Affiliations: J.M. Wainwright Memorial VA Medical Center, Walla Walla, WA,
San Donato Milanese, Italy
Correspondence to: Bayu Teklu, MD, FCCP, J.M. Wainwright Memorial VA Medical Center, 77 Wainwright Dr, Walla Walla, WA 99362
To the Editor:
Foresti et al in their Communication to the Editor in
CHEST (December 1998)1 recommended that one
perform a cytologic examination on every transudative pleural effusion,
because 4 of their 106 patients (3.8%) had positive results of
cytological examination with a transudative pleural fluid using
Light’s criteria.2 These same four patients had,
respectively, adenocarcinoma of the breast, lung adenocarcinoma,
undetermined adenocarcinoma, and non-Hodgkin’s lymphoma.
I have the following comments regarding their letter:
Light’s quoted criteria are not current. Light himself in
his book3 added a third criterion for qualification as an
exudate: a lactate dehydrogenase (LDH) level greater than two-thirds of
the upper limit of the serum LDH level. According to this criterion,
their second patient barely satisfies the criteria to be classified as
In their 1st paragraph, they quote Assi et al4 as
not recommending performance of cytological examination for
transudative pleural effusion. However, in their last paragraph, they
seem to suggest the opposite.
In the third paragraph, sentences two and four are identical.
Was it a typographical error?
Finally, it would be more appropriate to perform cytological
examinations on patients with transudative pleural effusions who have
proven malignancies at other sites, just as in the four patients of
Foresti et al. I disagree with them that cytologies should be performed
on all patients with transudative pleural effusions; it is not
cost-effective, and it is a significant departure from the usual method
that is taught and practiced.
The letter of Castro et al5 on the same topic
deserves a comment as well. They do not, like others,1
tell us whether positive results from pleural cytological examinations
followed or preceded the diagnosis of the different malignancies. They
also fail to supply negative results of cytological examinations of
pleural fluids, transudative or exudative. Without all this
information, their recommendation to perform cytological examinations
on all transudative pleural fluids is not warranted.
We thank Dr. Teklu for his interest in our Communication to the
Editor (December 1998)1 on positive results of pleural
fluid cytologic examination in transudative pleural effusions.
In regard to his comments, we would like to make the following remarks:
According to Light’s criteria,2the pleural
effusion of our second patient is a transudate. Moreover, in this
patient the pleural fluid cholesterol level was 25 mg/dL. This
fact3 also confirms that the pleural fluid can be
classified as a transudate.
The sentence in our last paragraph is unclear. We meant that
even in a cost-reduction environment, the performance of a cytological
examination is always important.
In the third paragraph, sentence one is a typographical error.
In three of our patients, malignancy was proven. In patient 2,
malignancy was unknown at the time of thoracocentesis.
In conclusion, despite Dr. Teklu’s interesting comments,
we believe that a cytological examination must be performed on every
patient with a transudative pleural effusion, since knowing whether a
pleural effusion is due to malignancy or to other causes is very
important for prognosis and therapy.
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