The Sentinel Lymph Node Biopsy and Wide Excision   April 12th, 2011

(Warning: The squeamish are hereby forewarned that this post features a few graphic images of wounds.)

As I related two posts back, the revelation (if that’s what you call it) that I had malignant melanoma was a real shocker.

I let myself be guided by wiser heads than mine, namely my dermatologist-in-passing (I had “borrowed” my father-in-law’s dermatologist to get my mole removed since I was thousands of miles from home). He referred me to a plastic surgeon at Concord Hospital, who was able to squeeze me into his schedule in just under a week (versus the three weeks or more it normally takes), and on March 29th, dragging my mother-in-law along to help me remember what was discussed, I learned that my melanoma was very high risk, but that my overall health was good (considering the melanoma), and that I had no obvious tactile or symptomatic indications that the cancer had metastasized (spread into my body).

I was scheduled to go into surgery three days later to get a wide excision and a sentinel lymph node biopsy, both of which would be used as a means to determine if the cancer had, in fact, invaded my body.

I did ask the doctor why a plastic surgeon would be performing my procedures, being naturally curious after have just finished seven seasons of Nip Tuck on iTunes a few months prior. The doctor explained that plastic surgeons, while presently associated mostly with cosmetic procedures, are in fact specialists in working with and understanding skin and how it works. Further, plastic surgeons got their start as regular surgeons back in the time of World War II when many soldiers would come home from the war with terrible wounds – wounds they only survived due to the introduction and use of penicillin. Those surgeons started to develop and specialize in techniques to help with the disfiguring woulds of the returning soldiers, to help them return to some sort of normalcy. And, in fact, a plastic surgeon, Joseph Murray, ended up receiving a Nobel Prize in medicine for performing a skin graft between identical twins.

The doctor added that it was really only after the wars ended that this new breed of “plastic surgeon” turned to elective cosmetic procedures as a professional venue, since their skills and knowledge of how skin functioned were inordinately useful in that context. At the same time, that same knowledge continued to be useful in addressing real medical problems, including skin cancer such as melanoma.

His answer was excellent, and made eminent sense as well, since the wide excision I would be subjected to would require the skill of an expert skin specialist, i.e. a plastic surgeon, to repair.

The Wide Excision

The purpose of the wide excision was to take a minimum 2 centimeter (about .8 inches) of skin from around the site on my right thigh where the melanoma was found to excise any nearby cancer cells that may have been missed in the initial mole removal.

The healing wound from where the mole was removed, two weeks prior to the wide excision. The wound diameter is about 1.5 centimeters across.

The healing wound from where the mole was removed, two weeks prior to the wide excision. The wound diameter is about 1.5 centimeters across.

In my case, since the area of removal was already about 1.5 cm across, it would mean a disc of about 5.5 cm would ultimately be cut out of my skin, and sent to the lab for pathological analysis to determine if any cancer cells remained. In fact, I was told the wound was ultimately about 7 cm across as the skin sagged after being cut.

In turn, in order to fix this gaping wound in my skin, the doctor would remove a small disc of skin, full depth, of about 3-4 cm across, from my belly at the waist (under where my belly hangs over, by just a little bit, of course), and use that as a skin graft to “plug” the wide excision after using a “purse string” (a sub-dermal suture) to tighten the flesh over my right thigh. Additionally, as I found, more skin from my waist line was removed in order to create a properly seal that could be sutured.

The result was a roughly 8 inch suture line along my waist line that looks like it could be a C-section scar (were I a woman). One positive effect of this skin graft removal is that I have had, in effect, a tummy tuck and now look marginally more svelte.

The area under my belly from which the skin graft for my thigh was removed, resulting in a bit of a tummy tuck.

The area under my belly from which the skin graft for my thigh was removed, resulting in a bit of a tummy tuck.

A week or so later, the wide excision area was healing well, although the image below may not reflect that to the non-medical observer.

The area of the wide excision on my thigh, one week after surgery, with skin graft and blue dye visible.

The area of the wide excision on my thigh, one week after surgery, with skin graft and blue dye visible.

The skin graft see above (the purple/red/pink flesh) is about 3-4 centimeters across.

The Sentinel Lymph Node Biopsy

The second part of the surgical procedure was something called a sentinel lymph node (SLN) biopsy. Lymph nodes are a key part of the body’s immune system, and research and statistical analysis and correlation has suggested over the last decade or so that melanoma (and some other cancers) are more survivable if it can be determined which lymph nodes closest to a source of cancer would be responsible for that site on the body, and then analyzing those lymph nodes (via biopsy) to see if they have cancer cells in them.

The closest lymph node in use is referred to as the “sentinel” lymph node, as it “stands guard”, as a sentinel would.

The sentinel lymph node is detected using an injected radioactive isotope (hurts like the dickens when it’s first injected, but the sting and burn passes quickly) and then using a gamma camera to track the path of the radioactive isotope through the lymphatic system to see which lymph nodes it collects in first, which in turn indicates the sentinel lymph node(s).

