Cautiously Optimistic

I got the results for the pathology of my melanoma today. My surgeon writes

Great news for you! Margins are clear and all the nodes are negative. Your staging remains a Stage IIA. You do not need more surgery. I will check with our medical oncologist regarding the need for immunotherapy

He has setup a referral to oncology so I'll meet with them next.

So, to break this down :

I don't need further ear surgery because the surgeons got all of the melanoma on the first attempt ("margins are clear"). I may have reconstruction done (a month out from now) to recreate some ear lobe with medical magic. This should go well as I retained a good amount of my ear, providing a good foundation to build from.

I won't need any further lymph nodes removed because all four sentinel lymph nodes that they took did not contain any cancer. Sometimes when they find cancer in the nodes, they may go back and take more nodes.

The staging of the cancer remains the same from when the first biopsy was done. This means that the assessment from the first biopsy (of just the melanoma tumor on the ear lobe) which was based on the type of tumor (T3a), depth of the tumor (2.5mm), the absence of ulceration, the increased mitotic rate,  and other attributes remains the same. The internet has lots of assertions about survivability and most of it looks good based on this, but I'm going to hold until I talk to an oncologist to understand specifically what this means for me in regards to statistical survivability, what treatments come next, and what to expect in the future.

I'm cautiously optimistic, I know this pathology isn't bad news (which I'm very happy about), but I don't yet know to what degree it's good news. I'm looking forward to meeting with an oncologist to find out more.

No News Yet

It's been a couple weeks since my surgery but the pathology results haven't come back yet. I've finished up applying vaseline to the healed incisions and am moving onto scar cream now.

What's next

In talking with my surgeon, despite not having pathology data back, I get the sense (just from how he talks about it) that the most likely result is that they will find melanoma in the lymph nodes and that I will go on to do immunotherapy. I think his expectation is driven by the initial depth of the tumor in the ear lobe. He's talked about what will happen next, which is that the pathology will come back and I'll get setup with an oncologist.

Post Surgery

I'll mention some details about surgey below so if that is icky, feel free to stop here.

I've healed up from surgery very well. I learned that during my surgery my surgeon found that when removing the tumor from my ear lobe he found clean dissections (no visible tumor infiltration) earlier than he was expecting and as a result didn't need to take as much of the ear lobe as originally planned. Once the pathology on the ear lobe comes back, either it will support what he saw during surgery and no more ear will need to be removed, or it will show that at a microscopic level the tumor did extend beyond where it could be seen visually in which case they'll need to do a second surgery to remove a bit more.

Another interesting thing about the ear surgery, which I didn't realize initially, is that only the front face of the ear lobe needed to be removed. As a result, the back of the ear lobe was folded forward and sutured to my ear. The result is that the front of what remains of my ear lobe is actually the back folded over. You can see this as the scar from one or two of my old ear piercings are visible on the front now.

I also confirmed that in regards to the lymph node removal, it was all done through the single neck incision (4 inches, oriented horizontally, pretty low on my neck). It was from this sincle incision that the surgeon removed 3 nodes pretty far above the incision (maybe 4 inches higher, as well as a single one down near the incision). I was pretty amazed that this was possible (traversing 4ish inches under the skin to remove something).

My surgeon confirmed that nothing about the lymph node removal was unexpected. The four nodes that he removed looked fine visually and nothing looked wrong in my neck while he was working.

My sensation on the surface of my skin on my neck and ear has changed  quite a bit since before the surgery. Most of my neck above the neck incision, and up to my jaw line and slightly into my cheek area, as well as the lower portion of my ear is numb at the surface skin layer. This is similar to what's happened to me in the past when I've been in motorcycle accidents. In those cases I lost feeling at the outermost skin layer. The nerves recovered over the subsequent 1 to 3 years. The surgeon said that the nerves would recover from the surgery as well (not sure how long it will take, hopefully months to a year). I'm also intermittently (once every 3 hours or so) experiencing nerve noise in the form of momentary instantaneous bolts of pain. They're only just slightly irritating in that they are incredibly brief.

There's some tightness in my neck that I'll likely just get used to.

Over the past 2 weeks, healing up from surgery, my pain has been very minimal (2 out of 10 at the most). I took over the counter painkillers for the first week or so and then stopped as I didn't need them.

Mental health

I've met once with a therapist so far. Our conversation was fairly introductory. We talked about methodologies to control negative thoughts. I have some homework on that topic. She identified that I'm dealing with some minor depression (I hadn't thought that I was but when she asked some screening questions, I realized that I am). I'm hoping to do better in regards to controlling where my thoughts are going and regaining my ability to think long term. At the moment I find myself unable to do any long term thinking, I suspect because doing so requires integrating into my thinking scary things that may be true in the long term.

I've not felt up to participating in the weekly tabletop role playing games. I hope to get to a mental position where I can restart that.

Support

I've gotten so many thoughtful and kind communications from folks. I really appreciate it.

I'll post again when I have an update.

