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We read with great interest the vivid correspondence between the authors of recent papers in the Annals of Surgical. 1–3 The discussion focuses on a possible survival benefit for patients treated by sentinel lymph node biopsy (SNLB) procedure compared with observation (OBS) and the potential cost-effectiveness of SNLB in the light of such a supposed survival benefit, based on the third interim results of the prospective Multicenter Selective Lymphad-enectomy Trial-1 (MSLT-1). 4 Interestingly, the discussion also focuses on the nodal relapse rates for both arms of the MSLT-1 trail (Table 1). Strikingly, there seems to be an increase in late relapses in both arms, which might either be the result of selection bias, as follow-up has not yet matured to 10 years in the entire MSLT-1 population and thus might lead to an overestimation of the data, or these continuous late relapses in both arms may indicate a failure rate of completion lymph node dissection (CLND) completeness. Interestingly we did not see any late relapses in our submicrometastases (\0.1 mm) patients. In light of the lack of survival benefit for the sentinel node (SN) procedure from the point of randomization in the MSLT-1 trial, the cost-effectiveness of the SN procedure as a staging procedure is debatable. Recently a study by Voit et al. demonstrated that presurgical ultrasound (US)-guided fine-needle aspiration cytology (FNAC) has a sensitivity of 65% compared with surgical SN procedure. 8 Moreover, the sensitivity of US-guided FNAC increases significantly with increasing SN tumor burden. 8 Considering that only 15–30% of all stage I/II melanoma patients are SN positive, 70– 85% are negative but still undergo a SN procedure. 4 US-guided FNAC has the potential to save 65–80% of SN-positive patients a SN staging procedure and to save an estimated 61–92% of SN-negative patients a surgical procedure, and the accompanying costs. Here we would like to submit the argument for ultra-sound-guided FNAC as a cost-effective alternative scenario to the surgical SN procedure. For the purpose of these calculations, based on the data by Voit et al., we considered that 40% will undergo an US with FNAC whereas 60% will have a benign US and will not undergo a FNAC. 8 Moreover , 50% will be FNAC positive and 50% will be FNAC negative. Finally, the negative patients will undergo routine US follow-up (four times a year), with an average of one FNAC. At our centers in The Netherlands and …

Potential Cost-Effectiveness of US-Guided FNAC in Melanoma Patients as a Primary Procedure and in Follow-Up