Access the full text.
Sign up today, get DeepDyve free for 14 days.
References for this paper are not available at this time. We will be adding them shortly, thank you for your patience.
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a major predictor for melanoma recurrence, and the descriptive “nodular” or “superficially spreading” classification is outdated.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).
Archives of Surgery – American Medical Association
Published: Nov 1, 2006
Keywords: melanoma,radical excision of lymph nodes
Read and print from thousands of top scholarly journals.
Already have an account? Log in
Bookmark this article. You can see your Bookmarks on your DeepDyve Library.
To save an article, log in first, or sign up for a DeepDyve account if you don’t already have one.
Copy and paste the desired citation format or use the link below to download a file formatted for EndNote
Access the full text.
Sign up today, get DeepDyve free for 14 days.
All DeepDyve websites use cookies to improve your online experience. They were placed on your computer when you launched this website. You can change your cookie settings through your browser.