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Journal of Clinical Oncology, Vol 24, No 32 (November 10), 2006: pp. 5178 © 2006 American Society of Clinical Oncology. DOI: 10.1200/JCO.2006.08.4301
In ReplyDepartment of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX We appreciate the opportunity to respond to Dr Miranda's letter regarding our recent publication in the Journal of Clinical Oncology.1 As Miranda states in his letter, the findings from his group2 and our own regarding the utility of radiographic staging for patients with sentinel node-positive melanoma are concordant. Miranda's letter raises two important points for patients with melanoma who are found to have a positive sentinel node. First, although our analysis found an association between measures of tumor aggressiveness (including primary tumor ulceration, depth of invasion, and sentinel node tumor burden) and true-positive radiologic staging evaluations, the majority of patients with these characteristics did have negative evaluations. We continue to stand behind our recommendation that these patients should be offered radiographic staging based not only on our analysis, but also on the finding that these features have the most meaningful prognostic influence for patients with melanoma.3 The pretest probability that a radiologic abnormality represents a true-positive finding of distant metastases in patients with thick and/or ulcerated melanoma may be three-fold higher than in patients who lack these features. In addition, if distant metastases are not present at diagnosis, these patients are at high risk for early development of distant metastases. Therefore, the initial staging evaluation in this subset of patients provides valuable reference information for comparison to subsequent imaging studies. The second point that Miranda raises is the issue of clinical symptoms. Our analysis focused on patients without localizing symptoms, signs, or other clinical findings that would suggest the presence of distant melanoma metastases. For the five patients in our study with positive radiologic staging evaluations, we closely re-examined the medical record to determine if any symptoms were present. In one of these five patients, there were nonspecific constitutional complaints and the examination was nonfocal. Otherwise, none of the five patients who were found to have distant melanoma metastases were symptomatic. Based on these data, we conclude that it is rare for asymptomatic sentinel node-positive melanoma patients to harbor radiologically detectable distant metastases. Although our analysis did not focus on the converse situation, we agree with Miranda that the presence of any focal or localizing symptoms in a melanoma patient should raise strong suspicion of stage IV disease. Authors' Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest. REFERENCES
1. Aloia TA, Gershenwald JE, Andtbacka RH, et al: Utility of computed tomography and magnetic resonance imaging staging before completion lymphadenectomy in patients with sentinel lymph node-positive melanoma. J Clin Oncol 24
: 2858
-2865, 2006 2. Miranda EP, Gertner M, Wall J, et al: Routine imaging of asymptomatic melanoma patients with metastasis to sentinel lymph nodes rarely identifies systemic disease. Arch Surg 139
: 831
-836, 2004 3. Balch CM, Buzaid AC, Soong SJ, et al: Final version of the American Joint Committee on Cancer staging system for cutaneous melanoma. J Clin Oncol 19
: 3635
-3648, 2001
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Copyright © 2006 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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