SNB Question/Concern

Aloha, sorry you have to deal with this.

As far as age is concerned, age alone is not a factor but rather how healthy they are and able to tolerate surgery.  Some 70 y/o's are more like 60 and others like 90.  We all age differently and much depends on other medical issues.

That being said, if the SNB is positive she will be upstaged to stage III.  That will qualifiy her for more treatments depending on if stage IIIA-C.

Interferon has little benefit and is toxic.  I personally wouldn't do it and would opt for a clinical trial instead, thus the need to see if LO is truely a stage III or high stage II.  With mel that deep, if she isn't a stage III or IV I would be shocked.  Thus the need to figure out what treatments other than interferon can she tolerate if she chooses.

If not doing a SNB, then the PET/CT is a great option but not sure if insurance will cover it since she isn't fully staged yet.  Right now she is only a stage II and no insurance that I know of will approve those scans.  Another option to evaluate the nodes is to do an ultrasound with needle biopsy if anything is fishy.  She should be followed up at short intervals becasue she is at such high risk for stage IV (depth & mitotic rate, location on body).

The SNB is pretty minor compared to the dissection and will give you her staging at this time.  With micromets upstaging her to stage III and thus more options, please realize that a PET/CT won't be able to pick that up becuase the tumor burden is too low to detect, but none the less is still there.

Janner has great insight on the thought processes used to guide her father's treatment plan.  It is a very individual road, but age alone is not a good reason to not do something.  70's today can be someone who is very debilitated or very spry and energetic.  It all depends on where LO falls in that spectrum.  Once you make a decision, never ever look back.  Always look forward and assess quality of life, risk versus reward.

A final note, since LO's mel was on the back, there is no telling what nodal basin will need monitoring.  Another good reason to do the SNB, or at least the injection to trace to what basin(s) to monitor.

Best of luck.

Been there, done that, got the scars to prove it – LOL!

Aloha, sorry you have to deal with this.

As far as age is concerned, age alone is not a factor but rather how healthy they are and able to tolerate surgery.  Some 70 y/o's are more like 60 and others like 90.  We all age differently and much depends on other medical issues.

That being said, if the SNB is positive she will be upstaged to stage III.  That will qualifiy her for more treatments depending on if stage IIIA-C.

Interferon has little benefit and is toxic.  I personally wouldn't do it and would opt for a clinical trial instead, thus the need to see if LO is truely a stage III or high stage II.  With mel that deep, if she isn't a stage III or IV I would be shocked.  Thus the need to figure out what treatments other than interferon can she tolerate if she chooses.

If not doing a SNB, then the PET/CT is a great option but not sure if insurance will cover it since she isn't fully staged yet.  Right now she is only a stage II and no insurance that I know of will approve those scans.  Another option to evaluate the nodes is to do an ultrasound with needle biopsy if anything is fishy.  She should be followed up at short intervals becasue she is at such high risk for stage IV (depth & mitotic rate, location on body).

The SNB is pretty minor compared to the dissection and will give you her staging at this time.  With micromets upstaging her to stage III and thus more options, please realize that a PET/CT won't be able to pick that up becuase the tumor burden is too low to detect, but none the less is still there.

Janner has great insight on the thought processes used to guide her father's treatment plan.  It is a very individual road, but age alone is not a good reason to not do something.  70's today can be someone who is very debilitated or very spry and energetic.  It all depends on where LO falls in that spectrum.  Once you make a decision, never ever look back.  Always look forward and assess quality of life, risk versus reward.

A final note, since LO's mel was on the back, there is no telling what nodal basin will need monitoring.  Another good reason to do the SNB, or at least the injection to trace to what basin(s) to monitor.

Best of luck.

Been there, done that, got the scars to prove it – LOL!

Aloha, sorry you have to deal with this.

As far as age is concerned, age alone is not a factor but rather how healthy they are and able to tolerate surgery.  Some 70 y/o's are more like 60 and others like 90.  We all age differently and much depends on other medical issues.

