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SLNB: To be or not to be?

Forums General Melanoma Community SLNB: To be or not to be?

  • Post
    Bob B.
    Participant

      I hope to learn from the far greater experience of you all.   Just as much, I hope the topic is useful for others.   

      Two years ago an oncologist in Brazil offered me a SLNB for a #1, primary (Lentigo Maligna Melanoma/WMM).  Two pathology reports showed a borderline Breslow thickness of .67 and .80.   However, the SLNB offer followed a WLE (without biopsy).  Lymphatic drainage would surely have compromised results of a SLNB, as I've lately learned.  (??)   In any case, other pronostic factors were good.

      I hope to learn from the far greater experience of you all.   Just as much, I hope the topic is useful for others.   

      Two years ago an oncologist in Brazil offered me a SLNB for a #1, primary (Lentigo Maligna Melanoma/WMM).  Two pathology reports showed a borderline Breslow thickness of .67 and .80.   However, the SLNB offer followed a WLE (without biopsy).  Lymphatic drainage would surely have compromised results of a SLNB, as I've lately learned.  (??)   In any case, other pronostic factors were good.

      I declined the SLNB.   No local recurrence for 28 months.   Maybe I was lucky.

      Next, I had #2 (Superficially Spreading Melanoma/SSM) excised two months ago- without a biopsy again, despite almost uniform use by dermatologists.   But in view of the excellent pathologist's doubts about "narrow margins", I had another excision/WLE performed.   The pathologist, with whom I had two fascinating conversations, turned out to have been right.  With the second excision, healthy margins had been obtained.  

      Two weeks ago #3 primary got the shave biopsy I again wished to avoid.   For two weeks pathology remained in doubt, so the tissue was sent for a second opinion:   Result:   Another, superficially small SSM.   I guess accurate prognosis (Breslow, mitotic rate, Clark, etc) with a shave biopsy is impossible.   But surprisingly, the pathologist's final report failed even to indicate shave depth.  (??)   Orally only, I learned the lesion had been "transected at .94".  

      A SLNB was duly suggested as the shave's actual depth below is unknown.   My question is, once again:   Do it or not?

      Despite the probability of even greater depth than ".94", I am reluctant.   Reasons:   Doubts about the two weeks of pathology dithering;  shave depth initially went unindicated by the pathologist who, unlike the previous pathologist, seems indisposed to discuss her report;  SLNB positive rate 5-10%;  SLNB non-therapeutic, used strictly for staging;  my uninformed concerns about shave biopsies; survival rates no better with than without;  widespread doubt about overuse.   But perhaps just as important, my usual "less is more…. best surgery is no surgery" prejudice. 

      I would really appreciate the kind advice of the experienced members who were so much help with #2.   What do you think?  

      Thanks!

       

       

    Viewing 5 reply threads
    • Replies
        Janner
        Participant

          Why did you allow a shave biopsy when you stated you wished to avoid that?  I would find a different doc if they won't work with your choices although finding a doc who will do a WLE without a biopsy first may prove to be more difficult.  Accurate diagnosis is possible with a shave biopsy if the biopsy doesn't transect the lesion.  Even when it is, it is usually possible to give a partial diagnosis like "at least .94mm deep and at least Clark Level III".  This is the reason why most of us prefer at least a punch biopsy instead of a shave to avoid the staging problems when a lesion has been cut through.

          I share your choice of avoiding surgery when necessary.  However, the standard SNB protocol is at 1mm and since the shave transected your lesion, you will never know the true depth.  In this case, I probably would do it only because the lesion could have been much deeper.  True, the SNB is diagnostic only but a positive node can address things sooner than waiting for something large enough to be palpated.  Lymph node disections have shown to have some survival benefits so a positive SNB could change your choice of future treatment to include a dissection.  If you know the lymph basin the lesion would drain to and if you had a doctor willing to do quarterly ultrasounds, I would consider that option as well.  There were clinical trials being done in the states regarding SNB vs ultrasound monitoring.  I haven't seen the results but that would be a less invasive route for borderline lesions.

          Sorry you've had another, but I'd probably proceed with the SNB and standard of care in this situation given the unknown properties of this lesion.

