I recently read with interest the special article published in your journal by Moreno-Ramírez et al1 on the proposed management of patients with melanoma and metastasis of the sentinel lymph node. I could agree more with the majority of the proposals, and I congratulate the authors on their efforts to put order on a controversial and continually changing topic. However, I disagree with the authors on at least one of the points supporting their proposal. Table 3 of the article states that the “Frequency of surgical morbidity is greater in patients who undergo immediate lymph node dissection than in those who enter follow-up with therapeutic dissection”, a statement the authors claim is supported by level 1b evidence.

This statement is surprising because the corresponding citation refers the reader to the MSLT-II study, in which no specific analysis was performed, nor any conclusion drawn, on the association between surgical morbidity and the moment at which lymphadenectomy is performed.2 In fact, discussion of adverse effects in the Results section of the cited article only mentions that “Adverse events were more common among patients after completion of lymph-node dissection than among patients in the observation group”, and makes no mention of “follow-up with therapeutic dissection”, suggesting that the findings of this study do not support the authors’ statement.

It is possible that Moreno-Ramírez et al are actually referring to the MSLT-I study,3 which shares the same first author with the MSLT-II study and compares morbidity associated with immediate versus delayed lymphadenectomy. However, if this is indeed the case, the conclusion is the opposite to that presented. The MSLT-I study3 concludes that there is no higher incidence of dysesthesias in the immediate lymphadenectomy group, and that lymphedema is significantly more frequent in the delayed versus the immediate lymphadenectomy group (20.4% and 12.4%, respectively; p = 0.04). These findings are in direct contrast to the statement in the aforementioned Table 3.1 In fact, in the MSLT-I study multivariate analysis to identify risk factors for lymphedema revealed that body mass index and delayed lymphadenectomy were the only factors for which a trend towards an association was observed, irrespective of the location (axillary or inguinal) of the lymphadenectomy.

It should be taken into account that the MSLT-I study included cases of melanoma in which sentinel node biopsy was indicated, while the MSLT-II study included patients with sentinel lymph node involvement. This difference should not alter the conclusions about the time point at which lymphadenectomy is performed, nor the corresponding level of evidence (given the design of the study).

In conclusion, without detracting from the article’s conclusions or the proposed decision-making algorithm, it would be prudent, and would better support the authors’ argument, to properly qualify and correct this point.