Melanoma

Melanoma is one of the most dangerous types of skin cancer.  It has the capacity to spread to the lymph nodes and, via the bloodstream, to distant organs.  Treatment depends on the features of the melanoma discovered when the specimen is assessed by the pathologists.  Many melanoma need further treatment after the initial excision.

 

Sentinel Lymph Node Biopsy

Key points

A sentinel lymph node is the first lymph node(s) to which cancer cells are most likely to spread from a primary tumor.

A sentinel lymph node biopsy (SLNB) can be used to help determine the extent, or stage, of cancer in the body.

What are lymph nodes?

Lymph nodes are small oval organs that are part of the body’s lymphatic system. They are found widely throughout the body and are connected to one another by lymph vessels. Groups of lymph nodes are located in the neck, underarms, chest, abdomen, and groin. A clear fluid called lymph flows through lymph vessels and lymph nodes.

Lymph originates from fluid “leaked,” out of small blood vessels called capillaries. This fluid contains many substances, including blood plasma, proteins, glucose, and oxygen. It bathes most of the body’s cells, providing them with the oxygen and nutrients they need for growth and survival. This fluid also picks up waste products from cells as well as other materials, such as bacteria and viruses, to help remove them from the body’s tissues. This fluid eventually collects in lymph vessels, where it becomes known as lymph. Lymph flows through the body’s lymph vessels and is returned to the bloodstream in the chest. Lymph nodes are important parts of the body’s immune system. They contain B lymphocytes, T lymphocytes, and other types of immune system cells. These cells monitor lymph for the presence of “foreign” substances, such as bacteria and viruses. If a foreign substance is detected, some of the cells will become activated and an immune response will be triggered.

Lymph nodes are also important in helping to determine whether cancer cells have developed the ability to spread to other parts of the body. Many types of cancer, including melanoma, can spread through the lymphatic system, and one of the earliest sites of spread for these cancers is nearby lymph nodes.

What is a sentinel lymph node?

A sentinel lymph node is defined as the first lymph node to which cancer cells are most likely to spread from a primary tumor. Sometimes, there can be more than one sentinel lymph node.

primary-tumour

What is a sentinel lymph node biopsy?

A sentinel lymph node biopsy (SLNB) is a procedure in which the sentinel lymph node is identified, removed, and examined to determine whether cancer cells are present. 
A negative SLNB result suggests that cancer has not developed the ability to spread to nearby lymph nodes or other organs. A positive SLNB result indicates that cancer is present in the sentinel lymph node and may be present in other nearby lymph nodes (called regional lymph nodes) and, possibly, other organs. This information can help a doctor determine the stage of the cancer (extent of the disease within the body) and develop an appropriate treatment plan.

What happens during an SLNB?

The day before your procedure radioactive tracer is injected into the scar, where the melanoma was removed, to locate the position of the sentinel lymph node (this process may take a couple of hours). On the day of surgery a blue dye in injected in the same place just before your operation. The surgeon then uses a device that detects radioactivity to find the sentinel node and looks for lymph nodes that are stained with the blue dye. Once the sentinel lymph node is located, the surgeon makes a small incision (about 4cm) in the overlying skin and removes the sentinel node. The sentinel node is then sent away to be checked for the presence of cancer cells by a pathologist. It takes about a week for the results to come back. Sentinel node biopsy usually requires a General Anaesthetic but can usually be done as a day-stay procedure without the need for admission to hospital overnight.

If there are cancer cells found then you surgeon will talk to you regarding further recommended treatment.

What are the potential benefits of Sentinel Lymph Node Biopsy?

SLNB allows accurate staging and therefore prognosis to be obtained. Whether the sentinel node is positive or negative is the biggest factor in determining a patient’s chance of survival. It allows the identification of people in whom removal of further lymph nodes could improve disease-specific survival, reduce the risk of distant spread of melanoma and reduce the risk of regional recurrence of melanoma.

What are the potential complications after Sentinel Lymph Node Biopsy?

SLNB requires a general anaesthetic rather than a local anaesthetic. This means that you are not able to drive for 24 hours and require 3-4 hours in hospital after the procedure to recover.

Removing the SLN requires another incision and therefore another scar and all the associated time to heal this.

There is a small risk of a transient swelling in the limb after the procedure.

Occasionally there is numbness or nerve-pain around the scar but this generally resolves with time.

 

Axillary Lymph Node Clearance

Is this operation necessary?

