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Malignant pleural effusion (MPE) is a common complication of thoracic and extrathoracic malignancies and is associated with high mortality and elevated costs to healthcare systems. Over the last decades the understanding of pathophysiology mechanisms, diagnostic techniques and optimal treatment intervention in MPE have been greatly advanced by recent high-quality research, leading to an ever less invasive diagnostic approach and more personalized management. Despite a number of management options, including talc pleurodesis, indwelling pleural catheters and combinations of the two, treatment for MPE remains symptom directed and centered around drainage strategy. In the next future, because of a better understanding of underlying tumor biology together with more sensitive molecular diagnostic techniques, it is likely that combined diagnostic and therapeutic procedures allowing near total outpatient management of MPE will become popular. This article provides a review of the current advances, new discoveries and future directions in the pathophysiology, diagnosis and management of MPE.

This letter summarizes the current literature on pleural fluid biomarkers that predict treatment response to chemical pleurodesis and indwelling pleural catheters in patients with malignant pleural effusion. We found evidence on pleural fluid biomarkers to be limited to a few small studies, where the biomarkers prognostic value was not tested in separate validation cohorts. Although low pleural fluid LDH, high glucose, and high pH levels are associated with pleurodesis success, no clinically valuable biomarker has been identified. Hence, further research on the inflammatory processes of malignant pleural effusion and during definitive pleural procedures is needed, as well as proper testing of potential biomarkers in separate model derivation and validation cohorts.

Background Pleural Mesothelioma (PM) is an asbestos-related cancer with poor prognosis. Despite the 1992 national asbestos ban, new cases continue to occur due to the long latency of the disease. The study aim was to evaluate incidence and survival trends of pleural mesothelioma in the Marche Region, central Italy, between 2013 and 2022. Methods This population-based incidence study included adult residents of the Marche Region between 2013 and 2022. Incident PM cases were identified from the Cancer Registry of Marche Region. Incidence rates per 100,000 person-years (py) were calculated and stratified by sex, age, and province of residence. Temporal trend and covariates effect were assessed with Poisson regression. Overall survival was estimated using the Kaplan-Meier method and compared across subgroups; adjusted hazard ratios (HR) were obtained from multiple Cox regression model. Results Between 2013 and 2022, there were 322 incident PM cases (82% male; median age 77 years). The crude incidence rate was 2.1 per 100,000 py (95% CI: 1.9–2.4), with no temporal change over the study period. The highest rates were observed in men, in age-group 75–79 years, and in the province of Ancona. One- and five-year survival rates were 48.8% and 8.3%, respectively. Older age and non-epithelioid histology were independently associated with higher mortality. Conclusions The incidence of pleural mesothelioma in the Marche Region remained stable between 2013 and 2022, with a peak in 2018 requiring further observation to confirm it. The persistently high burden among men, older adults, and those living in industrialized coastal areas reflects the legacy of historical asbestos exposure. Continued population-based surveillance, integrated with follow-up of previously exposed workers, remains essential to monitor disease trends and support timely diagnosis and appropriate care pathways.

Rationale Severe asthma is burdened by relevant socio-economic and clinical impact. Randomized controlled trials on Dupilumab showed efficacy and a good safety profile, but post-market studies are needed. Objectives To evaluate the impact of Dupilumab on (i) the use of anti-asthmatic drugs, including oral corticosteroids (OCS), (ii) the rates of asthma exacerbation-related hospital admissions, and (iii) the healthcare costs in patients with asthma. Methods Data were retrieved from Healthcare Utilization database of Lombardy region (Italy). We compared healthcare resources use between the 6 months after Dupilumab initiation (“post-intervention period”) and (i) the 6 months before Dupilumab initiation (“wash-out period”) and (ii) the corresponding 6 months of the prior year (“pre-intervention period”). Main results In a cohort of 176 patients, Dupilumab significantly reduced anti-asthmatic drugs use (including OCS and short-acting β2-agonists, inhaled corticosteroids (ICS)/long-acting β2-agonists and ICS alone) when comparing the “pre-intervention” to the “post-intervention” period. When considering hospital admissions, we observed a not statistically or marginally significant reduction between both periods before Dupilumab and the post-intervention period. Six-months discontinuation rate was 8%. Overall healthcare costs had a tenfold increase between the “pre-intervention” and “post-intervention” period, which was mainly led by the biologic drug cost. Conversely, expenditures connected to hospital admissions did not change. Conclusions Our real-world investigation suggests that Dupilumab reduced anti-asthmatic drugs use, including OCS, in comparison to a corresponding period in the prior year. However, long-term healthcare sustainability remains an open issue.

