Digesting last week’s SLNB conversation

To determine which are the sentinal nodes for a particular primary, they use a radioactive tracer injected at the site of the primary and track to which nodes that area drains.   With as many primaries as you've had, that sounds like it would be a complicated ordeal and would require SLNB in multiple locations possibly.

I'm not a medical practictioner, but if you are receiving regular scans, I think that is a better surveillance technique than the SLNB.   If you have a palpapable node, it seems that a PET would be able to tell you if it has tumor activity in it.  The biopsy would be able to find microscopic metastases that the PET wouldn't pick up, but if it's large enough to feel I'm thinking a PET would tell them a lot.

As a point of reference, my wife had a clear SLNB after a 4mm depth primary removal, all clear PET, no signs of melanoma, and six months later she was stage 4 with two brain mets, so the SLNB isn't the end – all that some facilities like to claim it is, in my opinion.

I think Jennier has pointed this out once before.

If your primary is >1mm, excuse me, now >.8mm, MM can be in your blood.

We should all be getting the immunotherapy drugs, Opdiva, but the system is slow to react.

I bet it will be another couple years before they swith gears.

So Bob, it would be hard to do any type of SNB now.  You wouldn't know exactly where to inject the tracer.  They typically do that before the WLE because the WLE may change the drainage paths.  They inject right at the primary center and that would be long gone in your case.  There would be no way to know really where to start the tracer and hope for a decent chance to actually hit the original sentinel node.

SNB vs scan.  SNB catches microscopic mets, scans only catch tumors typically around 5mm and larger depending on the resolution of the machine.  At this point, I think scans are more realistic.

I would think the pectoral area is a tough stretch for most of those primaries.  The ones on the arm itself would drain first to the armpit.  The shoulder would most likely drain there too but could also do neck or clavicle.  So the pectoral area would not be the 1st drainage basin for any of those (shoulder one is the iffy one).  If any of your primaries were on the trunk, those could also be candidates.

String of in situs coming from positive nodes?  No.  In situ grows from the epidermis downward.  Metastatic lesions grow from the lymph vessels deeper in the dermis.  Mets can grow upward toward the epidermis, or stay deeper along the lymph paths.  But if your pathologist has any credentials at all, he should be able to determine primary vs met.  Growth patterns are one way they do that.  Granted, there are some lesions that can't be determine for certain, but they are not typically in situ and it would be noted as such.  One veteran here had a 6.8mm primary/met that never could be resolved. 

We know you are a unique case, and nothing in this field is ever absolute.  My info above is generally how it works.  Feel free to ask more/comment – you know where to find me!  🙂

Hey Bob,

Sorry you are back up for more melanoma crap.  I agree with everything Janner said.  I wish it were otherwise….that something….SLNB…anything….could give you answers and stop what you're dealing with.  Right now, for all the reasons Janner noted, I don't thnk SLNB would do you any good.  We have come so far in melanoma with targeted therapy for BRAF+ melanoma and immunotherapy for many others.  Still, ever so many remain without effective therapy….all those who are not BRAF+, those for whom immunotherapy is not effective, those with 'strange' mutations, with mucosal and ocular melanoma, with multiple primaries, etc., etc.  I hope with everything I am, that the knowledge researchers have amassed about how melanoma works, what we do know to be effective ~ will lead to clarification, better treatment and management for all melanoma peeps.  And in our small ways, I think smart discussions and sharing of our thoughts and experiences here, can help do that as well.  Hang in there!!  I wish you my best.  Celeste

Hello Bob,

I just wanted to add that a SNB does not always show melanoma.  My husband had a 10.5 mm lesion on his head in Jan. 2008 and his SNB came back clear.  Nov. of the same year he had another lesion removed from his head.  In Oct. 2010 he became Stage IV after having 4 previous surgeries all in the head and neck area.  He had a unresectable lesion on his head and neck area at the spine C1/C2 area and mets in his lungs and liver.  If you want to read more about his journey you  can read his story on his profile.

He did the clinical trial of Ipi (Yervoy) 10 mg/kg and GMCSF (daily injections) and he became NED in July 2012 and has remained that way.  He stayed on the maintenance doses of the trial until Dec. 2013.

Judy loving wife of Gene (NED since 2012)