Melanoma

In 1992 I was told I would be bedridden for the rest of my life. I had my lymph nodes removed during a malignant melanoma surgery. My leg was as wide as my waist when I woke up from the surgery. I was told not to exercise for a full year. (I waited 9 months and just HAD to start exercising again!) The swelling went down very slowly. Twenty years later, I still deal with lymphedema on a daily basis. I maintain it well... sleep with my leg elevated, wear compression stocking, and I know which exercises reduce or increase the swelling. I recently published a book on my experience as a cancer patient and the twenty years since. Sentinel lymph node biopsy has revolutionized melanoma surgery, staging, prognosis, and aids in the decision for adjuvant therapy after definitive surgery. However, like all things there is some down side including pain and restriction of motion (usually limited to post operative period), numbness/paraesthesias (which can be permanent) and most problematic - lymphedema. The cause of post sentinel lymph node biopsy lymphedema is poorly understood but does not appear to be related to the number of lymph nodes removed (average sentinel node biopsy has 2-3 nodes). Complicating the issue further is the actual method of deciding if lymphedema is present. The methods vary from circumferential measurements above and below the elbow/knee at specified distances, perometry (measuring shadow size of each extremity), water displacement (volumetric analysis) and bioeimpedence (as extracellular fluid increases the ability to transmit electrical charge through the limb decreases). With all of those caveats, the risk of lymphedema after sentinel lymph node biopsy is ~5-10%; after a full lymphatic dissection, it is ~15-60% (and above that if the nodal area is radiated).

Some melanomas bleed and this may trigger the patient to seek medical care. Often in this scenario, the melanoma will have grown all the way through the epidermis - which is called ulceration. Sometimes, non-bleeding melanomas will also have grown through the epidermis and be 'ulcerated'. Ulcerated melanomas occur ~20% of the time and determining the presence of ulceration is important. Patients with an ulcerated melanomas have a worse prognosis, greater chance of a positive sentinel lymph nodes, and higher rate of systemic spread compared to patients whose melanomas do not have ulceration. Ulceration will increase the stage of the patient by one half of a stage (for example an ulcerated melanoma will be a Stage 2B compared to a Stage 2A for an identical thickness melanoma without ulceration). Some melanomas bleed and this may trigger the patient to seek medical care. Often in this scenario, the melanoma will have grown all the way through the epidermis - which is called ulceration. Sometimes, non-bleeding melanomas will also have grown through the epidermis and be 'ulcerated'. Ulcerated melanomas occur ~20% of the time and determining the presence of ulceration is important. Patients with an ulcerated melanomas have a worse prognosis, greater chance of a positive sentinel lymph nodes, and higher rate of systemic spread compared to patients whose melanomas do not have ulceration. Ulceration will increase the stage of the patient by one half of a stage (for example an ulcerated melanoma will be a Stage 2B compared to a Stage 2A for an identical thickness melanoma without ulceration).

The pathologist always checks the edges of the wide excision to ensure there is no melanoma present (implying that if they see it at the edge then it is also present on the other edge that was left behind). Fortunately, this is very rare (<1%) for melanoma - unlike breast cancer lumpectomy which has a positive edge (margin) ~10-40% of the time. The pathologist always checks the edges of the wide excision to ensure there is no melanoma present (implying that if they see it at the edge then it is also present on the other edge that was left behind). Fortunately, this is very rare (<1%) for melanoma - unlike breast cancer lumpectomy which has a positive edge (margin) ~10-40% of the time.

Everyone is usually very anxious until the surgery is over so I try to schedule their surgery as expeditiously as possible - usually within a few days to a week. In the interim, the patient may be getting scans (PET/CT, brain MRI) and they usually get a lymphoscintigraphy (radioactive dye that we use to find the sentinel node(s)) the afternoon before or morning of surgery. I like my patients to get a good nights sleep before surgery and to take a shower with an antibacterial soap the morning of their surgery. Everyone is usually very anxious until the surgery is over so I try to schedule their surgery as expeditiously as possible - usually within a few days to a week. In the interim, the patient may be getting scans (PET/CT, brain MRI) and they usually get a lymphoscintigraphy (radioactive dye that we use to find the sentinel node(s)) the afternoon before or morning of surgery. I like my patients to get a good nights sleep before surgery and to take a shower with an antibacterial soap the morning of their surgery.

