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Possible to have positive lymph node biopsy but clear margins on wide excision?

Possible to have positive lymph node biopsy but clear margins on wide excision?

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5/14/2019 12:11pm
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Replies: 4


My husband has been recently diagnosed with melanoma. The tumor was in his arm and had a thickness of 0.8mm with a Mitotic Rate of 1. There was no ulceration. They said there were cancer cells all the way up to the margins on his original excision. He goes to the VA for treatment. The tumor board there met and recommended he have a wide local excision and sentinel lymph node biopsy. They said that his was in the “gray area” so they weren’t going to twist his arm for the SLNB, but they recommended it. The surgeon we consulted with said if he was the patient he would have it done. So my husband agreed to follow the recommended plan and get the wide local excision and sentinel node biopsy done. He was scheduled to have surgery about 2.5 weeks from the consult. A few days later we got a call stating that the surgeon saw when he was scheduled and didn’t want my husband to wait that long to have the surgery. He wanted him to come in sooner and he would be with a different surgeon. We went in for the surgery yesterday and they had not scheduled him properly to have the SLNB done. When the surgeon came to meet with him and my husband mentioned it, the surgeon said my husband was not prepped for the node biopsy because he didn’t go to radiation so he couldn’t do that. My husband asked the surgeon to review his pathology report because he hadn’t seen it yet. The surgeon came back and said that my husbands tumor didn’t meet the criteria for the SLNB anyway, so he didn’t really need it. I asked why the tumor board and other doctors had recommended it. The surgeon said he didn’t know but would try to contact them. The surgeon said he texted the chief of surgery to ask but couldn’t get ahold of him. They told us he could get the wide local excision that day and come back later for the SLNB. I stated my concerns with that based on how the wide excision can change the lymphatic pathways. The resident doctors nodded. They said we could reschedule both if we wanted. The surgeon came back again and gave his reasons for why he thought the SLNB was unnecessary and how it would expose my husband to unnecessary radiation, etc. The nurses were telling my husband that this surgeon is very good and experienced with melanoma and he should trust him. Meanwhile the doctors and staff were getting antsy because they had other surgeries to do and were feeling rushed to get on with my husband’s. We finally agreed to let the surgeon just do the wide local excision yesterday.

We are, of course, now having regrets and wondering if we did the right thing. We hope that the biopsy from the wide local excision will be clear. If we get the pathology results back from the wide local excision and it has clear margins, should we feel pretty confident that it has been taken care of and the SLNB wasn’t necessary? Or is it possible for the margins to be clear on wide local excision but there to still be cancer in the lymph nodes?

I am also being treated by the VA, which hospital is your husband being treated at?

He is being treated at the John D. Dingell VA Medical Center in Detroit, Michigan. What about you?

First of all, melanoma and what to do with it is a crazy world as you have already experienced. In short...yes. You can acquire clear margins around a cutaneous lesion and still have a positive lymph node. However, that train has left the station in your husband's situation as sentinel node biopsy is not possible after a wide local excision as the lymph flow will have been disrupted and I would simply move forward with close observation and not beat yourself up about it. The odds are that with thin lesions, once they are removed, they are gone and patients do very well. As to why you got such mixed messages is that the recent (2017) guidelines state "SLN biopsy may be considered for thin melanomas that are T1b (0.8 to 1.0 mm Breslow thickness or less than 0.8 mm Breslow thickness with ulceration)..." So, your husband's lesion was right on the edge of that criteria and even then SLNB is not absolutely recommended, rather it "may be considered". Here is a report that includes more info, additional links, and a discussion of the recommendations if you are interested:
Hope this helps. I wish you and your husband my best. Celeste

Hello, I recently had a WLE done on 23 of April. , my tumor was .9 mm on my upper Back. I did have the SLNB taken from my left Auxiliary. I was told only very small chance there would be anything show up. I returned May 6 for follow up and results. All my Margins were good and and clear , my Lymph-nodes were clear. The surgery wasn’t bad at all. But the Slnb is normally done before the WLE.

Best of luck.