Chest
Volume 102, Issue 5, November 1992, Pages 1455-1459
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Clinical Investigations
A Prospective Study of Amylase-rich Pleural Effusions With Special Reference to Amylase Isoenzyme Analysis

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By analysis of pleural effusions from 200 patients, 25 cases of amylase-rich effusions were identified, for an overall incidence of 13 percent. Four of the 25 patients (16 percent) had evidence of pancreatitis. These patients had higher mean ratios of pleural fluid to serum amylase levels (18 ± 6.3 [SEM] vs 4.8 ± 1.3) compared to patients with nonpancreatic diseases (p = 0.003); all four exhibited a predominant pancreatic isoenzyme profile. Of the 21 patients with nonpancreatic amylase-rich effusions, lung cancer was the most commonly associated condition (8 patients). In 14 of the 21 patients in whom an isoenzyme profile was obtained, salivary-type amylase was predominant. Amylase-rich pleural effusions occur frequently, and pleural fluid isoamylase determination is specific for pancreatitis-associated effusions. The finding of a pleural effusion rich in salivary isoamylase should prompt an evaluation for carcinoma (particularly of lung primary), but may also be seen in other pleural inflammatory conditions.

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MATERIALS AND METHODS

Consecutive pleural fluid and corresponding serum samples from 200 patients seen in the Rotherham District General Hospital between Jan 1989 and Jan 1991 were analyzed for levels of total protein, glucose, amylase, and lactate dehydrogenase (LDH). Patients with a pleural fluid amylase level of more than 86 IU/L (upper limit of normal for serum) were identified as having an amylase-rich effusion, and if sufficient pleural fluid remained, an amylase isoenzyme determination was performed. The

RESULTS

The following tabulation listing numbers of cases shows the etiology of the 25 amylase-rich effusions:

Pancreatitis4
Adenocarcinoma of the ovary2
Metastatic carcinoma (unknown primary)1
Non-Hodgkin's lymphoma1
Chronic lymphatic leukemia1
Bilateral hydronephrosis1
Cirrhosis of the liver1
Pulmonary tuberculosis1

Among the benign causes for amylase-rich effusion not due to pancreatitis, parapneumonic effusion accounted for the majority (five cases); one patient had empyema. Of the four cases of

DISCUSSION

Amylase-rich pleural effusions are commonly associated with acute and chronic pancreatitis.2, 4, 5 Elevated serum amylase in association with a neoplasm was first described in 1951 by Weiss et al6 in a case of bronchogenic carcinoma, and subsequent descriptions of amylase-rich pleural effusions in bronchogenic carcinoma have been reported.7, 8 Although a few patients without malignancy have been described with nonpancreatic amylase-rich pleural effusions,2 no investigation of sequential

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      However, as a diagnostic marker for acute pancreatitis, total serum amylase measurement lacks specificity, with estimates ranging from as low as 86% to 95% if the threshold level is taken to be more than three times the upper limit of normal (7,8). The reason for this lack of specificity is twofold; first, amylase is ordinarily found in several other organs, such as in the salivary glands, liver, biliary tree, duodenum, stomach, esophagus, lung, heart, and fallopian tubes, and second, amylase can be ectopically produced by a number of solid organ and hematological malignancies (9,10). Thus, hyperamylasemia has been reported in numerous other non-pancreatic conditions, including mumps, parotitis, perforated peptic ulcer, perforated appendicitis, intestinal obstruction, mesenteric infarction, pulmonary embolism, pneumonia, myocardial infarction, lung cancer, breast cancer, lymphoma, and several tubo-ovarian disorders (11,12).

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    Manuscript received March 13; revision accepted April 29.

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