The chance of the sentinel node(s) having melanoma that has spread from the skin varies by the thickness of the primary melanoma (and other factors such as ulceration, mitotic rate, vertical growth phase). For melanomas <1 mm, it is ~5-7%; for 1-4 mm, it is 12-24%; and >4mm, it is ~25-40%. However the vast majority of time the sentinel node only has a microscopic deposit of melanoma so it is unusual to discover this at the time of sentinel lymph node biopsy. Therefore, I never (rarely) do a complete dissection at the time of sentinel lymph node biopsy, waiting instead for the final pathology report. If there is a 'positive' sentinel lymph node, then the standard of care is to remove the rest of the lymph nodes in that basin (neck, axilla, groin). These basins are defined by anatomic landmarks (not absolute number of nodes) and all tissue within those boundaries is removed. The number of lymph nodes removed will vary by patient with some patients having just a few and some patients having a lot (like most things in medicine the number of lymph nodes in a basin is a bell shaped curve). There is a large international study going on (Multicenter Selective Lymphadenectomy Trial- II) that is trying to determine if we need to do a complete dissection for those patients with a positive sentinel node. The study is a randomized (meaning a computerized coin toss) trial comparing the standard of care (complete lymphatic dissection) vs no further lymphatic surgery (with ultrasound examination of the lymph node basin every 3 months to look for metastatic lymph nodes). The patient can choose to be in the study but cannot 'pick' their therapy (surgery vs observation of their lymph nodes). If you want further information on this trial please email me at beitsch@aol.com The chance of the sentinel node(s) having melanoma that has spread from the skin varies by the thickness of the primary melanoma (and other factors such as ulceration, mitotic rate, vertical growth phase). For melanomas <1 mm, it is ~5-7%; for 1-4 mm, it is 12-24%; and >4mm, it is ~25-40%. However the vast majority of time the sentinel node only has a microscopic deposit of melanoma so it is unusual to discover this at the time of sentinel lymph node biopsy. Therefore, I never (rarely) do a complete dissection at the time of sentinel lymph node biopsy, waiting instead for the final pathology report. If there is a 'positive' sentinel lymph node, then the standard of care is to remove the rest of the lymph nodes in that basin (neck, axilla, groin). These basins are defined by anatomic landmarks (not absolute number of nodes) and all tissue within those boundaries is removed. The number of lymph nodes removed will vary by patient with some patients having just a few and some patients having a lot (like most things in medicine the number of lymph nodes in a basin is a bell shaped curve). There is a large international study going on (Multicenter Selective Lymphadenectomy Trial- II) that is trying to determine if we need to do a complete dissection for those patients with a positive sentinel node. The study is a randomized (meaning a computerized coin toss) trial comparing the standard of care (complete lymphatic dissection) vs no further lymphatic surgery (with ultrasound examination of the lymph node basin every 3 months to look for metastatic lymph nodes). The patient can choose to be in the study but cannot 'pick' their therapy (surgery vs observation of their lymph nodes). If you want further information on this trial please email me at beitsch@aol.com

The width of the wide excision is determined by the melanoma thickness and by the location on the body. Non-invasive or melanoma-in-situ is excisied with 5 millimeter margins. Non-cosmetically sensitive (face, ears) or funcitonally sensitive (hand, genitals) will generally have 1 cm of radial width per millimeter of thickness of melanoma up to 3 cm. This is typically cut in half for cosmetically/functionally sensitive areas. Rarely the margins will be positive and will require more excision. This is usually for melanoma-in-situ at the margin. The width of the wide excision is determined by the melanoma thickness and by the location on the body. Non-invasive or melanoma-in-situ is excisied with 5 millimeter margins. Non-cosmetically sensitive (face, ears) or funcitonally sensitive (hand, genitals) will generally have 1 cm of radial width per millimeter of thickness of melanoma up to 3 cm. This is typically cut in half for cosmetically/functionally sensitive areas. Rarely the margins will be positive and will require more excision. This is usually for melanoma-in-situ at the margin.

