Find Support

Delayed slnb

The information on this site is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. Content within the patient forum is user-generated and has not been reviewed by medical professionals. Other sections of the Melanoma Research Foundation website include information that has been reviewed by medical professionals as appropriate. All medical decisions should be made in consultation with your doctor or other qualified medical professional.

Delayed slnb

Posted By
Fortysomething
8/28/2020 5:25am
View other posts by
Activity
Replies: 6

Good morning
Had a call offering a sentinel lymph node biopsy,. Already have had the wle , but couldn’t do slnb due to covid-19. Wle was 3months ago and had set my mind to just see what happens.
Decided to have it done but fear of what happens next as kicked back in, has anyone else had a delayed slnb.

Gene_S - (8/28/2020 - 9:54am)

Hello,

My husband had his done at the same time as his WLE. I have heard that it is hard to find the original SLN that it would have drained to if not done at the same time.

Live 4 today. Thank God for all he has done for us. Looking forward to enjoying tomorrow.

Bubbles - (8/28/2020 - 10:32am)

As you are already aware, typically the SLNB is done at the same time as the WLE. (Granted these are not typical times!) Once the WLE is completed, the lymph channels are disrupted such that determining the location of the sentinel node is no longer possible. I would certainly ask my doc to explain how they are going to deal with this issue before proceeding. I can't imagine how they would ascertain that the node that "lights up" was truly first in the path prior to the WLE. I don't think anything bad will happen to you for having had this procedure. But you may be undergoing a procedure that does you no good and provides "information" that is of limited value. Seeing a melanoma specialist, if at all possible, is ALWAYS my recommendation and given the complex situation you are in, it is not only justified, it may be even more essential. I wish you my best whatever you do. Celeste

Fortysomething - (8/28/2020 - 11:23am)

Hi Celeste

Have that same worry that it’s not the correct way, but spoke to skin cancer nurse and it’s a plastic surgery team that do it
Your right it could be for nothing but would always regret it if something came up.

Regards

Andrew

Bubbles - (8/28/2020 - 12:36pm)

Happened across this article that you might find pertinent, as it addresses the issue of a delayed SLNB: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7367022/

I think the link should work and is valuable because of a figure included, but here is the written portion:

Deselecting Melanoma Patients for Sentinel Lymph Node Biopsy During COVID-19: Clinical Utility of Tumor Molecular Profiling
Alexander Meves, MD
Mayo Clinic, Rochester, MN
Alexander M.M. Eggermont, MD, PhD
Princess Máxima Center for Pediatric Oncology, Utrecht, NL

To the Editor:

The surgical management of newly diagnosed melanoma patients during the coronavirus disease 2019 (COVID-19) pandemic is challenging because access to health care facilities is restricted. Specifically, elective staging procedures such as the sentinel lymph node (SLN) biopsy are difficult to accommodate. As surgical capacity diminishes, surgical guidance for clinicians aims to restrict SLN biopsy in a stepwise fashion.1 , 2

SLN biopsy is a more complex and time-consuming procedure than is often appreciated because it requires the extensive use of hospital infrastructure and medical specialists. This is shown by a representative case of a Mayo Clinic patient who enrolled in a feasibility study of a molecular method aimed to identify melanoma patients who are so low risk for metastasis that they can safely forgo SLN biopsy (Figure ).3 This study was reviewed and approved by the Mayo Clinic Institutional Review Board. Following diagnosis, the patient met with a surgeon, underwent preoperative evaluation with customized testing to ensure a safe recovery, and completed a technetium-99m scintigraphy (single-photon emission computerized tomography [SPECT]) in nuclear medicine combined with computed tomography (CT) to produce SPECT-CT scans. This was followed by SLN biopsy and a wide local excision of the primary tumor in the operating room under general anesthesia. Tissue was paraffin-embedded, sectioned, and stained by hematoxylin and eosin; and melanocyte lineage-specific immunohistochemistry was determined and interpreted by anatomic pathologists. In this case, 3 weeks passed from melanoma diagnosis to finalized SLN biopsy result. Surgery was followed by postoperative care.

An external file that holds a picture, illustration, etc.
Object name is gr1_lrg.jpg
Figure
Summary of a case enrolled in a pilot study for clinicopathologic variables and gene expression profile (CP-GEP) based molecular testing at Mayo Clinic who underwent sentinel lymph node (SLN) biopsy in late 2019. Note the extensive use of hospital infrastructure, medical specialists, laboratory tests, and time to arrive at a negative SLN biopsy test result. In contrast, a simple molecular test performed on diagnostic biopsy tissue correctly identified the low risk nature of the patient’s primary melanoma with a turnaround time of just a few days. BD = Breslow depth; CBC = complete blood cell count; ECG = electrocardiogram; ENT = ear, nose and throat science (otorhinolaryngology); NCCN = National Comprehensive Cancer Network; SPECT-CT = single photon-emission computed tomography.

