Mrs JM, age 81, is a lifelong tennis fan. She played regularly throughout her youth and well into retirement. Because I was seeing her for treatment of metastatic melanoma, she was always a little sheepish about talking about her total lifetime sun exposure. It wasn’t until I had got to know her quite well that she admitted to using sunbeds before going on holiday each year to give her the best chance of coming home with a deep tan every summer.
She had had a melanoma removed from her upper arm just over 3 years before I met her. When she went to see her GP about a new swelling in her neck, she almost forgot to mention her previous melanoma. When the swollen lymph node in the neck was removed, it was found to contain melanoma. In retrospect, she had been more tired than usual for the last 2-3 months.
I arranged a PET scan and MRI of the brain, both of which were acquired within a couple of days of me meeting her for the first time. Unfortunately, the PET revealed that the melanoma had spread to a number of sites throughout the body – various bones, multiple lymph nodes, some deposits under the skin and also in the liver. We started treatment with immunotherapy straight away. The immunotherapy, pembrolizumab, was given as a drip into a vein for 30 minutes every three weeks.
Six months later, a PET scan showed an excellent response all over the body with a reduction in size and activity of all of the sites of disease. Many of the sites had disappeared.
Nineteen months after starting pembrolizumab, she developed slight, but persistent back pain. I repeated her scans and one of the bone metastases in the spine and one in the liver had started to grow. All other areas that previously had active melanoma were still controlled with the immunotherapy. I offered her stereotactic radiotherapy to the spine and to the liver. Both the spine and liver metastases received three radiotherapy treatment sessions of about 45 minutes each. Her tiredness got a little worse for 3-4 weeks after that radiotherapy, but not so much that she didn’t carry on with her life as normal. She had some mild nausea in the week after radiotherapy, but this settled quickly with some medication.
She completed 2 years of pembrolizumab with minimal side effects – and with excellent control of her melanoma. The spine and liver lesions have responded well to the stereotactic radiotherapy and never came back.
I always look forward to seeing her as she is clearly making the most of the time that this successful treatment has afforded her. The biggest challenge I had in caring for her was pinning her down on a clinic time to come and see me for her 4-year scan results. Unfortunately for me, this coincided with Wimbledon, so I was told – in no uncertain terms – that my appointment would need to fit around the tennis schedule.