Dr. Rapaport’s Experience with Melanoma Surgery
Dr. Rapaport is a recognized expert in the treatment of malignant melanoma. During his years at The H. Lee Moffitt Cancer Center and Research Institute in Florida, Dr. Rapaport was an active member of Moffitt’s Cutaneous Oncology Program and treated hundreds of melanoma patients. He and his colleagues pioneered the use of new techniques for assessing the spread of melanoma; these techniques have since become the standard of care at centers specializing in melanoma nationwide and worldwide.
In addition to his renown cosmetic surgery practice, Dr. Rapaport continues to specialize in the treatment of melanoma, receiving referrals from local and regional dermatologists, plastic surgeons, and by word of mouth from patients and their families. Dr. Rapaport continues to publish and lecture on the field, and has taught the course on malignant melanoma at the annual meeting of the American Society of Plastic and Reconstructive Surgeons for the past several years.
The following is a brief summary of some of the advances available in the management of melanoma. This is provided as educational material only and is not to be taken as medical advice. Individual patient circumstances will vary, and specific treatment recommendations can be made only on the basis of an individualized personal doctor-patient consultation.
Sentinel Node Biopsy and the Accurate Staging of Melanoma
When a patient is diagnosed with malignant melanoma, the two most important pieces of information to have are the thickness of the tumor (measured in millimeters or fractions of millimeters) and whether the melanoma has spread to the regional lymph nodes or beyond. In most cases, the regional lymph nodes are the first place to which the melanoma would spread, and knowing their status is crucial in determining the patient’s prognosis (long-term outlook for survival) and whether additional treatment will be required.
The lymph nodes are essentially biologic filters which are located primarily in the groins, underarms, and head and neck areas. Cells and other materials from surrounding areas flow through the lymph nodes, which can thereby pick up things like bacteria and trigger an immune response. Cancer cells can also flow into lymph nodes and basically stick or settle there, creating the first site of metastatic or distant spread for a cancerous tumor such as melanoma.
Melanomas greater in thickness than 0.75 millimeter (3/4 of a millimeter) have a real risk of having spread to regional nodes or beyond. The risk also exists in thinner tumors, but is much lower. In general, the thicker the melanoma, the greater the risk of spread. For example, tumors 3-4 millimeters in thickness have about a 25-30% risk of having spread to regional nodes.
Knowing whether a melanoma has spread to regional nodes is important for two main reasons. First, it gives us important prognostic information. A patient with a 2 millimeter thick melanoma with no lymph node spread may have about a 20% chance of suffering from widespread melanoma in the next five years, while in the same patient with lymph node spread the chance rises to about 60%. Even more importantly, knowing the status of the lymph nodes is important because there are now treatments available which can improve one’s chances of disease free survival and cure if the nodes are found to contain metastatic melanoma. Research conducted in the recent years has demonstrated for the first time that drug therapy can lead to significant improvement both in disease free survival and cure rates in patients with melanoma which has spread to regional nodes. The drug used, called Interferon alpha, stimulates the immune system to more effectively fight whatever cancer cells may still be remaining in the patient’s body. The therapy is continued over a one year period. The main side effects associated with Interferon therapy are flu-like symptoms, which in some patients can be severe. Nonetheless, this form of therapy has been shown to improve disease free survival and cure rates by as much as 40%.
As the above review demonstrates, it is now especially important to determine whether or not melanoma has spread to a patient’s lymph nodes. Up until just a few years ago the only way to make such a determination was to remove all of the lymph nodes in the region in question and send them to the pathologist for microscopic review. For example, a patient with a melanoma of the arm or upper back might have all the lymph nodes removed from an underarm area (the regional lymph node basin felt to drain the skin affected by melanoma). There were several problems with this approach. The operation itself was a major one, and was in retrospect unnecessary for the majority of patients in whom the melanoma had not yet spread. Additionally, the pathologist had to study multiple lymph nodes, at times as many as thirty or more, in an attempt to find potentially one microscopic site of melanoma cells in one node. The chances were therefore higher to miss the diagnosis in such a case. Finally, there are many circumstances where it is simply not possible to guess to which lymph node basin a melanoma might have spread first, and in such cases though much surgery may be done there is the real risk that it is being performed on the wrong lymph node basin entirely.
This is where the concept of sentinel node surgery comes in. The sentinel node is defined as the first node (or nodes) to drain a given melanoma site. The relatively recent discovery is that with a special type of scan (called lymphoscintigraphy) it is possible to determine not just to which lymph node basin but also to which specific lymph node a melanoma would spread if it has spread at all. The scan involves injecting a minute amount of radioactive material (a dose far lower than a simple chest x-ray) into the skin immediately surrounding the melanoma site. Images are then taken to determine to where that skin drains, and the precise lymph node(s) to which the skin drains is determined. At the time of surgery a special blue dye is injected as well as the radioactive material, and using the surgeon’s ability to see the dye as well as a specially designed radioactivity detector, the sentinel node is found and removed. The patient therefore undergoes a relatively small outpatient procedure, and the pathologist receives generally one or two lymph nodes upon which highly sensitive and specialized studies can be carried out. The result is a highly accurate method of determining whether lymph node spread of tumor has occurred, all with far less risk, less pain and less surgery to the patient. In cases where pathologic review reveals there to be lymph node involvement with tumor, then further surgery can be performed as needed, and the patient can then be subsequently referred for appropriate Interferon, vaccine, or other therapy.
The technique of sentinel node surgery (also called sentinel lymphadenectomy) has become standard of care at the nation’s most experienced centers caring for melanoma patients. Indeed, recently it has also been used on patients with breast cancer, to help both limit and improve the accuracy of their lymph node surgery, with very promising results.
Sentinel node evaluation techniques are highly specialized, requiring extensive experience on the part of the surgeon, special equipment, and a dedicated team of nuclear medicine and pathology specialists. Dr. Rapaport has performed hundreds of such procedures, including a large number of sentinel node procedures in the head and neck area, universally considered the most difficult area of the body for this procedure.
While Dr. Rapaport does not participate in HMO’s, he will often accept “assignment” as an out of network doctor. Dr. Rapaport is a medicare provider.
Malignant melanoma is by far the most dangerous form of skin cancer. Early diagnosis and appropriate treatment are the keys to reducing the risk of melanoma once it does occur. Fortunately, recent advances have greatly improved our ability to accurately determine the degree of spread of melanoma, and thereby to better determine who may benefit from therapy with a drug called Interferon, which may lead to increased survival or even cure rates.