We would like to respond to Krynyckyi and Kim in their second letter to the editor concerning our recent article.1
First, we would like to comment on the remark made by Dr. Krynyckyi regarding the e-mail communication in which he asked whether lymphoscintigraphy was used. The personal e-mail response by the first author was insufficient as a result of interpretation problems, and this is regretted. As we stated in our first reply to the letter to the editor, lymphoscintigraphy was performed as described by Rutgers et al.2
Because the primary topic of our article was short-term morbidity of the upper limb after sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND), we emphasized the methodology for assessment of this morbidity. In our opinion, Rutgers et al.2 provided a good description of the technique that was used. However, we modified the injection method as mentioned in our first reply, and we used the gamma probe to locate the sentinel lymph node. In his second letter, Dr. Krynyckyi discussed several issues concerning the SLNB technique itself. He also suggested that these differences in techniques probably produced the variation in morbidity. This could be true, but to the best of our knowledge, this result has never been published in the literature. With regard to this issue, we also wish to cite Rutgers,3 who stated that if identification only of the sentinel lymph node in the axilla is desired, then neither the type of tracer used nor the site of injection appears to matter, as high identification rates and low false-negative rates have been reported in association with a number of different techniques performed after reasonable learning periods by well trained teams. In the same article, Rutgers reports that surgeons' learning curves, which encompassed ≥ 20–30 cases, involved the performance of ≥ 6 procedures each month.3 The three experienced surgeons in our study fulfilled these criteria.
The initial correspondence by Krynyckyi et al. probably was initiated by our unexpected conclusion—i.e., that there was no significant difference in morbidity (6 weeks after surgical treatment) between patients who underwent ALND and patients who underwent SLNB.1 Because of an incorrect merging of the data, we came to this incorrect conclusion. After correction of this error, we conclude that significant short-term treatment-related upper limb morbidity and associated activity of daily living (ADL) disabilities arise after SLNB or ALND. In addition, our findings suggest that there are significant differences in short-term treatment-related morbidity and ADL between patients who undergo SLNB and patients who undergo ALND.1