Background: The role of endoscopic ultrasound with bronchoscope fine-needle aspiration (EUS-B-FNA) in the diagnosis of suspected malignant pulmonary lesions adjacent to the esophagus has been poorly investigated. The aim of the present study was to assess the accuracy of EUS-B-FNA for the diagnosis and molecular profiling of paraesophageal pulmonary lesions, as well as its predictors of success. Materials and Methods: Patients who underwent EUS-B-FNA for the diagnosis of paraesophageal lesions were consecutively enrolled in four Italian centers. Demographic, clinical, procedural, pathological, and molecular characteristics of the malignant samples were collected. The primary outcome was the diagnostic accuracy for pulmonary malignancies. Secondary outcomes were diagnostic yield and predictors of success for diagnosis and molecular profiling. Results: 107 adult patients (60 [56.1%] males; median (interquartile range) age: 69 [60–70] years) were enrolled. The diagnostic accuracy of EUS-B-FNA was 95.3% in the overall cohort and 95.2% in the 99 patients with a final diagnosis of malignancy. Neither clinical nor procedural variables significantly affected the diagnostic accuracy, whereas rapid on-site evaluation (ROSE), performed by pathologists or trained pulmonologists, was a strong predictor for a complete molecular profiling (OR [95% CI]: 12.9 [1.2–137.4]; p value: 0.03). Conclusion: EUS-B-FNA is a safe and accurate method for the diagnosis of paraesophageal pulmonary lesions. The presence of ROSE is relevant for a complete molecular profiling in this selected cohort of patients with advanced lung cancer.

IntroductionThere is a wide global variation in research priorities and current clinical practise among pleural medicine practitioners. Research performed today will inform future clinical practice, but the patient’s voices are often not heard in setting the research agenda. The International Multicentre Pleural Research Collaborative (IMPACT) European Respiratory Society (ERS) Clinical Research Collaboration (CRC) aims to present a consensus document from both pleural disease experts and patients, which will guide pleural disease research in the immediate future. The objective is to ensure a focus on scientifically valid, clinically meaningful and patient-centred pleural disease research with global relevance.Methods and analysisThe core working group will collate a list of previously identified research questions in the key topics in pleural disease: pleural infection, pleural malignancy, pneumothorax, pleural mesothelioma and non-malignant pleural effusions. These questions will be ranked in importance (based on a judgement of scientific merit, significance, innovation, relevance and feasibility) using a Delphi method, by a panel of pleural disease experts. The questions which reach consensus will be subject to a Delphi method survey of patients. The patient-modified list will be discussed in a consensus group meeting involving both experts and patients, who will produce the final prioritised list of research questions.Ethics and disseminationEthical approval will be waived for the active involvement of patients as either advisors or participants in questionnaires. The results will be reported in the form of a peer-reviewed publication with an open access license, according to the ACCORD (ACcurate COnsensus Reporting Document) guidelines for consensus-based research.

Background Shipping and port-related air pollution has a significant health impact on a global scale. The present study aimed to assess the mortality burden attributable to long-term exposure to ambient particulate matter (PM 2.5 , PM 10 ) and nitrogen dioxide (NO 2 ) in the city of Ancona (Italy), with one of the leading national commercial harbours. Methods Exposure to air pollutants was derived by dispersion models. The relationship between the long-term exposure of air pollution exposure and cause-specific mortality was evaluated by Poisson regression models, after adjustment for gender, age and socioeconomic status. Results are expressed as percent change of risk (and relative 95% confidence intervals) per 5 unit increases in the exposures. The health impact on the annual number of premature cause-specific deaths was also assessed. Results PM 2.5 and NO 2 annual concentrations were higher in the area close to the harbour than in the rest of the city. Positive associations between each pollutant and most of the mortality outcomes were observed, with estimates of up to 7.6% (95%CI 0.1, 15.6%) for 10 µg/m 3 increase in NO 2 and cardiovascular mortality and 15.3% (95%CI-1.1, 37.2%) for 10 µg/m3 increase PM 2.5 and lung cancer. In the subpopulation living close to the harbour, there were excess risks of up to 13.5%, 24.1% and 37.9% for natural, cardiovascular and respiratory mortality. The number of annual premature deaths due to the excess of PM 2.5 and NO 2 exposure (having as a reference the 2021 World Health Organization Air Quality Guidelines) was 82 and 25, respectively. Conclusions Our study confirms the long-term health effects of PM and NO 2 on mortality and reveals a higher mortality burden in areas close to shipping and port-related emissions. Estimating the source-specific health burdens is key to achieve a deeper understanding of the role of different emission sources, as well as to support effective and targeted mitigation strategies.