Initial Surgery

Summary

I had my surgery yesterday in which the surgeons at Kaiser removed some of my earlobe (in order to remove any additional melanoma) and 4 lymph nodes (in order to biopsy to understand if the melanoma spread). The surgery went well and I feel fine. I'm not going to post any photos for the time being, I'll wait on that until I look a bit more presentable.

Before Surgery

I went to Kaiser at 11am. There was a bit of a mixup, I was supposed to get nuclear medicine imaging done first before surgery so everything ended up being delayed by about an hour.

I went to nuclear medicine and they injected my earlobe with some radioactive liquid, a radiotracer. That tracer then percolated from my earlobe into my local lymph system. I then had nuclear medicine imaging where a machine scans you for the gamma radiation coming from those radiotracers. An interesting thing about this is that the process takes a long time. 15 minutes in my case, a giant device slowly moved around my head scanning/detecting.

I then went back to pre-op surgery, got rid of my clothes and got into a gown, got an IV line put in, some leg massage cuffs (prevent blood clots), blood pressure cuff, oxygen level finger light scanner, had a brief chat with the anesthesiologist, my surgeon, facial reconstruction surgeon and one of the operating room physicians (I think) and got wheeled into the operating room.

Surgery

The operating room had a counter with computers, a big display, and the other stuff you'd expect (lights, operating table, etc) as well as Rock With You playing on the radio. The surgeon and his assistant were looking over the nuclear medicine imagery of me on their computers. I got moved onto the operating table. Everyone gathered around me for the "time out" where everyone goes around and says to each other what they're going to be doing. The anesthesiologist had me breathe in some big oxygen breaths in a mask (I imagine to bridge the time between when the general anesthesia hits via IV and when they intubate me).

I was pretty calm, elevated heart rate I imagine but generally fine, not much anxiety.

The whole thing from being wheeled into the operating room and the general anesthesia taking hold must have been a couple minutes, a short time.

I remember having a short dream about some medical procedure (not this surgery, something else) and feeling happy about how well it was going.

Recovery

I woke up in surgery recovery a moment later. Hours had passed (The surgery was planned for 160 minutes) in surgery and I'd apparently been asleep in recovery for 40 minutes.

My memory of the subsequent 20ish minutes finishing up in recovery is pretty good but a bit hazy.

Likely due to a combination of the delay with the nuclear medicine mixup, me being asleep in recovery for 40 minutes and it being 5pm on a Friday, all the doctors had left. Thankfully my surgeon had earlier called Kris and shared some info with her on how everything went.

I got a little urine bottle to pee into (didn't feel up to stumbling to the bathroom). Nurse helped me get unplugged and undone from everything. I got my clothes on somehow, I think I put them on, just slowly. Got out of the bed and into a wheelchair and got rolled out to the curb to meet Kris.

In that I'd been getting IV fluid for hours, I got to the car and then told Kris she'd need to help me walk back in so I pee again. We went back in and I relieved myself. Went back to the car and drove home.

No nausea (sometimes a side effect of general anesthesia) minimal pain (maybe 2 out of 10).

So What Did They Do?

Here's what I've pieced together (because I wasn't conscious during surgery) from what my surgeon told Kris and from looking at myself in the mirror after.

For some reason my surgeon didn't end up taking as much of my ear as he'd planned. The plan was for 1cm around the site but he decided to take less. So all I'm missing at the moment is the lobe and a section distal from the lobe (seemingly all cartilage is still there and intact). The biopsy of what they took will show the margins of the melanoma and either confirm they got it all or that they didn't and will need to take more.

They took 4 lymph nodes out and my surgeon said they looked fine to the naked eye, but we'll only really know what's up after the study is done. Prior to surgery he said it typically takes 7-10 days to get results back.

It appears as if they made a single 4 inch wide horizontal incision in my lower neck to go for the lymph nodes (and a few small ones right up and around the ear). I'm guessing though since I don't know exactly what they did.

It looks like they'd prepped my right ear (the good one) to take a piece of cartilage in order to "bank" it near my left ear for the purpose of later reconstruction, but they didn't end up doing that. I don't know if this was driven by the fact that they ended up taking less of the left ear than planned or if it'll happen at another time.

Some nerves to the skin around my neck were affected as there are sections that are now numb. The same thing has happened to me in the past from motorcycle accidents. In those cases I got feeling back after a few years to the section of skin that I'd lost feeling for.

So I have stiches on and around my ear and along that neck incision.

Back At Home

I got back last evening after Velle was asleep (Kris's mom was kind enough to cover for us), had some food, hung out with Kris for a bit and then tried to go to sleep. Turns out sleeping under general anesthesia counts just like normal sleeping so it was as if I'd had a 4 hour nap during the day (I didn't get to sleep until midnight).

Pain has remained 1 or 2 out of 10. I don't get to shower until Sunday night/Monday morning but I'll live. Throat is almost entirely recovered from intubation yesterday (some roughness, coughing a bit, nothing big).

Got the adhesive off of one of my eyelids (they tape your eyes shut). Still have some of the gunk they put in your eyes to protect them left over in my left eye. I'll have to see if I can think of how to flush that without a shower.

So now I'll hang out and heal up and wait to hear back about results.