The stage of melanoma is determined from 3 factors - tumor thickness, lymph node status and distant spread. Tumor thickness is determined from the initial removal of the 'funny looking mole' and is literally a measurement of thickness under the microscope. Other factors of the primary melanomas are important - the main one being whether the melanoma is ulcerated or not. Ulcerated melanomas are 'upstaged' by 1/2 a tumor size stage compared to non-ulcerated melanomas. Other important factors (but not changing the tumor thickness stage) include mitotic rate (how fast the melanoma is dividing), regression, vertical growth phase and lymphovascular invasion. Lymph node status is determined by whether or not the melanoma has spread from the melanoma to the regional lymph nodes. This is usually determined by sentinel node biopsy. The number of affected lymph nodes is important along with the quantity of spread within the lymph node(s). If the sentinel lymph node is 'clean' (without melanoma), then the stage is determined by the thickness and ulceration status of the primary melanoma. If the melanoma has spread to the regional lymph nodes, the patient is classified as stage 3. Lastly is the determination of whether or not the patient's melanoma has spread through the body. This is usually done with CT or PET/CT scans and maybe a brain scan (CT or MRI). If the melanoma has spread elsewhere in the body (lung, liver, bone, brain, etc), then the patient automatically jumps to stage 4 regardless of the tumor thickness or lymph node status. The stage of melanoma is determined from 3 factors - tumor thickness, lymph node status and distant spread. Tumor thickness is determined from the initial removal of the 'funny looking mole' and is literally a measurement of thickness under the microscope. Other factors of the primary melanomas are important - the main one being whether the melanoma is ulcerated or not. Ulcerated melanomas are 'upstaged' by 1/2 a tumor size stage compared to non-ulcerated melanomas. Other important factors (but not changing the tumor thickness stage) include mitotic rate (how fast the melanoma is dividing), regression, vertical growth phase and lymphovascular invasion. Lymph node status is determined by whether or not the melanoma has spread from the melanoma to the regional lymph nodes. This is usually determined by sentinel node biopsy. The number of affected lymph nodes is important along with the quantity of spread within the lymph node(s). If the sentinel lymph node is 'clean' (without melanoma), then the stage is determined by the thickness and ulceration status of the primary melanoma. If the melanoma has spread to the regional lymph nodes, the patient is classified as stage 3. Lastly is the determination of whether or not the patient's melanoma has spread through the body. This is usually done with CT or PET/CT scans and maybe a brain scan (CT or MRI). If the melanoma has spread elsewhere in the body (lung, liver, bone, brain, etc), then the patient automatically jumps to stage 4 regardless of the tumor thickness or lymph node status.

The wide excision part of your surgery to to remove any melanoma cells that are in the vicinity of your primary (original) melanoma. The amount of skin that is removed varies somewhat by location for cosmetic (face) or functional (hand) reasons but generally for melanoma thickness <1mm - 1 cm in all directions is removed, for 1-2mm melanomas- 2cm in all directions and >2mm melanomas -= 3cm in all directions. These excisions usually create a circle of skin missing. Circles can't be closed into a straight line so a 'flap' must be created to fill the space. This 'flap' is either an elongation of the circle wide excision into an ellipse (the ellipse must be 3 times as long as it is wide to close properly) or a rotation flap (where skin from beside the wide excision is elevated and rotated into the defect). The incisions are always longer than you expect so don't worry that it was 'too long' - it is only as big as is necessary to remove the melanoma. The wide excision part of your surgery to to remove any melanoma cells that are in the vicinity of your primary (original) melanoma. The amount of skin that is removed varies somewhat by location for cosmetic (face) or functional (hand) reasons but generally for melanoma thickness <1mm - 1 cm in all directions is removed, for 1-2mm melanomas- 2cm in all directions and >2mm melanomas -= 3cm in all directions. These excisions usually create a circle of skin missing. Circles can't be closed into a straight line so a 'flap' must be created to fill the space. This 'flap' is either an elongation of the circle wide excision into an ellipse (the ellipse must be 3 times as long as it is wide to close properly) or a rotation flap (where skin from beside the wide excision is elevated and rotated into the defect). The incisions are always longer than you expect so don't worry that it was 'too long' - it is only as big as is necessary to remove the melanoma.

The margins of the wide excision are examined to make sure there is no melanoma at the edges. Rarely there is melanoma present along part of the margin (usually non-invasive melanoma in situ) and this will need to re-excised to 'negative' margins. The sentinel lymph node is the critical piece of information since it will determine if all surgical therapy is over (lymph node doesn't have any melanoma cells in it) or that more surgery (completion lymph node dissection) and possibly systemic therapy is needed. The margins of the wide excision are examined to make sure there is no melanoma at the edges. Rarely there is melanoma present along part of the margin (usually non-invasive melanoma in situ) and this will need to re-excised to 'negative' margins. The sentinel lymph node is the critical piece of information since it will determine if all surgical therapy is over (lymph node doesn't have any melanoma cells in it) or that more surgery (completion lymph node dissection) and possibly systemic therapy is needed.

