Pleural effusion: a raised CEA made malignancy more likely.

Clinical bottom line (level 4)

  1. Malignancy was the commonest cause of pleural effusions.
  2. A raised serum or pleural fluid CEA made malignancy more likely, but was not diagnostic.
  3. No biochemical test could safely exclude malignancy.
Marel et al: Chest 1995; 107 (6): 1598-1603
Expires October 2003

The study

Setting: university hospital, Czech Republic

171 patients (aged mean 52 years, ?% male) admitted with pleural effusions

Excluded if
  • aged <18 or >70



    • Independent ?blinded reference standard, applied in all patients from a consecutive appropriate spectrum.
    Reference standard:
      • cytology, pleural biopsy specimen or autopsy
      • known malignancy and no other alternative diagnosis
    Diagnostic test: serum and fluid:
    • CEA
    • IgM
    • tissue polypeptide

    The evidence

    pre-test probability of malignancy: 63%, (95% CI: 56% to 70%)

    differential diagnosis number of patients prevalence
    (95% CI)
    malignant 76 44%
    (37% to 52%)
    para malignant 32 19%
    (13% to 25%)
    parapneumonic 20 12%
    (6.9% to 17%)
    empyema 11 6.4%
    (2.8% to 10%)
    tuberculosis 11 6.4%
    (2.8% to 10%)
    congestive heart failure 6 3.5%
    (0.8% to 6.3%)
    traumatic haemothorax 5 2.9%
    (0.4% to 5.4%)
    pancreatic 3 1.8%
    (0.0% to 3.7%)
    pulmonary embolism 3 1.8%
    (0.0% to 3.7%)
    other cause 4 2.3%
    (0.1% to 4.6%)


    diagnostic test malignancy no malignancy LR+
    (95% CI)    		 post-test probability LR-
    (95% CI)    		 post-test probability
    serum CEA > 8.0 mg/dl 37 4 5.4
    (2.0 to 14)     		90% 0.70
    (0.60 to 0.82)     		55%
    serum IgM > 230 U/ml 58 18 1.9
    (1.2 to 2.9)     		76% 0.65
    (0.50 to 0.84)     		53%
    serum tissue polypeptide > 100 U/ml 91 11 4.8
    (2.8 to 8.3)     		89% 0.19
    (0.12 to 0.30)     		25%
    fluid CEA > 10 ng/ml 40 6 3.9
    (1.8 to 8.7)     		87% 0.70
    (0.59 to 0.82)     		54%
    fluid IgM > 80 U/ml 59 17 2.0
    (1.3 to 3.2)     		78% 0.62
    (0.48 to 0.80)     		52%
    fluid: serum tissue polypeptide ratio > 5.0 55 11 2.9
    (1.7 to 5.2)     		83% 0.59
    (0.48 to 0.74)     		50%
    total 108 63

    • Four-step diagnostic workup, with % diagnosis at each step:
      • history, examination, chest X-ray, macroscopic examination and first cytological study of pleural fluid- 34.5%
      • second cytological study, microscopic examination of fluid, biochemistry, tumour markers, and bacteriology- 35.7%
      • needle biopsy, lung scan or pulmonary angiography, bronchoscopy- 26.8%
      • thoracoscopy, open pleural biopsy- 3.0%

    Comments

    1. No other biochemical tests were found to be helpful in distinguishing malignant and non-malignant effusions.

    Citation

    1. Marel M, Stastny B, Melinova L, et al: diagnosis of pleural effusions: experience with clinical studies, 1986 to 1990. Chest 1995; 107 (6): 1598-1603
    Contributor: Chris Ball and Clare Wotton, October 2000
    Reviewer:

    Clinical Question.
    Patient pleural effusion
    Intervention or Exposure serum and fluid CEA, IgM, tissue polypeptide
    Outcome malignancy