Surgery is one of the most effective methods of treating skin cancer. This involves cutting the skin cancer out, known as surgical excision. The wound can then be sutured closed. If the wound is large or in an area where there is lack of tissue, then reconstruction may be required. This may be in the form of skin grafts or flaps. The specimen that is removed is sent for histological assessment to ensure it is completely removed.

What is a skin graft ?

A skin graft is a piece of skin that is transferred from one area of the body to another. They can be full thickness or split thickness depending on the dermal content of the skin graft. Once the skin graft has been applied to the wound, it is secured in place with stitches and a dressing and is allowed to heal. Generally this takes approximately a week. The area where the graft is harvested from is either stitched closed in the case of a full thickness skin graft, or dressed to allow to heal in the case of a split thickness skin graft.

The applied skin graft needs to gain a blood supply from the wound bed in order to survive. Occasionally the graft can either partially or fully fail. A wound infection may also occur which makes graft failure more likely. Bleeding beneath the graft may lead to the development of a haematoma, a collection of clotted blood, which can also contribute to graft failure. If the graft fails, then dressings will need to be applied to the wound to allow it to heal by itself.

What is a flap ?

A flap has its own blood supply unlike a skin graft. Flaps are useful in reconstructing defects with poor vascularity, exposed vital structures and where skin grafts are inappropriate or would lead to a poor cosmetic outcome. Flaps are also useful in reconstructing defects where post-operative radiotherapy is planned as they are less susceptible to the ill effects of radiotherapy compared to skin grafts. Flaps can be either local, regional, distant or free. A local flap is composed of tissue adjacent to the defect. A regional flap is from the same anatomical region as the defect eg. forehead flap for nasal reconstruction. A distant flap is from a different part of the body, away from the region of the defect eg. pectoralis major flap in head and neck reconstruction. A free flap is completely detached from the body and connected to vessels close to the defect to re-establish its blood supply and allow it to survive.

Sentinel lymph node biopsy (SLNB) is a staging investigation for malignant melanoma. Malignant melanoma can spread through the lymphatic vessels to the surrounding lymph nodes, either in the head & neck, axilla or groin. Involvement of the lymph node can be identified through clinical examination if it is large enough however microscopic involvement can only be identified through SLNB. If your SLNB test is positive, then you will be referred to an oncologist for consideration for further treatment.

What does SLNB involve ?

SLNB involves three steps :

1. A lymphoscintigram
2. Intraoperative lymphatic mapping with blue dye
3. Sentinel lymph node biopsy

Lymphoscintigram

A lymphoscintigram is a type of nuclear medicine scan that helps to accurately identify the location of the lymph node that drains the area around the primary melanoma. It involves an injection of a radioactive tracer around the primary melanoma site. The scan is then performed to detect the lymph node where the radioactive tracer has collected. Although the tracer is radioactive, it does not pose a significant risk to you because the dose that is used is very small and the radioactive material has a very short half life, meaning it does not remain radioactive for long. The scan itself is painless however the injection may sting. You may also develop some redness around the injection site for a few hours after.

Intraoperative lymphatic mapping with blue dye

This involves the injection of a blue dye, Patent Blue V, into the skin around the primary melanoma site. It is done in theatre just before the operation and after you have been anaesthetised. The blue dye travels to the draining lymph node and helps with accurate identification of the sentinel lymph node.

Sentinel lymph node biopsy

A small incision is made to access the lymph node basin and the sentinel lymph node is identified with the help of the previous lymphoscintigram and blue dye mapping. The sentinel lymph node is removed and sent for pathological examination. If it is positive, then you will be offered complete clearance of all the lymph nodes in the region.

Further information can be downloaded here in this Sentinel Lymph Node Biopsy guide

What is a lymph node dissection ?

A lymph node dissection is a surgical procedure to remove all the lymph nodes within a particular basin, usually for the treatment of cancer. An axillary or inguinal block dissection involves the clearance of all the lymph nodes in the axilla/armpit or the groin respectively. It is done when there is a proven positive lymph node for cancer found in the lymph node basin.

The procedure itself is performed under a general anaesthesia and takes approximately 2 hours. You will usually need to stay in hospital for a number of days. At the end of the procedure, a drain will be inserted to drain any excess fluid. This is removed once drainage has subsided, but this can take a period of up to 3 weeks. In the meantime, if you are well, you can be discharged with the drain and instructions on how to look after it. There are of course risks and complications associated with the procedure but your surgeon will go through these with you during the consultation.