Pathology reports usually take 2-5 days to return depending on the complexity of the case with most cases being done in 2-3 days. The sentienl node is thoroughly examined by both routine stains (hematoxylin and eosin) and special melanoma specific stains (HMB45). Pathology reports usually take 2-5 days to return depending on the complexity of the case with most cases being done in 2-3 days. The sentienl node is thoroughly examined by both routine stains (hematoxylin and eosin) and special melanoma specific stains (HMB45).

Your surgeon needs your records including biopsy pathology report(s) and any other operative report you may have had. If you have had any scans, the reports and preferably a CD-ROM containing the actual scan images would be important. Often these records are forwarded to the surgeon fromt eh dermatologist or primary care physician but it is always very helpful if you check to make sure the surgeon has all pertinent records. Your surgeon needs your records including biopsy pathology report(s) and any other operative report you may have had. If you have had any scans, the reports and preferably a CD-ROM containing the actual scan images would be important. Often these records are forwarded to the surgeon fromt eh dermatologist or primary care physician but it is always very helpful if you check to make sure the surgeon has all pertinent records.

In my experience, patients come into my office fearing that they are going to die of their melanoma when the reality is that the vast majority of melanoma patients are cured of their melanoma - so most patients are reassured and relieved. The surgeon will give them a detailed discussion about melanoma and how it could potentially spread - locally, regionally and systemically and a plan to deal with each of these. Local spread requires a Wide Excision around the melanoma - generally 1cm radially out from the biopsy for each millimeter of thickness up to ~3cm from the biopsy site. Regional spread requires a sentinel lymph node biopsy to determine if the melanoma has spread to that lymph node. Systemic spread is assessed with body scans such as PET/CT, regular CT's, and MRI's. In my experience, patients come into my office fearing that they are going to die of their melanoma when the reality is that the vast majority of melanoma patients are cured of their melanoma - so most patients are reassured and relieved. The surgeon will give them a detailed discussion about melanoma and how it could potentially spread - locally, regionally and systemically and a plan to deal with each of these. Local spread requires a Wide Excision around the melanoma - generally 1cm radially out from the biopsy for each millimeter of thickness up to ~3cm from the biopsy site. Regional spread requires a sentinel lymph node biopsy to determine if the melanoma has spread to that lymph node. Systemic spread is assessed with body scans such as PET/CT, regular CT's, and MRI's.

Most patients with an invasive melanoma (of any Breslow thickness) should see a surgical oncologist. The main reason being to decide if there are features of the primary melanoma that would indicate a need to assess the sentinel (first draining) lymph node. Essentially all patients with a melanoma of 1.0 mm thickness and above should get a sentinel lymph node biopsy. Below 1.0 mm, there are certain features that would warrant getting a sentinel lymph node including ulceration, mitoses (cell divisions) >1, lymphovascular invasion, thickness >0.75mm, Clark's level 4 (Clark was a pathologist who measured melanomas based on the level it penetrated through the layers of the skin) and sometimes for patient reassurance. This last point is very loose but sometimes the psychological well being of having a 'clean' sentinel node biopsy is worth the very low chance of morbidity (pain, infection, extremity swelling). Most patients with an invasive melanoma (of any Breslow thickness) should see a surgical oncologist. The main reason being to decide if there are features of the primary melanoma that would indicate a need to assess the sentinel (first draining) lymph node. Essentially all patients with a melanoma of 1.0 mm thickness and above should get a sentinel lymph node biopsy. Below 1.0 mm, there are certain features that would warrant getting a sentinel lymph node including ulceration, mitoses (cell divisions) >1, lymphovascular invasion, thickness >0.75mm, Clark's level 4 (Clark was a pathologist who measured melanomas based on the level it penetrated through the layers of the skin) and sometimes for patient reassurance. This last point is very loose but sometimes the psychological well being of having a 'clean' sentinel node biopsy is worth the very low chance of morbidity (pain, infection, extremity swelling).

Dysplastic nevi are generally larger than ordinary moles and have irregular and indistinct borders. They have 'funny looking' or 'atypical' melanocytes (the benign cells that make pigment that protects against the sun and are the cells that can turn into melanomas). They may be a precursor lesion to a melanoma although most dermatopathologists use the more appropriate name for precursor lesions - atypical melanocytic hyperplasia with dysplasia (mild, moderate or severe). Dysplastic nevi are generally larger than ordinary moles and have irregular and indistinct borders. They have 'funny looking' or 'atypical' melanocytes (the benign cells that make pigment that protects against the sun and are the cells that can turn into melanomas). They may be a precursor lesion to a melanoma although most dermatopathologists use the more appropriate name for precursor lesions - atypical melanocytic hyperplasia with dysplasia (mild, moderate or severe).