          Janner

            Bob B.
            Participant

              An anomaly… For the last two weeks I've been looking forward to hearing your opinion. And perhaps from Jerryfromfauq, Minnesota and others who might care to reply. i failed to receive an alert, and only now spotted your reply. Thanks! Why did I "allow a shave biopsy"? Hey, good one! But you have answered your own question: Here in San Diego I tried a dozen derms. But they all insisted on a biopsy (almost always a shave) before WLE. I finally got a very good derm surgeon here to WLE my #2 primary- only by claiming "I'd had a biopsy done in Brazil." A lie. The system wore me done, insurance protocols spoke louder. A month ago I asked the PA with 6 years derm experience in the 'star' oncologist's office to shave a #3 mel I'd been (stupidly) tracking for 2 years. He also did a basal cell I've mostly ignored a decade or more. Point by interesting point that you have made? (1) "Avoid surgery"? I don't, derms do! Difficult to get past their fixation on biopsies. Not that I am "against biopsies"- when there is doubt. Of which I had none, and am batting 1000 with primaries #1, 2 & 3. Small favors, God? (2) SLNB You are probably right to get one. However, multiple pathology dithering for two weeks, no report depth indicated (?), and pressure from the university head of derm department (whose mission I assume detours from your usual clinician's), and from his resident to get a SLNB- I found irritating. (3) SLNB before/after WLE? I questioned the derm resident's pressure for an immediate SLNB for a couple reasons: a. As you may have noticed, I don't respond to pressure. πŸ™‚ b. Derm resident prescribed SLNB before lead derm, or onc, had even seen me? I don't think so. Do you? c. Derm resident says SLNB, first. Otherwise, a WLE must be followed by a complete lymph node dissection since it would disturb the lymphatic drain field too much to target the sentinel node afterwards. Contradicting her, the top onc surgeon's nurse says a SLNB after WLE is "doable", if in fact not ideal. d. Derm resident says simply "add on" the (verbal-only) shave depth to the eventual WLE depth. You don't agree, do you? e. Pathologist responsible for the "depth-less' report has for 2 weeks refused my courteous invitations to discuss by phone. May be unusual for pathologists to discuss their reports directly with patients- but is it against some "protocol" or other? When someone is not forthcoming, transparent, I don't know… I begin to suspect a "problem" with the report, maybe fear of litigation. Fear of this particular bogeyman is apparently well deserved.. I guess you see my doubts, the differing opinions, the pathology/pathologist unknowns? You may be right about the SLNB. However, I'm leaning toward the WLE to see if the surgeon, a highly respected lymphatic surgeon, gets it. . Surgical margins she plans to use are a generous @1.5cm. Compared with the previous, derm surgeon who 'undermargined' at 0.5cm, I'm reassured. BTW, her margins for 0.5 Breslow are 1.0cm which she says are the most up to date. I hadn't heard that, but if it errs, it's on the side of generous. Which I like If the WLE fails at conclusive histologic margins, I'm hoping a reasonable back up will still be a SLNB, regardless of what that resident says. And if still positive, a lymphadenectomy, I suppose. On the other hand… (3) Ultrasound "Sounds" like you have given me some homework. As the SSM is on the right pectoral, I assume the appropriate basin is the right armpit. I'll ask about this. (4) Gerson Therapy? Off the wall question, as AMA opinion is clearly this is quackery. I'm alternative, but cautious. Any thoughts? Thanks again. Your opinion and suggestions are invaluable!

