We thank the author for his interest in our article and find his observations very interesting and enlightening. However, we believe it necessary to make some clarifications.

Even before the publication of the 2009 American Joint Committee on Cancer (AJCC) Staging and Classification, various authors had studied melanoma metastasis from an unknown primary site and concluded that survival in such cases was higher than in known primary cutaneous melanomas and metastases with a similar clinical presentation.

This improved survival has been reported for metastases in the skin and subcutaneous tissue and for local lymph node disease with an unknown primary site. The survival rates are similar to those expected for regional disease (stage III) and nonmetastatic disease.1–3

In the latest AJCC classification, single skin or subcutaneous metastases are considered to be satellite or in-transit metastases, while metastases in the lymph nodes are considered to be regional. In both cases they are categorized as stage III and are therefore associated with higher survival rates.4

This classification, however, is based only on the observation of better survival in such cases and no consideration is given to the origin of these cutaneous or subcutaneous lesions classified as satellite or in-transit (and therefore metastatic) lesions.

We are interested in the fact that these lesions might also have a primary origin, as this would have new implications for the management of patients beyond a mere classification determining survival and prognosis. As reported by Lee et al.,5 23% of patients with solitary dermal melanoma (SDM) may have nodal disease at the time of diagnosis or later and would therefore benefit from sentinel node biopsy and, if indicated, lymphadenectomy. It is noteworthy that sentinel node biopsy would not be indicated if the disease was already considered to be metastatic, although lymphadenectomy might be an option if there is nodal involvement following on from an in-transit metastasis.

Given the different potential origins of a single focus of melanoma in the dermis or subcutaneous tissue, we agree that a diagnosis of primary dermal melanoma is just one option when faced with SDM.