Utility of hyaluronic acid in pleural fluid for differential diagnosis of pleural effusions: likelihood ratios for malignant mesothelioma

Our plain-English summary of Utility of hyaluronic acid in pleural fluid for differential diagnosis of pleural effusions: likelihood ratios for malignant mesothelioma, by S. Atagi, M. Ogawara, M. Kawahara, et al (Japanese Journal of Clinical Oncology, 1997).

The study

• Authors: S. Atagi, M. Ogawara, M. Kawahara, M. Sakatani, K. Furuse, E. Ueda, S. Yamamoto
• Journal: Japanese Journal of Clinical Oncology
• Published: 1997;27(5):293-7
• Cited by: 19 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

The level of hyaluronic acid (HA) was determined in the pleural fluid of 99 patients, including 19 with malignant mesothelioma, 27 with lung cancer, 1 with breast cancer, 1 with mediastinal tumor and 51 with non-malignant diseases. With a cut-off level at 100 micrograms/ml, the pleural fluid concentration of HA was high in 36.8% of patients (7 of 19) with malignant mesothelioma and 1.3% of patients (1 of 80) with lung cancer and other malignant and non-malignant diseases. The mean concentration of pleural fluid HA was significantly higher in patients with mesothelioma than in those with lung cancer and other malignant and non-malignant diseases. The pre-test probability of MM was 5.9% in this series. The LRs for > or = 100, 50-99 and < or = 49 micrograms/ml are 28.3, 3.3 and 0.5, respectively; these put the post-test probabilities at 64, 17 and 3%, respectively. Indeed, in cases of uncommon disease such as MM, the post-test probability is low even if the cut-off level of HA is > or = 100 micrograms/ml. The discrimination between malignant mesothelioma and lung cancer needs special attention. In these two diseases, the LRs of MM for pleural fluid CEA > 30, 10-30 and < 10 ng/ml were 0.2, 1.9 and 2.4, respectively. The pre-test probability of MM for HA > or = or 100 micrograms/ml is 64%. Furthermore, because the LR for CEA is < 10 ng/ml, the post-test probability is 81%. When the combination of two markers is considered, the high level of HA and the low level of CEA may be useful for the differential diagnosis of MM from pleuritis carcinomatosa.

In plain English

This study at a chest hospital in Osaka, Japan, measured hyaluronic acid (HA) in fluid drained from around the lungs (pleural fluid). Between February 1994 and January 1995 the authors tested 85 consecutively admitted patients with pleural effusion plus 14 samples from patients already diagnosed with mesothelioma: 99 patients, 19 with malignant pleural mesothelioma and 27 with lung cancer. Asbestos exposure was not discussed. Mean HA was 515.8 micrograms per millilitre in mesothelioma patients and 32.8 in lung cancer patients; mesothelioma levels were significantly higher than in other patients (p = 0.048). HA of 100 or more was found in 7 of 19 mesothelioma patients and 1 of 80 others. With mesothelioma making up 5.9% of consecutive patients, such a result put the calculated probability of mesothelioma at 64%. In 13 mesothelioma and 25 lung cancer patients, another marker, CEA, was significantly lower in mesothelioma (p = 0.018). The authors concluded that combining HA and CEA may help distinguish mesothelioma from cancer spread to the pleura, noting HA alone may be insufficient.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Prospective diagnostic-test study of consecutive patients with pleural effusion, with stored samples from previously diagnosed mesothelioma patients added; likelihood ratios calculated for a pleural fluid marker
• Who was studied: 99 patients with pleural effusion at National Kinki Central Hospital, Osaka, Japan, February 1994 to January 1995: 85 consecutively admitted patients plus 14 samples from patients previously diagnosed with malignant mesothelioma. In total, 19 had malignant pleural mesothelioma, 27 lung cancer, 30 tuberculous pleuritis, 7 pyothorax and the rest other conditions.
• Exposure: Not an exposure study; asbestos or fiber exposure is not reported. The measures studied were hyaluronic acid (HA) and, in some patients, carcinoembryonic antigen (CEA) levels in pleural fluid.
• Main results:
  • Mean HA in pleural fluid was 515.8 ± 1201.1 (range 24–5100) µg/ml in mesothelioma patients versus 32.8 ± 14.9 µg/ml in lung cancer patients. HA was significantly higher in mesothelioma patients than in patients with other pleural effusions including lung cancer (p = 0.048).
  • At a cut-off of 100 µg/ml, HA was high in 7 of 19 mesothelioma patients and 1 of 80 other patients, giving a sensitivity for mesothelioma of 36.8% and a specificity of 98.7%.
  • Likelihood ratios for mesothelioma were 28.3 for HA of 100 µg/ml or more, 3.3 for 50 to 99, and 0.5 for 49 or less. Mesothelioma made up 5.9% of the consecutive series (5 of 85). Starting from that pre-test probability, an HA of 100 or more gave a post-test probability of 64%.
  • In 13 mesothelioma patients and 25 lung cancer patients, median pleural fluid CEA was 6.1 ng/ml in mesothelioma and 1045.2 ng/ml in lung cancer, significantly lower in mesothelioma (p = 0.018).
  • Among patients with mesothelioma or lung cancer, likelihood ratios for mesothelioma were 0.2 for CEA above 30 ng/ml, 1.9 for 10 to 30, and 2.4 for below 10.
  • In the authors' worked example, a patient with HA of 100 µg/ml or more (probability 64%) and CEA below 10 ng/ml would have a post-test probability of mesothelioma of 81%. With HA of 100 or more and CEA above 30, it would be 26%.
• The authors' conclusion: The authors concluded that considering the two markers together, HA and CEA levels may be useful for telling malignant mesothelioma apart from pleural carcinomatosa (cancer spread to the pleura).
• Limitations the authors state:
  • The authors stated that HA measurement in pleural fluid alone may be of insufficient practical clinical value.
  • The authors noted that because mesothelioma is uncommon, the probability of mesothelioma after testing stays low even with HA of 100 µg/ml or more.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Lung cancer, Mesothelioma, Pleural plaques and thickening.

Medical terms in this study, explained in our Lexicon: Hyaluronic Acid, Differential Diagnosis, Pleural Effusion, Malignant Mesothelioma, Lung Cancer, Mesothelioma.

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