              Bob B.
              Participant

                An anomaly… For the last two weeks I've been looking forward to hearing your opinion. And perhaps from Jerryfromfauq, Minnesota and others who might care to reply. i failed to receive an alert, and only now spotted your reply. Thanks! Why did I "allow a shave biopsy"? Hey, good one! But you have answered your own question: Here in San Diego I tried a dozen derms. But they all insisted on a biopsy (almost always a shave) before WLE. I finally got a very good derm surgeon here to WLE my #2 primary- only by claiming "I'd had a biopsy done in Brazil." A lie. The system wore me done, insurance protocols spoke louder. A month ago I asked the PA with 6 years derm experience in the 'star' oncologist's office to shave a #3 mel I'd been (stupidly) tracking for 2 years. He also did a basal cell I've mostly ignored a decade or more. Point by interesting point that you have made? (1) "Avoid surgery"? I don't, derms do! Difficult to get past their fixation on biopsies. Not that I am "against biopsies"- when there is doubt. Of which I had none, and am batting 1000 with primaries #1, 2 & 3. Small favors, God? (2) SLNB You are probably right to get one. However, multiple pathology dithering for two weeks, no report depth indicated (?), and pressure from the university head of derm department (whose mission I assume detours from your usual clinician's), and from his resident to get a SLNB- I found irritating. (3) SLNB before/after WLE? I questioned the derm resident's pressure for an immediate SLNB for a couple reasons: a. As you may have noticed, I don't respond to pressure. πŸ™‚ b. Derm resident prescribed SLNB before lead derm, or onc, had even seen me? I don't think so. Do you? c. Derm resident says SLNB, first. Otherwise, a WLE must be followed by a complete lymph node dissection since it would disturb the lymphatic drain field too much to target the sentinel node afterwards. Contradicting her, the top onc surgeon's nurse says a SLNB after WLE is "doable", if in fact not ideal. d. Derm resident says simply "add on" the (verbal-only) shave depth to the eventual WLE depth. You don't agree, do you? e. Pathologist responsible for the "depth-less' report has for 2 weeks refused my courteous invitations to discuss by phone. May be unusual for pathologists to discuss their reports directly with patients- but is it against some "protocol" or other? When someone is not forthcoming, transparent, I don't know… I begin to suspect a "problem" with the report, maybe fear of litigation. Fear of this particular bogeyman is apparently well deserved.. I guess you see my doubts, the differing opinions, the pathology/pathologist unknowns? You may be right about the SLNB. However, I'm leaning toward the WLE to see if the surgeon, a highly respected lymphatic surgeon, gets it. . Surgical margins she plans to use are a generous @1.5cm. Compared with the previous, derm surgeon who 'undermargined' at 0.5cm, I'm reassured. BTW, her margins for 0.5 Breslow are 1.0cm which she says are the most up to date. I hadn't heard that, but if it errs, it's on the side of generous. Which I like If the WLE fails at conclusive histologic margins, I'm hoping a reasonable back up will still be a SLNB, regardless of what that resident says. And if still positive, a lymphadenectomy, I suppose. On the other hand… (3) Ultrasound "Sounds" like you have given me some homework. As the SSM is on the right pectoral, I assume the appropriate basin is the right armpit. I'll ask about this. (4) Gerson Therapy? Off the wall question, as AMA opinion is clearly this is quackery. I'm alternative, but cautious. Any thoughts? Thanks again. Your opinion and suggestions are invaluable!