.  An axillary lymph node clearance is intended to remove all the lymph nodes and possible tumour-containing tissue from the armpit region. The arm-pit (axilla) lymph nodes can be considered to filter the fluid returning from the arm and parts of the upper back and chest. The lymph nodes assist in the local response to wounds. Certain types of skin cancer, especially melanoma, have cells capable of detaching and travelling to the lymph nodes. Here they usually continue to grow. In order to help prevent melanoma growing in this region and to help prevent further spread, if a lymph node in the armpit is found to contain tumour it is often necessary to remove all the lymph nodes and associated tissue as completely as possible.

What is involved in the operation?

Right axilla just after operation

Fig. 1 Right axilla just after operation

An axillary dissection is performed under a general anaesthetic so you will not be awake during the procedure. Once you are asleep local anaesthetic will be injected into the area of surgery to provide additional comfort after the operation. The procedure involves making a varied length incision in the axillary skin (see a typical example in figure 1). The important blood vessels, muscles and nerves of the axilla can be exposed in this way, allowing a complete and relatively safe operation. There are several important structures that run through the axilla and the operation is planned and performed to remove all the lymph nodes and associated tissue without causing damage to these. SMU surgeons remove the smaller pectoralis minor muscle that lies behind the larger and functionally important pectoralis major muscle to ensure as thorough an operation as possible. One side effect of axillary dissection is the removal of a small nerve that supplies sensation to the inner aspect of the upper arm: most patients will have a small region of numbness here after the operation but this is not troublesome.

axilla-fig2

Fig. 2

After the lymph nodes and associated tissue is removed the wound is washed out. Any large wound produces fluid (like that in a blister) so a surgical drain is placed to collect this. The drain is a soft flexible silicone tube that is connected to a suction bottle and will be checked frequently after the operation and changed as required by the nursing staff (see figure 2). This will generally be in place for several days after the operation. The wound is then closed using stitches and/or staples and a dressing is applied.
The Pathologist assesses the tissue removed from the axilla. The results of this will be discussed with you. Information from this analysis is very important in your ongoing care and may determine the need for radiotherapy and other treatments.

Before the Operation

You will need to come into the hospital a few hours before your operation, having fasted (no food or fluid for 6 hours). A full stomach can cause regurgitation of the stomach contents when an anaesthetic is administered leading to inhalation of this into the lungs: an empty stomach is very important.

Preparing for a General Anaesthetic

The anaesthetic doctor will visit you in hospital before your operation to discuss your general health and fitness for anaesthetic. Please let your anaesthetist know if you have had problems with anaesthesia in the past, including nausea and vomiting after anaesthetics. Modern anaesthetic techniques and drugs can reduce this. If you are very anxious, again, please let the anaesthetic doctor know.

Most medications should be continued up to and including the day of surgery, taken with a small sip of water. Two very important exceptions are tablets that thin the blood (for example: aspirin, ibuprofen, cartia, warfarin, clopidigrel) and diabetic tablets (you will be fasting). Your surgeon and anaesthetist should be aware that you take these medications and will instruct you on what to do leading up to the operation. Many alternative medications can affect blood clotting so please inform your surgeon if you are taking any of these.

You will also have special stockings to help prevent blood clots in the legs and usually an injection of a drug, into the abdomen skin, that reduces the risk of blood clots in a controlled fashion. Your surgeon will see you just before going into the operating theatre and will mark the site of the proposed operation. Any last questions can be asked at this time.

After the Operation

Generally the procedure takes 1 to 2 hours. After surgery you will be taken to the recovery ward that is specially equipped and staffed to monitor patients post-operatively. Pain relief and anti-nausea medication will be provided. It is important to let the recovery staff know if you are in pain or feel sick so that more medication can be given.

The days after the operation

Fig. 3

There are benefits of getting up and around fairly soon after an operation. These include better lung function and reduced risk of blood clots (deep vein thrombosis or DVT and pulmonary embolus). For this reason the nursing staff will encourage you to mobilise as early as comfort allows. You may be provided with a sling to rest your arm in which assists with pain relief. You can eat and drink as soon as you feel like it after the operation. Your drain will be checked frequently and emptied/replaced as required.

Most patients, depending on their level of fitness and home circumstances, spend 1 or 2 nights in hospital and then go home with their drain in place. The nursing staff will train you in its care and arrange follow-up prior to you leaving hospital. You will be provided with a prescription for analgesia and possibly antibiotics. If these are non-absorbable stitches/sutures these will be removed after 10-14 days.

