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Biopsy or Not?

Forums Cutaneous Melanoma Community Biopsy or Not?

  • Post
      Hello! I am new to this forum and would appreciate any advice you can give me. Here is my back story:

      Received stage 1A diagnosis in 2008 on left ankle with no recommendation for SNB. Treated for skin checks every 6 months. They were on the fence wether it was a abnormal spitz nevi but categorized it as melanoma.

      Fast forward 11 years! Noticed lump in left groin in November of 2019 and diagnosed with stage 3B for one large 3cm lymph node that was removed in Dec 2019. They took out 3 other nodes in area and all were negative. There was no indication of a second skin lesion or tumor so the doctors think my recurrence is related to my 2008 tumor on my left ankle. Was put on Optivo every two weeks for adjuvant therapy and have had 3 doses that started early Jan 2020.

      I received second PET (late Jan) showing a small (slightly less than 10mm) inflamed lymph node in the Porta Hepatis region behind the liver. The rest of my scan shows clear. My oncologist recommended to wait out another scan (3 months) to see if it’s status changes. His thought is that It is a possible reaction to the Optivo immunotherapy I am on that can cause inflamed nodes OR It is cancer in the node and hopefully the Optivo will start to treat it. I understand his thoughts but I was only on the therapy for 1 month and typically people don’t start reacting till 8-12 weeks but it is possible based on others comments online having early reactions.

      It’s in a tough spot to get to but I have a gastro ent/ultrasound scheduled for next Tuesday where they think they might be able to biopsy it. My issue with this is if it is cancer and it is even possible to have surgery to extract it? Also I would most likely have to go off my immunotherapy treatment for at least two months (2-4 weeks before and 2-4 weeks after surgery) and is that worth it?

      It’s like a game of chess. Is it worth knowing? Stress if I know/stress if don’t! Seems strange that Melanoma would possibly jump between these two locations and show only one node indicated now. I also know by talking to the PET scan technician that my second PET scan machine has a better camera and more sensitivity than the one I used last November.

      Appreciate your candid thoughts!

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          A biopsy or waiting 3 months for a PET scan are both reasonable options. The lymph node could be responding to an infection. A visible sore on my neck showed active on a December 2017 PET scan. That sore disappeared.

          When I had cataract surgery on both eyes in August 2018, I needed 3 weeks without Opdivo infusions before and after that surgery. I was receiving Opdivo every 2 weeks. I skipped 2 infusions of Opdivo. If your lymph node biopsy shows melanoma or your next PET scan shows more activity in it, radiation might be an alternative to surgery. With radiation you could continue receiving Opdivo. In April 2018 I received radiation to a cancerous lymph node while continuing to receive Opdivo infusions. This combination of radiation and immunotherapy seems to have worked.

              Thank you for the information on radiation – will look into this option if the node is positive. Not sure if radiation in this area behind the liver is recommended or not due to its sensitive location.
              Sorry you are dealing with this – but here are my thoughts:

              1. Given that the scan you reference was in Jan, and you are to have another scan in 3 months – you don’t have that long until the follow-up scan.
              2. As you noted, it is too early determine much of anything in the way of a response from your Opdivo (nivolumab) doses. When dealing with immunotherapy of all stripes, melanoma experts recommend – “Be patient with the patient.” Still, the spot that is noted on your recent scan could be an inflammatory response by the influx of t cells to a patch of melanoma cells that Opdivo has stimulated them to do away with as we speak. Or….as is common with findings on scans, it could be a red herring that we only have to deal with because now we know it is there. Either way – in light of those facts, waiting to rescan would be an acceptable plan.
              3. Recent positive reports on “NEO-adjuvant” responses – treating the patient with known melanoma intact – is another reason why waiting to rescan may be wise. Here are lots of reports on neoadjuvant treatment:
              4. Another reason to be a bit leery of biopsy is that if not done very carefully with proper technique by a surgeon well versed in the removal of cancerous lesions, the biopsy itself can be a source of spread.
              5. That said, I see no reason why surgery or biopsy would necessitate a cessation of your Opdivo. Stopping therapy would not be something I would want to experience were I in your shoes.
              6. The only reason I can see for biopsy at this point, is that if it is positive for melanoma, you would know that you were Stage IV and therefore eligible for the ipi/nivo (ipilimumab [yervoy] WITH nivolumab [opdivo]) immunotherapy combo. If you (or your doc) wouldn’t switch to that therapy (it is only approved for Stage IV patients currently) then I’m not sure the biopsy would have much value at this time. If you’re not going to switch to ipi/nivo, then I guess I don’t really see the point. And lots of Stage IV patients do perfectly well on nivo alone. I am one. Stage IV in 2010 after brain and lung mets. Nivo trial until 2013. No further treatment and remain NED for melanoma today.

              I hope I haven’t made the situation more confusing – but melanoma ain’t easy! Ask more questions as you have the need. There are many smart and caring peeps on this forum! I wish you my best. celeste

                  Thanks for the advice! I am planning on doing the biopsy so that I can make sure I have the most options like going on the additional immunotherapy Yervoy. Only issue would be additional risk of reactions by adding Yervoy – looks like the risk goes way up. hopefully it is a false positive for cancer and ends up just being a node fighting off infection. I have researched and told by doctors that the risk of spreading cancer via fine needle biopsy is extremely low and hope this is the case.
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