Skin Cancer

About Melanoma Surgery and Sentinel Biopsy

Posted on by peter.kim

About Melanoma Surgery and Sentinel Biopsy (Sentinel Lymph Node Biopsy)

According to Melanoma Institute Australia, Australia has one of the highest rates of melanoma in the world. Overall, almost 14,000 Australians were expected to be diagnosed with melanoma in 2017, with the incidence rate in Queensland vastly exceeding rates in all other states and territories as well as internationally. 

Of these cases, it is estimated that 2,500 will occur in Australians aged 25–49 years. Indeed, melanoma is the most common cancer in young Australians (aged 15–39 year) making up 20% of all cancer cases.

While melanoma represents 2% of all skin cancers, it causes 75% of skin cancer deaths. In 2014, more than 1,400 Australians died from melanoma – that is one person every five hours.

Should I have a sentinel biopsy or not?

Sentinel lymph node biopsy is a surgical procedure that is used to find out the extent of cancer in the lymph nodes.

The sentinel node biopsy procedure for melanoma is an important part of staging and treatment for this type of skin cancer. It helps to identify whether there are cancer cells in the lymph nodes and if they have spread to other areas of the body.

Melanoma spreads via lymphatics.  The first place the melanoma spread is to the lymph nodes that drains the lymphatic fluid from the area of the skin where the melanoma was located.

An accurate diagnosis of whether the melanoma has spread to the lymph gland is important because there are additional treatments that can be offered early on to avoid unnecessary morbidity and mortality. Sentinel biopsy is 95% accurate in picking up melanoma in the lymph gland if there is one.

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Sentinel biopsy is only offered to some patients who are diagnosed with a melanoma.

Cancer Council Australia recommends that SLNB should be considered for all patients with melanoma >1 mm in thickness and for those with melanoma >0.75 mm with other high-risk pathological features.

Generally speaking:

  • if your melanoma is less than 0.75mm thick, do not require Sentinel biospy as the risk of metastasis is so low that risk of compliation following the biospy outweights the benefit.

  • If the melanoma i is >1mm thick, then the sentinel biopsy is recommended as the chance of metastasis is more than 5%.

  • If melanoma is between 0.75mm and 1mm thick, then Sentinel biopsy is recommended only if you have these features are present: ulceration, mitotic rate >1, Clark level IV or V or lymphovascular invasion.

What does Sentinel biopsy involve?

It is a procedure that is performed in the hospital.

The nuclear dye is injected into the skin area where there was a melanoma. The dye will drain to the nearest lymph gland. The nuclear radiography is used to follow the dye to localise the lymph gland. The lymph gland is removed usually under local anaesthesia. The gland is sent for histological examination. You will be notified of the result will take few days.

A sentinel node biopsy can be done at the same time as a wide local excision, or it can be done on its own. The main benefit to doing it at the same time as a wide local excision is that if there are any cancer cells found in the sentinel node, then they can be removed along with all of the other skin cancers. on the same day.The main benefit to doing it on its own is that some people with skin cancers don’t have any cancer cells in the sentinel node, so you wouldn’t have to remove them if they weren’t there. .

What are the possible complications and side effects of a sentinel node biopsy?

There is a risk of bleeding, infection, or allergic reactions from the needles. There is also a risk of the tumor being missed or over-estimated.

Bleeding can be controlled by applying digital pressure. Infection is rare, but if it occurs, antibiotics are given immediately to settle the infection. Allergic reactions are rare and treated with steroids or antihistamines.

Melanoma Recurrence

According to Cancer Council Australia, the peak risk period for recurrence following treatment of stage I–III melanoma is the first 12–24 months. At least 80% of recurrences occur within 3 years of diagnosis of primary melanoma, with less than 5% occurring after 10 years.

Follow up

Melanoma survivors should be made aware of their risk of developing further primary melanomas, and of the consequent need for careful lifelong skin surveillance.

The follow-up schedule will be individualised on a case-by-case basis with more frequent follow up in individuals with larger melanomas, but as a general rule, we recommend a follow up every 3 months for 1-2 years followed by a regular life long skin checks. 

Adjuvant immunotherapy

Our body fights the cancer through the immune system.

Cancer is characterised by the accumulation of genetic alterations and the loss of normal cellular regulatory processes. Some cancer cells produce “checkpoint molecules”, they become invisible to, and escape from, the immune system. The immunotherapy binds to the checkpoint molecules and make them visible to our immune system. As a result, our immune system removes the cancer.

Adjuvant immunotherapy has recently become a treatment option for patients with melanoma. Sentinel lymph node biopsy (SLNB) plays a critical role in identifying the subset of patients at high risk of recurrence or relapse following complete resection who may benefit from immunotherapy. Immunotherapy has been shown to improve relapse free survival in resected stage 3 and 4 melanoma.

The main medications used for immunotherapy is Anti-PD1 monoclonal antibody. Currently, pembrolizumab and nivolumab are listed under PBS.

A range of adverse effects have been noted and they can affect the immune system, skin, gastrointestinal, liver and lungs. It is important to diagnose the complications early and to promptly seek medical advice as they can be treated.

A range of adverse effects have been noted and they can affect the immune system, skin, gut, liver, and lungs. It is important to diagnose the complications early and to promptly seek medical advice as they can be treated.

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References

  1. Sosman JA, Atkins, MB, Shah S. UpToDate. Adjuvant therapy for cutaneous melanoma, April 2019 [Internet]. [cited 2019 May 18]. Available from: https://www.uptodate.com/contents/adjuvant-therapy-for-cutaneous-melanoma.  

  2. Kwak M, Farrow NE, Salama AKS, Mosca PJ, Hanks BA, Slingluff CL, et al. Updates in adjuvant systemic therapy for melanoma. J Surg Oncol. 2019 Jan;119(2):222–31. 

  3. Cancer Council Australia. Cancer Guidelines Wiki. What type of biopsy should be performed for a pigmented lesion suspicious for melanoma? [cited 2019 June 16]. Available from: https://wiki.cancer.org.au/australia/Clinical_question:What_type_of_biopsy_should_be_performed_for_a_suspicious_pigmented_skin_lesion%3F. 

  4. Cancer Council Australia. Cancer Guidelines Wiki. When is a sentinel node biopsy indicated? [cited 2019 May 18]. Available from: https://wiki.cancer.org.au/australia/Clinical_question:When_is_a_sentinel_node_biopsy_indicated%3F.  

  5. Gershenwald JE, Scolyer RA. Melanoma Staging: American Joint Committee on Cancer (AJCC) 8th Edition and Beyond. Ann Surg Oncol. 2018 Aug;25(8):2105–10.  

  6. Melanoma Institute Australia. Melanoma Facts and Statistics [Internet]. [cited 2019 May 18]. Available from: https://www.melanoma.org.au/understanding-melanoma/melanoma-facts-and-statistics/. 

  7. Melanoma Institute Australia. Sentinel Node Biopsy. Information for Patients [Internet]. [cited 2019 June 16]. Available from: https://www.melanoma.org.au/understanding-melanoma/support-patient-stories/patient-support/patient-information-brochures/sentinel-node-biopsy/. 

  8. Cancer Council Australia. Cancer Guidelines Wiki. Ideal settings, duration and frequency of follow-up for patients with melanoma [cited 2019 May 18]. Available from: https://wiki.cancer.org.au/australia/Clinical_question:What_is_the_ideal_setting,_duration_and_frequency_of_follow-up_for_melanoma_patients%3F. 

 

 

peter.kim