<-- This is my dad, and last year he had to undergo a second operation to try to eradicate his skin cancer. Of the literally hundreds of types of cancer, melanoma is one of the most common cancers in young adults (<30 years old), and the rates of melanoma diagnoses have only been increasing over the past several decades [1]. I am writing this post with my dad's full permission to spread some awareness. |
We want to tell you about his experience with melanoma, a form of skin cancer that occurs when the pigment-producing cells present in your skin, eyes, or elsewhere mutate and become cancerous. To keep the length of text a bit shorter, I’m going to break this up into two posts: Biopsies and Surgeries and Post-Op. We hope that by sharing the details of his journey, from the medical jargon to the types of tests to the changes in lifestyle, we will be a resource for those who need reassurance or a connection with someone who's been down this long and lonely road. Please feel free to message us directly if you'd like to share your experiences with us, we'd be happy to hear about them :)
Nearly everyone in my family is already at an increased risk for skin cancers, melanoma included [2]. Most of us have light skin with lots of freckles/moles of all shapes and colors, and we can often be found outdoors in the sunlight. My dad is no exception to these risk factors, and his hobbies (hunting, motorcycles and cars, playing with the dogs, building things around the house) have had him outdoors sweating off any SPF he might’ve put on for basically his entire life. | |
Dad also used tanning beds a few times over the years – the Skin Cancer Foundation says that more people develop skin cancer because of indoor tanning than develop lung cancer because of smoking [3].
My dad’s original melanoma was discovered when one of the freckles on his right upper post arm became a lot darker, raised up from the skin, and itchy. After a biopsy in September 2011, around his 38th birthday, he received the diagnosis in bold below. With each diagnosis I’ll be providing an orange-text “translation” from the medical terms into simpler ones. Please keep in mind that I am not a medical doctor, but I have research training and will provide evidence-backed sources [#] for everything - all sources are also linked at the end of the post.
Melanoma, Breslow thickness at least 0.5 mm
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Breslow thickness measures in millimeters the distance between the upper layer of the epidermis and the deepest point of tumor penetration...[and] is considered one of the most significant factors in predicting disease progression [4].
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Atypical melanocytes extend to the base and to a peripheral margin of the biopsy
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Melanocytes are the melanin-producing cells in your body, and can be found in various tissues, including your skin and eyes [5]. Having atypical melanocytes means that your cells do not look normal, and this report is saying that the unusual cells cover most of the biopsied tissue.
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No ulceration identified
Ulceration is when the skin over the melanoma site starts to break down [6]. This diagnosis is why my dad’s nearby lymph nodes weren’t initially tested via biopsy. |
As of January 1, 2018, invasive tumors continue to be considered early and thin (stage I) if nonulcerated and less than 1 millimeter (mm) in Breslow depth. However, tumors that are greater than .8 mm in Breslow depth (or under .8 mm but ulcerated) are now considered concerning enough to have moved from category T1a to T1b, and may be considered for sentinel lymph node biopsy to verify whether melanoma cells have spread to the local lymph nodes [4].
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No lymph/vascular or perineural invasion identified
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This part of the diagnosis is saying that they didn’t detect potentially cancerous cells in my dad’s vascular fluids, i.e. the lymph fluid and blood that was taken with the biopsy, or in his nearby nerve fibers [7].
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Mitotic activity: 1-2 mitoses per mm2
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Mitosis is the process of one cell dividing into two new ones. All of the cells in your body do this regularly, but cancerous cells divide a lot faster - that’s how tumors can grow so quickly. When a technician is looking at a biopsy, they count the number of splitting cells that they can see in a square millimeter portion of their microscope slide [8].
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Tumor infiltrating lymphocytes: present,
non-brisk |
A tumor-infiltrating lymphocyte is a type of white blood cell that is trying to attack your cancer and subdue it. In my dad’s case, his white blood cells were there but were only working on the outer edges of his melanoma [9].
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No evidence of regression or satellite metastases
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Since this was my dad’s first melanoma spot, it’d be classified as a new primary [10].
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His melanoma spot (along with a lot of the tissue in his arm) was surgically removed in November 2011. I called it his sharkbite surgery because it looked like a great white had taken a bite out of his biceps. You can see the scar from that surgery in some of the pictures below.
You can also see in these pictures that my dad used to love getting tattoos. At this point, he’s got two completed half-sleeves on his lower right leg and upper left arm. He was in the process of filling in his upper right arm sleeve this past spring, which included tattooing over the original melanoma spot. On May 12, 2018 he thought that his anchor tattoo might be infected, so he went for a physical and had some blood work tests done; all of these came back within normal ranges. But around May 28/29 he felt a lump in his right armpit.
Thankfully my dad has always been proactive about his health; he got an ultrasound scheduled as soon as he came back from a business trip. On June 12, a doctor explained that the previous day's ultrasound results were inconclusive because of all the recent tattooing - ink could have impregnated his lymph nodes and come up dark on the ultrasound. My dad didn't know this at the time, but your body immediately begins to break down your new tattoo, and your nearby lymph nodes suck up all the ink they can before passing it harmlessly through your body and out in your urine [11]. That's why new tattoos only look "fresh" for about a month or so. The doctor recommended a biopsy, and my dad was handed two pieces of paper. One was a prescription that said:
To Be Ordered: Ultrasound Guided Biopsy of an Enlarged Right Axillary Node
Diagnosis: R59.0 – Localized enlarged lymph nodes
Instructions: ASAP
Diagnosis: R59.0 – Localized enlarged lymph nodes
Instructions: ASAP
The other demonstrated how worried the radiologists were. It included plenty of medical terms, but the impression was clear enough: Large hypoechoic solid mass [a spot that looks darker than the rest of the ultrasound] right axilla [armpit] without significant hyperemia [blood flow]. Therefore I doubt this represents postinflammatory lymph node from recent tattoo. Patient has history of melanoma in this arm. Therefore metastatic melanoma should be excluded. Biopsy is recommended.
