PSA: Skin Cancer, Tattoos and Medical Mishaps

February was an interesting month for the extended Bixby family. We received a call from W's mom letting us know that our brother-in-law Matt had been diagnosed with metastatic malignant melanoma. Matt is the husband of W's sister, a former Navy man, air traffic controller in California, a groomsman at our wedding, cyclist, photographer and all around great guy. Do a simple google search or take a look at wikipedia and either way, it didn't look good for Matt. What began as a skin 'thing' that started to bleed and caused a visit to the physician, turned into the removal of one of the lymph nodes under his arm, the insertion of a drain and the beginning of a long, strange trip.

February 6th email:

'The good news is I am drain free. The not so good news is the sentinel group of lymph nodes that were removed showed signs of discoloration. "All three nodes appear involved with metastatic malignant melanoma." The next step is to have a PET scan. This will detect any other metabolic activity in the body. If no other activity is detected, then it's safe to say that the cancer is only in the lymph nodes in the left underarm. This is what we are hoping for. If the scan picks up something else, then chemotherapy is in the near future. I'll know more after the PET scan.'

February 10th email:

I am finally able to report some good news. The members of my lymph node army (Company L, 124th Infantry, 1st division, CEF) that sacrificed themselves have already received full honors. The PET scan report is very wordy and most of them we had to look up. So the short of it is "No evidence for residual regional metastases, and no evidence for distant metastases." Our battle isn't over, but we are very close to having an course of action. Tomorrow we are meeting with an Oncologist that my surgeon actually sent his mother to for treatment of colon cancer. I have also asked for a referral to ____ Melanoma Clinic. So far it sounds like surgery is going to be the number one option for a cure. This means I could possibly undergo further removal of the lymph nodes in the left underarm. We will know more very soon.

On February 27th we received news from Matt detailing the February 23rd surgery to remove his remaining sentinal lymph nodes and photos of his support team, comprised of his wife and the members of operation sofa recovery, their two dachshunds. He also sent photos of his underarm and the drain tube leading to a collection bag ace-bandaged to his chest.

Here is Matt's overview of the event and the shocking finale:

January of this year I was diagnosed with a melanotic melanoma on my left forearm. I underwent surgery to remove the melanoma and had the sentinel lymph node removed for testing. During the surgery the doctor noticed discoloration to a couple of lymph nodes including the sentinel node. He removed all the ones he could see that were black. The initial pathology report said that the nodes appeared to be metastaic melanoma. This was based up on the black granular color of the substance that was throughout the lymph nodes. The lymph node slides were sent off to ____ for a second opinion. I visited with an oncologist to discuss further treatment options and discuss trials that I qualified for in the Bay Area. After talking to the surgeon that performed the first surgery, I took both his and the oncologist's advice and had a second surgery to remove the rest of the lymph nodes in my le ft underarm. The second surgery was on 2/23. On 2/27, I went in for a follow up to the second surgery. After the doctor took a look at my drain, he prepared me for more news. At this point I wasn't sure if I could handle any more "bad" news. He discussed the _____ pathology report with me, and I was shocked. The black granular substance that the first pathologist thought was metastatic melanoma was actually tattoo ink. I was confused. The doctor had to explain it to me again, and he emphasized that there was no evidence of cancer in any of the lymph nodes from the first surgery. It is all very surreal. Hopefully, this will help someone.

Final statements:

• Yes, Matt had a cancerous growth on his left forearm that needed to be removed. Removal of his first lymph node was a given considering the proximity of the growth to the node. Prescription for life for this outdoor man....sunscreen and REI clothing with built in SPF.
• Yes, Matt has a tattoo.....a rather large one that the first physician actually talked to him about while removing the first lymph node. (In fact, I think he has several.)
• Yes, Matt is delighted to be cancer free and healthy.
• Yes, someone in the medical community missed something. Whether someone neglected to read their medical literature or forgot to write down in the H&P (history & physical) that Matt has a large tattoo or took their first view for fact instead of performing a histological lab assessment, that is for Matt to decide if he would like to investigate further.
• Yes, the tattoo link to a misdiagnosis of malignant melanoma is well documented in medical publications. A ten second google and pubmed search yielded numerous citations. The following are from the Dermatology Online Journal.

“Black pigmented lymph nodes can occur by carbon deposits of tattoo pigment as in our case. It is prudent to seek a history of tattooing and tattoo removal in all melanoma patients.”

“Metastatic deposits of malignant melanoma in regional lymph nodes have a poor prognosis that worsens with the number of positive lymph nodes. The finding of a pigmented lymph node during lymph-node dissection may entice the overzealous surgeon to progress with radical surgery of the draining area. Extreme caution is recommended during surgery in patients with a tattoo or with a previous tattoo and presenting with malignant melanoma and pigmented lymph nodes. Histological and immunohistochemical confirmation of metastatic malignant melanoma in the sentinel lymph node is imperative before proceeding to complete regional lymph-node dissection. This decision would avoid unnecessary radical surgery and subsequent patient morbidity.” Chikkamuniyappa S et al. Dermatology Online Journal 11 (1): 14.