We thank Montagna and El-Tamer for the appreciative editorial in the current issue of Annals of Surgical Oncology, which we have been reading with interest.1 It provides a clear and contemporary view in the ongoing debate on axillary staging in neoadjuvant-treated patients.

Montagna and El-Tamer address two questions regarding our study, “Comparing Methods for Targeted Axillary Dissection in Breast Cancer Patients: A Nationwide, Retrospective Study,” which we hereby would like to clarify with supplementary information. As mentioned in the editorial, we reported that the surgical success of excision of a marked lymph node is lower when ink on the skin is used to guide the excision. Montagna and El-Tamer are asking for a more detailed description of this procedure. In detail, the procedure was performed by marking the metastatic lymph node with a coil, and, on the day of surgery, an axillary ultrasound was performed during which a pen was used to mark the axillary skin superficial to the coil-bearing lymph node. The surgeon would then place the skin incision near the marking on the axillary skin and excise the lymph node underneath, expecting the coil to be in that lymph node.

Furthermore, Montagna and El-Tamer are asking for information on further treatment decisions for patients with nondetection of the marked lymph node. This could indeed be interesting information, and we therefore would like to supplement that in the Danish guideline, nondetection of the marked lymph node is an indication for axillary lymph node clearance. This was opted for in the vast majority of patients, including patients where metastases were found in the sentinel node. In a few patients, axillary radiotherapy was chosen instead of axillary lymph node clearing after multidisciplinary team conferences, bearing patient preferences in mind.

We hope that this additional information can clarify any questions readers may have.