I appreciate the observations of Professor Pitak-Arnnop, especially the tutorial pertaining to French grammar.

As clearly stated in the paper, this is a retrospective outcome study evaluating the role of adjuvant radiotherapy (RT) after surgery for patients at high risk for local recurrence after surgery alone. We also included 2 patients with incompletely resectable pleomorphic adenoma (PA) who were treated with RT alone by default. The goal of the paper is not to compare the outcomes of definitive RT and RT following “adjuvant” surgery. Only 2 patients were treated with RT alone and they are not comparable to those suitable for attempted gross total resection.

If one were to design a prospective randomized trial it would be to compare surgery alone versus surgery and adjuvant RT in patients thought to be at high risk for local recurrence after surgery alone. This would be impractical for several reasons. First, as stated in the “Discussion,” the local control rate after surgery alone for previously untreated PA exceeds 95% and very few patients would be eligible for such a trial. Indeed, we treated only 25 patients over 38 years, averaging less than 1 patient per year. Second, 20 of 25 patients had gross or microscopic residual disease and were at very high risk for local progression. One might think that if it was worthwhile operating on these patients initially, that it would be worth considering adjuvant RT to eradicate known or suspected residual diseases.

Finally, Professor Pitak-Arnnop is correct in stating that we did not present data pertaining to the outcomes after salvage surgery alone for patients with multinodular recurrences after prior surgery. Although it is my impression that such patients have a very high risk of local recurrence after surgery alone, all of our patients received RT and we do not have data to address this question.

Sincerely,