- Email: [email protected]
Imatinib or transplant for chronic myeloid leukaemia?
CORRESPONDENCE
countries that can define their priorities convincingly (but do not have large populations of poor people), funding for corrupt and dictatorial governments that have little regard for their poorest citizens, and the enormous waste of the limited talents of many developing countries that have been spent on inventing new approaches to developing competitive proposals to satisfy yet another under-resourced aid bureaucracy with little chance of success. That Périn and Attaran are urging a repeat of the failed design for the Global Fund that Attaran proposed in his and Sach’s 2001 Lancet article2 as the basis for allocating donor support for the health sector as a whole, is shameful. If there was ever a need for evidence-based thinking about international health policy to replace ideological befuddlement, Périn and Attaran have demonstrated it in their Viewpoint. Cliff Lenton LentonGROUP, 1420 NW Lovejoy Street, Portland, OR 97209, USA (e-mail: [email protected]) 1
2
Périn I, Attaran A. Trading ideology for dialogue: an opportunity to fix international aid for health? Lancet 2003; 361: 1216–19. Attaran A, Sachs J. Defining and refining international donor support for combating the AIDS pandemic. Lancet 2001; 357: 57–61.
Sir—Ines Périn and Amir Attaran1 want to replace ideology with dialogue in international medical aid. But by basing donor funding exclusively on a recipient country’s proposals they assume that governments of such countries always act in the best interests of the populations they represent. However, in many countries people suffer exactly because of the negligence, corruption, and unfair policies of their governments. Périn and Attaran suggest that submitted proposals should be assessed only if they are technically sound and fiscally accountable. This way of thinking presents exactly the same problems as the World Bank’s conditional loans policies they criticise. The negative examples they cite represent countries where populations suffer because of irrational medical policies; precisely the reason why medical aid is so essential. The most acute needs are usually noted among populations under irresponsible governments. Few will disagree that dialogue is necessary, but discussions need to involve more than assessment of recipient proposals. In Armenia, health professionals look with great pride at the Soviet health-care system. However,
172
with a public health-care budget of about US$10 per person and real allocation often being only half of this amount,2 a system that emphasises specialist centres, long multi-drug treatments, and frequent and long hospital stays cannot be maintained.3 An oversized and underpaid medical corps (a doctor’s salary is about US$15–30 per month) requires underthe-table payments before any services are provided.4 Protocols updated at central level do not easily lead to better quality of care, more user-friendly services, more respect of patients’ rights, or more rational drug use, because the usual, donor-funded training courses are insufficient to change a 7-decades-old medical tradition. Most health professionals would like to rebuild the old system, and requests to humanitarian organisations continue to focus on renovation of buildings and donation of drugs and equipment, with little concern for the actual accessibility, quality, and cost-efficiency of services provided. Armenia’s recent HIV/AIDS proposal to the Global Fund for AIDS, Tuberculosis, and Malaria was fairly well written thanks to input from United Nations consultants. However, no proposal has yet been submitted for tuberculosis despite its being arguably a much bigger public-health problem; and care for sexually transmitted infections, a key issue in HIV prevention in this context, was largely neglected. Périn and Attaran’s model of dialogue is being tested in the Global Fund, but the application mechanism guarantees neither that proposals are made bottomup, nor that priority problems are tackled. What I understand by dialogue is an engagement in practical work alongside local counterparts to see if different approaches can work in practice, to understand the needs of the people, and to ensure that those most in need benefit from essential services. Tido von Schoen-Angerer Médecins Sans Frontières, Manushyan St 48, Yerevan 375012, Armenia (e-mail: [email protected]) 1
2
3
4
Périn I, Attaran A. Trading ideology for dialogue: an opportunity to fix international aid for health? Lancet 2003; 361: 1216–19. Mkrtchyan A. New tendencies in health care of Armenia (in Russian). Yerevan: Printing House Akop Meghapart, 2001. Cassileth BR, Vlassov VV, Chapman CC. Health care, medical practice and medical ethics in Russia today. JAMA 1995; 273: 1569–73. Hovhannissyan S, Tragakes E, Lessof S, Aslanian H, Mkrtchyan A. Health care systems in transition: Armenia. European Observatory on Health Care Systems 2001. http://www.who.dk/document/e73698.pdf (accessed May 16, 2003).