The surgeon, later the same day, will use a hand-held gamma particle sensor, in conjunction with an injection of a large particle blue dye, to locate the sentinel lymph node, both visually and via instruments so he can remove the lymph node, and perhaps one or two others in the same region.

Typically, but not always, for a melanoma on the thigh, like mine, the sentinel lymph node will be in the area of the groin on the same side of the body as the melanoma. That proved to be the case for me, and I have a nice suture at my right groin as a a memento.

The area from which the sentinel lymph node was remove, near right groin.

The area from which the sentinel lymph node was remove, near right groin.

The blue dye that is injected to help the surgeon visually locate the sentinel lymph node after he locates the general area with the handheld gamma detector is quite tenacious, and it’s likely to leave a long time, even life-long, “tattoo” on the skin where it was injected and then coursed through the lymphatic network.

Another side effect which is merely temporary is that it might turn one’s urine green (yellow plus blue), as was my situation (and no, I have no pictures of this rather interesting bodily output). The green faded to a tinge, and then completely away after several days.

After the Surgery

After the wide excision and SLN biopsy is recovery, which requires minimal strain on all the surgical sites. In my case that meant mostly bed rest with my leg horizontal, and the use of two crutches for several days. A week and a half after surgery, I’m now down to one crutch to try and minimize any potential stress to the skin graft.

More importantly, some number of days after the biopsy – I was told it would probably be 7-8 days – the lab returns the results of the pathology on the skin from the wide excision and the SLN(s).

My  results came back last Thursday, six days after the day of surgery:

The lab results on my wide excision and sentinel lymph node.

The lab results on my wide excision and sentinel lymph node.

The lab result on the skin from the wide excision was clean. I was not nearly so lucky on the sentinel lymph node – it contained an approximately 2.0 mm malignant melanoma.

Coming Up Next

As a result of the above lab pathology, I was told the next step was most likely to get more specialized surgical help to remove the remaining lymph nodes in my right groin in the hopes that the cancer could be removed surgically, and that that would probably need to be followed up by some sort of treatment depending on how much (of any) other cancer was found in the other lymph nodes.

As I don’t reside in the U.S., I’m not geographically bound, and when I explained this to my doctor and asked for a recommendation for the best possible place in the U.S. for further treatment, he referred me to a doctor at Massachusetts General Hospital, which our subsequent research has shown to be one of the top cancer facilities nationwide, with a dedicated melanoma program.

Tomorrow morning I have my first appointment at Mass General, to learn what the near-term future holds for me. The anxiety is almost (but not really) worse than the disease.


(Note: An excellent technical paper on the subject of sentinel lymph nodes, given to me by my very excellent plastic surgeon, is entitled “The Role of Lymphatic Mapping and Sentinel Lymph Node Biopsy in the Staging and Treatment of Melanoma”, by Wayne K. Stadelmann, M.D., from “Clinics in Plastic Surgery”, Volume 37, Issue 1, pages 79-99, January 2010 (link to the abstract and place for purchase – not cheap at $31.50, but incredibly informative if you’re a science geek.)

 

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14 Responses

April 13th, 2011 at 13:26
Roger Burnham Says:

While many of us have been touched indirectly by cancer, we wonder how we’d would feel and/or react to it personally.

You are doing us all a service by “live blogging” the experience; Thanks!

Stephen Jay Gould (one of my intellectual heroes) was diagnosed with peritoneal mesothelioma in 1982 and had a median lifespan of only eight months after diagnosis. He died in 2002.
[ http://en.wikipedia.org/wiki/Stephen_Jay_Gould ]

CancerGuide.org [ http://www.cancerguide.org ] hosts a wonderful essay by Stephen. Here is the editors intro:
============================================================
As far as I’m concerned, Gould’s The Median Isn’t the Message is the wisest, most humane thing ever written about cancer and statistics. It is the antidote both to those who say that, “the statistics don’t matter,” and to those who have the unfortunate habit of pronouncing death sentences on patients who face a difficult prognosis. Anyone who researches the medical literature will confront the statistics for their disease. Anyone who reads this will be armed with reason and with hope. The Median Isn’t the Message is reproduced here by permission of the author.
============================================================

The essay is here[ http://www.cancerguide.org/median_not_msg.html ].

Oh yes, and do not forget xkcd’s take [ http://xkcd.com/836/ ] on sickness.

Our thoughts are with you Jake & Linda. Please let Marcia and I know if you can use some feet/hands/mouths/navels on Bonaire.

Roger & Marcia

April 13th, 2011 at 16:50
ann joseph Says:

Thinking of your challenge and the very straightforward manner with which you have chosen to manage it. My hat’s off to you.

April 13th, 2011 at 21:53
Jake Richter Says:

Roger,

Thanks very much for the links and comments. I will be reviewing them.

Jake

May 7th, 2011 at 11:14
JW Says:

Hey Jake,

While trying to do a bit of research I stumbled onto your blog. Thanks a million for doing this. I was diagnosed 3 weeks ago with Melanoma. Clark Level 3 / .6mm on my right calf. My head has been crazy with questions and a bit spooked. I had a wide excision on Monday, May 2nd. I am meeting with an oncologist tomorrow Monday, May 9th. I am concerned after reading your blog why they did not do a sentinel biopsy on me?

