DELAYED POST

Dave had a consultation with his Savannah oncologist on July 19th, and I'm just now summarizing it.  Sorry for the delay - we left shortly after his appointment to spend a week at the beach with our youngest grandson, and had very limited internet service.  Now we're home and I'm finally getting back to the blog.

In the Wild Dunes pool

Dave updated his oncologist with what we learned at MD Anderson, and told him we are going back in early August for further discussions, a CT scan on his lung, and potentially the Isolated Limb Perfusion (ILP).  His doctor, a very thoughtful and reflective man, was supportive of Dave's desire to learn more about options for treatment.  I do not want to name the doctor because it is possible I would incorrectly characterize his comments.  What Dave and I understood, was that his feeling was ILP may be beneficial, but on the other hand there is a good chance the surgery may have already eliminated as much melanoma as possible, and there are risks to consider regarding damage to his arm.  If Dave has 'in transit' melanoma, which has not been detected, ILP is not aggressive enough.  If he had a 'local recurrence' it may have been taken care of by the surgery and ILP could be too aggressive.  Unfortunately, there is no way to know for sure.  We are hoping the discussions with the MDA melanoma specialist and the ILP surgeon next week will help Dave make a confident decision about what to do.  He can always wait and see, with periodic monitoring.

JULY 10th GOOD TELECON

We had a very positive conversation this afternoon with the Physician Assistant (PA) of the surgeon, Dr. Merrick Ross, who would perform the ILP on Dave's arm, if that is what is decided.

He told us:
+ Dr. Ross is 'probably' the preeminent surgeon performing ILPs in the USA
+ Dr. Ross has had to amputate only one limb after ILP, but that patient had multiple problems
+ The risk of amputation is less than 1%
+ The hospital stays for arm ILP is generally 3-4 days after surgery
+ Recovery is in the ICU so if any problems, specifically muscle damage, is detected it can be treated immediately and effectively.

I noted in an earlier post that Dave's next appointment at MD Anderson is July 31.  That has changed.  The current schedule is:
Aug. 5 - CT scan on the lung
Aug. 6 - Consultation with Dr. Ross
Aug. 7 - ILP, possibly
Aug. 8-9 or 10 - Recovery in ICU
Aug. 10 or 11 - Discharge

The PA reminded us that if Dave's melanoma is determined to be 'locally recurrent' meaning it was probably a vestige of his original melanoma, it is a less risky situation than having 'in transit' melanoma which has already gotten in his blood stream and is traveling.  (Remember, this is grossly simplified and I am not totally accurate in my descriptions.)  However, ILP may be too aggressive for locally recurrent melanoma, and Dave may be sent home to closely and regularly monitor his body for additional changes.  Frankly, that sounds good to me.

ILP - ISOLATED LIMB PERFUSION

This blog is not for medical professionals, as I am sure they will cringe at my primitive explanations.  I will be attempting to describe, in grossly simplistic terms, some issues we are facing. I am not a fan of TMI, yet I want to give a Big Picture overview.  You can, of course, google for more detailed information.

Dave has, basically, been given 4 possible treatment options:
1.  12-18 months of the drug interferon, which makes you feel like you have the flu.  The risk of melanoma recurring is reduced by only 3-10%.
2.  Participate in a clinical trial.  He would get one of three drugs (no placebo) for 12-18 months:
     a.  Interferon (same as above)
     b.  High dosage of ipilimumab
     c.  Low dosage of ipilimumab
Although there has been success with ipilimumab, the side effects can be devastating.
3.  Isolated Limb Perfusion with the drug melphalan - a 5-8 hour procedure with a 5 day hospital stay.
4.  Do nothing

He has been told his melanoma will most likely return, and at shorter intervals, so he does have an interest in preventive options.

As of today he is leaning toward the ILP, as it seems to give the best results with the fewest side effects.

In simplistic terms, he would have a tourniquet put on his arm, chemo would be pumped in, and the chemo and his arm would be heated.  The chemo would then be filtered out.  There is the possibility of the ILP damaging his arm so badly it may need to be amputated.  We do not know how often that happens, and that is, of course the extreme case.  Less extreme cases include skin, nerve and muscle damage.

Considering Dave has no sign of cancer in him now, though also knowing it is almost certain to recur, it is hard to decide to put yourself through any of these options.

We are still researching and have lots of questions for the doctors before Dave decides what to do.

THE TIMELINE

Here's the history of Dave's melanoma to date:

February 2006 - Dave had a couple of 'pimples' on his upper right arm that wouldn't heal.  Our dermatologist recognized them as melanoma, though they did not look like freckles or moles.  They were removed and the pathology report confirmed the diagnosis.  Two follow-up PET scans in 12 months showed no more cancer activity.

April 2013 - Dave felt a lump under his skin, at the bottom of his scar from his previous surgery.  It became inflamed and his skin got red.  His surgeon thought it looked like an infected cyst and put Dave on antibiotics for a week, then surgically removed the lump.  The pathology report concluded the 'cyst' was actually a recurrent melanoma.

May 2013 - Dave had a brain MRI and a whole body PET scan, both of which were negative for cancer cell activity.  Two small spots were detected on the PET scan, one on his liver and one on his lung, that might require further examination.  He had an MRI on his liver, again with a negative result.  The spot on his lung was determined to be "likely tiny cyst" with no required follow-up.  Dave had a second surgery on his arm to be sure the margins were clean, and they were.

June 2013 - Lots of research going on about whether or not to have additional therapy, and what kind.  Therapy (chemo) would be to lower the risk of melanoma recurring.  Dave requested a consultation with melanoma specialists at MD Anderson in Houston, TX.

July 1, 2013 - Dave had a his consultation at MD Anderson with Dr. Agop Bedikian, who told him his melanoma is Stage 3C.  Dr. Bedikian would recommend a therapy called "Isolated Limb Perfusion" and also having a CT in about a month to be absolutely certain the spot on his lung has not grown.

ANOTHER BLOG? HERE'S WHY...

We are so fortunate to have many many people interested in how Dave is doing.  Since I fall behind updating everyone, I decided to start a blog to post the latest news.  Now you can check at your leisure, or subscribe and get every last detail as soon as I write it!

The name of this blog, Dave's Happy Trails on the Medical Maze, is a derivative of my last blog about him and his hike on the Appalachian Trail.  www.HappyTrailsFromSavannah.blogspot.com

It is, of course, my intention for this blog to be short and sweet - short lived with a sweet outcome.  

The Eiffel Tower is pictured as a reminder of where we hope to be this time next year!