Ted sat on the examining table, his tie at half-mast, haggard after a day of trading stocks and bonds. I had taken a skin sample from his back the week before, a small piece from a much larger growth located in the upper center of his 5-foot 8-inch 270-pound frame. He had returned for removal of the sutures.
"You have a melanoma," I said softly, yet firmly.
He finally seemed to pay attention.
I had worried that Ted might not return at all. Nothing in his previous behavior had indicated that he was aware of, or willing to acknowledge, the danger on his back. He had come to me only after a mutual friend urged him to do so. They had played racquetball together, and the friend had noticed a large black mole on Ted's back. Until recently, Ted had ignored his friend's concern.
"I just didn't have time for it," he told me. "I'm on the phone from early morning on. And in the evening, I have to get out and socialize to get more clients. And the ladies want my time. It's endless."
"How long has it been on your back?" I asked.
"Maybe about two years," Ted said. "Lately it's been itching a lot. Am I going to die?" he asked, a trace of worry in his voice.
"This is serious," I told him. "You have a chance of survival if you get this taken care of right away."
Even before I sent the sample to the lab for diagnosis, I knew he had melanoma. In melanoma, there are four basic warning signs, which can be recalled as ABCD: Asymmetry (if a line was drawn through the middle, the two sides would not match); Border (irregular in shape, with scalloped or notched edges); Color (typically brown or black and sometimes mixes of red, white, and blue); and Diameter (larger than a quarter of an inch, the size of a pencil eraser). Ted's tumor was asymmetrical with many areas of pigmentation, ranging from slightly pink to dark blue.
"Can you take it out now?" he asked. "I'd trust you to do it."
"I appreciate your trust," I told him. "But no, I can't."
"Why not?" he asked. "I'll pay you in cash. I don't have insurance, and I don't want to go to a hospital."
"If it were a different type of skin cancer, something less problematic, I would cut it out. But this is too important. I do general dermatology. Others concentrate primarily on melanomas."
I gave Ted copies of all his pathology reports, pertinent office notes, lab data, and the number of a specialist at a nearby teaching hospital. He called a couple of days later, almost begging me to do the surgery. I insisted that he go to a specialist and have all the proper tests, including studies of nearby lymph glands to check whether the cancer had spread. Melanoma arises from accumulated DNA damage in a skin cell. The damage so deranges the cell's ability to control its growth that it multiplies repeatedly. The early stages are classified by the tumor's thickness and by how many layers of skin the tumor has invaded. The deeper the melanoma has advanced through the layers of skin, a measure known as Clark's level of invasion, the more likely it is to be fatal.
Human skin has three major layers. The most superficial is the epidermis, the middle is the dermis, and the lowest is subcutaneous connective tissue. Ted had a Clark's level stage III melanoma: The melanoma had grown into the middle of the dermis but had not yet reached the deepest layer.
In the past few years, great advances have been made so that the surgery for a safe and thorough melanoma removal requires cutting away much less tissue. With thin melanomas, outpatient procedures under local anesthesia are sufficient. Healing generally occurs in one to two weeks, and scars are minimal. But when the melanoma has progressed beyond stage II, as in Ted's case, the key question becomes: Has the tumor shed cells and spread beyond the original site? If it has, the lymph nodes closest to the tumor are the most likely site of metastases.
I hadn't detected any swelling of nodes in Ted's armpits or neck, but that didn't mean the tumor hadn't spread. A new method, called lymphoscintigraphy, can map the lymph system using a small amount of a radioactive substance injected at the site of the melanoma. With the help of a scanner, the path of lymphatic fluid draining from the melanoma to the nodes can be traced. The surgeon can examine the results and biopsy only the lymph nodes that are in line to receive lymph fluid from the melanoma. If the cancer is suspected to have spread widely, the physician may order more extensive scans, such as CT scans or MRI scans.
In Ted's case, a preoperative evaluation included a complete blood count, a chest X ray, and liver function studies to help rule out extensive metastases. A preoperative lymphoscintigraphy showed the presence of a tumor in the nodes in one of his armpits. Surgery was scheduled to remove the melanoma and the affected nodes.
In stage III and IV disease, additional therapy may follow surgery. Several cancer drugs are used to treat melanoma. In addition, experimental melanoma vaccines are being studied. These vaccines are designed to boost the body's defenses against an existing melanoma, and many of them are in clinical trials for patients with stage III and IV disease. Another experimental strategy is to treat patients with naturally occurring immune-system factors that discourage a tumor's growth and spread.
I saw Ted one more time, about 10 weeks after his operation. "I'm glad you got me to the right place," he said. "I didn't realize what a mess I was in."
I reminded him that many patients who had malevolent growths for only six months or less died tragically young. He had been lucky so far, but unless he changed his lifestyle, he wasn't likely to lead a long, healthy life.
"Do I have a higher chance of another melanoma?"
"Yes, the chances of having another melanoma are greater with a history of melanoma. You need checkups every three months for three years and then yearly for life," I said. "With careful watching, most second melanomas are caught early and treated by surgical excision."
"Is there a special melanoma diet?"
"No, but you'll do better keeping a well-balanced diet with folic acid, vitamins B6, B12, C, and A, and iron and zinc."
"Is it safe to donate blood?"
"In most cases, blood centers will not accept blood from someone who has had cancer," I said.
"Should I avoid the sun?"
I explained that the Skin Cancer Foundation recommends that all people avoid the sun as much as possible, especially during the hours of 10 a.m. to 4 p.m. I told him to use a sunscreen with a sun protection factor of 15 or greater and to always wear a hat and sunglasses outdoors. People with a fair complexion, blue eyes, and blond hair are the most susceptible to melanomas, as are people with a history of blistering sunburns during childhood.
"I have a sister who has some dark moles on her skin. Whom should she see?"
"A dermatologist." General physicians typically don't have enough experience to diagnose skin lesions.
Although I had made the diagnosis and the surgeon and others had played crucial roles, the real hero in this story is Ted's friend. Without his concern, I doubt that Ted would still be alive.
Robert A. Norman is a dermatologist in Tampa, Florida. The cases described in Vital Signs are based on true stories. Some details have been changed to protect patients' privacy.
