Author reply

We have read the letters from Drs. Skoog and Tani addressed to Dr. Frable and to ourselves. Their comments are greatly appreciated. First, we would like to reassure them that we are fully aware of and respect their pioneering work regarding fine-needle aspiration (FNA) of lymphoma. Second, we have not overlooked the groundbreaking work of European cytopathologists in lymphoma. The work of Drs. Skoog and Tani was cited in our first article regarding FNA and lymphoma published in 1997.1 In that article, we stated that experienced pathologists had reported that the combination of cytomorphologic examination and certain ancillary tests (immunohistochemistry, flow cytometry, etc.) can result in the reliable FNA diagnosis of certain types of lymphoma. We cited five references, one of which was by Drs. Skoog and Tani; three references were from Europe (Sweden, Finland, and Poland)2, 4 and only two references were from the U.S.5, 6 We cited three references (one from Canada,7 one from Australia,8 and only one from the U.S.9) to support our claim that FNA has been accepted as a screening test for unexplained and persistent lymphadenopathy as well as for the staging and monitoring of tumor recurrence or treatment response in those patients with a history of lymphoma. The Australian and European references predated the American publications, thus confirming our recognition of the pioneering work performed by these authors. Second, our review article in Cancer Cytopathology was meant, as the title implies, to introduce the revised European–American classification of lymphoid neoplasms (REAL classification) to the cytopathology community. It was not our intent to review the English literature regarding the use of FNA in the cytodiagnosis of lymphoma, but rather to limit the review "in the context of its [the REAL classification] the adaptability to the cytologic diagnosis of lymphoid neoplasms," as stated in our "Methods" section. Unfortunately the letter by Drs. Skoog and Tani quoted only the first part of our abstracted methods. The review emphasized the methodologies and approaches around the time of and after publication of the REAL classification. We pointed out the importance of immunophenotyping, either by flow cytometry or immunocytochemistry, although we admitted our bias toward flow cytometry early in the article. We explained our preference was due in part to our own institutional experience,10 as well as the ability of flow cytometry to study large number of cells and to detect small populations of cells and low intensity staining. The majority of the references we cited reflected this approach. We appreciate their contributions in the field of immunochemistry. We believe that using either technique depends greatly on the institutional experience. Most likely, both techniques produce comparable results in experienced hands. Again, we want to stress that we have not been biased toward the U.S., as Drs. Skoog and Tani were concerned with in one of their letters. For example, the majority of the references that covered molecular techniques as applied to FNA were from Europe and Japan. In one of the letters by Drs. Skoog and Tani there is a reference to the Kiel classification, of which we are fully aware. We appreciate its contribution to the understanding of the pathology of lymphomas. It is the Kiel concept of centrocyte versus centroblast that we adopted in our study regarding the value of a transformed lymphocyte count to predict lymphoma progression.1 As a matter of fact, the majority of clinical researchers in the U.S. realize the importance of the pioneering works performed in Europe, which have resulted in part from the differences in clinical practice between the two continents. One of the difficulties in establishing FNA of lymphoma as a primary diagnostic procedure in the U.S. is the lack of cytologic/histologic correlative studies in this country. After a lymph node is aspirated, it is very difficult to resect it for "research purposes," as is done in Sweden (as stated in one of the letters by Drs. Skoog and Tani). We apologize for any misunderstanding. We hope that this article is taken in the context that it was not meant to be a historical review, which is why some authors whom Drs. Skoog and Tani believe worthy of recognition were not included. However, we do agree that a historical review of the pioneering works concerning FNA of lymphoma would be worthwhile at the current time. One of the European authors with years of experience in this field might be the best candidate to undertake this challenging task. Finally we should keep the politics out of lymphoma FNA, not only between hematopathologists and cytopathologists,11 but also between the European and American communities. In the last American Society of Hematology meeting, Dr. Armitage, who moderated a symposium on lymphoma classification, noted that the politics of lymphoma, (Kiel classification vs. the Working Formula) delayed progress in this area for generations. Let us hope that the rather young field of lymphoma FNA is kept out of this mess! Nancy A. Young M.D.*, Tahseen Al-Saleem M.D.*, * Department of Pathology, Fox Chase Cancer Center, Philadelphia, Pennsylvania

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