Ann Surg Oncol DOI 10.1245/s10434-017-6230-7 LETTER – MELANOMAS Pre-SN Ultrasound-FNAC can be Sensitive for Lymph Node Metastases in Melanoma Patients if Performed with the Use of the Berlin Criteria Christiane A. Voit, MD, PhD1, Alexander C. J. van Akkooi, MD, PhD2, Orlando Catalano, MD3, and Alexander M. M. Eggermont, MD, PhD4 Humboldt University, Berlin, Germany; 2Erasmus University Medical Center – Daniel den Hoed Cancer Center, Rotterdam, The Netherlands; 3National Cancer Institute ‘‘Fondazione G. Pascale’’, Naples, Italy; 4Institut de Cancérologie, Gustav Roussy, Villejuif, France 1 Christiane A. Voit: Deceased. criteria.4 Furthermore, they specifically report that they have not used the recently published Berlin ultrasound morphology criteria by our group.3 This is quite disappointing, because we have recently demonstrated that the use of these criteria has significantly increased the sensitivity of ultrasound in melanoma.5 Without the use of these criteria, the yield of the technique is approximately 30% (20–40%), but with the use of the new criteria, the possible sensitivity can be 70–80%.2,6,7 Finally, the authors report that they offered patients who had a suspicious ultrasound to undergo a repeat ultrasound with FNAC. Only ten patients (3.1%) underwent this procedure, when 65 patients had an abnormal ultrasound result. With the introduction of the criterion of peripheral perfusion as early sign of metastasis and the very low threshold to perform FNAC, the sensitivity of ultrasoundFNAC can be significantly improved. Now, the authors have only managed to FNA large metastases in patients with very advanced tumors (T4). In our hand, metastases of only 0.4 mm in maximum diameter have successfully been demonstrated by FNAC. We conclude that the title and the conclusions of this paper are premature and misleading. Ultrasound-guidedFNAC, when performed to the currently best available standard, which includes lymphoscintigraphy, the correct morphology criteria and frequent use of FNAC, can be useful for identifying nodal metastases in clinically nodenegative patients, especially in T3/T4 tumors. Ó Society of Surgical Oncology 2017 REFERENCES TO THE EDITORS: With great interest, we read the article by Christy Chai et al. describing the use of ultrasound (US) for the assessment of sentinel (SN) lymph node.1 However, we would like to stress some crucial differences, and caution the interpretation of the results from this study. First, blind lymph node screening with ultrasound is difficult, especially in truncal melanomas, which could drain two or more lymph node basins. Forty percent of the patients in this study had truncal melanomas. Not only the correct basin, but also the location within that basin, could be guided by the addition of lymphoscintigraphy, which could increase the sensitivity of ultrasound. Second, the most important factor contributing to the sensitivity of an ultrasound technique is the morphology criteria, which were used to determine if a node is considered benign, suspicious, or malignant.2,3 The authors report that they did not use absolute criteria, which seems a rather loose and undisciplined way of using a technique. A recent systematic review from one of us showed the discrepancies and unclear aspects among the published articles on pre-SLN biopsy US, highlighting the need for definitive, clearly defined, and univocal diagnostic First Received: 29 October 2017 A. C. J. van Akkooi, MD, PhD e-mail: a.v.akkooi@nki.nl 1. Chai CY, Zager JS, Szabunio MM, et al. Preoperative ultrasound is not useful for identifying nodal metastasis in melanoma patients undergoing sentinel node biopsy: preoperative ultrasound in C. A. Voit et al. clinically node-negative melanoma. Ann Surg Oncol. 2012;19(4):1100–106. 2. Voit CA, van Akkooi AC, Schafer-Hesterberg G, et al. Rotterdam criteria for sentinel node (SN) tumor burden and the accuracy of ultrasound (US)-guided fine-needle aspiration cytology (FNAC): can US-guided FNAC replace SN staging in patients with melanoma? J Clin Oncol. 2009;27:4994–5000. 3. Voit C, van Akkooi AC, Schafer-Hesterberg G, et al. Ultrasound morphology criteria predict metastatic disease of the sentinel nodes in patients with melanoma. J Clin Oncol. 2010;28:847–52. 4. Catalano O. Critical analysis of the ultrasonographic criteria for diagnosing lymph node metastasis in patients with cutaneous melanoma: a systematic review. J Ultrasound Med. 2011;30:547–60. 5. Catalano O, Setola SV, Vallone P, et al. Sonography for locoregional staging and follow-up of cutaneous melanoma: how we do it. J Ultrasound Med. 2010;29:791–802. 6. Starritt EC, Uren RF, Scolyer RA, et al. Ultrasound examination of sentinel nodes in the initial assessment of patients with primary cutaneous melanoma. Ann Surg Oncol. 2005;12:18–23. 7. Sanki A, Uren RF, Moncrieff M, et al. Targeted high-resolution ultrasound is not an effective substitute for sentinel lymph node biopsy in patients with primary cutaneous melanoma. J Clin Oncol. 2009;27(33):5614–19.