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Retired doctor Martin Trotsky was combing his hair one day last fall when his comb bumped up against a painful red pimple on his scalp.
Rather than ignore it, he kept an eye on it for the next two weeks. When it didn't go away, he went to see his doctor. The "pimple" turned out to be melanoma -- the most dangerous form of skin cancer -- and Trotsky turned immediately to the melanoma specialists at the University of Michigan Comprehensive Cancer Center.
That swift action may have saved his life. Almost immediately, the U-M team did an "early warning" procedure that told Trotsky his cancer had just started to spread. And based on that warning, the team found and removed the tiny glands called lymph nodes in his neck that the cancer was using as a highway to the rest of his body.
Because his cancer was found early, treated early, and perhaps kept from spreading, Trotsky's outlook is far better than it would have been if the cancer been caught later.
Although he and his doctors will have to be vigilant for the rest of his life, in case the cancer returns, he was spared a far worse fate: surgery that could have destroyed muscles in his shoulder and face, and a much higher risk of death from his cancer.
The "early warning" procedure that has helped Trotsky and many melanoma patients nationwide is called sentinel lymph node (SLN) mapping. It has been used for years in patients whose melanoma lesions are below their neck. But many doctors have considered it too tricky to do on the 20 percent of melanoma patients whose cancer is on the much more delicate and intricate areas of the head and neck.
The U-M melanoma team, one of the most experienced in the country, disagrees. They've been doing SLN mapping on the faces, throats, scalps, ears and necks of melanoma patients for several years -- and recently published results of a study showing they are able to do it with 95 percent accuracy, and without damaging tiny nerves and muscles in the area. They found early signs of spreading cancer in about 18 percent of patients who had the procedure -- giving them a jump on treatment.
"The point of sentinel lymph node mapping is to catch the melanoma at the lymph node stage, where you can only see it under the microscope," explains Carol Bradford, M.D., the U-M surgeon who performed Trotsky's operations. "This allows us to treat it very aggressively and very effectively, and offer patients, even with cancer that has spread to the lymph nodes, a good chance of beating their disease."
Bradford, an associate professor of otolaryngology at the U-M Medical School and chief of head and neck surgery, led the team that published the study in the Archives of Otolaryngology. She explains that SLN mapping is a way to quickly assess the threat of melanoma -- showing whether cancer cells have entered nearby lymph nodes and might spread further.
SLN mapping focuses on the lymphatic system, an interlaced network of vessels, ducts, nodes and glands that usually carries helpful, disease-fighting components throughout the body.
The lymphatic system can also act as a kind of highway for melanoma cells, giving them a direct route from the skin cancer to the bloodstream, which can carry them to other sites where they can form new tumors. The rest stops on this highway are tiny bean-shaped structures called lymph nodes, which gather and filter the lymph fluid that carries foreign objects like bacteria, viruses and cancer cells. Lymph nodes and ducts in the head drain to ones lower down.
Before SLN mapping came along, surgeons removed entire sections of the lymphatic system of many melanoma patients, just in case the cancer had spread. But only about 10 percent to 20 percent of patients actually turned out to have cancer cells in their lymph nodes -- meaning that many had undergone the invasive and potentially dangerous surgery for no real reason.
SLN mapping aims to spare most patients the agony of major surgery by identifying those patients who need the most aggressive treatment: those whose cancer was already in their lymph nodes. "Once the lymph nodes are involved, there is a risk that this deadly disease will spread throughout your system," Bradford explains. But even if it has, it's best to treat it early.
The SLN mapping procedure involves an injection of a radioactive tracer and blue dye near the melanoma site, and the use of radiation detectors and minimally invasive surgical techniques. "Those blue and radioactive particles spread to the lymph nodes nearby, so that the surgeon knows which ones to biopsy," says Bradford. "We can often do this with an incision of one inch or smaller, to just specifically biopsy the lymph node at risk." The patient can go home that day.
Then, a specially trained pathologist examines the removed nodes, looking for melanoma cells. Because such nodes are the first stop for traveling cancer cells, they're called "sentinel" nodes, like sentinel soldiers at military bases who are the first to spot intruders.