IntroductionPleural infection is a common problem associated with a high mortality. The aim of this study is to address current knowledge gaps in this condition by describing the global burden of disease and assessing the regional and seasonal variation in causative organisms, demographic characteristics, clinical presentation, comorbidities, pleural effusion characteristics, management strategies and outcomes. These data will inform future research and management guidelines.Methods and analysisWe will conduct an international multicentre point prevalence survey at two seasonal time points during the year. At each seasonal time point, data will be collected for 4 weeks on every episode of pleural infection presenting to the sites. Important demographic characteristics, medical history, clinical and imaging features, laboratory results, treatments and outcomes will be collected and analysed with a combination of descriptive and inferential statistics.Ethics and disseminationThe study will be performed in accordance with the Declaration of Helsinki and the International Conference on Harmonisation/Good Clinical Practice. This trial received ethical approval from the Comitato Etico Regione March, Italy, Prot. 2024 266. Institutional approvals will be acquired at all sites. All data will be treated confidentially and collected anonymously into an access-controlled electronic database. Results will be disseminated at conferences and in peer-reviewed publications.

Background Pleural disease (PD), particularly malignant pleural effusion (MPE), is a common cause of hospital admission and its prevalence is rising worldwide. Recent advances in diagnostic and therapeutic options, such as Indwelling Pleural Catheters (IPCs), have simplified PD treatment, allowing an effective outpatients management. Therefore, dedicated pleural services can improve PD care, guaranteeing specialized management and optimizing time and cost. We aimed to provide an overview on MPE management in Italy, mainly focused on distribution and characteristics of pleural services and IPCs use. Methods A nationwide survey, endorsed by the Italian Thoracic Society, was distributed by email to members of selected subgroups in 2021. Results Ninety (23%) members replied, most of whom being pulmonologists (91%). MPE resulted the most common cause of pleural effusion and was managed with heterogenous approaches, including talc pleurodesis via slurry (43%), talc poudrage (31%), repeated thoracentesis (22%) and IPCs insertion (2%). The setting of IPC insertion was inpatient care in 48% of cases, with a predominance of draining frequency every other day. IPC management mainly relied on caregivers (42%). The presence of a pleural service was reported by 37% of respondents. Conclusions The present study provides an extensive overview of MPE management in Italy, showing a highly heterogeneous approach, a scarce prevalence of out-patient pleural services, and a still limited adoption of IPCs, mainly due to lack of dedicated community care systems. This survey emphasizes the need of promoting a higher spreading of pleural services and an innovative healthcare delivery with more favourable cost-benefit ratio.

IntroductionIn the last decades, many haemostatic substances included oxidized cellulose topically applied have been used during surgery and their use have become a common practice. Oxidized cellulose (OC) is one of the most used haemostatic substances. However, different studies have shown the persistence of OC deposits after surgical procedures that may simulate recurrent malignancies and abscesses. We present a case series of patients with enlarged on CT and PET-FDG positive lymphadenopathies due to foreign body inflammatory reaction to OC after lung surgery for pulmonary malignancies.MethodsRetrospective chart review of patients from 2021 to 2022 who underwent EBUS-TBNA for the characterization of hilar and/or mediastinal lymphadenopathies and a histopathological diagnosis of foreign body inflammatory reaction to OC.ResultsEight patients were referred to “Ospedali Riuniti di Ancona” ( n = 7) and “Ospedale San Martino” (Genoa) ( n = 1) Interventional Pulmonology Units for the characterization of hilar and/or mediastinal lymphadenopathies. All the evaluated patients underwent surgical procedures for lung cancers within the previous 12 months. EBUS-TBNA was performed in all the patients to rule out nodal metastasis. The cyto-pathological evaluation revealed amorphous acellular eosinofilic material surrounded by inflammatory reaction. As no other apparent causes might explain this finding and considering the temporal relationship between the lymphadenopathy and the lung surgery, foreign body inflammatory reaction to OC is the most likely cause of the phenomenon.ConclusionIn patients who underwent surgery for lung cancer, especially within few months, the development of lymph node foreign body reaction due to surgical material retention should always be considered.