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.
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.
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 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 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 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.)