Imatinib or transplant for chronic myeloid leukaemia? Sir—In his account of the development of imatinib and its remarkable clinical efficacy in chronic myeloid leukaemia, Edward Sausville (April 26, p 1400)1 alludes to the dilemma that faces newly diagnosed patients who in the preimatinib era would have been obvious candidates for early allogeneic stem-cell transplantation. We agree with his view that the long-term benefit of imatinib cannot yet be reliably assessed, but feel he has perhaps underemphasised the likelihood of cure in patients who, for long periods after transplant, have no evidence of residual disease even at the molecular level. Sausville draws attention to the fact that stem-cell transplants are hazardous, but omits mention of the fact that reduced intensity allografts are undoubtedly safer and could be as good as conventional transplants for treating the disease.2,3 The decision not to offer selected newly diagnosed patients the option of an allograft as primary treatment is probably simplistic. A good case can be made for identifying transplant candidates by combining the use of the Sokal or Hasford risk criteria to define a patient with standard or poor prognosis with non-transplant therapy with the Gratwohl score to identify a patient with a good chance of survival after transplant and consequently a reasonably good chance of cure.4,5 In the next few years, improved knowledge of overall survival data with imatinib, improved understanding of the effect on survival of complete cytogenetic responses to imatinib, and updated assessment of reduced intensity conditioning allografts should allow more definite recommendations. In the meantime, we believe that the younger patient who is not low-risk and who has an HLA-identical sibling or a molecularly HLA-matched unrelated donor should still be offered the choice of an initial trial of imatinib or an upfront transplant. *John Goldman, Jane Apperley, Edward Kanfer, Eduardo Olavarria, David Marin Department of Haematology, Imperial College London, Hammersmith Hospital, London W12 0NN, UK (e-mail: [email protected]) 1
2
Sausville EA. Imatinib for chronic myelogenous leukaemia: a 9 or 24 carat gold standard? Lancet 2003; 361: 1400–01. Or R, Shapira MY, Resnick I, et al. Nonmyeloablative allogeneic stem cell transplantation for the treatment of chronic myeloid leukemia in first chronic phase. Blood 2003; 101: 441–45.
THE LANCET • Vol 362 • July 12, 2003 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet
CORRESPONDENCE
3
4
5
Uzunel M, Mattsson J, Brune M, Johansson J-E, Ringden O. Kinetics of minimal residual disease and chimerism in patients with chronic myeloid leukemia after non-myeloablative conditioning and allogeneic stem cell transplantation. Blood 2003, 101: 469–72. Gratwohl A, Hermans J, Goldman JM, et al. Risk assessment for patients with chronic myeloid leukaemia before allogeneic blood or marrow transplantation. Lancet 1998; 352: 1087–92. Goldman JM, Druker BJ. Chronic myeloid leukemia: current treatment options. Blood 1001; 98: 2039–42.
Sir—Allogeneic stem-cell transplantation has evolved over the past two decades into a remarkably effective treatment for chronic myelogenous leukaemia and is the only curative therapy. Consequently, it is now possible to predict a long-term survival in excess of 70% for young patients with an HLA-identical sibling donor. However, only a limited number of patients with chronic myelogenous leukaemia are eligible for allogeneic transplantation. So the evidence that imatinib mesylate has the capacity to induce complete cytogenetic remissions in up to two-thirds of patients treated in the early chronic phase represents a major breakthrough in the management of this disease. However, Edward that Sausville’s recommendation1 allografting should only be undertaken in patients who fail to achieve, or lose, a significant cytogenetic response to imatinib seems premature. Although the excellent results of allografting come from studies with follow-up rates of more than 10 years, there is no evidence that responses to imatinib are durable. Indeed, experience with this agent in patients with advanced disease shows that responses in most patients are brief and last only a few months at best.2 Sustained molecular responses to imatinib seem to be rare and it is unclear whether any patients will be cured (however one seeks to define this term) by this agent. In addition, resistance to imatinib will probably become an increasingly common problem, especially with long-term use. This might be less of an issue if resistance to imatinib manifests itself as a slow and orderly relapse into chronic phase. However, there is real concern that patients may relapse abruptly into an advanced stage of the disease, in which transplantation cannot be safely or effectively done. Delaying transplantation prejudices its outcome3 and, consequently, the inevitable postponement associated with a lengthy period of imatinib therapy may compromise the efficacy of the only proven curative therapy available for
patients with this disease. It seems, therefore, prudent to retain allogeneic transplantation as an important upfront therapy in younger patients with a suitable donor, for the present at least. Advice to the contrary is based on only a limited experience with imatinib and could be judged to be overly optimistic in years to come. *C Craddock, B Augustson, S Basu *Department of Haematology, University Hospital, Birmingham B15 2TH, UK (CC, BA, SB); and Department of Haematology, Royal Wolverhampton NHS Trust, Wolverhampton, UK (SB) (e-mail: [email protected]) 1
Sausville EA. Imatinib for chronic myelogenous leukaemia: a 9 or 24 carat gold standard? Lancet 2003; 361: 1400–01. 2 Sawyers CL, Hochhaus A, Feldman E, et al. Imatinib induces hematologic and cytogenetic responses in patients with chronic myelogenous leukemia in myeloid blast crisis: results of a phase II study. Blood 2002; 99: 3530–39. 3 Weisdorf DJ, Anasetti C, Antin JH, et al. Allogeneic bone marrow transplantation for chronic myelogenous leukemia: comparative analysis of unrelated versus matched sibling donor transplantation. Blood 2002; 99: 1971–77.
