To the Editor:

The case reports and review of the literature by Haaverstad et al was interesting (2001;2(2):69). I was surprised that neither chemotherapy or radiotherapy was offered to the renal tumor patients who had such extensive surgery.

                                                                                 J.C. DAVIDSON
                                                                                 Emeritus Consultant Physician,
                                                                                 Hamad Medical Corporation
                                                                                 Morses Farm, Tibberton, Glos.
                                                                                 United Kingdom

The authors reply:

To the Editor:

Regarding Dr. Hamish Davidson's comment on why our patients with extensive renal cancer did not receive chemo- or radiotheraphy, we would like to respond briefly.
We do not give any chemotherapy to these patients because neither mode of treatment really works except surgery.
Traditional chemotherapy is useless and immunotheraphy with interferon interleukins may have some marginal benefits. However, interleukin therapy is quite toxic with patients requiring hospitalization and even ICU support on occasions.
There is currently an EORTC study on interleukin in poor risk renal cell cancer patients - the control arm is no treatment.
Such a study would be unethical if there is proof that biological immune modulation is beneficial.

                                                                            RUNE HAAVERSTAD, MD
                                                                            Consultant Cardiothoracic Surgeon
                                                                            Trondheim, Norway
                                                                            PHILIP MATTHEWS, MB, BS, FRCS
                                                                            Consultant Urologic Surgeon                     
                                                                            Cardiff, United Kingdom

Aggressive Lipid Lowering In Patients With Coronary Heart Disease

To The Editor:

I read with interest Professor Karnik's article on lipid lowering in patients with coronary heart disease (CHD) (2001; 2 (1): 16-19). It was a clear and concise article. However, I wish to point out that the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, has been published recently and updates the existing guidelines (1,2). These updated guidelines raise persons with diabetes without CHD, most of whom have multiple risk factors, to the risk level of CHD risk equivalent.
 The panel also used Framingham projections of 10-year absolute CHD risk (i.e., the percent probability of having a CHD event in 10 years) to identify certain patients with multiple (2+) risk factors for more intensive treatment. Another important feature is to recommend treatment beyond LDL lowering for persons with triglycerides ž200mg/dL. 
In addition, the panel stated that these guidelines are intended to inform, not replace, the physician's clinical judgment, which must ultimately determine the appropriate treatment for each individual.

                                                                            AMAR SALAM, MB, BS, MRCP
                                                                          Department of Cardiology &
                                                                   Cardiovascular Surgery
                                                                            Hamad Medical Corporation
                                                                      Doha, Qatar