Letters to the Editor

Evaluating Lymphadenopathy Using Lymph Node FNA

to the editor: I read with great interest the article by Drs. Bazemore and Smucker, "Lymphadenopathy and Malignancy."1 My colleagues and I recently reviewed the lymph node fine-needle aspiration (FNA) results on superficial and deeply seated lymph nodes from 439 patients with and without a previous diagnosis of malignancy.2 We found that patients in our series2 with a history of malignancy were more than twice as likely to show malignancy on lymph node FNA compared with those without such a history (87 percent versus 41 percent) in our series.2 This is an important detail to elicit in the history, supported by our data, but perhaps so obvious as to not have been mentioned more explicitly in the article.1

Also, the authors1 recommend excisional biopsy as the initial diagnostic procedure of choice for lymphadenopathy. Lymph node FNA has its limitations. Differentiating between malignant and reactive lymphoid proliferations has traditionally been the most challenging aspect of lymph node FNA cytology,3 especially with low-grade lymphoma. However, the routine use of ancillary studies such as flow cytometry in conjunction with cytologic findings improves diagnostic accuracy to the point that lymph node FNA is quite comparable to excisional biopsy in making that distinction. Immunocytochemistry, in situ hybridization, and polymerase chain reaction also can be performed on lymph node FNA specimens, and core or excisional biopsy can always be performed after lymph node FNA to confirm or further classify lymphoproliferative disorders for prognostication. For diagnosing metastatic malignancy, lymph node FNA is excellent, given that "foreign cells are easily visualized in [a] background of lymphoid elements."4

Lymph node FNA is a cost-effective, valuable tool for the primary diagnosis of lymph nodes containing metastatic or hematologic malignancy, and for staging or monitoring of relapse in patients with known malignancy.5 Provisional diagnoses can be made rapidly in the clinic using the Diff-Quik staining method. Lymph node FNA is a safe and simple technique that can be used to sample lymph nodes in multiple sites or surgically inaccessible sites (under ultrasonography or computed tomography guidance), and in patients who might not tolerate a surgical biopsy procedure. Physicians can always proceed with excisional biopsy if indicated on lymph node FNA "triage." Given these strengths, I was surprised that the authors did not more enthusiastically recommend lymph node FNA for evaluating lymphadenopathy.

KRISTIAN T. SCHAFERNAK, M.D., M.P.H.
Northwestern Memorial Hospital
Department of Pathology-Feinberg 7-344
251 E. Huron St.
Chicago, IL 60611

References

editor's note: This letter was sent to the authors of "Lymphadenopathy and Malignancy," who declined to reply.

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'Quantum Sufficit' Artwork Considered Offensive

to the editor: The illustration by Peter Brunke that accompanied the September 15, 2003 "Quantum Sufficit"1 piece on fetal sex prediction as a correlate of maternal caloric intake was offensive in its blatant sexism. It portrayed a pregnant woman eating a large meal and, therefore, presumably carrying a male fetus, with her partner smiling. Next to her was another pregnant woman, eating a small meal and, therefore, presumably carrying a female fetus, with her partner scowling.

While a charitable interpretation of the cartoon might conclude that the partner of the woman eating the large meal was happy because his partner had a big appetite, this is clearly not the message. Rather, the cartoon illustrates that men are happy when expecting male infants and unhappy when expecting female infants.

This is the 21st century, and physicians and health policy advocates in the United States are addressing issues of health disparity, including those of gender. In other parts of the world, female infants and children are still selectively denied their birthrights, food, and education. It is disgraceful for a journal like American Family Physician to publish such a sexist illustration.

Dana Kent, M.D.
Seaside Family Health Center
P.O. Box 847
1150 Fremont Blvd.
Seaside, CA 93955

Reference

editor's note: Dr. Kent's point is well taken. I agree that this illustration should not have been used for the reasons given. I apologize for this unintended oversight.

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Diagnosis of Malaria Should Be Considered by U.S. Physicians

to the editor: I read with great interest the article, "Prevention of Malaria in Travelers"1 in the August 1, 2003 issue of American Family Physician. The authors provide an excellent introduction to prophylactic measures against malaria in nonimmune travelers, with a special emphasis on protective gear, chemoprophylaxis, and patient education.

Because of global travel, family physicians in the United States must have an increasingly high index of suspicion for malaria. Two groups of persons should be considered with regard to imported malaria:persons who are nonimmune and immigrants to the United States. Persons not previously exposed (i.e., nonimmune) have an atypical clinical picture that often leads to delays in diagnosis. In an atypical clinical presentation, patients may present with symptoms of diarrhea, cough, and myalgias; the classic tertian (fever occurring every 48 hours) or quartan (occurring every 72 hours) pattern rarely will be present; and they will have a delayed onset of symptoms after travel to an endemic area. In addition, the use of over-the-counter medication may blunt the fever and other symptoms. The atypical presentation of malaria in the nonimmune population should prompt early examination of blood smears in any patient with fever and a history of travel. Plasmodium falciparum malaria in a nonimmune patient should be treated as an emergency, because without treatment this type of malaria can be lethal in only hours.2

It also is increasingly common for immigrants to present to the emergency department seeking care for typical malaria symptoms. These patients may tell the physicians that they have malaria. Promptly performing a blood smear in these patients will save time and unnecessary testing.3

SALOUM CISSE, M.D., M.P.H.
University of Mississippi Medical Center
Department of Family Medicine
2500 N. State St.
Jackson, MS 39216

References

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Therapy with ACE Inhibitors and ARBs in Heart Failure

to the editor: In the American Family Physician article, "Combination Therapy with ACE Inhibitors and Angiotensin-Receptor Blockers in Heart Failure,"1 the authors state that adding an angiotensin-receptor blocker (ARB) to angiotensin-converting enzyme (ACE) inhibitor therapy for heart failure does not reduce mortality compared with treatment with an ACE inhibitor only. However, when the addition of valsartan to "optimal" pharmacologic therapy for heart failure was tested in the Valsartan Heart Failure Trial (Val-HeFT),2 researchers found that mortality rates were higher in patients who were already receiving an ACE inhibitor and a beta blocker.2,3 Thus, patients who were already receiving the standard recommended heart failure therapy (an ACE inhibitor plus a beta blocker4) actually fared worse with the addition of valsartan. In the Candesartan in Heart Failure: Assessment of Mortality and Morbidity (CHARM)-Added study,5 the investigators report that the addition of candesartan to combination therapy with an ACE inhibitor and a beta blocker reduced mortality; however, the reduction was not statistically significant.5

Thus, the addition of ARBs to therapy with ACE inhibitors plus beta blockers does not decrease mortality. Further, it must be recognized that there is a risk of this combination increasing mortality, making it nonbeneficial and potentially harmful.

WILLIAM E. CAYLEY, JR., M.D., M.DIV.
Augusta Family Medicine Clinic
207 W. Lincoln
Augusta, WI 54722

References

editor's note: This letter was sent to the authors of "Combination Therapy with ACE Inhibitors and Angiotensin-Receptor Blockers in Heart Failure," who declined to reply.

Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2672; fax: 913-906-6080; e-mail: afplet@aafp.org. Please include your complete address, telephone number, fax number, and e-mail address. Letters should be submitted on disk, double-spaced, fewer than 500 words, and limited to one table or figure and six references. Please submit a word count. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the AAFP permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.

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