CT-guided biopsy for diagnosis of malignant disease in pleural effusions Sir—Nick Maskell and colleagues (April 19, p 1326)1 report that CTguided biopsy is better than standard pleural biopsy in patients with cytology-negative suspected malignant pleural effusions. I have, however, several questions about the general applicability of their findings. Maskell and colleagues excluded any patient with a unilateral effusion with a pleural protein concentration of less than 35 g/dL. These effusions were assumed to be transudative if the patients had heart failure or hypoalbuminaemia. One of us (DT) and colleagues2 previously noted that, in a survey of clinical practice in Bristol, 14% of unilateral malignant effusions had protein content below 35 g/dL. Furthermore, Gotsman and co-workers’ study3 of patients with heart failure and pleural effusion undergoing thoracentesis showed that two thirds had pleural fluid exudate with 10% having malignant effusions. It is exactly this type of patient that presents the greatest diagnostic challenge in clinical practice. Why did Maskell and colleagues not use the well-established Light criteria4 to ascertain whether these patients’ pleural effusions were exudative or transudative?
THE LANCET • Vol 362 • July 12, 2003 • www.thelancet.com
We are surprised at the number of patients with malignant mesothelioma in their study—20 (61%) of 33 malignant effusions were mesothelioma. This finding contrasts again with our Bristol series,2 in which six (22%) of 27 cytology-negative consecutive effusions were mesothelioma. Furthermore, Trail and colleagues5 from Oxford have suggested that abnormalities detected by thoracic CT are more accurate in the diagnosis of primary as opposed to secondary malignant disease in pleural effusions. The limited number of patients without mesothelioma in Maskell and colleagues’ study makes it difficult to generalise the findings to clinical practice with a smaller proportion of mesothelioma cases. Maskell and colleagues state that 1700 additional biopsy procedures would be avoided in the UK if CTguided biopsy was the first-line biopsy method in these patients; they also suggest that there is a potential cost saving. This interpretation of their results is rather simplistic, because most pleural interventions in malignant pleural effusion are related to the control of fluid accumulation not just to diagnosis. A CT-guided biopsy without drainage leaves patients in need of additional pleural procedures. Maskell and colleagues admit that thoracoscopy has a greater sensitivity in detection of malignant disease in pleural effusions than CT-guided biopsy. Furthermore, the ability to undertake pleurodesis at the time of thoracoscopy in patients with cancer is an important advantage in terms of reducing the number of pleural interventions that may lead to tumour seeding of the chest wall. Surely, therefore, the best approach for patients with cytology-negative suspected malignant pleural effusions is thoracoscopy with drainage and pleurodesis as part of the same intervention? Gavin D Perkins, *David Thickett Department of Medical Sciences, University of Birmingham, Birmingham B15 2TH, UK (e-mail: [email protected]) 1
2
3
4 5
Maskell NA, Gleeson FV, Davies RJO. Standard pleural biopsy versus CT-guided cutting-needle biopsy for diagnosis of malignant disease in pleural effusions: a randomised controlled trial. Lancet 2003; 361: 1326–31. Thickett DR, Armstrong L, Millar AB. Vascular endothelial growth factor (VEGF) in inflammatory and malignant pleural effusions. Thorax 1999; 54: 707–10. Gotsman I, Fidlender Z, Meirovitz A, Dratva D, Muszkat M. The evaluation of pleural effusions in patients with heart failure. Am J Med 2001: 375–78. Light RW. Diagnostic principles in pleural disease. Eur Respir J 1997; 10: 476–81. Trail Z, Davies R, Gleeson F. Thoracic computed tomography in patients with suspected pleural effusions. Clin Radiol 2001; 56: 193–96.
