The 1993 retrospective review in 21 patients mentioned by Fuller [1] that showed a complete response of 88% after 1 month with the use of 500 mg of intrapleural doxycycline was not available when our review was done. We agree that the issues raised by Drs. Fuller and Ruckdeschel concerning first-dose efficacy, length of hospital stay, and total costs require further study; however, we disagree that sufficient comparative data exist to state that bleomycin is more efficacious and cost-effective than doxycycline, particularly because higher doxycycline doses may have produced different results [2, 3]. It is hoped that more definitive answers will be provided by the results of the comparative National Cancer Institute Intergroup Trial. Our review was not a meta-analysis, nor was it designed to be one. A meta-analysis or formal research overview sets criteria for acceptance of study trials and attempts to integrate statistical end points; such reviews are "systematic reviews of specific clinical questions that use statistical methods to combine the results of previous research" [4]. Our review consisted of data extracted from all identified trials and combined into summary totals, a process that, unlike meta-analysis, is easily repeatable by others. Dr. Ruckdeschel's point concerning the superiority of bleomycin over tetracycline in the only randomized trial is moot because of the unavailability of tetracycline. A recent report of death associated with intrapleural bleomycin should be noted [5].

We thank Drs. Wallace and Siddiqui for acquainting us with the recent literature on the use of intrapleural quinacrine and autologous blood, respectively. Because a United States Pharmacopeia formulation is unavailable, clinicians may have a concern regarding the source, purity, and sterility of acquired quinacrine in the United States.