We are pleased to publish Krista M. Rubin's review of the new American Joint Committee on Cancer melanoma staging guidelines in this issue, as well as her interview with Dr. Stephen Hodi, the chief investigator of the recent Phase 3 clinical trial of ipilimumab. As well as being a prolific author on pigmented lesions and melanoma, Krista serves on the Editorial Board of the Journal of the Dermatology Nurses' Association and works on the front lines at Massachusetts General Hospital's Melanoma and Pigmented Lesion Center. I saw her in action this month, not just as author and Editorial Board member, but as nurse practitioner, caring for a patient I referred to her center.
I had seen the patient, a woman just over 50, for a routine skin check, referred to have a likely seborrheic keratosis (SK) checked. The SK was indeed an SK, but what the patient was more concerned about was a firm, round, 2-cm-diameter nodule, located on her anterior thigh, with no epidermal change, which could only be appreciated on palpation. It had been present, not symptomatic, but getting larger, for about 5 years. When she noticed a second, much smaller lump, a 5-mm nodule higher on her thigh, she became uneasy. She wanted to start with just one biopsy, and the larger lesion was punch biopsied that day, with dermatofibroma the leading clinical diagnosis.
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The dermatopathologist's call opened with "I'm afraid I have bad news," likely metastatic melanoma. She called again the next morning, reporting that immunoperoxidase stains were consistent with that diagnosis. The suspicion was that the patient had had a mole removed at some point from that leg, or something frozen, but the patient denied any such history, and repeated thorough skin checks were negative. The patient started to feel harassed by the question, repeated by each clinician in turn, and said she felt as if people thought she was purposely withholding information. "Why would I do that?!"
The patient's smaller lesion was biopsied-also metastatic melanoma-and the larger lesion excised, and she began a series of appointments with the multidisciplinary team at the Melanoma and Pigmented Lesion Center at Mass General, to whom I had referred her after getting the results of her first biopsy. The patient's last appointment was to be with Krista Rubin and Dr. Donald P. Lawrence, clinical director of the Center, once all the results were in, to review her diagnosis and staging, and discuss next steps. (The patient gave her permission for her case to be described in this editorial.)
What followed in the next few weeks was an ordeal for the patient. PET-CT demonstrated low-grade uptake in inguinal lymph nodes on the same side as the melanoma, but it was not known whether this finding was "reactive," in response to a MRSA infection at the excision site, or due to metastasis. Brain MRI and full body PET-CT were otherwise negative. The patient had to wait 2 long weeks, while her infection was treated, before a lymph node biopsy could be performed, which would settle the question.
She became increasingly desperate to learn how her melanoma would be staged, and started to feel as if this information was being withheld. She became fixated on interferon, reading horror stories on the Web about nausea and vomiting; she started to show the strain of waiting, and vehemently stated that she refused to consider interferon-even though no one had suggested it. The most helpful thing I could tell her was that since the initial biopsies, she had not had any additional, definitive bad news.
Krista Rubin and I were communicating almost daily during this period, concerning publication details of her article on melanoma staging, and it was helpful to be able at the same time to discuss our mutual patient. Krista counseled me to tell her that reading about someone else's Stage III or Stage IV melanoma did not apply to her case. Krista's expertise, and the clarity and calm with which she could explain a very confusing situation, was invaluable, as I relayed the patient's questions, and her answers back to the patient.
Krista e-mailed me, the afternoon she met with the patient. The news was reassuring: All tests for evidence of further spread were negative, including the lymph node biopsy and immunohistochemistry evaluation. The patient delivered flowers the next day, "Christmas came early for me this year, and I wanted to share my joy." The plan is for PET-CT and brain MRI every 3 months for the next year, then to consider increasing the interval to every 6 months. She will have continued close derm surveillance. There is no role for radiation or for interferon.
It is ironic, yet fitting, that our mutual patient, while Krista Rubin prepared her article on the staging guidelines for melanoma, should have a melanoma that could not be staged. "Melanoma does not always play by the rules[horizontal ellipsis]. You can't really give her melanoma a stage: there is no primary, and no lymph node involvement. We could call it an in-transit melanoma of unknown primary." The most likely scenario, Krista said, "is that there was a primary melanoma, and that her body recognized it and completely regressed it, but before it was completely regressed, it had spread." She said metastatic melanoma with unknown primary "is hard to get your mind around." Krista Rubin has already offered to write on the topic for a future issue of the Journal of the Dermatology Nurses' Association. "Melanoma completely fascinates me. Nobody is protected. It is hard to conceptualize that a spot on your skin can wreak so much havoc."[black small square]
Barbara B. Starr