What are the side effects and complications of a block dissection ?

In specialist skin cancer centres, this is a routine operation and the vast majority of patients have a good result. However as with any procedure it is important to understand the potential side effects and complications associated with the general anaesthetic and the procedure itself. There is a risk of developing blood clots in your legs or lungs, associated with the surgery and stay in hospital. To reduce this risk, you will be given blood thinning injections and compression stockings to wear whilst in hospital.

In terms of the surgery itself, you will have a scar which can rarely become lumpy and stretched. There is a risk of developing wound infections and wound breakdowns. If you develop a wound infection, you will be given antibiotics. The risk of wound breakdown is higher in groin dissections, and if this occurs, then you will require dressings to help the wound heal by itself. This will be supported by our specialist team of plastic surgery nurses. In addition, there are important nerves in both areas that can be damaged or stretched. In the majority of cases, the nerves are only stretched which result in temporary sensory change or muscle weakness however it may be permanent if the nerve is damaged during surgery. There is also a risk of developing seromas in the area of surgery. A seroma is a collection of straw coloured lymph fluid that occurs due to the disruption of the lymphatic flow following surgery. Lymphoedema can also occur in the limb that has been operated on. This is a condition whereby the operated limb becomes swollen due to lymph fluid collecting within it. If this occurs, you will be referred to a lymphoedema clinic where you will be given compression stockings to wear and techniques to reduce the swelling.

What follow up will I require ?

Following your discharge, the wound is examined after a week to ensure that all is healing well. If you have been discharged with a drain, this will also be reviewed and removed when the drainage reduces to an acceptable amount. The pathology result of the block dissection usually takes 2-3 weeks and will be discussed with you in detail at your follow up appointment. This is usually at 6 weeks following the surgery. You will then require routine follow up dependent on your type of cancer.

Further information can be found here in this Block Dissection guide

What is isolated limb infusion ?

Isolated limb infusion is an operation performed under general anaesthesia for treating melanoma and some other cancers that are isolated to an individual limb and where surgery or other treatment methods are not possible. It involves isolation of the circulation within the involved limb with the use of a tourniquet. This allows the use of high concentrations of chemotherapy agents as the drugs are confined within the treated limb.

The operation itself takes approximately 3 hours. Prior to the operation, you will undergo investigations which include blood tests, a CT scan to look for spread of the cancer, and a pre-anaesthetic assessment. In addition, there will be some other specific tests that will be performed to measure the volume of the treated limb to ensure that the right amount of chemotherapy agents are used.

On the day of surgery, tubes will be inserted into the blood vessels in the limb to be treated. These same tubes are used to circulate the blood and to deliver the chemotherapeutic agents once the limb has been isolated with the tourniquet. Following the surgery, you will be under strict bed rest and the treated limb will be monitored for side effects or complications. You will normally be in hospital for 7-10 days.

What are the side effects and complications of ILI ?

The side effects and complications that are commonly encountered include the limb becoming swollen, warm and red. There may also be some peeling of the skin and nails and hairs on the limb may stop growing for a few weeks. Occasionally some patients complain of altered sensation or pins and needles in the limb which improves after a few weeks. Rarely the swelling and inflammation that occurs to the limb is so severe that it may affect the blood supply to the limb. If this occurs, the pressure needs to be relieved with an operation called a fasciotomy. Despite this, the damage can be so severe that it may lead to an amputation of the limb. Another serious side effect is clotting of the veins and arteries within the limb. This may also lead to an amputation. To reduce this risk, you will be given compression stockings to wear and blood thinning injections whilst you are in hospital.

What improvement should I expect to see with ILI ?

It may take a few weeks for the results of the treatment to be obvious. Approximately 70-80% of patients will gain a benefit from ILI. 40% of patients will experience complete resolution of the tumours in their limb. A further 40% of patients will have a partial response with shrinking of the tumours (partial response). 20% of patients will not exhibit a response to the treatment. It is impossible to know which group you will fall into prior to having the treatment.

What follow up will I require ?

Initially you will be reviewed weekly for the first 2 weeks in the dressings clinic to ensure that the limb is healing well. Following this, your dressings can be done either at home by the district nurses or at your local GP practice. We will then aim to review you at 6 weeks and again at 12 weeks if all is going well. If you have been referred from out of region, we will try to minimise your visits by sharing your care with your local hospital doctors.