                Bob B.
                Participant

                  An anomaly… For the last two weeks I've been looking forward to hearing your opinion. And perhaps from Jerryfromfauq, Minnesota and others who might care to reply. i failed to receive an alert, and only now spotted your reply. Thanks! Why did I "allow a shave biopsy"? Hey, good one! But you have answered your own question: Here in San Diego I tried a dozen derms. But they all insisted on a biopsy (almost always a shave) before WLE. I finally got a very good derm surgeon here to WLE my #2 primary- only by claiming "I'd had a biopsy done in Brazil." A lie. The system wore me done, insurance protocols spoke louder. A month ago I asked the PA with 6 years derm experience in the 'star' oncologist's office to shave a #3 mel I'd been (stupidly) tracking for 2 years. He also did a basal cell I've mostly ignored a decade or more. Point by interesting point that you have made? (1) "Avoid surgery"? I don't, derms do! Difficult to get past their fixation on biopsies. Not that I am "against biopsies"- when there is doubt. Of which I had none, and am batting 1000 with primaries #1, 2 & 3. Small favors, God? (2) SLNB You are probably right to get one. However, multiple pathology dithering for two weeks, no report depth indicated (?), and pressure from the university head of derm department (whose mission I assume detours from your usual clinician's), and from his resident to get a SLNB- I found irritating. (3) SLNB before/after WLE? I questioned the derm resident's pressure for an immediate SLNB for a couple reasons: a. As you may have noticed, I don't respond to pressure. πŸ™‚ b. Derm resident prescribed SLNB before lead derm, or onc, had even seen me? I don't think so. Do you? c. Derm resident says SLNB, first. Otherwise, a WLE must be followed by a complete lymph node dissection since it would disturb the lymphatic drain field too much to target the sentinel node afterwards. Contradicting her, the top onc surgeon's nurse says a SLNB after WLE is "doable", if in fact not ideal. d. Derm resident says simply "add on" the (verbal-only) shave depth to the eventual WLE depth. You don't agree, do you? e. Pathologist responsible for the "depth-less' report has for 2 weeks refused my courteous invitations to discuss by phone. May be unusual for pathologists to discuss their reports directly with patients- but is it against some "protocol" or other? When someone is not forthcoming, transparent, I don't know… I begin to suspect a "problem" with the report, maybe fear of litigation. Fear of this particular bogeyman is apparently well deserved.. I guess you see my doubts, the differing opinions, the pathology/pathologist unknowns? You may be right about the SLNB. However, I'm leaning toward the WLE to see if the surgeon, a highly respected lymphatic surgeon, gets it. . Surgical margins she plans to use are a generous @1.5cm. Compared with the previous, derm surgeon who 'undermargined' at 0.5cm, I'm reassured. BTW, her margins for 0.5 Breslow are 1.0cm which she says are the most up to date. I hadn't heard that, but if it errs, it's on the side of generous. Which I like If the WLE fails at conclusive histologic margins, I'm hoping a reasonable back up will still be a SLNB, regardless of what that resident says. And if still positive, a lymphadenectomy, I suppose. On the other hand… (3) Ultrasound "Sounds" like you have given me some homework. As the SSM is on the right pectoral, I assume the appropriate basin is the right armpit. I'll ask about this. (4) Gerson Therapy? Off the wall question, as AMA opinion is clearly this is quackery. I'm alternative, but cautious. Any thoughts? Thanks again. Your opinion and suggestions are invaluable!

                Janner
                Participant

                  Why did you allow a shave biopsy when you stated you wished to avoid that?  I would find a different doc if they won't work with your choices although finding a doc who will do a WLE without a biopsy first may prove to be more difficult.  Accurate diagnosis is possible with a shave biopsy if the biopsy doesn't transect the lesion.  Even when it is, it is usually possible to give a partial diagnosis like "at least .94mm deep and at least Clark Level III".  This is the reason why most of us prefer at least a punch biopsy instead of a shave to avoid the staging problems when a lesion has been cut through.

                  I share your choice of avoiding surgery when necessary.  However, the standard SNB protocol is at 1mm and since the shave transected your lesion, you will never know the true depth.  In this case, I probably would do it only because the lesion could have been much deeper.  True, the SNB is diagnostic only but a positive node can address things sooner than waiting for something large enough to be palpated.  Lymph node disections have shown to have some survival benefits so a positive SNB could change your choice of future treatment to include a dissection.  If you know the lymph basin the lesion would drain to and if you had a doctor willing to do quarterly ultrasounds, I would consider that option as well.  There were clinical trials being done in the states regarding SNB vs ultrasound monitoring.  I haven't seen the results but that would be a less invasive route for borderline lesions.

                  Sorry you've had another, but I'd probably proceed with the SNB and standard of care in this situation given the unknown properties of this lesion.

                  Janner

                  Janner
                  Participant

                    Why did you allow a shave biopsy when you stated you wished to avoid that?  I would find a different doc if they won't work with your choices although finding a doc who will do a WLE without a biopsy first may prove to be more difficult.  Accurate diagnosis is possible with a shave biopsy if the biopsy doesn't transect the lesion.  Even when it is, it is usually possible to give a partial diagnosis like "at least .94mm deep and at least Clark Level III".  This is the reason why most of us prefer at least a punch biopsy instead of a shave to avoid the staging problems when a lesion has been cut through.

                    I share your choice of avoiding surgery when necessary.  However, the standard SNB protocol is at 1mm and since the shave transected your lesion, you will never know the true depth.  In this case, I probably would do it only because the lesion could have been much deeper.  True, the SNB is diagnostic only but a positive node can address things sooner than waiting for something large enough to be palpated.  Lymph node disections have shown to have some survival benefits so a positive SNB could change your choice of future treatment to include a dissection.  If you know the lymph basin the lesion would drain to and if you had a doctor willing to do quarterly ultrasounds, I would consider that option as well.  There were clinical trials being done in the states regarding SNB vs ultrasound monitoring.  I haven't seen the results but that would be a less invasive route for borderline lesions.

