December 2005         

Sentinel Node Imaging for Melanoma

HISTORY:  This is the first visit to the Cancer Center for this 33 year old Caucasian female with history of melanoma on the left low back.  She states that she has always been careful about sun exposure.
No other skin cancers. No family history of melanoma. No personal history of melanoma.

The patient had a mole on her back all her life. She noticed a little thickness of it recently. She went to a physician who excised it. Pathology was done at the is signed out as malignant melanoma, nodular, Clark level III, and total thickness 2 mm. The patient denies any systemic symptoms.

Physical Exam:  Just to the left of the mid-line down at about L1, there is a 1 cm incision that is healing well. There is a little pigmented mole up above it that is somewhat atypical.  Both axillae and both groins are clinically negative.

Discussion:  I talked to her about the thickness of melanoma. I pointed out that a 2 mm lesion was intermediate. We will want to get the slides and have them reviewed. I pointed out that this lesion could spread to almost any lymph-node bearing area. Therefore, a lymph scan followed by node biopsy is important. Since it is thicker than 1 mm, she will need a sentinel node biopsy.

Her husband is in the military and is being transferred about December 22nd. Therefore, I think we should simply do an excision of the primary area, a sentinel node biopsy, and defer any node dissection
(if needed) until she moves somewhere and can find a surgeon that can do this for her. She understands this and agrees.

Plan:

1. Get slides here
2. Routine lab to include chest x-ray, EKG, CBC, liver function tests, SMA 6-60, calcium, phosphorous, coagulation profile, blood sugar.
3. Schedule wide local excision of trunk melanoma with sentinel node biopsy from appropriate node-bearing areas. Lymph scan will be done the day before. Therefore, we will know what areas we are going to biopsy before she goes to the OR.

We will await permanent section reports on these. If nodes are involved, we will defer her dissection to another surgeon wherever she winds up in the next month.

Radiology Report:

TECHNIQUE: 1mCi Tc 99m sulfur colloid was administered to the patient at the melanoma site. Immediate imaging was done.

FINDINGS: Two definite nodes were noted over the axilla. One dominant node was marked anteriorly as number 1. However, Only on the lateral view, the dominant node turn out to be superimposed two nodes. One supraclavicular nodes were noted which were marked as number 2. Questionable small nodes were noted just below the two dominant nodes. However, this was not marked.

At the same time the axillary nodes were visualized, three left inguinal nodes were visualized. They were marked A, B, and C according to the time of appearance, respectively.

IMPRESSION:
1. ONE LEFT AXILLARY AND ONE SUPRACLAVICULAR NODES ARE MARKED AS NUMBER 1 AND 2 RESPECTIVELY. 2. THREE LEFT INGUINAL NODES WERE MARKED AS A, B, AND C ACCORDING TO THE TIME OF APPEARANCE

Operative Report:

PROCEDURE:
Wide local excision of melanoma, sentinel lymph node biopsy.

SPECIMENS:
Wide local excision of melanoma of the back. Two sentinel lymph nodes from the left axilla. One palpable node on the left axilla. Two sentinel lymph nodes from left groin.

PREOPERATIVE NOTE:
A 33-year-old patient that had a biopsy of a suspicious lesion on her back that came back as melanoma, Clark III, 2 mm in thickness. The patient was about to move out of state due to military
transfer. Since the severity of the melanoma, the patient was expeditiously referred for assessment. The decision to take the patient to the operating room and have wide local excision of the lesion and sentinel lymph nodes was made. An attempt to review the slides from previous biopsy was made but this was not possible due to the short period of time. Discussion was made with the patient and family regarding the plans of doing wide local excision and sentinel lymph node biopsy and in case the sentinel lymph node returned to be positive she is going to have to undergo axillary lymph node dissection once she gets settled after the move. Risks and benefits of the procedure were discussed with the patient and she decided to proceed.