173
For personal use. Only reproduce with permission from The Lancet
countries that can define their priorities convincingly (but do not have large populations of poor people), funding for corrupt and dictatorial governments that have little regard for their poorest citizens, and the enormous waste of the limited talents of many developing countries that have been spent on inventing new approaches to developing competitive proposals to satisfy yet another under-resourced aid bureaucracy with little chance of success. That Périn and Attaran are urging a repeat of the failed design for the Global Fund that Attaran proposed in his and Sach’s 2001 Lancet article2 as the basis for allocating donor support for the health sector as a whole, is shameful. If there was ever a need for evidence-based thinking about international health policy to replace ideological befuddlement, Périn and Attaran have demonstrated it in their Viewpoint. Cliff Lenton LentonGROUP, 1420 NW Lovejoy Street, Portland, OR 97209, USA (e-mail: [email protected]) 1
2
Périn I, Attaran A. Trading ideology for dialogue: an opportunity to fix international aid for health? Lancet 2003; 361: 1216–19. Attaran A, Sachs J. Defining and refining international donor support for combating the AIDS pandemic. Lancet 2001; 357: 57–61.
Sir—Ines Périn and Amir Attaran1 want to replace ideology with dialogue in international medical aid. But by basing donor funding exclusively on a recipient country’s proposals they assume that governments of such countries always act in the best interests of the populations they represent. However, in many countries people suffer exactly because of the negligence, corruption, and unfair policies of their governments. Périn and Attaran suggest that submitted proposals should be assessed only if they are technically sound and fiscally accountable. This way of thinking presents exactly the same problems as the World Bank’s conditional loans policies they criticise. The negative examples they cite represent countries where populations suffer because of irrational medical policies; precisely the reason why medical aid is so essential. The most acute needs are usually noted among populations under irresponsible governments. Few will disagree that dialogue is necessary, but discussions need to involve more than assessment of recipient proposals. In Armenia, health professionals look with great pride at the Soviet health-care system. However,
172
with a public health-care budget of about US$10 per person and real allocation often being only half of this amount,2 a system that emphasises specialist centres, long multi-drug treatments, and frequent and long hospital stays cannot be maintained.3 An oversized and underpaid medical corps (a doctor’s salary is about US$15–30 per month) requires underthe-table payments before any services are provided.4 Protocols updated at central level do not easily lead to better quality of care, more user-friendly services, more respect of patients’ rights, or more rational drug use, because the usual, donor-funded training courses are insufficient to change a 7-decades-old medical tradition. Most health professionals would like to rebuild the old system, and requests to humanitarian organisations continue to focus on renovation of buildings and donation of drugs and equipment, with little concern for the actual accessibility, quality, and cost-efficiency of services provided. Armenia’s recent HIV/AIDS proposal to the Global Fund for AIDS, Tuberculosis, and Malaria was fairly well written thanks to input from United Nations consultants. However, no proposal has yet been submitted for tuberculosis despite its being arguably a much bigger public-health problem; and care for sexually transmitted infections, a key issue in HIV prevention in this context, was largely neglected. Périn and Attaran’s model of dialogue is being tested in the Global Fund, but the application mechanism guarantees neither that proposals are made bottomup, nor that priority problems are tackled. What I understand by dialogue is an engagement in practical work alongside local counterparts to see if different approaches can work in practice, to understand the needs of the people, and to ensure that those most in need benefit from essential services. Tido von Schoen-Angerer Médecins Sans Frontières, Manushyan St 48, Yerevan 375012, Armenia (e-mail: [email protected]) 1
2
3
4
Périn I, Attaran A. Trading ideology for dialogue: an opportunity to fix international aid for health? Lancet 2003; 361: 1216–19. Mkrtchyan A. New tendencies in health care of Armenia (in Russian). Yerevan: Printing House Akop Meghapart, 2001. Cassileth BR, Vlassov VV, Chapman CC. Health care, medical practice and medical ethics in Russia today. JAMA 1995; 273: 1569–73. Hovhannissyan S, Tragakes E, Lessof S, Aslanian H, Mkrtchyan A. Health care systems in transition: Armenia. European Observatory on Health Care Systems 2001. http://www.who.dk/document/e73698.pdf (accessed May 16, 2003).