Thanks again…… your writing has really helped me.
JW

May 7th, 2011 at 12:25
Jake Richter Says:

I would guess that it might be because your thickness was only 0.6mm. Mine was over times that thickness at 2mm. However that would be an excellent thing to ask you doctor.

I know I did not get a Clark factor for my melanoma but it has been staged as Stage 3B.

Good luck with your treatment and please let me know how it goes.

Jake

May 7th, 2011 at 13:07
JW Says:

Thanks a million for your reply Jake!!

I noticed in your biopsy report that your Clark Level was 4. I am seeing Dr. Rene Gonzalez (Colorado University Oncology) Anschutz Campus on Monday…… I will let you know how it goes and I will be asking why they did not do a sentinel node on me. Gonzalez is the leading guy on a couple of new clinical trials and has had great success with some very new, cutting edge stuff. I will let you know what I find out.

Jake, we are both going to beat this!! No Worries!! OK, maybe a few worries. Here is the deal, I am 47 with a great wife and 3 great kids. I love the Lord, my wife, my kids and my business…. other then Melanoma I am healthy as a horse…. a chubby horse.

Well, even though I can hardly walk I am off to a baseball game…. I will catch up with you later. Have great day!!

Thanks again Jake!!

May 11th, 2011 at 09:54
Jake Richter Says:

Hi JW,

I just posted a new blog entry about the lymphadenectomy. How did your meeting on Monday go?

Jake

May 11th, 2011 at 11:26
JW Says:

Good morning Jake,

Wow….. after reading about your Monday all I can say is that you are one tough son of a gun. What a day you had. How are you feeling? I am praying for you.

My meeting went well. The frustration for me is not knowing where the cancer may have gone in my body. My personality does not do well with “unknowns”. They are taking a second look at my pathology and we should hear back today. Dr. Gonzalez does not think additional treatment or discovery work is necessary unless additional symptoms of cancer show up. It is wait and see with a follow up every 90 days.

Great story. I have been set up to have lunch next week with a Colorado Springs Fire Fighter who had Stage 5 Melanoma of the brain. He went through the treatments at CU and just last week he re-passed his tests and return to work. Crazy good…..

Hang tough Jake….. I am off to CA for business today but I will check in with you later this week.

JW

May 11th, 2011 at 14:49
Jake Richter Says:

Hi JW,

I’m feeling better today than I did yesterday, so that’s good.

As far as “unknowns”, cancer cause and therapy are filled with unknowns unfortunately. Definitely read “Emperor of All Maladies” to get an idea of how cancer treatment has evolved over the last century or so – pretty scary how little is still known, but how much more is known than even a few decades ago.

Let me know how your lunch goes next week with the fire fighter (although I thought that cancer is only staged to Stage IV, not V).

Good luck and keep us posted!

Jake

May 16th, 2011 at 18:17
JW Says:

Hey Jake,

How are you doing? How is your head? I read your post on the 13th and wanted to give it a few days before checking in. I am praying for you. Let me know when you decide on a treatment.

I am meeting with the fireman on Wednesday and will give you a report as well as find out what treatment they used in his case. It was a home run…… yours will be too!!

Hang tough man!!

JW

May 20th, 2011 at 13:35
JW Says:

Hey Jake,

How are you doing? I have been thinking about you daily.

I had a great meeting with Dave (the Colorado Springs Fireman). He just finished his treatments and is doing great. He had stage 4 (you were right) as it was in his brain. They removed the cancer (size of an egg) and then treated him with a higher trial doses of Interleukin. He is back to work!! It is a crazy great story. I am going to meet with his doctor next week just to better understand his treatments as I want to know and share as much as possible.

Hang tough….. the three of us are going to beat this!!

JW

May 23rd, 2011 at 21:08
Jake Richter Says:

Hi JW,

Interleukin-2 is great stuff, if it works, but the treatment is brutal. Check out the blog from Melanoma Mom where she describes her treatment: http://melanomamom.blogspot.com/

Looks like I will be going with pegylated Interferon-alpha 2b (known as PEG or Sylatron) when I am done with this darn drain and finished with my healing processing. Check out my latest blog post.

You hang in there too!

Jake

September 13th, 2011 at 11:58
Cindy Says:

Thank you for sharing your difficult experience. I’ve been looking for actual patient experiences and it hasn’t been easy. I found out this week I have a melanoma on my right upper thigh, level 4. It’s not as big in size as yours and does contain subcutaneous cells. I had a stage 2 melanoma awhile back so history isn’t great! I see a surgeon consult to schedule wide excision and sentinel node biopsy tomorrow. Thank you letting me know I’m not alone. You’re brave!

September 14th, 2011 at 13:46
Jake Richter Says:

Hi Cindy,

You are definitely not alone. And I agree that learning that is a great comfort, even in the face of adversity.

I hope your SLN comes back clean. Keep me posted and be strong!

Jake