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Patterns of Recurrence in Patients With Melanoma After Radical Lymph Node Dissection—Reply

Patterns of Recurrence in Patients With Melanoma After Radical Lymph Node Dissection—Reply In reply We read with interest the commentary made by Dr Badruddoja. We humbly think that the title does reflect the contents of the article, including the search for factors predictive of the pattern of failure. It seems that Dr Badruddoja was eager to present his personal view that elective lymph basin dissection causes immunological and other shortcomings. Thus, in his opinion, it is responsible for higher rate of systemic failures. While this may or may not be correct, this was not a part of our study, so we cannot comment on it. Dr Badruddoja uses partial and inaccurate information from our article to present his agenda: Dr Badruddoja failed to carefully read the first part of the “Methods” section. It is stated there that prophylactic RLND was performed from 1990 to 1994, as was the US standard of care for intermediate-thickness melanoma. From 1994 on, it was abandoned and replaced by the sentinel node technique. Dr Badruddoja failed to carefully read the second part of the “Methods” section, where it is clearly stated that ulceration, regression, mitotic rate, and so forth were considered and analyzed as potential predictors of recurrence. Cytology results are not considered a major predictor for melanoma recurrence, and the descriptive “nodular” or “superficially spreading” classification is outdated. Dr Badruddoja failed to carefully read the “Results” section and Table 4. Multiple factors were analyzed for their impact on any form of recurrence. Not only Breslow thickness greater than 4 mm, but also 5 other factors were identified by univariate analysis. Multivariate analysis, however, left only Breslow thickness, previous tempering, and extracapsular invasion as significant predictors of recurrence. Furthermore, the same analysis was performed specifically for surgical field recurrence. The 52% failure rate is in no way “very high.” It is within the 50% to 60% range typical of stage III melanoma. The high percentage of systemic events does not necessarily reflect a surgical failure (most of the time it does not), and has nothing to do with “experienced hands,” as put by Dr Badruddoja. In-transit failure reflects the biology of the tumor, and is not a surgical failure. Dr Badruddoja's statement in this regard is not in line with the current concepts on this phenomenon. Dr Badruddoja argues that lumping together prophylactic lymph node dissection, RLND for micrometastases and RLND for macrometastases is a methodological mistake. This may be correct, but one should remember, that intermediate-thickness melanoma is associated with 20% to 25% lymph node involvement. For the issue of tempering, including the prophylactic lymph node dissection cases in the analysis might have only reduced the impact of tempering on the entire series by “diluting” the number of surgical field recurrences. The purpose of this article was to explore the pattern of recurrence after RLND, with a particular search for predictors of overall and surgical field failures. Previous tempering was identified as the only significant predictor of surgical field recurrences. Such interventions are avoidable, and avoiding tempering may reduce the rate of surgical failures. Dr Badruddoja's letter opted not to refer to this at all. Correspondence: Dr Gutman, Department of Surgery B, Rabin Medical Center, Beilinson Campus, Petah Tiqva 49100, Israel (hgutman@post.tau.ac.il). http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Surgery American Medical Association

Patterns of Recurrence in Patients With Melanoma After Radical Lymph Node Dissection—Reply

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Publisher
American Medical Association
Copyright
Copyright © 2006 American Medical Association. All Rights Reserved.
ISSN
0004-0010
eISSN
1538-3644
DOI
10.1001/archsurg.141.11.1145-b
Publisher site
See Article on Publisher Site

Abstract

In reply We read with interest the commentary made by Dr Badruddoja. We humbly think that the title does reflect the contents of the article, including the search for factors predictive of the pattern of failure. It seems that Dr Badruddoja was eager to present his personal view that elective lymph basin dissection causes immunological and other shortcomings. Thus, in his opinion, it is responsible for higher rate of systemic failures. While this may or may not be correct, this was not a part of our study, so we cannot comment on it. Dr Badruddoja uses partial and inaccurate information from our article to present his agenda: Dr Badruddoja failed to carefully read the first part of the “Methods” section. It is stated there that prophylactic RLND was performed from 1990 to 1994, as was the US standard of care for intermediate-thickness melanoma. From 1994 on, it was abandoned and replaced by the sentinel node technique. Dr Badruddoja failed to carefully read the second part of the “Methods” section, where it is clearly stated that ulceration, regression, mitotic rate, and so forth were considered and analyzed as potential predictors of recurrence. Cytology results are not considered a major predictor for melanoma recurrence, and the descriptive “nodular” or “superficially spreading” classification is outdated. Dr Badruddoja failed to carefully read the “Results” section and Table 4. Multiple factors were analyzed for their impact on any form of recurrence. Not only Breslow thickness greater than 4 mm, but also 5 other factors were identified by univariate analysis. Multivariate analysis, however, left only Breslow thickness, previous tempering, and extracapsular invasion as significant predictors of recurrence. Furthermore, the same analysis was performed specifically for surgical field recurrence. The 52% failure rate is in no way “very high.” It is within the 50% to 60% range typical of stage III melanoma. The high percentage of systemic events does not necessarily reflect a surgical failure (most of the time it does not), and has nothing to do with “experienced hands,” as put by Dr Badruddoja. In-transit failure reflects the biology of the tumor, and is not a surgical failure. Dr Badruddoja's statement in this regard is not in line with the current concepts on this phenomenon. Dr Badruddoja argues that lumping together prophylactic lymph node dissection, RLND for micrometastases and RLND for macrometastases is a methodological mistake. This may be correct, but one should remember, that intermediate-thickness melanoma is associated with 20% to 25% lymph node involvement. For the issue of tempering, including the prophylactic lymph node dissection cases in the analysis might have only reduced the impact of tempering on the entire series by “diluting” the number of surgical field recurrences. The purpose of this article was to explore the pattern of recurrence after RLND, with a particular search for predictors of overall and surgical field failures. Previous tempering was identified as the only significant predictor of surgical field recurrences. Such interventions are avoidable, and avoiding tempering may reduce the rate of surgical failures. Dr Badruddoja's letter opted not to refer to this at all. Correspondence: Dr Gutman, Department of Surgery B, Rabin Medical Center, Beilinson Campus, Petah Tiqva 49100, Israel (hgutman@post.tau.ac.il).

Journal

Archives of SurgeryAmerican Medical Association

Published: Nov 1, 2006

Keywords: melanoma,radical excision of lymph nodes

There are no references for this article.