Imatinib or transplant for chronic myeloid leukaemia? Sir—In his account of the development of imatinib and its remarkable clinical efficacy in chronic myeloid leukaemia, Edward Sausville (April 26, p 1400)1 alludes to the dilemma that faces newly diagnosed patients who in the preimatinib era would have been obvious candidates for early allogeneic stem-cell transplantation. We agree with his view that the long-term benefit of imatinib cannot yet be reliably assessed, but feel he has perhaps underemphasised the likelihood of cure in patients who, for long periods after transplant, have no evidence of residual disease even at the molecular level. Sausville draws attention to the fact that stem-cell transplants are hazardous, but omits mention of the fact that reduced intensity allografts are undoubtedly safer and could be as good as conventional transplants for treating the disease.2,3 The decision not to offer selected newly diagnosed patients the option of an allograft as primary treatment is probably simplistic. A good case can be made for identifying transplant candidates by combining the use of the Sokal or Hasford risk criteria to define a patient with standard or poor prognosis with non-transplant therapy with the Gratwohl score to identify a patient with a good chance of survival after transplant and consequently a reasonably good chance of cure.4,5 In the next few years, improved knowledge of overall survival data with imatinib, improved understanding of the effect on survival of complete cytogenetic responses to imatinib, and updated assessment of reduced intensity conditioning allografts should allow more definite recommendations. In the meantime, we believe that the younger patient who is not low-risk and who has an HLA-identical sibling or a molecularly HLA-matched unrelated donor should still be offered the choice of an initial trial of imatinib or an upfront transplant. *John Goldman, Jane Apperley, Edward Kanfer, Eduardo Olavarria, David Marin Department of Haematology, Imperial College London, Hammersmith Hospital, London W12 0NN, UK (e-mail: [email protected]) 1
2
Sausville EA. Imatinib for chronic myelogenous leukaemia: a 9 or 24 carat gold standard? Lancet 2003; 361: 1400–01. Or R, Shapira MY, Resnick I, et al. Nonmyeloablative allogeneic stem cell transplantation for the treatment of chronic myeloid leukemia in first chronic phase. Blood 2003; 101: 441–45.
THE LANCET • Vol 362 • July 12, 2003 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet
CORRESPONDENCE
3
4
5
Uzunel M, Mattsson J, Brune M, Johansson J-E, Ringden O. Kinetics of minimal residual disease and chimerism in patients with chronic myeloid leukemia after non-myeloablative conditioning and allogeneic stem cell transplantation. Blood 2003, 101: 469–72. Gratwohl A, Hermans J, Goldman JM, et al. Risk assessment for patients with chronic myeloid leukaemia before allogeneic blood or marrow transplantation. Lancet 1998; 352: 1087–92. Goldman JM, Druker BJ. Chronic myeloid leukemia: current treatment options. Blood 1001; 98: 2039–42.
Sir—Allogeneic stem-cell transplantation has evolved over the past two decades into a remarkably effective treatment for chronic myelogenous leukaemia and is the only curative therapy. Consequently, it is now possible to predict a long-term survival in excess of 70% for young patients with an HLA-identical sibling donor. However, only a limited number of patients with chronic myelogenous leukaemia are eligible for allogeneic transplantation. So the evidence that imatinib mesylate has the capacity to induce complete cytogenetic remissions in up to two-thirds of patients treated in the early chronic phase represents a major breakthrough in the management of this disease. However, Edward that Sausville’s recommendation1 allografting should only be undertaken in patients who fail to achieve, or lose, a significant cytogenetic response to imatinib seems premature. Although the excellent results of allografting come from studies with follow-up rates of more than 10 years, there is no evidence that responses to imatinib are durable. Indeed, experience with this agent in patients with advanced disease shows that responses in most patients are brief and last only a few months at best.2 Sustained molecular responses to imatinib seem to be rare and it is unclear whether any patients will be cured (however one seeks to define this term) by this agent. In addition, resistance to imatinib will probably become an increasingly common problem, especially with long-term use. This might be less of an issue if resistance to imatinib manifests itself as a slow and orderly relapse into chronic phase. However, there is real concern that patients may relapse abruptly into an advanced stage of the disease, in which transplantation cannot be safely or effectively done. Delaying transplantation prejudices its outcome3 and, consequently, the inevitable postponement associated with a lengthy period of imatinib therapy may compromise the efficacy of the only proven curative therapy available for
patients with this disease. It seems, therefore, prudent to retain allogeneic transplantation as an important upfront therapy in younger patients with a suitable donor, for the present at least. Advice to the contrary is based on only a limited experience with imatinib and could be judged to be overly optimistic in years to come. *C Craddock, B Augustson, S Basu *Department of Haematology, University Hospital, Birmingham B15 2TH, UK (CC, BA, SB); and Department of Haematology, Royal Wolverhampton NHS Trust, Wolverhampton, UK (SB) (e-mail: [email protected]) 1
Sausville EA. Imatinib for chronic myelogenous leukaemia: a 9 or 24 carat gold standard? Lancet 2003; 361: 1400–01. 2 Sawyers CL, Hochhaus A, Feldman E, et al. Imatinib induces hematologic and cytogenetic responses in patients with chronic myelogenous leukemia in myeloid blast crisis: results of a phase II study. Blood 2002; 99: 3530–39. 3 Weisdorf DJ, Anasetti C, Antin JH, et al. Allogeneic bone marrow transplantation for chronic myelogenous leukemia: comparative analysis of unrelated versus matched sibling donor transplantation. Blood 2002; 99: 1971–77.