                    Sorry you've had another, but I'd probably proceed with the SNB and standard of care in this situation given the unknown properties of this lesion.

                    Janner

                    JC
                    Participant

                      Are shave biopsies generally considered not good?  That's about all my derm does.  But, I thought sometimes a deep shave is preferred to punch, because punch sometimes doesn't get wide enough margins.  Are quarterly ultrasound of nodes something all stage I/II should be getting??

                        Janner
                        Participant

                          Punches may not always get wide enough margins, but they rarely compromise staging because they get depth well past what a shave gets.  If the lesion is too wide for a punch, I prefer a conservative excisional biopsy.  Derms do shaves because they are fast, easy and require no stitches.  Easy money (being cynical here) and no need to schedule a followup appointment to remove stitches.  I hate them because they are more painful for healing as well as have the possibility to compromise staging.  My cutaneous oncologist will not do a shave biopsy on anything suspected of melanoma.  However, this means I might have to wait a little for a biopsy to fit into a surgery schedule because it usually won't happen at the consult appointment.  Shaves are convenient, but not always a good choice.  The downside is just what Bob is dealing with here – a lesion that was transected and he will NEVER know the true depth.  Doing a WLE at this point will only tell him if he has residual melanoma present.  But you can't add the original depth to any residual depth because the slices done for the pathology of the biopsy versus the WLE will never line up.  You just can't "add" anything after a shave biopsy.

                          As for quarterly monitoring of lymph nodes via ultrasound, that is not currently recommended for stage I/II.  In general, it might be considered for those who have a positive SNB with only micro cells in it and therefore choose not to have the lymph node dissection – a very invasive procedure.  I suggested it for Bob because of his unique away of approaching melanoma and his reluctance to have surgeries.

                          Bob B.
                          Participant

                            What your cutaneous oncologist says is where I'm coming from as well:   No shave biopsy if suspected melanoma.   

                            Reluctance about surgeries?  Ha, there you go again, 'misrepresenting' me.  πŸ™‚ …  I'm absolutely avid for excision, skip biopsies if they look like melanoma at all.   Derms' excuse is that melanoma is not always easy to spot.   I'm sure they are right.   But not when I've been watching them spread for so long:    #2 for 2 years;  #3 for 8 months:  #1 I got onto late as hidden from view astride trapezius (therefore no idea how long, but no local recurrence after WLE 2 years ago, lucky) 

                            As mentioned, my reluctance about shaves was worn down by the health industry (including insurance) "best practice", protocols.   And am positive I have no idea what I'm talking about-  nonetheless I'm also leary of punches:  Is there really no chance diseased tissue can migrate with the punch through the lesion into the health tissue into which it penetrates?  I've heard something similar can happen with prostate needle biopsies infecting surrounding tissue.  This is academic for me, only at this stage.   Maybe in the future.   Just wondering..

                            Bob B.
                            Participant

                              What your cutaneous oncologist says is where I'm coming from as well:   No shave biopsy if suspected melanoma.   

                              Reluctance about surgeries?  Ha, there you go again, 'misrepresenting' me.  πŸ™‚ …  I'm absolutely avid for excision, skip biopsies if they look like melanoma at all.   Derms' excuse is that melanoma is not always easy to spot.   I'm sure they are right.   But not when I've been watching them spread for so long:    #2 for 2 years;  #3 for 8 months:  #1 I got onto late as hidden from view astride trapezius (therefore no idea how long, but no local recurrence after WLE 2 years ago, lucky) 

                              As mentioned, my reluctance about shaves was worn down by the health industry (including insurance) "best practice", protocols.   And am positive I have no idea what I'm talking about-  nonetheless I'm also leary of punches:  Is there really no chance diseased tissue can migrate with the punch through the lesion into the health tissue into which it penetrates?  I've heard something similar can happen with prostate needle biopsies infecting surrounding tissue.  This is academic for me, only at this stage.   Maybe in the future.   Just wondering..

                              Bob B.
                              Participant

                                What your cutaneous oncologist says is where I'm coming from as well:   No shave biopsy if suspected melanoma.   

