A Map Across The Atlantic

A woman’s search for answers about melanoma brought her from Romania to Savannah’s Lewis Cancer & Research Pavilion

When St. Joseph’s/Candler built the Nancy N. and J.C. Lewis Cancer & Research Pavilion (LCRP) in 2006, the goal was to provide the kind of high quality cancer care that patients previously had to travel outside of Savannah to find. Six years later, the LCRP’s ability to offer advanced care to patients in their own hometown remains a rare blessing.

So what are the options for patients who do not have a facility like the LCRP in their city, where—along with technological advancements being made—difficult cases are reviewed by a panel of experts? That was the question faced by Mirela, a young lawyer from Bucharest, Romania, in Southeastern Europe. She had four lesions on her upper back that were potentially melanoma, the deadliest form of skin cancer, and went to a surgeon to have the lesions removed and the melanoma staged.

“Unfortunately, all of the four moles excised were placed in the same container,” Mirela recalls. “One of them was an aggressive melanoma. But because we were not sure which one it was, the surgeon’s opinion was not to perform a biopsy on the sentinel nodes, which are the first lymph nodes that this melanoma would go to.”Howard A. Zaren, MD

Unsatisfied with this decision, Mirela was curious what her options might be in the United States. She contacted a friend who practices medicine in Hinesville, who in turn connected her with George Negrea, MD, an oncologist at the LCRP. Dr. Negrea, who is also Romanian, then connected Mirela with the LCRP’s Medical Director, Howard A. Zaren, MD.

“Mirela wanted to be staged so she could determine whether or not she needed further treatment,” Zaren says. “She came to me and said no one will operate because they don’t know where the melanoma is. I told her that it is a difficult situation because there were four lesions and there were all close together.”

However, Dr. Zaren wanted to give Mirela the chance to make an informed choice about her care.

“When it comes to a difficult case like this, we present the case to a whole group of medical oncologists,” Zaren says. “These experts come to a multi-disciplinary conference on a weekly basis for just this kind of problem.”

After presenting the case at the conference, Dr. Zaren then presented options to Mirela. Zaren notes that there was not a consensus among the team—some agreed with the surgeon in Romania, while others suggested a more aggressive approach that involved taking off a wider area around all four lesion sites and doing a sentinel node biopsy.

“I presented both options to Mirela and she chose the latter,” Zaren says. “She wanted to be sure, and the only way to be sure was if she was pathologically staged. We took a wider excision of the site, then took a sample from the sentinel nodes. All the pathology was negative, so right now she does not need any further treatment.”

“This was exactly what I wanted,” Mirela says. “I feel so lucky to have had a friend here.”

Dr. Zaren then developed a plan for Mirela that included mole-mapping.

“With mole mapping, we look at every mole that is bigger than four or five-millimeters, record it digitally and measure it,” Zaren says. “We’ll follow-up in a year and if anything changes, we’ll know it.”

Luckily for Mirela, the technology needed for her follow-up is available in Romania. But Dr. Zaren assured Mirela that her connection with the LCRP will remain open.

“She’s free to have any of her doctors call me.”

Mole-mapping: An Advanced Screening Tool

“To treat melanoma most effectively, we need to catch it when it’s local and has not spread to the lymph nodes,” says Dr. Zaren. “The issue here is a change in the mole.”

“The old way to track changes was to take a bunch of photos of the moles that caused concern,” Zaren says. “That is sort of hit-and-miss. Mole-mapping is an entire system of screening. It digitally records every mole that is bigger than 4-5 millimeters, which is about the size of a pencil eraser. Then it maps the exact location of the mole on the body.”

Nurses who are specially trained in the mole-mapping procedure are known as melanographers. Dana Coleman, who is also an Oncology Nurse Navigator at the LCRP, was one of the first to be trained.

“Our melanographer training emphasizes accurate clinical assessment,” Coleman says. “Marrying the mole-mapping technology with our clinical findings ensures a more precise screening for any change in a lesion's size, shape, color and border." 
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