OPERATIVE NOTE:
Prior to the operation on the day before the operation the patient went to nuclear medicine for injection of radioactive colloid and then for lymphoscintigraphy. This identified a couple of nodes in the left axilla and also a couple of nodes in the left groin, so a decision to do a sentinel lymph node biopsy from the left axilla and left groin was made. After proper identification of the patient and informed consent was obtained, the day after the lymphoscintigraphy the patient was taken to the operating room and placed in the right decubitus position. After adequate endotracheal intubation and general anesthesia was obtained, the patient's left axilla, back, and left groin were prepped and draped in a surgical sterile fashion. We
initiated the procedure by excising the lesion on the back. This was done in an elliptical incision fashion obtaining a 2-cm margin. The skin was incised sharply and it was deepened with electrocautery all
the way down to the muscle fascia. The skin and subcutaneous tissue including fascia were excised. Hemostasis was achieved. At this time there was a suspicious lesion on top of the _____, the reason why this was excised in the same fashion. Then we turned our attention to the left axilla where with the gamma probe we localized the sentinel lymph node. A longitudinal incision just below the hairline was made and
dissection was carried down until the sentinel lymph node was identified. A count of 500 was obtained and the lymph node was dissected free and excised. Then another sentinel lymph node was identified with a count of 600 and equally this was dissected free and excised. Then another palpable lymph node was identified. This did not have any count but it was still excised and sent as a specimen. One more time the axillary bed was scanned with the gamma probe and no other counts were obtained. Hemostasis was achieved and the wound was packed.

Then we turned our attention to the left groin where a longitudinal incision was performed and dissection was carried down with electrocautery. With the gamma probe the left groin sentinel node with a count of 205 was identified. The lymph node was dissected free and excised and sent as a specimen. Then another sentinel lymph node was identified with a count of 60 which was dissected free, excised, and sent as specimen two. On screening of the groin bed no other counts were obtained. Hemostasis was achieved and packed open. At this point we proceeded to close our incisions. The patient tolerated the procedure well and was taken to the recovery room in stable condition.

Pathology Report

CLINICAL DATA:
33 year old white female
Date of operation: December 15, 2005
Name of operation: Wide local excision melanoma back
Preoperative diagnosis: Melanoma back

DIAGNOSIS:
A) SKIN, BACK, EXCISIONAL BIOPSY: COMPOUND NEVUS WITH MILD DYSPLASIA, TRANSECTED. (SEE COMMENT)

B) SKIN AND SOFT TISSUE, BACK, WIDE LOCAL EXCISION: CHANGES CONSISTENT WITH PREVIOUS BIOPSY SITE; NEGATIVE FOR RESIDUAL MELANOMA.

C) LYMPH NODES, LEFT AXILLARY SENTINEL COUNT 500, BIOPSY: TWO LYMPH NODES, POSITIVE FOR MELANOMA (2/2). (SEE COMMENT)

D) LYMPH NODES, LEFT AXILLARY SENTINEL COUNT 500, BIOPSY: ONE OF THREE LYMPH NODES POSITIVE FOR MELANOMA (1/3). (SEE COMMENT)

E) LYMPH NODE, LEFT GROIN SENTINEL COUNT 60, BIOPSY: ONE LYMPH NODE, NEGATIVE FOR MALIGNANCY (0/1). (SEE COMMENT)

F) LYMPH NODE, SENTINEL LEFT GROIN COUNT 205, BIOPSY: THREE LYMPH NODES, NEGATIVE FOR MALIGNANCY (0/3). (SEE COMMENT)

G) LYMPH NODE, LEFT AXILLARY, BIOPSY: ONE LYMPH NODE, NEGATIVE FOR MALIGNANCY (0/1).

COMMENT:
The mole in specimen A was reviewed with the physician in dermatopathology. Multiple levels and HMB-45 immunostains performed on the sentinel nodes show microscopic foci of melanoma in blocks C1, C2, and D3, with no extranodal extension.

The patient will be advised that additional follow-up and lymph node dissection will be necessary when she relocates to another state in a few weeks.
 

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Images courtesy of University of Arkansas for Medical Sciences Dept of Nuclear Medicine.