Sentinel Lymph Node Biopsy

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11/20/2012 10:43pm
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Replies: 3

I will try to make a long story short. Back in August I had an 8 mm mole removed from my calf that turned out to be melanoma.  The original path report showed .89 breslow depth, Clarks level III, no ulceration, and it did not list a mitotic rate. My dermatologist did a WLE and said he does not recommend SLNB's for melanomas under 1mm breslow. The WLE came back all margins clear. In the meantime, I scheduled an appointment with an oncologist that specializes in melanoma at the Ohio State University for a second opinion.  He had the original lab forward my slides to his pathologist.  The original lab took over a month to forward the slides.  I finally saw him today and his pathologist shows the mitotic rate is "approximately 1/mm2". He was struggling with whether or not to do a SLNB because he usually does it if the mitotic rate is higher than 1 and does not do it if it is lower than 1 and mine is "approximately 1".  He tried to call the pathologist to get her opinion and could not reach her.  He finally decided to have me see the surgical oncologist to let him decide. They should be calling me in the next few days with my appointment date and time for that. 

I am a little shocked because I was hoping and assuming that I was just going today to get the final all clear and instead I am back into another waiting game and it appears I have gone from T1a to T1b based on that mitotic rate.  I found an article on the Skin Cancer Foundation's website that says the AJCC Melanoma Staging System recommends a SLNB for patients with "T1 melanomas and secondary features associated with increased risk for nodal micrometastases: ulceration, mitotic rate greater than or equal to 1/mm2, or Clark's level IV, especially when the primary melanoma exceeds 0.7 mm in thickness". So mine is greater than 0.7 mm in thickness and has a mitotitic rate equal to 1/mm2, which means that I should have this test.  Of course, this is just one opinion. 

On one hand, I do not want another surgery, but on the other hand I would rather be safe than sorry.  Does anyone else have any experience with this?  If I do end up having the SLNB, what is the recovery time and how soon can I expect to go back to work?  I have a desk job that does not require any manual labor or heavy lifting. 

Janner - (11/20/2012 - 11:21pm)

A mitosis of <1 is still stage 1A, so approximately 1 may still be interpreted as stage 1A.  You can always get another opinion on the pathology.  Third time might favor one or the other diagnosis.  As for the SNB and lesions over .7mm or under 1mm or somewhere in between, it depends much on the institution.  Some do it only on lesions > 1mm unless they have other negative factors.  Some places have other criteria.  Prior to the end of 2010, the mitosis didn't even enter the equation and the SNB was done based on depth alone and possibly ulceration.  So depending where you go, you are in a gray area with mitosis and SNB recommendation.  However, I have another concern.  The SNB ideally should be done PRIOR to the wide excision.  The WLE removes a large chunk of skin and may alter the drainage paths to the sentinel node.  A surgeon MAY be able to find "A" Sentinel Node after the WLE, but there is no way to guarantee it is "THE" sentinel node.  I have heard doctors guarantee they can find the sentinel node after a WLE, but the sentinel node procedure was developed and tested and designed to be done prior to the WLE.  So if your surgeon recommends the SNB now, please be aware that there may be a larger margin for error given that you've already had the WLE.  The prior WLE might skew the results.   In the end, you need to do what makes you feel comfortable, not anyone else!

Janner

Last primary was .88mm, 1 mitosis, no SNB in 2001 as the criteria then was <1mm and no ulceration.

POW - (11/21/2012 - 9:07am)

Janner is right, as usual. The sentiel node biopsy should be done before the WLE disrupts the lymph vessels surrounding the lesion. I'm not sure how much comfort I would get from a negative sentinel node biopsy performed after the WLE. Could I trust that result?

In your case, you probably did NOT need an SNL. It might have been nice for your peace of mind, but not really medically necessary. For all of us on this jouney, all that we and our doctors can do is make the best decision we can with the information we have at the time and then resist the urge to second-gues ourselves. Your doctor was not "wrong" to skip the SNL. And if you want peace of mind, you could arrange to have periodic CT scans or PET scans for the next year or two to assure yourself that there are no mets anywhere. 

Anonymous - (11/21/2012 - 9:50am)

But weigh the risk/benefit of scans for you. . . it is radiation exposure