You may feel tired for a few days post-operatively and will need to take at least the next 1-3 weeks off work in even the quietest of jobs. You may drive when you feel confident of full control; for most people this takes a couple of weeks or more. You should check with you insurance company regarding their policy concerning ‘impairment to drivers’.

What are possible side effects of the operation?

Most people cope with the operation very well and have few problems. The most common problems relate to prolonged lymph flow in the drains, or collection in the axilla, or minor wound infections. The types of problems are usually managed simply, without needing admission to hospital.

Your surgeon will have discussed the benefits and the risks of the procedure at your prior consultation and this document is not intended to replace that discussion, however, in broad terms possible side effects can be broken down as follows:

Early, relatively common side effects:

Numbness around wound and inner upper arm, minor wound infection, small haematoma (blood collection)
Shoulder stiffness, usually improving over 3-6 weeks. This sometimes requires physiotherapy.

Early, uncommon side effects:

Damage to nerves supplying muscles, damage to vessels, excessive bleeding needing re-operation, major wound infection requiring re-operation. Deep vein thombosis (clots in the veins), pulmonary embolism (clots in the lungs)

Late, relatively common side effects:

Scar at site of incision, numbness around wound and inner upper arm, seroma (fluid collection) in wound

Late, uncommon side effects:

Lymphoedema (swelling of the arm), large seroma (fluid collection) requiring repeated drainage. Neuralgic (nerve-related) pain in the arm or axilla.

 

Preventing Lymphoedema

Lymphoedema is noticeable to about 10% of patients that have this operation. If it occurs there is a fluid retention in the limb which can be obvious to look at and may create problems using the limb. It may be uncomfortable or even painful. Lymphoedema mostly happens within 12 months of melanoma surgery but may occur many years later. It may be precipitated by trauma to the arm especially if there is penetration of the skin and infection occurs. Some people find constriction from carrying heavy loads of shopping bags on the arm or such similar insults may cause lymphoedema to occur.

Lymphoedema is best avoided but if it does occur active and ongoing therapy, often with compression garments and manual lymphatic drainage techniques, is required from the earliest stage it is recognised. This would require referral to a specialist lymphatic therapist.

Recovery

Most people recover very well from axillary dissection and are able to return to their usual work and recreational activities after a reasonable period of time. The scar under the arm becomes less noticeable with time (see fig 3).

You will be followed up at regular intervals to check on healing and to have regular melanoma checks performed. The surgery is being performed because of the excellent chance it will stop the melanoma progressing in the axilla and to give you the best chance it won’t spread from the axilla to elsewhere in the body. However, it doesn’t stop the melanoma recurring elsewhere in the body.

It is important to discuss any issues raised by reading this information booklet with your surgeon. Your surgeon will be only too happy to discuss any concerns or questions you have.

Groin Lymph Node Clearance

Is this operation necessary?

A groin lymph node clearance is intended to remove all the lymph nodes and possible tumour-containing tissue from the groin region. The groin lymph nodes can be considered to filter the fluid returning from the leg and parts of the lower back and abdomen. They assist in the local response to wounds. Certain types of skin cancer, especially melanoma, have cells capable of detaching and travelling to the lymph nodes. Here they usually continue to grow. In order to help prevent tumour growing in this region and to help prevent further spread, if a lymph node in the groin is found to contain tumour it is usually necessary to remove all the lymph nodes and associated tissue as completely as possible.

What is involved in the operation?

A groin lymph node clearance is performed under a general anaesthetic so you will not be awake during the procedure. Once you are asleep local anaesthetic will be injected into the area of surgery to provide additional comfort after the operation. The procedure involves making a long incision in the groin. The structures of the groin can be exposed in this way, allowing a complete and safe operation. There are several important structures that run through the groin and the operation is planned and performed to remove all the lymph nodes and associated tissue without causing damage to these. One side effect of groin dissection is the removal of small nerves that supply sensation to the upper thigh: most patients will have a small region of numbness here after the operation but this is not troublesome. Sometimes it is necessary to remove lymph nodes from above the level of the groin.

These lymph nodes are located in the back of the abdomen. Removal of these lymph nodes requires a larger incision extending further up the abdomen. The muscles of the abdominal wall are split to give access to the lymph nodes and then repaired prior to closure of the skin wound.

After the lymph nodes and associated tissue is removed the wound is washed out. Any large wound produces fluid (like that in a blister) so a surgical drain is placed to collect this. The drain is a soft flexible silicone tube that is connected to a suction bottle and will be checked frequently after the operation and changed as required by the nursing staff. This will generally be in place for many days after the operation. The wound is then closed using stitches and/or staples and a dressing is applied.