Dysplastic nevi don't 'turn into' an invasive melanoma but are a marker for a patient that is a risk of developing a melanoma in the future. These patients are usually seen twice a year by their dermatologist. Dysplastic nevi don't 'turn into' an invasive melanoma but are a marker for a patient that is a risk of developing a melanoma in the future. These patients are usually seen twice a year by their dermatologist.

The 'cure' rate of Stage 1a melanoma is excellent and approaches 100% (there are few if any absolute 0%'s or 100%'s in medicine). The highest risk of recurrence of any melanoma is within the first 2 years so I see all my invasive melanoma patients every 3 months for the first 2 years and then every 6 months for 3 years and then yearly. However, there is also risk of developing a second melanoma unrelated to the initial melanoma at a rate of 0.5-1.0% per year for the rest of their life. Therefore, follow up should be every 3-6 months with their dermatologist in addition to the visits with their surgical oncologist. The 'cure' rate of Stage 1a melanoma is excellent and approaches 100% (there are few if any absolute 0%'s or 100%'s in medicine). The highest risk of recurrence of any melanoma is within the first 2 years so I see all my invasive melanoma patients every 3 months for the first 2 years and then every 6 months for 3 years and then yearly. However, there is also risk of developing a second melanoma unrelated to the initial melanoma at a rate of 0.5-1.0% per year for the rest of their life. Therefore, follow up should be every 3-6 months with their dermatologist in addition to the visits with their surgical oncologist.

Currently micrometastases are detected with the microscope using both standard H&E staining of slices of the sentinel lymph node as well as with melanoma specific imunostains (immuno-histo-chemistry or IHC). There are techniques to evaluate sentinel lymph nodes by PCR (polymerase chain reaction) that detect submicroscopic deposits of melanoma cells in the lymph nodes; however they are only experimental at this time. Currently micrometastases are detected with the microscope using both standard H&E staining of slices of the sentinel lymph node as well as with melanoma specific imunostains (immuno-histo-chemistry or IHC). There are techniques to evaluate sentinel lymph nodes by PCR (polymerase chain reaction) that detect submicroscopic deposits of melanoma cells in the lymph nodes; however they are only experimental at this time.

The amount of the metastatic deposit does have prognositic significance - the larger the deposit - the worse the prognosis; the more lymph nodes that contain melanoma - the worse the prognosis. There is a lot of controversy about adjuvant therapy (therapy for the entire body after the definitive surgery) for patients with node positive melanoma. Some oncolgists have the opinion there is no proven therapy that is effective while others believe in alpha-interferon (typically given for a full year after surgery). It is a bit of a 'belief' or 'faith' issue and should be discussed with your surgeon and medical oncologist. The amount of the metastatic deposit does have prognositic significance - the larger the deposit - the worse the prognosis; the more lymph nodes that contain melanoma - the worse the prognosis. There is a lot of controversy about adjuvant therapy (therapy for the entire body after the definitive surgery) for patients with node positive melanoma. Some oncolgists have the opinion there is no proven therapy that is effective while others believe in alpha-interferon (typically given for a full year after surgery). It is a bit of a 'belief' or 'faith' issue and should be discussed with your surgeon and medical oncologist.

An average lymph node is about 1/2 an inch in length (1.2 cm). The vast majority of 'positive' lymph nodes (those with spread of the melanoma from the skin to the lymph node(s)) in our era are 'micrometastatic' - that is deposits < 2 millimeters in size. An average lymph node is about 1/2 an inch in length (1.2 cm). The vast majority of 'positive' lymph nodes (those with spread of the melanoma from the skin to the lymph node(s)) in our era are 'micrometastatic' - that is deposits < 2 millimeters in size.

Extracapsular extension is usually only seen under the microscope by the pathologist examining the involved lymph node. Rarely, extracapsular extension can be so extensive that the lymph nodes 'grow together' or become matted - this is ominous and denotes a very aggressive melanoma. Extracapsular extension is usually only seen under the microscope by the pathologist examining the involved lymph node. Rarely, extracapsular extension can be so extensive that the lymph nodes 'grow together' or become matted - this is ominous and denotes a very aggressive melanoma.