follow-up of 6 months (range, 2 to 12 months), no malignant seeding was detected and accrual continues. This finding supports that local radiotherapy to the sites of invasive procedures should be included in the management of malignant pleural mesothelioma.
Salih Emri, MD, Y alcin Karakoca, MD, and Y. Izzettin Baris, MD, Department of Chest Diseases, Hacettepe University, Ankara, Turney; and Faruk Zorlu, MD, and Fadil Akyol, MD, Department of Radiation Oncology, Hacettepe University; and Hadi Akay, MD, Ibni-Sina University, Department of Chest Surgery, Ankara
results indicate that l32-agonist response cannot reliably identifY steroid responders. The reasons for the impressive association between reversibility to l32-agonist and response to corticosteroids found by Weiner and colleagues are unclear. The degree of l32-agonist reversibility in this study was quite high, suggesting that patients in this study represent a small subgroup of patients with COPD. The author of the corresponding editorial (CHEST 1995; 108: 1486-87) states that using l32-agonist reversibility "better identifies patients who will benefit from inhaled corticosteroids from those with ... response to oral corticosteroid therapy trial." Until more convincing data on a larger number of patients are available, corticosteroid trials remain to be the only reliable way of deciding which patients with stable COPD will benefit from inhaled corticosteroids.
David P. Joyce, Medical Student, The Toronto Hospital, University of Toronto, Toronto, Ontario, Canada
1 Bari~ Yi, Bilir N, Artvinli M, et al. An epidemiological study on an Anatolian village environmentally exposed to tremolite asbestosis. Br J Ind Med 1988; 45:838-40 2 Sel~uk ZT, <;oplii L, Emri S, et al. Malignant pleural mesothelioma due to environmental mineral fiber exposure in Turkey: analysis of 135 cases. Chest 1992; 102:790-96 3 Tansan S, Emri S, Sel~uk T, et al. Treatment of malignant pleural mesothelioma with cisplatin, mitomycin C, and alpha interferon. Oncology 1994; 51:348-51
Who Benefits From Inhaled Corticosteroids? To the Editor: The usefulness of corticosteroids in stable COPD has been an issue of controversy for many years. Although several studies have shown benefits of these agents over placebo, it is generally recognized that this is the result of large responses to corticosteroids in a minority of patients. Several authors have attempted to determine patient characteristics which might predict responses to corticosteroids. The recent report by Weiner and colleagues (CHEST 1995; 108:1568-71) sheds an interesting light on this issue. Their study concluded that the majority of patients with COPD who respond to inhaled 132-agonist also have a response to inhaled corticosteroids. Although the authors quote one study that supports the use of inhaled 13 2-agonist to identifY steroid responders, several other studies have shown failure of l32-agonist reversibility to predict steroid response. Roberston and colleagues1 failed to show significant differences in reversibility to salbutalmol in 25 corticosteroid responders as compared with nonresponders. Similarly, Harding and Freedman2 found that greater reversibility to isoprenaline during the placebo phase of their study did not predict corticosteroid response. Weir and colleagues3 examined responses to corticosteroids in patients with considerable reversibility to salbutamol (>50%) and concluded that the proportion of steroid responders in that group was not different than the proportion of responders with less l32-agonist reversibility. Likewise, Eliasson et al4 confirm a lack of relationship between l32-agonist reversibility and response to oral corticosteroid. Finally, although Mendella et al5 demonstrated that significantly more steroid responders had l32-agonist reversibility, there was substantial overlap with steroid nonresponders. These
1 Robertson AS, Gove RI, Wieland GA, et al. A bouble-blind comparison of oral prednisolone 40 mgld with inhaled beclomethasone dipropionate 1500 Jlg/d in patients with adult onset chronic obstructive airways disease. Eur J Respir Dis 1986; 146(suppl):565-69 2 Harding SM, Freedman S. A comparison of oral and inhaled steroids in patients with chronic airways obstruction: features detennining response. Thorax 1978; 33:214-18 3 Weir DC, Gove RI, Robertson AS, et al. Corticosteroid trials in non-asthmatic chronic airflow obstruction: a comparison of oral prednisolone and inhaled beclomethasone dipropionate. Thorax 1990; 45:112-17 4 Eliasson 0, Hoffman J, Trueb D, et al. Corticosteroids in COPD: a clinical trial and reassessment of the literature. Chest 1986; 89:484-90 5 Mendella LA, Manfreda J, Warren PW, et al. Steroid response in stable chronic obstructive pulmonary disease. Ann Intern Med 1982; 96:17-21
A Week-long Course of Inhaled p-Agonist or Anticholiner~ic Agent May Reduce Dyspnea Durmg Exercise in COPD To the Editor: In a recent issue (CHEST 1995; 108:730-35), Blosser and colleagues have reported that 1-week use of either 13-agonist or an anticholinergic agent can stretch the exercise performance as indicated by 12-min walking distance in COPD patients. Because beneficial effects of the long-term use of the agents on exercise performance were not entirely detennined, the current findings may be very important. The authors, however, failed to demonstrate that the dyspnea during exercise is reduced by a week-long course of ipratropium in the patients. We would like to point out that the data from the authors may suggest a significant reduction in dyspnea by the use of either albuterol or ipratropium if the data are properly analyzed. Although the authors performed several statistical analyses on the differences in the Borg scale between the groups, the central issue is a strategy of assessing dyspnea rather than statistical methods. Because the assessment of dyspnea by the Borg scale may not be comparable between the different workloads, Communications to the Editor