                                Reluctance about surgeries?  Ha, there you go again, 'misrepresenting' me.  πŸ™‚ …  I'm absolutely avid for excision, skip biopsies if they look like melanoma at all.   Derms' excuse is that melanoma is not always easy to spot.   I'm sure they are right.   But not when I've been watching them spread for so long:    #2 for 2 years;  #3 for 8 months:  #1 I got onto late as hidden from view astride trapezius (therefore no idea how long, but no local recurrence after WLE 2 years ago, lucky) 

                                As mentioned, my reluctance about shaves was worn down by the health industry (including insurance) "best practice", protocols.   And am positive I have no idea what I'm talking about-  nonetheless I'm also leary of punches:  Is there really no chance diseased tissue can migrate with the punch through the lesion into the health tissue into which it penetrates?  I've heard something similar can happen with prostate needle biopsies infecting surrounding tissue.  This is academic for me, only at this stage.   Maybe in the future.   Just wondering..

                                Janner
                                Participant

                                  Punches may not always get wide enough margins, but they rarely compromise staging because they get depth well past what a shave gets.  If the lesion is too wide for a punch, I prefer a conservative excisional biopsy.  Derms do shaves because they are fast, easy and require no stitches.  Easy money (being cynical here) and no need to schedule a followup appointment to remove stitches.  I hate them because they are more painful for healing as well as have the possibility to compromise staging.  My cutaneous oncologist will not do a shave biopsy on anything suspected of melanoma.  However, this means I might have to wait a little for a biopsy to fit into a surgery schedule because it usually won't happen at the consult appointment.  Shaves are convenient, but not always a good choice.  The downside is just what Bob is dealing with here – a lesion that was transected and he will NEVER know the true depth.  Doing a WLE at this point will only tell him if he has residual melanoma present.  But you can't add the original depth to any residual depth because the slices done for the pathology of the biopsy versus the WLE will never line up.  You just can't "add" anything after a shave biopsy.

                                  As for quarterly monitoring of lymph nodes via ultrasound, that is not currently recommended for stage I/II.  In general, it might be considered for those who have a positive SNB with only micro cells in it and therefore choose not to have the lymph node dissection – a very invasive procedure.  I suggested it for Bob because of his unique away of approaching melanoma and his reluctance to have surgeries.

                                  Janner
                                  Participant

                                    Punches may not always get wide enough margins, but they rarely compromise staging because they get depth well past what a shave gets.  If the lesion is too wide for a punch, I prefer a conservative excisional biopsy.  Derms do shaves because they are fast, easy and require no stitches.  Easy money (being cynical here) and no need to schedule a followup appointment to remove stitches.  I hate them because they are more painful for healing as well as have the possibility to compromise staging.  My cutaneous oncologist will not do a shave biopsy on anything suspected of melanoma.  However, this means I might have to wait a little for a biopsy to fit into a surgery schedule because it usually won't happen at the consult appointment.  Shaves are convenient, but not always a good choice.  The downside is just what Bob is dealing with here – a lesion that was transected and he will NEVER know the true depth.  Doing a WLE at this point will only tell him if he has residual melanoma present.  But you can't add the original depth to any residual depth because the slices done for the pathology of the biopsy versus the WLE will never line up.  You just can't "add" anything after a shave biopsy.

                                    As for quarterly monitoring of lymph nodes via ultrasound, that is not currently recommended for stage I/II.  In general, it might be considered for those who have a positive SNB with only micro cells in it and therefore choose not to have the lymph node dissection – a very invasive procedure.  I suggested it for Bob because of his unique away of approaching melanoma and his reluctance to have surgeries.

                                  JC
                                  Participant

                                    Are shave biopsies generally considered not good?  That's about all my derm does.  But, I thought sometimes a deep shave is preferred to punch, because punch sometimes doesn't get wide enough margins.  Are quarterly ultrasound of nodes something all stage I/II should be getting??

                                    JC
                                    Participant

                                      Are shave biopsies generally considered not good?  That's about all my derm does.  But, I thought sometimes a deep shave is preferred to punch, because punch sometimes doesn't get wide enough margins.  Are quarterly ultrasound of nodes something all stage I/II should be getting??

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