis of non small cell lung carcinoma (NSCLC), this means that thoracentesis in terms of cytologic study, gives definitive diagnosis on malignant cells which is relevant to my study. It is a quick, sensitive and highly specific method for detecting lung malignancies. In other words it a confirmatory test. Tuder (11) was doing study on histopathological criteria for diagnosis of malignant neoplasm involve pleura, on 11 pleurectomy specimens containing absolute malignant cells and identified that the most important feature for a diagnosis of malignancy was the pattern of neoplastic access of the fibrous sub pleural tissue. 8.5 Sensitivity, specificity of thoracentesis for pleural fluid and pleural biopsy. Renshaw, Dean, Antman, Sugarbaker and Cibas (28) stated that the overall sensitivity of cytologic examination for the diagnosis of malignant mesothelioma is 32%, which mean that cytologic evaluation of pleural fluid from thoracentesis for diagnosing malignant cells alone is low. Therefore Renshaw, Dean, Antman, Sugarbaker and Cibas (28) had recommended immediate pleural biopsy in patients in whom malignant mesothelioma is suspected and when cytologic evaluation of pleural fluid gives negative results. That is if the pleural biopsy is positive for malignant mesothelioma, then the result for cytologic evaluation of pleural fluid is false negative. Hsu (30) verified that the cytopathology correlation was 96.5% accurate with 0.1 % false positive results and 0.18% false negative results by cytology. The sensitivity of cytologic detections was 6.7% higher than that of pleural biopsy. This result shows that pleural fluid or thoracentesis is reliable in detecting malignant

ID # s080176 cells in cytologic evaluation with higher sensitivity and also low false negatives and low false positives. Attanoos and Gibbs (9) stated that all subtypes of malignant mesothelioma, open pleural biopsy produced the highest diagnostic accuracy of 100 percent sensitivity and 95 percent specificity. This article specified that pleural biopsy is reliable and a confirmatory technique for diagnosing malignant pleural effusion. According to Light and Lee (12), pleural biopsy increases diagnostic yield and confirmation of malignant pleural effusion especially in computed tomography guided pleural biopsy. Bueno, Reblando and Glickman (3) said that pleural biopsy was proposed as the diagnostic gold standard when they investigated the accuracy of open pleural biopsy for diagnosis and subtype identification of malignant pleural mesothelioma (MPM). Thus, this resulted showed a sensitivity of pleural biopsy for MPM is 97% with a specificity of 56%. They concluded that open pleural biopsy is accurate and should be considered as the gold standard diagnostic method for malignant pleural mesothelioma (MPM). These articles demonstrated that pleural biopsy goes in hand with thoracentesis for pleural fluid and also pleural biopsy is a confirmatory test to detect and diagnose malignant pleural effusion. All the articles discussed in this project are global international articles; however there are no regional and local articles identified in the search. Thus, this literature review demonstrated that there was no similar study done on this particular topic in the region and also locally. So the result identified from the global articles would relevant to the setting where the studies were done, somehow these global articles aid in demonstrating how reliable thoracentesis is when used to detect malignant cells in malignant pleural effusion.

ID # s080176 9.0 CONCLUSION Thoracentesis for pleural fluid is a screening test done in Cytopathology departments that is dependable as an initial procedure or step performed to detect malignant cells from malignant pleural effusion. The advantage of thoracentesis for pleural fluid over other procedures is that the tumor cells are abundant in pleural fluid. Sahn (22) in one article stated that, cytology is a more sensitive test for the diagnosis of malignant pleural effusion than percutaneous pleural biopsy, this is because pleural metastases tend to be central and if clinicians suspected a malignant effusion, several hundred milliliters of fluid should be removed at the initial diagnostic thoracentesis. Therefore thoracentesis or pleural fluid is also a main back bone tool of medical procedures that aid in determining the presence of malignant cells in malignant pleural effusion. This procedure is also helpful when used together with other procedures such pleural biopsy, thoracoscopy for the overall diagnosis of pleural malignant effusion which shows that thoracentesis never done alone to detect malignant cells in diagnosing malignant pleural effusion, it also need support from other procedures. Pleural fluid cytologic examination is a useful initial step in the diagnostic work up of patients suspected with malignant pleural effusions.

ID # s080176 10.0 RECOMMENDATIONS Some recommendations based on the reviewing of the articles: 1. There is need for more hands on study that is similar study to the present study to be done locally. 2. Thoracentesis is reliable as a screening test for malignancy. 3. Thoracentesis aids in detecting unknown pleural effusion. 4. Pleural biopsy must be done together with thoracentesis when thoracentesis failed to diagnose malignant pleural effusion, before final diagnosis of malignant cells is made.