Aggressive melanoma easily metastasizes, including to SLN, and a positive SLN biopsy result identifies patients with an increased risk of relapse and in need of adjuvant therapy. However, most melanoma does not metastasize to SLN. Nodal metastasis is found in less than 20% of patients who undergo SLN biopsy.3 Although the removal of negative SLN has no discernible therapeutic effect, all patients who undergo SLN biopsy encounter a greater than 10% risk of complications.4 There is a need for methods to identify patients who are so low risk that they can safely forgo SLN biopsy. We have previously reported on a melanoma risk-stratification approach which combines clincopathologic (CP) variables with a gene expression profile (GEP) from primary diagnostic biopsy tissue.3 Using the CP-GEP test, up to 80% of patients with T1b, 48% of patients with T2a, and 24% of patients with T2b melanoma may forgo the SLN biopsy procedure as they are categorized as low risk for nodal metastasis with an error rate of less than 5%.3 , 5 Test results are available within days (Figure) and do not require the patient to interact with health care providers. Hospital resources can be prioritized to other tasks.

New melanoma risk-stratification methods offer the opportunity to deselect low-risk patients for SLN biopsy. If, on the other hand, molecular testing indicates higher risk, patients can be prioritized for surgery after COVID-19 restrictions are relaxed. Molecular testing is now available through accredited clinical labs in the United States and have the potential to support the management of melanoma patients during the COVID-19 pandemic.

As I had mentioned in your previous thread - molecular/ctDNA testing may be of considerable value you to you. Yours, c

Fortysomething - (8/28/2020 - 4:10pm)

Hi Celeste

Thanks for posting it’s very informative.Unfortunatley I’m in England on nhs and don’t think they do this testing. Whenever I ask about polypoid melonoma everyone says it’s just a variant of nodular.

Bubbles - (8/28/2020 - 6:19pm)

I actually agree that polypoid melanoma is a variant of nodular. It is not the fact that your melanoma was labeled polypoid that I find concerning - rather it is the depth of your initial lesion and the fact that it was ulcerated. Should you wish to pursue - honestly, I'm not sure how valuable it would be to you - the CP-GEP testing that the article I shared is addressing, you could. For the test to be done, the lab does not need you - they just need a bit of tissue from your lesion sent to them. Your lab could send a specimen from your lesion to a lab that does this test. I don't know that your insurance program would cover it and I don't know the cost. I'm sure you could call or email an affiliated lab and ask. Here is some additional info on it: https://www.practiceupdate.com/content/primary-cutaneous-melanoma-risk-s...

In case that doesn't work, this report notes:

Published in Dermatology
Journal Scan / Research · June 28, 2020

Primary Cutaneous Melanoma Risk Stratification Using a Clinicopathologic and Gene Expression Model
International Journal of Dermatology

TAKE-HOME MESSAGE
Tissue from 50 histopathologically confirmed cases of melanoma was sent from Mayo Clinic to a CAP/CLIA-certified laboratory in San Diego for CP-GEP testing. For this send-out lab, tissue should be submitted fixed in formalin and embedded in paraffin either as a block or on glass slides. Tissue was sufficient for testing in 47 cases. All tissue was received within 48 hours of sending, and reports were generated within 5 working days of tissue receipt.

This CP-GEP test is intended to identify those patients with cutaneous melanoma who are low risk for nodal metastasis in order to prevent unnecessary sentinel lymph node biopsies. This study suggests that CP-GEP testing of cutaneous melanoma biopsy tissue as a send-out lab is feasible.
– Caitlyn T. Reed, MD

We have recently reported on the CP‐GEP model to identify patients with primary cutaneous melanoma who may forgo the sentinel lymph node (SLN) biopsy procedure because of their low risk of nodal metastasis.1, 2 The CP‐GEP model combines clinicopathologic (CP) variables, Breslow thickness, patient age, and the expression of eight genes related to epithelial‐to‐mesenchymal transition3, 4 to categorize patients into two groups: low risk or high risk for nodal metastasis (Fig. 1). Here, we report on a feasibility study of cutaneous melanoma patients seen at Mayo Clinic (MC) between October and December of 2019 who had their diagnostic biopsy tissue tested by CP‐GEP in a CAP/CLIA‐certified laboratory in San Diego (operated by SkylineDx). The primary objective of this study was to evaluate the feasibility of standardized CP‐GEP testing in a certified laboratory in the United States and to evaluate and optimize the requisitioning logistics. This pilot study was conducted under the framework of the Falcon Melanoma R&D program, which aims to investigate the relevance of gene expression‐based testing in personalized healthcare. The CP‐GEP model for predicting nodal metastasis, which we here refer to as the Merlin test, is the first diagnostic test developed under this program. The human investigations performed in this study were completed after approval by the Mayo Clinic Institutional Review Board and in accordance with the requirements of the Department of Health and Human Services, where appropriate.

Testing for circulating DNA requires a blood draw. I have written extensively about it on my blog. You can use the search bubble if you are interested. I would imagine there are places in the UK that are doing it, though - like here in the US - it is probably not done routinely.
For what it's worth. c