For many of the tens of thousands of melanoma patients diagnosed each year in the United States, SLN mapping guides their treatment starting soon after the cancer is found. U-M's Multidisciplinary Melanoma Program team performs it on many of the 1,300 newly diagnosed melanoma patients that come to the U-M Comprehensive Cancer Center each year.
But at many centers, SLN mapping often hasn't been offered to patients whose cancer is on their head or neck, because it requires a surgical team experienced at operating on the ultra-small structures under the face and scalp. One false move with a scalpel could paralyze parts of the face or shoulders. Instead, such patients have had to wait for visible signs that their cancer has grown or spread. And that can greatly reduce their chances of living, Bradford explains.
Studies have shown that patients whose cancer cells have entered their lymph nodes have a much worse potential for survival. The average five-year survival rate for melanoma patients is about 89 percent. But once the cancer spreads to the lymph nodes, the survival rate drops to a range of 13 percent to 70 percent, depending on how many lymph nodes have melanoma cells.
Now that the U-M team has shown SLN mapping can be used safely and effectively on the head and neck, the outlook for such patients is much brighter.
"If melanoma of the head and neck is diagnosed early, before it spreads to the lymph nodes, it's very curable," Bradford says. "However, if it gets to be advanced, large and particularly deep, and it spreads to the lymph nodes, the chances of beating it drop significantly."
Even if SLN mapping shows cancer cells in the lymph nodes, the patient may have surgery to remove more at-risk nodes, and treatment with a drug called interferon to stop cancer growth. "For those patients, it's a huge advantage because we diagnosed the disease very early, and they can get all the extra treatment they need," Bradford explains.
Bradford's patient Martin Trotsky can vouch for that. "Of the eight nodes that they dissected, two were positive for cancer," he recalls. "The sentinel node mapping definitely showed some spread, which I would not have known that I had otherwise, allowing them to do the surgery and the treatment that was necessary and would give me the best benefit."
"Had I not had this done, I guarantee you that within six months or so, I would've had enlarged nodes in my neck," he continues. "And then the prognosis would've been not nearly as good."
For more information on melanoma treatment at the U-M Comprehensive Cancer Center, which is part of the U-M Health System, call the Cancer AnswerLine at 800-865-1125 or visit http://www.cancer.med.umich.edu/clinic/melclinic.htm.
Facts on melanoma and sentinel lymph node mapping:-Melanoma is a form of skin cancer that begins in the cells called melanocytes that produce the skin's coloring. -Melanoma is the most dangerous form of skin cancer. It accounts for about 4 percent of skin cancer cases, but it causes about 79 percent of skin cancer deaths.-The American Cancer Society estimates that 54,200 Americans will be diagnosed with melanoma in 2003. -About 7,600 people will die of melanoma this year.-The earlier a melanoma is found and treated, the better a patient's chances will be. -Melanoma often starts when a normal mole on the skin becomes cancerous. The "ABCD rule" can help distinguish a normal mole from a melanoma:
Asymmetry: One half of the mole does not match the other half.
Border Irregularity: The edges of the mole are ragged or notched.
Color: The color over the mole is not the same. There may be differing shades of tan, brown, or black, and sometimes patches of red, blue, or white.
Diameter: The mole is wider than 6 millimeters (about a quarter inch). -Sentinel lymph node mapping can be used to determine whether a newly diagnosed melanoma has begun to spread to the lymph nodes. This can help guide treatment.
For more information on melanoma diagnosis and treatment on the World Wide Web:
U-M Comprehensive Cancer Center Melanoma Clinichttp://www.cancer.med.umich.edu/clinic/melclinic.htm
Melanoma Home Page: National Cancer Institutehttp://www.cancer.gov/cancerinfo/types/melanoma
What You Need to Know about Melanoma: National Cancer Institutehttp://www.cancer.gov/cancerinfo/wyntk/melanoma
Melanoma Localization: Skin Cancer Foundation http://www.skincancer.org/melanoma/localization.php
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