ID # s080176 11.0 IMPLICATIONS OF STUDY RESULTS The study result would suggest thoracentesis reliablity from 2008 to 2010 at CWMH as a screening test for pleural cancer and also conservation for patients.

12.0 DISSEMINATION OF RESULT 1. Write a report to the Ministry of health of Fiji 2. Oral presentation to Histology and cytology department 3. Publication

ID # s080176 13.0 WORK PLAN and TIME FRAME (2011)

Activities Proposal write- up Ethical approval Data collection Analysis Write- up

April

May

June

July

August

Sept

Nov.

14.0 BUDGET ITEMS/RESOURCES ESTIMATED COSTS (FJD)

Services

Photocopying Printing Binding $ 50.00

Supplies /stationary Grand total cost for the study

$ 50.00

$ 100.00

ID # s080176 15.0 REFERENCE (1) Light R, Maggregor I, Luchsinger P, et al. Pleural effusions: The diagnostic Separation of Transudates and Exudates. Annual of Internal Med. 1972 Oct; 77 (4): 507. (2) Salyer W, Eggleston J and Erozan Y. Efficacy of pleural needle biopsy and pleural fluid cytopathology in the diagnosis of malignant neoplasm involving the pleura. Chestjrnl. 1975 May; 67 (5): 536. (3) Bueno R, Reblando J, and Glickman J, et al. Pleural biopsy: A reliable method for determing the diagnosis but not subtype in mesothelioma. Ann Thorac Surg. 2004 May 4; 78: 1774-6 (4) Johnston, William W. The malignant pleural effusion. Cancer. 1985 Aug 15; 56 (4): 905-9. (5) Heffner J E. Diagnostic evaluation of a pleural effusion in adults.UpToDate. 2010 April 27. (6) Awasthi A, Gupta N, Srinivasan R, Nijhawan R and Rajwanshi A. Cytopathological spectrum of unusual malignant pleural effusions at a tertiary care centre in north India. Cytopathology. 2007 Jan 23; 18 (1): 28-32 (7) Prakash U B and Reiman H M. Comparison of needle biopsy with cytologic analysis for the evaluation of the pleural effusion: analysis of 414 cases. Mayo Clin Proc. 1985 Mar; 60 (3): 158-64. (8) Poe RH, Israel RH, Utell M J, Hall WJ, Greenblatt D W and Kallay MC. Sensitivity, Specificity, and Predictive values of closed pleural biopsy. Arch Intern Med. 1984; 144(2): 325-28 (9) Attanoos R L and Gibbs A R. The comparative accuracy of different pleural biopsy techniques in the diagnosis of malignant mesothelioma. Histopathology. 2008 Jul 21; 53(3): 340-4. (10) Paulose R R, Shee C D, and Abdelhadi A I. Accurracy of touch imprint cytology in diagnosing lung cancer. Cytopathology. 2004 Mar 25; 15 (2): 109-112. (11) Tuder R M. Malignant disease of the pleura: a histopathological study with special emphasis on diagnostic criteria and differentiation from reactive mesothelium. Cytopathology. 2007 Apr 3; 10 (8): 851-65. (12) Light R W and Lee C G. Pleural effusion. Encyclopedia of Respiratory Medicine. 2006 May 2: 353-58. (13) Ayman O, Soubani, Marco K, Michelson, Ashok K. Pleural fluid findings in patients with the acquired immunodeficiency syndrome. Southern Med Journ. 1999 Apr; 92(4): 400-2. (14) Fartoukh M, Azoulay E, Galliot R, et al. Clinical documentated pleural effusions in medical ICU patients. Chest. 2002 Jan; 121(1): 178-184 (15) Miloslav M, Boris S, Libuse M, Eva S, Light WR. Diagnosis of Pleural effusions. Chest. 1995 June; 107 (6): 1598-1603 (16) Porcel JM. Pearls and myths in pleural fluid analysis. Respiratory. 2010 Jun 21; 16(1): 44-52 (17) Porcel JM, Vives M. Etiology and pleural fluid characteristics of large and massive effusions. Chest. 2003 Sept; 124 (3): 978-983

