There wasn’t anything unusual about her at first glance. She seemed like the typical grandmotherly 68 year old lady that I see every day. She lived alone. Her four kids were in the area and she saw her grandchildren most weekends. She had been a homemaker most of her life. She lived comfortably off her husband’s pension and her own social security. She was in the hospital for “weakness and fatigue”. The internist had run a battery of tests, sent bloodwork, consulted half a dozen specialists. The investigations were unrevealing. Her heart was ok. She had some mild cortical atrophy. She was a little anemic but the upper and lower endoscopies were negative. She looked thin and wan when I walked into the room to introduce myself. She seemed to sink into the crevices of the hospital bed with a defeated resignation. Her voice was tepid and quiet and I had to pull the chair up close to the bed to hear her.
I had been called with regards to a “lump” on her back. How long has it been there, I asked her gently. She looked away, pausing for a moment. It’s so embarrassing, she said. I should have seen someone sooner. I neglected myself. She couldn’t look at me. She kept staring at her hands folded across her lap. It’s ok, I said. Would you mind if I took a look?
I helped her with the buttons on the hospital gown. At the tip of her shoulder blade was a giant gauze dressing. As I moved to peel back the tape holding it in place, a foul, festering odor was released. The gauze was heavy with moisture. I'm so sorry, she said. I know it smells. It's fine, I said. Underneath the dressings was a tennis ball sized fungating mass, serum seeping from the ulcerated surfaces. She slowly shook her head with her eyes closed, wrinkled hands folded across her mouth like a steeple.
-How long has it been there?
-Two years, she whispered. I thought it might just go away.
-Does it hurt?
-No. Only sometimes. If I bump it. I ought to have seen someone sooner. I was so busy taking care of my husband. He was ill, you know. I didn't want to think about anything else. I didn't have time....
For two years she functioned as a caretaker for her deteriorating husband. She fed him, bathed him, cleaned him when he soiled himself. Everything was directed toward him, all her energies, everything outside herself. Is this a deeper form of love, this extreme self denial? I had to sit down. I couldn't say anything. I covered her back up. We sat in silence in that dim little hospital room for a good five minutes. This quiet, frail little old lady. No one in the family knew what she had quietly endured. She had downplayed her husband's decline. Denied all offers of assistance. Always kept the lesion carefully concealed and perfumed. And now she was done hiding. She was here.
-You must miss him, I said after a time.
-You have no idea, she said, looking at me finally. And suddenly, I thought I saw a glint of determination in her eyes, the very drive that had gotten her through the past two years.
-But I want to get better now, she said. I just hope it isn't too late.
A core biopsy revealed a poorly differentiated malignant melanoma. After lymphoscintigraphy confirmed that the right axilla was the primary lymphatic drainage basin, we proceeded with a wide local excision and concommitant sentinel node biopsy. Melanoma, as opposed to other skin cancers (squamous, basal cell), has a tendency to spread to the regional lymphatics. The thicker the melanoma, the higher the chance of metastasis. As I began the axillary dissection, my heart dropped as I encountered clumps of matted, enlarged lymph nodes. The lesion itself was excised uneventfully, a twenty minute procedure, and just like that it was gone.
When I saw her in the office a week later for drain removal and a discussion of the final pathology she wasn't alone. All four of her daughters accompanied her. The two flanking her sides both held her hand. There was a rosy color to her cheeks that was lacking a week before. She smiled. She seemed at ease, finally. Surrounded by her loved ones, the burden of concealment cast off, comforted by her new-found transparency.
The most important factor in melanoma staging is thickness, usually discussed in terms of millimeters. Her melanoma was 5 centimeters thick, an exponentially thicker lesion than what we typically encounter. But the margins were clean and her wound had healed nicely. What about the lymph nodes, one of the daughters asked. Amazingly, all the lymph nodes were negative, I said. Some of them were enlarged but this was secondary to reactive inflammation rather than metastatic spread.
And then that little exam room became the warmest, most festive place in northeast Ohio. There was crying and laughing and squeals of delight. My patient's eyes glistened with tears, her shoulders shuddering. I tried to modulate the excitement somewhat (still a big lesion, poorly differentiated, etc) but not too much. Now was a time for good news and optimism. The pathology on the lymph nodes was entirely unexpected; I never would have guessed it.
It seemed the rest of the family was committing to my patient in the same fashion that she had done for their father. She was moving in with the eldest daughter. The girls were taking care of everything. Things were going to get a lot easier. Never again would she have to endure anything on her own. She hugged me on the way out, even gave me one of those embarassed quick pecks on my cheek.
When I'm in a room with a patient, I try to keep my emotions in check. You don't want some doctor breaking down in front of you, turning into a blubbering sack of goo. Sitting here on a Sunday writing this story allows a different perspective. For some reason I have a hard time letting go of this particular patient. She had something to teach me; and the further I get from the actual events, the more I seem to understand. I'm still quite young, and have a lot to learn. I'm grateful for the opportunity to interact with human beings in the intimate setting that the doctor/patient relationship affords. I think we all carry our own lesions with us throughout life, whether it resides on our back, or our leg, or deep within the recesses of our hearts. We all have them. There's no shame in that. And it's a good thing to know that the burden can be lessened the moment we decide to reveal it, the moment we decide we don't want to endure it alone anymore....