The Pathologist assesses the tissue removed from the groin and this will be discussed with you. Information from this analysis is very important in your ongoing care and may determine the need for radiotherapy and other treatments.

Before the Operation

You will need to come into the hospital a few hours before your operation, having fasted (no food or fluid for 6 hours). A full stomach can cause regurgitation of the stomach contents when an anaesthetic is administered leading to inhalation of this into the lungs: an empty stomach is very important.

Preparing for a General Anaesthetic

The anaesthetic doctor will visit you in hospital before your operation to discuss your general health and fitness for anaesthetic. Please let your anaesthetist know if you have had problems with anaesthesia in the past, including nausea and vomiting after anaesthetics. Modern anaesthetic techniques and drugs can reduce this. If you are very anxious, again, please let the anaesthetic doctor know.
Most medications should be continued up to and including the day of surgery, taken with a small sip of water. Two very important exceptions are tablets that thin the blood (for example: aspirin, ibuprofen, cartia, warfarin, clopidigrel) and diabetic tablets (you will be fasting). Your surgeon and anaesthetist should be aware that you take these medications and will instruct you on what to do leading up to the operation.
You will also have special stockings to help prevent blood clots in the legs and usually an injection of a drug, into the abdomen skin, that reduces the risk of blood clots in a controlled fashion. Your surgeon will see you just before going into the operating theatre and will mark the site of the proposed operation. Any last questions can be asked at this time.

After the Operation

Generally the procedure takes 1 to 3 hours, depending on the extent of surgery required. After surgery you will be taken to the recovery ward that is specially equipped and staffed to monitor patients post-operatively. Pain relief and anti-nausea medication will be provided and it is important to let the recovery staff know if you are in pain or feel sick so that more medication can be given.

The days after the operation

The benefits of getting up and around soon after an operation need to be balanced with aggravating bleeding and discomfort in the wound. In most cases I prefer my patients to remain on bed rest at least the night of their operation, and usually the second night as well. After this you will be encouraged to mobilise as comfort allows. You can eat and drink as soon as you feel like it after the operation. Your drain bottle will be checked frequently and emptied/replaced as required. Most patients, depending on their level of fitness and home circumstances, spend 5 to 7 nights in hospital and then go home, often with their drain in place. The nursing staff will train you in its care and arrange district nurse follow-up prior to you leaving hospital. You will be provided with a prescription for analgesia and possibly antibiotics.

You may feel tired for a few weeks post-operatively and will need to take at least the next two to four weeks off work in even the quietest of jobs. You may drive when you feel confident of full control; for most people this takes several weeks. You should check with you insurance company regarding their policy concerning ‘impairment to drivers’.

What are possible side effects of the operation?

Most people cope with the operation very well and have few longstanding problems. The most common problems relate to prolonged lymph flow in the drains, or collection of lymph fluid in the groin after the drains are removed, or minor wound infections. These types of problems are reasonably frequent but are usually managed simply, without needing admission to hospital.

We will have discussed the benefits and the risks of the procedure at your prior consultation and this document is not intended to replace that discussion, however, in broad terms possible side effects can be broken down as follows:

Early, relatively common side effects:
Numbness around wound and upper thigh, minor wound infection and delayed healing, small haematoma (blood collection). Seroma (collection of lymph fluid under the scar) With a more extensive procedure involving removal of the nodes in the pelvis and back of the abdomen the bowel may rest for 2-3 days making it uncomfortable to eat solids. Fluids may be recommended orally until the bowels open.

Early, uncommon side effects:
Damage to nerves supplying muscles, damage to vessels, excessive bleeding needing re-operation, major wound infection requiring re-operation, Deep Vein Thrombosis (clots in the leg veins), Pulmonary Embolism (clots in the lungs). A general anaesthetic increases the risk of chest infections.

Late, relatively common side effects:
Scarring, numbness around wound and upper thigh, seroma (fluid collection) in wound, mild lymphoedema (swelling) of the leg.

Late, uncommon side effects:
Significant lymphoedema (swelling of the leg) requiring physiotherapy and compression garments, large seroma (fluid collection) requiring repeated drainage.

Recovery

Most people recover very well from groin dissection and are able to return to their usual work and recreational activities after a reasonable period of time. The scar in the groin becomes less noticeable with time. You will be followed up at regular intervals to check on.

It is important to discuss any issues raised by reading this information booklet with your surgeon. I am only too happy to discuss any concerns or questions you have.