CT-guided biopsy for diagnosis of malignant disease in pleural effusions Sir—Nick Maskell and colleagues (April 19, p 1326)1 report that CTguided biopsy is better than standard pleural biopsy in patients with cytology-negative suspected malignant pleural effusions. I have, however, several questions about the general applicability of their findings. Maskell and colleagues excluded any patient with a unilateral effusion with a pleural protein concentration of less than 35 g/dL. These effusions were assumed to be transudative if the patients had heart failure or hypoalbuminaemia. One of us (DT) and colleagues2 previously noted that, in a survey of clinical practice in Bristol, 14% of unilateral malignant effusions had protein content below 35 g/dL. Furthermore, Gotsman and co-workers’ study3 of patients with heart failure and pleural effusion undergoing thoracentesis showed that two thirds had pleural fluid exudate with 10% having malignant effusions. It is exactly this type of patient that presents the greatest diagnostic challenge in clinical practice. Why did Maskell and colleagues not use the well-established Light criteria4 to ascertain whether these patients’ pleural effusions were exudative or transudative?
THE LANCET • Vol 362 • July 12, 2003 • www.thelancet.com
We are surprised at the number of patients with malignant mesothelioma in their study—20 (61%) of 33 malignant effusions were mesothelioma. This finding contrasts again with our Bristol series,2 in which six (22%) of 27 cytology-negative consecutive effusions were mesothelioma. Furthermore, Trail and colleagues5 from Oxford have suggested that abnormalities detected by thoracic CT are more accurate in the diagnosis of primary as opposed to secondary malignant disease in pleural effusions. The limited number of patients without mesothelioma in Maskell and colleagues’ study makes it difficult to generalise the findings to clinical practice with a smaller proportion of mesothelioma cases. Maskell and colleagues state that 1700 additional biopsy procedures would be avoided in the UK if CTguided biopsy was the first-line biopsy method in these patients; they also suggest that there is a potential cost saving. This interpretation of their results is rather simplistic, because most pleural interventions in malignant pleural effusion are related to the control of fluid accumulation not just to diagnosis. A CT-guided biopsy without drainage leaves patients in need of additional pleural procedures. Maskell and colleagues admit that thoracoscopy has a greater sensitivity in detection of malignant disease in pleural effusions than CT-guided biopsy. Furthermore, the ability to undertake pleurodesis at the time of thoracoscopy in patients with cancer is an important advantage in terms of reducing the number of pleural interventions that may lead to tumour seeding of the chest wall. Surely, therefore, the best approach for patients with cytology-negative suspected malignant pleural effusions is thoracoscopy with drainage and pleurodesis as part of the same intervention? Gavin D Perkins, *David Thickett Department of Medical Sciences, University of Birmingham, Birmingham B15 2TH, UK (e-mail: [email protected]) 1
2
3
4 5
Maskell NA, Gleeson FV, Davies RJO. Standard pleural biopsy versus CT-guided cutting-needle biopsy for diagnosis of malignant disease in pleural effusions: a randomised controlled trial. Lancet 2003; 361: 1326–31. Thickett DR, Armstrong L, Millar AB. Vascular endothelial growth factor (VEGF) in inflammatory and malignant pleural effusions. Thorax 1999; 54: 707–10. Gotsman I, Fidlender Z, Meirovitz A, Dratva D, Muszkat M. The evaluation of pleural effusions in patients with heart failure. Am J Med 2001: 375–78. Light RW. Diagnostic principles in pleural disease. Eur Respir J 1997; 10: 476–81. Trail Z, Davies R, Gleeson F. Thoracic computed tomography in patients with suspected pleural effusions. Clin Radiol 2001; 56: 193–96.
173
For personal use. Only reproduce with permission from The Lancet