On June 18 my dad had an ultrasound guided biopsy, and was given this report the following day:
Final Pathologic Diagnosis
*****Positive Report*****
Ultrasound guided biopsy, Right Axilla 5 cmfn:
Metastatic melanoma.
BRAF and C-Kit molecular testing to follow.
*****Positive Report*****
Ultrasound guided biopsy, Right Axilla 5 cmfn:
Metastatic melanoma.
BRAF and C-Kit molecular testing to follow.
It had been nearly 7 years since his melanoma spot and the surrounding tissue was removed from his arm. I don't know that I have the language to describe what he was feeling at this time, and even if I did I think I wouldn't want to put it into words. All he knew for sure was that he wanted to get the treatment ball rolling as quickly as possible. He had a CT/PET scan done on June 23 and a brain MRI on June 27 to verify that the cancer was limited to just the one spot in his body, established his team of doctors at Sloan Kettering on June 25, and went in for surgery to remove all of the possibly cancerous lymph node(s) from his right axilla on July 10.
His surgical oncologist, Dr. Coit, told him afterwards that they were fairly aggressive with the surgery because it was difficult to tell which lymph nodes were impregnated with tattoo ink and/or his melanoma. Dr. Coit told us that of the 48 lymph nodes they removed from Dad's right arm, armpit, and pectorals, only one was cancerous.
Dr. Coit indicated that the only potential downside from removing all these lymph nodes was lymphedema, a general form of swelling that typically happens in your arms or legs. That said, Dr. Coit said he was confident that lymphedema should not be a concern in this particular case because Dad is young, not overweight, and active. It also helped that Dad’s afflicted area was in his arm, as Dr. Coit said most lymphedema swelling from this kind of surgery will occur in legs. The best thing one can do to avoid lymphedema is stay fit and active.
Dad really didn’t need much encouragement to keep moving. In fact, we almost had to tie him down during his post-op recovery period. It was supposed to be two weeks of chilling on the couch, icing his armpit a lot, and managing his Jackson-Pratt drains. These drains are inserted into the surgical site to drain out the fluid that collects in the recently-emptied space to prevent your skin from becoming a gross version of a water balloon.
Every day we had to glove up and check his bandages around the insertion points and measure the fluid that was collected, and Dr. Coit prefers to remove the drains when the fluid volume is <25 mL per drain. As you can see from the chart below, Dad wasn’t quite there at the two-week mark (July 23), so he had to keep his drains in for a third week.
The drain removal was not particularly gentle, but Dad was so relieved to be rid of them. He was unable to sleep soundly (shoutout to fellow side-sleepers), shower as thoroughly (or as often) as he liked, and he was constantly worried about snagging the tubes on drawer handles and other such hazards. You can probably tell just by looking at them, but having tubes stitched to your side was uncomfortable to say the least.
We all drove into New York City to be there for the post-op consultation on July 23rd and the drain removal on July 30th. I'll pick up the Post-Op part of My Dad's Melanoma story there, be sure look for that post on March 25th. As I said in the beginning, please feel free to message us directly or leave a comment if you'd like to talk to either one of us about any of the things we're sharing here. There are also dozens of Melanoma Message Boards available to join. And to everyone reading this, please PROTECT YOUR SKIN!!! Until next time, cheers :)
SOURCES/BIBLIOGRAPHY
SLOAN KETTERING MEMORICAL CENTER LINKS
Cancer Types - Melanoma
Cancer Care - Doctors - Daniel Coit
Cancer Care - Caring For Your Jackson-Pratt Drain
- American Cancer Society (cancer.org) - Key Statistics for Melanoma Skin Cancer
- Centers for Disease Control and Prevention (cdc.gov) - What Are the Risk Factors for Skin Cancer?
- Skin Cancer Foundation (skincancer.org) - Skin Cancer Facts & Statistics
- Skin Cancer Foundation (skincancer.org) - Guide to Staging - Melanoma
- Cold Spring Harbor Perspectives in Medicine, Yuji Yamaguchi (Medical, AbbVie GK, Mita, Tokyo 108-6302, Japan) and Vincent J. Hearing (Laboratory of Cell Biology, National Cancer Institute, National Institutes of Health, Bethesda, Maryland) - Melanocytes and Their Diseases
- American Cancer Society (cancer.org) - Melanoma Skin Cancer Stages
- Pigment Cell and Melanoma Research, Cedric Gaggioli and Erik Sahai (Tumour Cell Biology Laboratory, Cancer Research UK, London Research Institute, London, UK) - Melanoma invasion – current knowledge and future directions
- Skin Cancer Foundation (skincancer.org) - The Revised Melanoma Staging System and the Impact of Mitotic Rate
- National Cancer Institute (cancer.gov) - NCI Dictionary of Cancer Terms > tumor-infiltrating lymphocyte
- Melanoma Research Foundation (melanoma.org) - Patient Community > Difference between satellite, in-transit and new primary melanoma?
- National Health Service, United Kingdom (link to research provided at the bottom of the article) - Tattoo ink particles can spread into lymph nodes
SLOAN KETTERING MEMORICAL CENTER LINKS
Cancer Types - Melanoma
Cancer Care - Doctors - Daniel Coit
Cancer Care - Caring For Your Jackson-Pratt Drain