That being said, if the SNB is positive she will be upstaged to stage III.  That will qualifiy her for more treatments depending on if stage IIIA-C.

Interferon has little benefit and is toxic.  I personally wouldn't do it and would opt for a clinical trial instead, thus the need to see if LO is truely a stage III or high stage II.  With mel that deep, if she isn't a stage III or IV I would be shocked.  Thus the need to figure out what treatments other than interferon can she tolerate if she chooses.

If not doing a SNB, then the PET/CT is a great option but not sure if insurance will cover it since she isn't fully staged yet.  Right now she is only a stage II and no insurance that I know of will approve those scans.  Another option to evaluate the nodes is to do an ultrasound with needle biopsy if anything is fishy.  She should be followed up at short intervals becasue she is at such high risk for stage IV (depth & mitotic rate, location on body).

The SNB is pretty minor compared to the dissection and will give you her staging at this time.  With micromets upstaging her to stage III and thus more options, please realize that a PET/CT won't be able to pick that up becuase the tumor burden is too low to detect, but none the less is still there.

Janner has great insight on the thought processes used to guide her father's treatment plan.  It is a very individual road, but age alone is not a good reason to not do something.  70's today can be someone who is very debilitated or very spry and energetic.  It all depends on where LO falls in that spectrum.  Once you make a decision, never ever look back.  Always look forward and assess quality of life, risk versus reward.

A final note, since LO's mel was on the back, there is no telling what nodal basin will need monitoring.  Another good reason to do the SNB, or at least the injection to trace to what basin(s) to monitor.

Best of luck.

Been there, done that, got the scars to prove it – LOL!

Hi

What your onc is saying tallies with what I have read about the view on SLNB here in Australia, see:

http://www.racgp.org.au/afp/2014/july/sentinel-lymph-node-biopsy/

The summary on the 2014 paper above is this:

• SLNB does not alter survival prospects
• SLNB provides added accuracy to survival prognostic figures
  • 70% vs 90% for melanoma Breslow thickness of 1.2–3.5 mm
• SLNB has a 10% complication rate
• If positive, no added treatment can be offered that has demonstrated survival benefits
  • this includes no apparent survival benefit in proceeding to CL
  • SLNB-positive patients can be offered enrolment into further melanoma studies.

Are you under the care of a melanoma specialist? I think a 2nd opinion froma melanoma specialist who is familiar with what trials might be around would be really worthwhile.

Hi

What your onc is saying tallies with what I have read about the view on SLNB here in Australia, see:

http://www.racgp.org.au/afp/2014/july/sentinel-lymph-node-biopsy/

The summary on the 2014 paper above is this:

• SLNB does not alter survival prospects
• SLNB provides added accuracy to survival prognostic figures
  • 70% vs 90% for melanoma Breslow thickness of 1.2–3.5 mm
• SLNB has a 10% complication rate
• If positive, no added treatment can be offered that has demonstrated survival benefits
  • this includes no apparent survival benefit in proceeding to CL
  • SLNB-positive patients can be offered enrolment into further melanoma studies.

Are you under the care of a melanoma specialist? I think a 2nd opinion froma melanoma specialist who is familiar with what trials might be around would be really worthwhile.

Hi

What your onc is saying tallies with what I have read about the view on SLNB here in Australia, see:

http://www.racgp.org.au/afp/2014/july/sentinel-lymph-node-biopsy/

The summary on the 2014 paper above is this:

• SLNB does not alter survival prospects
• SLNB provides added accuracy to survival prognostic figures
  • 70% vs 90% for melanoma Breslow thickness of 1.2–3.5 mm
• SLNB has a 10% complication rate
• If positive, no added treatment can be offered that has demonstrated survival benefits
  • this includes no apparent survival benefit in proceeding to CL
  • SLNB-positive patients can be offered enrolment into further melanoma studies.

Are you under the care of a melanoma specialist? I think a 2nd opinion froma melanoma specialist who is familiar with what trials might be around would be really worthwhile.

