Stage 1 -- but now a concerning brain MRI

Posted By
casagrayson
7/9/2018 7:45pm
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Replies: 7

I'm at a loss here on what to do.  My husband has had two primaries -- one along the mandible that was classified as T1b, and another in situ on the scalp.  He has gone for full skin checks every six months or more frequently ever since.

He has been having some issues with his eye, which he thought was just a drooping eyelid that could be fixed with minor cosmetic surgery.  Long story short, a visit to the cosmetic dermatologist morphed into an ophthalmologist visit, where it was determined he has optic disc swelling, motility issues, and nerve issues causing the drooping eyelid.  The ophthalmologist ordered an MRI of the eye orbits and the brain.  The radiololgist was informed of the previous melanoma, of course, as well as other medical issues (headaches, major fatigue, dizziness).

Here was the finding by the radiologist:

1. Multifocal FLAIR hyperintensity involving the left parietal lobe, left occipital lobe, and posterolateral right frontal lobe, as well as the right temporal lobe. Much of the signal abnormality appears related to small cortical venous structures. There is an additional focus of FLAIR hyperintensity involving the right temporal lobe cortex or overlying leptomeninges with slightly more nodular associated enhancement, less convincingly contiguous with an adjacent cortical venous structure. This could represent vasculitis, particularly if the patient is receiving immunotherapy therapy for the given history of melanoma. Areas of subacute infarct are thought to be less likely, given the apparent vascular nature. Perineural metastatic disease cannot be excluded, but is less likely.

I reviewed the MRI myself (I have quite a bit of experience having had my own pituitary tumor, and I run a pituitary disease medical support group) and I definitely see the "nodules" that the radiologist references.  There are at least 8 tiny spots that light up.  Here's my dilemma.  The radiologist suggests another scan in 3 months.  The ophthalmologist wants a neuro consult (which is not available until Aug 29).  I'm wondering if we should find a melanoma specialist to read the MRI/report just to rule out possible micro metastases.

Am I overreacting?  Should we just go with the flow and wait until the end of August, and see a neuro who does not specialize in melanoma?

Strength and Courage,

Susan

I have said for years...if you have melanoma...especially anything beyond the most basic Stage I presentation...you need a melanoma specialist.  As I understand it, your husband is NOT on immunotherapy...so that interpretation of the results is not accurate.  It may well be vasculitis.  But...with the history of melanoma, location of disease, and other signs and symptoms (headache, ophthmalogic issues, syncope)....find a melanoma specialist ASAP!!!!  Hopefully, such expertise will not be warranted.  However, it is simple enough and could give you the definitive answers you need.  I wish you my best.  Celeste

With Melanoma there is no overreacting.  Please see a melanoma specialist.  I had a few tiny brain mets which went away with immunotherapy but better to jump on the train early than to miss it and try to deal with things later.  At least have the initial appointments and go from there.  Good wishes to you.

Thank you both.  That's certainly how I was leaning -- after all, what is the harm?  

One of my friends died of melanoma about four years ago.  He had a Stage 1 melanoma removed from his thigh, and years later they found metastatic melanoma in the liver when he went to the ER for what he thought was appendicitis.  :(  Keytruda was just hitting the scene in a big way, but it was too late for Trey.  I called his wife and asked who his melanoma specialist was in Denver (who works in conjunction with MD Anderson).  I emailed Dr. Gonzales with the situation and the MRI report, and he got back with me the same day saying "Yes, he definitely needs to be seen here.  The tumor might be meningeal, as well."  Our initial appointment is July 31.  

Hopefully Dr. Lewis will review everything and say "There's no melanoma metastases here -- you've wasted my time!"

 

Strength and Courage,

Susan

The nurse practictioner called yesterday and tried to cancel the appointment.  She said that they couldn't see my husband because they require that he has a diagnosis of melanoma before being seen, as they are a treatment center.  I explained that he did have a melanoma diagnosis, but she kept trying to say that he needed a Stage III or IV diagnosis in order to be seen.  

I don't get it.  He has an abnormal MRI with lesions.  Who else would I go to in order to rule out or confirm a melanoma metastases?  She finally agreed to let us keep the appointment, but said the tumor board might change that next week.  

So who do we go to?  How do we determine if this is melanoma or something else?  She suggested just going to a regular neurologist. I thought I was doing the proactive thing, but she made me feel really stupid.

Strength and Courage,

Susan

Hopefully, they will not, in the end, cancel the appointment.  However, if they do...see a neurologist.  Then, if they think the lesions are tumors....I am sure that your husband will be referred to a melanoma specialist.  But...hopefully you will be seen in the appointment you currently have.  I still hope that these are vascular blips rather than anything more complicated.  c

They have confirmed the appointment.  Of course, now I feel like someone who has Munchausen's Syndrome by Proxy (wanting to make my husband sick).  I suppose I'll just tell the doctor that "with even a remote possibility of metastases we wanted to be seen by the experts".  And hopefully dear hubby will not downplay everything that has happened -- he's a master at that once he gets in front of a doctor.

Strength and Courage,

Susan

We had the appointment at the melanoma clinic.  We didn't get to see the director (the one who mentioned meningeal disease) but his associate.  Nice enough guy.  Did a cursory exam, asked a bunch of questions, and said "you look good"!  He said that the potential for a metastases of a Stage 1 after so many years was almost impossible, and that the fact that my husband has had these eye/head symptoms for many months was reassuring (i.e. if it were melanoma he'd be in much worse shape by now).  I asked him if he looked at the MRI and the report, and he said he had but couldn't even figure out what the radiologist was referring to.  He also said that when the melanoma box gets checked on the patient form, radiologists get overly cautious.  So, we were dismissed with a "call us if you need us".

I know it's good news, and we need to trust the experts. This disease is just so darn unpredictable.

Strength and Courage,

Susan