Day 1 - A talk with the surgeon

Afternoon

My first trip to the plastic surgeon is over. She specialize in melanoma surgery. Her name is Andri Neuman.
She talked well and answered many questions. 
Normally they try to remove any melanoma skin, as shallow as possible, and still get 100% of the possible cancer cells. My sores were very deep. She says that makes it much more difficult to get all the bad cells. She also said that Angiosarcoma is bad news, It spreads quickly through the blood, NOT the lymph system. I hoped that the lymph blockage would trap the cancer in the lower left leg. Not so :-(
 The words "Poorly Differentiated" are especially bad news. That means a much larger and deeper  incision will be necessary. She wants to remove a patch of skin 26 x 18 cms. That is most of the way around my leg. The deepest biopsy wound is about 1 cm deep. They talk about 1-2 mm being considered deep. Also the "Poorly Differentiated" and the "brisk mitotic activity" means that the sores may reappear in the new grafted skin.

 She said the one wound that was basal cell carcinoma, was a non issue, and that type of cancer seldom gets worse or spreads. Removal of it, is final removal of the cancer. The other four wounds are the problem.

She also said that if she has to go deep, a simple skin graft will probably not take. There will be too much blood and wound goo for the new skin to get a grip and start healing. So she said that she would probably take the bad skin and bad muscle and veins away, and apply a VacPac. It is a large bandage that is made of plastic, and hooked up to a vacuum pump to supply a constant sucking to the wound for about 5 days till the wound gets cleaned out and dries out, THEN she will do the skin graft using skin from the thigh. 
 She said I should be able to walk around to the shops with the VacPac on, but will have to carry the battery powered suction machine with everywhere for about 5 days. She said the use of the VacPac first should also reduce significantly the hospital time after the actual skin graft.
 
 http://www.sbu.se/en/Published/Alert/Vacuum-Assisted-Wound-Closure-Therapy/
 
 Her concern about the large amount of muscle and skin she will have to remove, lead her to decide to do the oncology tests first. If the cancer has NOT spread past the lower leg, then she will want to be 100% to get everything, so as to possibly stop the cancer once and for all. If it has already spread, then getting every single cancer cell will not be as big a priority. That is like closing the barn door after the horse has run away.
 Also there is a thing called "sentinel lymph glands". There are many tiny lymph glands throughout the body. By checking these with a PET scan, it will tell if the cancer has spread out, and maybe how far. If the spread is in a finite area, then she may want to extend the area she removes, to include the small lymph nodes..
 
 So she decided to send me to the oncologist first, before she operates. So on Tuesday the 11th I see Dr. R Marais.
  Dr. Marais and Dr. Neuman chatted about me for 5 minutes. It was all in Afrikaans, and Latin. I understood little. 
  The plan is to start chemo therapy, do a PET scan, and maybe a needle biopsy of the lymph glands. Then using this knowledge, allow the skin removal to proceed in the best way.
  Then back to the oncology people to continue treatment.
 
  Getting a Doctor to tell plain facts and make a prediction is almost impossible. I asked questions like what is the survival rate, and what is the chance of an amputation. To all of these she said she did not know. I then used a trick we used with weathermen during my aviation career. I asked her "If in 6 months time you hear that I had to have my leg amputated, would you be surprised?" She said "No".
  I asked "If in 3 months time you heard that I had died from Melanoma, would you be surprised." She replied she would be shocked.
  Then I asked her "What other possible scenarios, 6 months from now, that would be bad for me, would not surprise you." She answered "Lung Cancer".
  That was a bit of a shock. I asked her to explain that. She said that the Angiosarcoma is cancer that is spread via the veins, and the veins are returning blood to the lungs to be re oxygenated, so the lungs will be a prime target for this type of cancer. Another reason she wanted to start chemo sooner rather than later.
  
  This weekend is a long three day one, and I will enjoy it to the fullest. It will probably be my last semi-normal weekend, for a long time.