I admit to not being familiar with the primary literature on SLNB, regarding whether removal of malignant SNLs improves the patient's outlook.  However, it would seem strange to me that this is merely a diagnostic measure.  Had ET's SNL been positive, the surgeon would have resected adjacent lymph nodes and in fact done a complete lymph node discetion, even with the possible/probable complication of lymphadema.  Why would she do that, if the procedure would have no value?  After all, one positive lymph node would give her the needed data to stage ET at stage III — if that were the only worth.  So this idea that there's no treatment value to a SLNB makes no sense to me.

ET had only the SNL removed and sent to path.  It came back negative, and I feel she was lucky.  Her tumor was 9mm deep, 6/mm^2 mitotic rate, Clark V, microscopic satellitosis, lymphatic invasion, perineural invasion.  So it's not a foregone conclusion that a large tumor would have already reached the SLN.

I think the risk to LO (at her age) would be the anesthesia.  However, the newer gaseous anesthetics do not compromise the patient's well being as much as the older i.v. anesthetics.  But yes, there is risk.

Personally, I'd do a PET/CT first.  If it reveals a metastatic disease, then there's no point in doing the SNLB.  If it's clean, then I'd do the SLNB.  Cut the disease out, and you might get lucky.

From what I've read and heard, interferon doesn't make much sense, especially if you're not young and fighting with all your might for 50 more years of life.

I agree with others: Get a second opinion.  Or simply state what you want to do, and it sounds like your surgeon will do it.  We've stood our ground and advocated strongly for ET, and her physicians have been very helpful getting her where she needs to be.  She would be in a very different place if we had unquestioningly followed all the advice/recommendations handed her.

I'll add (and I hope I'm not off base) that some treatment directions are based on cost to the insurance company.  Physicians are caught in the middle and don't like being there.  They want to treat patients and give them all the opportunities they are able.  But they contract with insurance companies to be within their provider networks, and there is sometimes a LOT of pressure on doctors to avoid prescribing treatments that are deemed (the by the insurance company) "unnecessarily" costly.  I've known a number of doctors and nurses in hospital settings, and they do complain about this state of affairs.

I admit to not being familiar with the primary literature on SLNB, regarding whether removal of malignant SNLs improves the patient's outlook.  However, it would seem strange to me that this is merely a diagnostic measure.  Had ET's SNL been positive, the surgeon would have resected adjacent lymph nodes and in fact done a complete lymph node discetion, even with the possible/probable complication of lymphadema.  Why would she do that, if the procedure would have no value?  After all, one positive lymph node would give her the needed data to stage ET at stage III — if that were the only worth.  So this idea that there's no treatment value to a SLNB makes no sense to me.

ET had only the SNL removed and sent to path.  It came back negative, and I feel she was lucky.  Her tumor was 9mm deep, 6/mm^2 mitotic rate, Clark V, microscopic satellitosis, lymphatic invasion, perineural invasion.  So it's not a foregone conclusion that a large tumor would have already reached the SLN.

I think the risk to LO (at her age) would be the anesthesia.  However, the newer gaseous anesthetics do not compromise the patient's well being as much as the older i.v. anesthetics.  But yes, there is risk.

Personally, I'd do a PET/CT first.  If it reveals a metastatic disease, then there's no point in doing the SNLB.  If it's clean, then I'd do the SLNB.  Cut the disease out, and you might get lucky.

From what I've read and heard, interferon doesn't make much sense, especially if you're not young and fighting with all your might for 50 more years of life.

I agree with others: Get a second opinion.  Or simply state what you want to do, and it sounds like your surgeon will do it.  We've stood our ground and advocated strongly for ET, and her physicians have been very helpful getting her where she needs to be.  She would be in a very different place if we had unquestioningly followed all the advice/recommendations handed her.

I'll add (and I hope I'm not off base) that some treatment directions are based on cost to the insurance company.  Physicians are caught in the middle and don't like being there.  They want to treat patients and give them all the opportunities they are able.  But they contract with insurance companies to be within their provider networks, and there is sometimes a LOT of pressure on doctors to avoid prescribing treatments that are deemed (the by the insurance company) "unnecessarily" costly.  I've known a number of doctors and nurses in hospital settings, and they do complain about this state of affairs.