ID # s080176 (18) Mohamed KH, Mobasher A A M T, Yousef A I, et al. Pleural lavage: A novel diagnostic approach for diagnosing exudates pleural effusion. Lung. 2000; 178: 371-79. (19) Grace W, Gant MJ, Cathi L, Washam, Daniel H, Sterman. Use of an Implantable pleural catheter for trapped lung syndrome in patients with malignant pleural effusion. Chest. 2001 June; 119(6): 16411646. (20) Thomas JL. Management of Malignant Pleural Effusions. Chest. 1993 April; 103 (4): 385-89. (21) Assi K, Caruso JL, Herndon J, Patz EF. Cytologically proved malignant pleural effusion. Chest. 1998 May; 113(5): 1302-04. (22) Sahn SA. Pleural disease related to metastatic malignancies. Eur Respir J. 1997; 10: 1907-13. (23) Bartter T, Akers SM, Pratter MR. The evaluation of pleural effusion. Chest. 1994 Oct; 106 (4): 1209-14 (24) Harris P, Nagy S, Vardaxis N, eds. Mosbys dictionary of medicine, nursing & health professions. 1st edn. Marrickville: Elsevier; 2006. 1702. (25) Porcel JM, Light RW. Diagnostic approach to pleural effusion in adults. Am Fam physician. 2006 Apr 1; 73(7): 1211-20. (26) Putnam JB. Malignant pleural effusions. Surg Clin N Am. 2002; 82: 867-83. (27) ChyrYang P, Tay Luh K, Bing Chang D, Dong Wu H, Jen Yu C, Hsong Kuo S. Value of Sonography in determining the nature of pleural effusion. AJR. 1992 July; 159: 29-33. (28) Renshaw AA, Dean BR, Antman KH, Sugarbaker DJ, Cibas ES. The role of cytologic evaluation of pleural fluid in the diagnosis of malignant mesothelioma. Chest. 1997 Jan; 111 (1): 106-09. (29) Klein JS, Heffner JE. Recent advances in the diagnosis and management of malignant pleural effusions. Mayo Clin Proc. 2008 Feb; 83 (2): 235-50. (30) Hsu C. Cytologic detection of malignancy in pleural effusion: A review of 5,255 samples from 3,811 patients. Diagn Cytopathol [ serial on the internet]. 1987 March 12; [cited 2011 Oct 6]; 3 (1): [3 screens]. Available from: onlinelibrary.wiley.com/doi/10.1002/dc.2840030103/abstract

ID # s080176 16.0 BIBLIOGRAPHY Assi Z, Caruso JL, Herndon J, Patz EF. Cytologically proved malignant pleural effusions. Chest. 1998 May; 113 (5): 1302-04 Cragun HW, Pleural effusion failures. Chest. 2002 Nov; 122 (5): 1505-06. Decamp MM, Mentzer SJ, Swanson SJ, Sugarbaker DJ. Malignant effusive disease of the pleura and pericardium. Chest. 1997 Oct; 112 (4): 291-95. McGuire FR, Gourdin T, Finley JL, Downie G. Xanthomatous pleuritis mimicking mesothelioma. Respir. 2009; 77: 215-18. Menzies R, Charbonneau M. Thoracoscopy for the diagnosis of pleural diseas. Ann of Intern Medicine. 1991 Feb 15; 114 (4): 271-75. Poe RH, Levy PC, Israel RH, Ortiz CR, Kallay MC. Use of fiberoptic bronchoscopy in the diagnosis of bronchogenic carcinoma. Chest. 1994 June; 105 (6): 1663-67. Rivera MP, Detterbeck F, Mehta AC. Diagnosis of lung cancer. Chest. 2003 Jan; 123 (3): 129-36 Yacovone ML, Kartan R, Bautista M. Intercostal artery laceration following thoracentesis. Respir Care. 2010 Nov; 55 (11): 1495-98

ID # s080176 17.0 APPENDIXES 17.1 Annex 1. List of Abbreviations. CWMH CRC NHRC ICU MPM SCLC NSCLC CT FNU TTF-1 NHN Colonial War Memorial Hospital College Research Committee National Health Research Committee Intensive Care Units Malignant Pleural Mesothelioma Small Cell Lung Carcinoma Non Small Cell Lung Carcinoma Computed Tomography Fiji National University Thyroid Transcription factor 1 National Hospital Number

17.2 Annex 2. Glossary Pleural biopsy: is a technique used as a diagnostic method to confirm if pleural effusion is suspected to be malignancy. It is useful when thoracentesis has not able to verify a specific diagnosis of malignant pleural effusion. Pleural effusion: abnormal accumulation of fluid in the intrapleural spaces. Pleural fluid: filtrate from the parietal pleura, enters the pleural space and is then reabsorbed through the parietal pleural stomata. Fluids obtained from the pleural space and this space normally contains between 7 and 14 ml of fluid. Malignant: describing a tumour that invades and destroys the tissue in which it originates and has the potential to spread to other sites in the body through the blood stream and lymphatic system. Malignant pleural effusion: Malignant pleural effusion is usually suspected as a complication that is related to development of tumor or infection in individuals who have diagnostic thoracentesis findings. Thoracentesis: the insertion of a hollow needle into the pleural cavity through the chest wall in order to withdraw fluid, blood, pus or air.