Friday, October 10, 2008

Diagnosis

Recap

I got a copy of a letter from Dr. Amatruda to Dr. Korteum the other day. I thought Dr. Amatruda did a dandy job of clearly and concisely encapsulating the issues. With a few edits, here is what it said:
Today I had the opportunity to meet your patient Mr. David Sinkula. Thank you for referring this 38-year-old man. He was seen for medical oncology consultation regarding management of malignant melanoma which was just resected from his left shoulder.

Mr. Sinkula is a generally healthy man of 38. He works as a software engineer. He also has an avocation as a blogger. He does not have active medical problems. He acknowledges problems with anxiety and depression. He is currently on Zoloft 100 mg daily. He also notes [...] alcohol intake of probably ["more than two" --Dave] beers per night. He has been advised to cut this down because his liver tests have been off a bit in the past. He smokes about one pack per day.

About a year ago he had a scaling lesion taken off of his scalp. This was a seborrheic keratosis. He had an episode of atrial fibriliation about five years ago. This has not recurred. However, he had an episode of lightheadedness around June. He came to the emergency room and had no overall problems related to dizziness. However. they advised him to seek attention for a mole on his back. He described this as a lesion that blistered, got raised, then flattened out. and then began to raise up again. It had a pigmented area as part of it. You saw him and biopsied this. It was a melanoma 5.2 mm in depth down to Clark level IV. There were 4 mitoses per 10 high powered field. It was ulcerated. It was a T4b lesion. We recommended removal with sentinel node biopsy. Prior to this time he had a PET scan. The PET scan showed no abnormalities in the region of the melanoma. There were no supraclavicular, cervical. or axillary nodes. There was a small area in the dome of the liver of a nonspecific nature. There are no abnormalities in the chest.

On September 16 he had wide excision and sentinel node biopsy. The sentinel node in the left supraclavicular region was negative. The test was technically difficult because the injection from the signal blocked some of the nodal groups. Therefore, it is reassuring that he did have his PET scan which showed no abnormal uptake in nodal groups prior to surgery. He also had some esophageal inflammation. No mass or density was seen. I suspect this is related to [...] alcohol use and maybe to tobacco to some extent.

He is recovering nicely from his surgery which was only a week ago. The wound is coming together well. I see him now to advise on follow-up and therapy options. His family history is negative for early-onset cancers to the extent that he knows it. He does not really know his father's family history that well because his father was the youngest of a large family and the patient himself is the youngest of a large family [correction: family of four: Mom, Dad, my sister, and me]. He has one sister. There is no cancer on his mother's side of the family. His maternal grandmother had COPD. His father had COPD. One paternal aunt had some form of liver disease. He has two children; one biologic and one stepchild.

On examination he is a slender man in good spirits. He is noted to be pretty chipper. This relates to his nice recovery from surgery and also. I think, a relatively good period of time at work. There is really not too much that is notable on exam. He has no scar or abnormality on his scalp. The lesion on his left shoulder is excised with a scar that is coming together over the top of his left shoulder. There is no posterior cervical. supraclavicular. or axillary adenopathy. His back shows no masses or density. His liver and spleen are not enlarged. The cardiac exam is regular and rapid. He has a brownish-red mole on his left chest which he has been watching. He does not believe that it has recently changed.