I admit to not being familiar with the primary literature on SLNB, regarding whether removal of malignant SNLs improves the patient's outlook.  However, it would seem strange to me that this is merely a diagnostic measure.  Had ET's SNL been positive, the surgeon would have resected adjacent lymph nodes and in fact done a complete lymph node discetion, even with the possible/probable complication of lymphadema.  Why would she do that, if the procedure would have no value?  After all, one positive lymph node would give her the needed data to stage ET at stage III — if that were the only worth.  So this idea that there's no treatment value to a SLNB makes no sense to me.

ET had only the SNL removed and sent to path.  It came back negative, and I feel she was lucky.  Her tumor was 9mm deep, 6/mm^2 mitotic rate, Clark V, microscopic satellitosis, lymphatic invasion, perineural invasion.  So it's not a foregone conclusion that a large tumor would have already reached the SLN.

I think the risk to LO (at her age) would be the anesthesia.  However, the newer gaseous anesthetics do not compromise the patient's well being as much as the older i.v. anesthetics.  But yes, there is risk.

Personally, I'd do a PET/CT first.  If it reveals a metastatic disease, then there's no point in doing the SNLB.  If it's clean, then I'd do the SLNB.  Cut the disease out, and you might get lucky.

From what I've read and heard, interferon doesn't make much sense, especially if you're not young and fighting with all your might for 50 more years of life.

I agree with others: Get a second opinion.  Or simply state what you want to do, and it sounds like your surgeon will do it.  We've stood our ground and advocated strongly for ET, and her physicians have been very helpful getting her where she needs to be.  She would be in a very different place if we had unquestioningly followed all the advice/recommendations handed her.

I'll add (and I hope I'm not off base) that some treatment directions are based on cost to the insurance company.  Physicians are caught in the middle and don't like being there.  They want to treat patients and give them all the opportunities they are able.  But they contract with insurance companies to be within their provider networks, and there is sometimes a LOT of pressure on doctors to avoid prescribing treatments that are deemed (the by the insurance company) "unnecessarily" costly.  I've known a number of doctors and nurses in hospital settings, and they do complain about this state of affairs.

I had a SNB for mine and it tested positive so I had the CLND and I developed lymphadema. Let me tell you, it does change your life. Of course mine is on my leg so maybe an arm wouldn't be as bad. That is just something to consider and at that age I guess I don't know if they would even want to do that.It's a pretty big surgery. I got an infection in mine and that required another dreadful hospital experience. Just some things to think about. I'm young, only 33. So I would do it all over again but also younger and more able to handle things. I think the Dr. is right about Interferon, personally I wouldn't go with that. The CLND in my case was a big surgery so it's alot to think about. General health should play a roll in your decision as well.

I had a SNB for mine and it tested positive so I had the CLND and I developed lymphadema. Let me tell you, it does change your life. Of course mine is on my leg so maybe an arm wouldn't be as bad. That is just something to consider and at that age I guess I don't know if they would even want to do that.It's a pretty big surgery. I got an infection in mine and that required another dreadful hospital experience. Just some things to think about. I'm young, only 33. So I would do it all over again but also younger and more able to handle things. I think the Dr. is right about Interferon, personally I wouldn't go with that. The CLND in my case was a big surgery so it's alot to think about. General health should play a roll in your decision as well.

I had a SNB for mine and it tested positive so I had the CLND and I developed lymphadema. Let me tell you, it does change your life. Of course mine is on my leg so maybe an arm wouldn't be as bad. That is just something to consider and at that age I guess I don't know if they would even want to do that.It's a pretty big surgery. I got an infection in mine and that required another dreadful hospital experience. Just some things to think about. I'm young, only 33. So I would do it all over again but also younger and more able to handle things. I think the Dr. is right about Interferon, personally I wouldn't go with that. The CLND in my case was a big surgery so it's alot to think about. General health should play a roll in your decision as well.