Is This The Sound Of The Second Shoe Dropping?

Back when Harvey had his mysterious and quickly-resolved rash on his hands and legs, the transplant team referred him to the Dermatology Department. They examined the rash, did a punch biopsy and later opined that the rash could be consistent with GVHD. Not exactly a strong finding of GVHD, just that it could be GVHD.

Since I am not one to miss an opportunity, I pointed out a small dark patch of skin that Harvey has sported on his right cheek for more than a decade. It had an uneven shape, was darker in some places than in others, with irregular borders. I thought these were sufficient reasons to be concerned, but what do I know, I am only a layperson, an over anxious spouse. We have asked a series of dermatologists to look at it over the last seven years. Each time we were told it was nothing to worry about. Since we were now in the presence of a real expert in oncological dermatology, I brought the “spot” to the attention of the attending physician.

Once again, we were told this is probably nothing more than keratosis, a case of hyper-pigmentation and of no medical consequence. But since it is something that is causing us concern, we were offered the option of having the offending patch frozen off.

I am sure many of you have had moles and the like frozen off with liquid nitrogen. It takes but a few minutes, they do not even use any local anesthesia. The doctor was obviously a senior guy who has done this a million times before and it took less than a minute to douse the patch (about 3mm by 6mm in size) with super cold liquid nitrogen.

Post-Freeze Guidance

We were told the area would blister, weep, and then the sore would form a crust and heal over. No need for any dressing or special handling. Not even a scheduled follow-up appointment. It was all pretty much a routine thing. I felt a little silly about insisting on this consultation and procedure, a long string of dermatologists had pronounced it of no medical consequence. Harvey rolled his eyes at my excessive caution, but went along with the procedure because of all the times I have preached the risk of squamous cell carcinoma in immune compromised CLL patients.

Now They Tell Us

The big freeze was 6 days ago. Sure enough, the site produced a most impressive blister that produced copious amounts of “weeping”. Then the blistered skin sloughed off, leaving behind a round, red, angry looking sore. No problem, the darn thing did not hurt at all and we were calmly waiting for it to crust over and begin healing.

Today our ever so observant PA (Physician’s Assistant) decided she did not like the way the site looked. She then went the extra mile and got us in to see someone at the Dermatology Department right away (Thank you, Emily!). In walked a doctor and his 3 interns under training. They looked at the site, touched it, hemmed and frowned, and finally opined it looked “odd”. Great. Please define odd, I asked humbly.

Well, they said, it could be nothing, just a case of inflamed skin tissue. Or, on the other hand, it could be squamous cell carcinoma, basal cell carcinoma etc. They then proceeded to tell me that skin cancer can be quite dangerous in CLL patients and immune compromised patients, especially when they are under immune suppressants like cyclosporine as part of their post transplant care. Yeah, I really needed this lecture about the dangers of skin cancer in CLL patients.

Meanwhile, We Wait

The medical consensus is to use a topical steroid cream on the spot, to see if that will take care of the potential inflammation. One week later, the site will be evaluated again. If it still looks “odd”, the next step is a biopsy to see if it is indeed squamous cell carcinoma or some other type of skin cancer. Surgery looms, if the biopsy comes back positive for some form of skin cancer.

I am fit to be tied. It is not as if I have been careless or remiss in addressing a potential problem. I brought it to the attention of countless oncologists and dermatologists. None of them suggested any action other than ignoring it. I am tempted to think they looked at Harvey’s brown skin and assumed he would have a low risk of skin cancer. Now, right when we are going through a complex cord blood transplant, we may have to wage a war on a second front.

I almost did not write about this latest development, it is such a depressing report. But then I remembered I promised to tell the whole truth about Harvey’s journey - and this is very much part of that experience. We hope for the best at our next meeting with the dermatologists, we hope the steroid cream does what it is supposed to do. But even if they pronounce satisfaction and that it was, after all, only inflammation that caused the site to look “odd”, I think this time I am going to insist on a full biopsy.

Be well, stay out of the sun!