My impression:
  1. Malignant melanoma. He has a stage IIC melanoma with a T4b primary tumor. Therefore, he has a significant risk of recurrence. I would estimate about a 50% recurrence risk in ten years' time and about a 35% recurrence risk at five years' time.
  2. He needs to have some additional staging before we firmly define what therapy he should take. Specifically he needs an MRI scan looking at the liver to evaluate the small area of abnormality in the liver seen on PET scan.
  3. I recommended that he consider adjuvant therapy with interferon. I recommended one month of interferon given intravenously. I note that that this therapy reduces the risk of recurrence. In his case it reduced the risk of recurrence by about 5 to 10%. The cost of interferon is a significant increase in fatigue. It sometimes causes severe headaches. It sometimes causes nausea. It can cause aches in the muscles. The overwhelming symptom is that of fatigue. It may cause depression. I do not think it would necessarily make his depression worse since he is already taking effective antidepressant agents for it. Interferon is designed to cause autoimmune toxicities. These may include patchy depigmentation of the skin, autoimmune hypothyroidism, autoimmune elevation of rheumatoid factor antinuclear antibody. If these occur it is a good sign. It predicts that someone will not likely have recurrence of melanoma, at least in the first five to ten years. We discussed how melanoma might come back. I noted that recurrence refers to melanoma coming back in a site aside from the primary site in the skin. It may involve spread to lymph nodes and to other areas more distant in the skin or possibly to lungs or liver. If melanoma does come back, as you know, it tends to keep coming back. Therefore, it is very difficult to cure in that setting. I think that interferon given for one month intravenously is his best option. He also could take interferon for one month followed by 11 months of subcutaneous shots. Right now I would probably avoid the 11 months. He does not have any nodal disease. I think 11 months of lower dose therapy might be a significant drain on his energy and might set him up for worsening depression. He could take part in a clinical trial which is a comparison of a month of interferon with observation. At this point I do not think he is inclined to take part in a trial. He also could take part in a trial at Mayo Clinic which is evaluating the effects of an antimelanoma vaccine. The vaccine is given as injections into the skin; usually a total of seven or eight injections over two to three months. The toxicity of this is much less than interferon. However, there is no clear evidence that vaccine does help to keep melanoma from recurring.
I think he understood things pretty well. He took notes. I asked him to review the copy of this letter.

Plan:
  1. MRI scan of the liver.
  2. Liver function tests. CSC. and HLA typing. The HLA typing is done to define his ability to take melanoma vaccine.
  3. Cut back on alcohol. He needs to be on a lower level of alcohol intake to safely get the interferon since the interferon by itself causes liver function abnormalities. If he already starts off with abnormal liver function enzymes, he won't be able to get much interferon before he has to stop the dose to allow recovery of the liver. I think he understands this and is in agreement.
I have asked him to return to my clinic in three months. At that time we will review his thinking regarding interferon versus the Mayo Clinic clinical trial and also further define the schedule and location of follow-up.

Thank you for the opportunity to participate in David Sinkula's care. Please call if you have any questions or concerns.

Sincerely,

THOMAS AMATRUDA, M.D.
The Latest

In addition, Dr. Amatruda called me this afternoon. As before, the good/bad comes in either of two starts: "Do you want to hear the results?" or "I'd like to set up a for you to come in and..." I drew the latter.

I'm nowhere near as gifted as Dr. Amatruda in summing up the situation, so I'll have to wing it a bit. The result of the liver biopsy was melanoma on the liver. I believe this means
metastatic melanoma on the liver. Wikipedia doesn't paint a pretty picture of it:
When there is distant metastasis, the cancer is generally considered incurable. The five year survival rate is less than 10%. The median survival is 6 to 12 months. Treatment is palliative, focusing on life-extension and quality of life. In some cases, patients may live many months or even years with metastatic melanoma (depending on the aggressiveness of the treatment). Metastases to skin and lungs have a better prognosis. Metastases to brain, bone and liver are associated with a worse prognosis.

Well, I'm always one to examine the worst case first and then see that things can only get better -- so I guess that's the tale of the tape that shows me running behind the odds.

Now to the bright side. One of the things that Dr. Amatruda mentioned in our discussion this afternoon was that he thought it was odd that the liver biopsy result came back the way it did. I took that as meaning, to one degree or another, I was possibly an outlier in the statistics of medical outcomes. That is, in my words, I was likely in the group of one of the small tails.

I take that as being positive, insomuch as with a few of the things that Dr. Amatruda mentioned, because being so is possibly making more treatment options available to me. There sounded like there is quite a variety: from surgery to in-situ heat-something, to the immune boosting, to combinations of these and others.

Anyways, that's my story and I'm sticking to it. (Until I hear otherwise.)

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