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‘They Saved My Life’: An Unexpected Melanoma Diagnosis After Kidney Scan

May 21, 2021

At the end of 2018, Al Bingham, an otherwise healthy 74-year-old, developed low back pain and a fever. With Bingham’s history of kidney stones, his primary care physician ordered an ultrasound that, instead, showed a mass above the kidney where the adrenal gland sits.

A CT scan showed this baseball-size tumor in the gland, but also a similar mass in his left lung. Although he never smoked in his life, some specialists thought he had lung cancer that had spread to the adrenal gland.

Dr. Mario Katigbak, Chief of Thoracic Surgery at Hartford Hospital, did the requisite biopsy of the lung mass. To everyone’s surprise, the cancer was a metastasis from melanoma, a dangerous tumor derived from the pigment cells in the skin. This patient did not recall a history of melanoma of the skin. Extensive evaluation did not reveal a primary melanoma in the skin, eyes, or other areas.

“Well, that just blew us all away,” Bingham said. “I never had any sign of skin cancer anywhere.”

The patient then met Dr. Omar Eton, a melanoma expert for more than 30 years and Medical Director of Hartford HealthCare’s Cancer Institute’s new Cutaneous Melanoma and Skin Cancer Center, part of Hartford HealthCare’s alliance with Memorial Sloan Kettering Cancer Center. Eton said that while unusual, Bingham’s case is referred to as  “melanoma of unknown primary.”

“Molecularly, the tumor had a signature consistent with sun (ultraviolet light) exposure  so he probably had a skin melanoma somewhere, and his own immune system likely eradicated it,” Dr. Eton said. “But some of those cancer cells escaped his immune system, and metastasized elsewhere.”

The prognosis was pretty grim — patients typically live about eight months after diagnosis with two visceral organs involved (lung and adrenal gland). Dr. Eton invoked a frontline combination regimen of two immunotherapy agents he had been using for years but which, coincidentally, were Nobel Prize-winning in the fall of 2018. Furthermore, because clinical trials often can provide an optimal venue, Eton elected to enroll the patient in a frontline trial out of Memorial Sloan Kettering Cancer Center, testing an adaptive dosing strategy for the two agents.

So in January 2019, Bingham began infusions of two drugs, ipilimumab and nivolumab, which are antibodies that  stimulate the inherent ability of  the patient’s own immune cells  to attack the tumor cells.

Because melanoma can be the deadliest form of skin cancer once it spreads, the new Cutaneous  Melanoma and Skin Cancer Center brings together an expert team of aggressive melanoma fighters from several specialties, including surgical oncology, cutaneous oncology, surgical subspecialists (such as head and neck), plastic surgeons, medical oncology, radiation therapists, interventional radiology and ophthalmology (for eye melanomas).

“As a new center of excellence  for melanoma in the Northeast in the alliance with Memorial Sloan Kettering,” Dr. Eton said, “we also engage in collegial relationships with local and out-of-state cancer centers and with Industry – with the goal to make it easier for patients to be treated locally, avoiding costly and logistically challenging travel to New York or Boston or other states.

Besides the potential magic of anti-cancer  immunotherapy which has both extended survival and quality of life for a majority of patients, another major development has been the discovery of tumor “driver mutations” that now can be targeted with pills.  Hence, the melanoma program routinely identifies molecular factors that could prove lucrative now or even in the future when new treatments emerge. Importantly, Dr. Eton noted, from the patient’s perspective, that “lives are being extended to years rather than months and these are good years. They are quality of life years. That’s what’s so dramatic about these treatments.”

Three months after starting treatment, Bingham’s CT scans showed the tumors were shrinking. This means his own immune system was now seeing and killing billions of his own tumor cells – this being done naturally, quietly, without symptoms. But as would be expected from treatments that override self-tolerance, the patient’s lymphocytes were also attacking his lungs, causing “pneumonitis” which could be life-threatening if not detected early.

To manage the cancer and the side effects, Bingham proved the ideal patient and partner in his care. A retired CPA and corporate chief financial officer, Bingham said “spreadsheets have always been my thing.” He started collecting data on himself, his daily temperature, blood pressure, oxygen saturation rates before and after walks, number of steps  and miles walked per day. This allowed Eton to precisely dose the prednisone to manage the  pneumonitis while  Bingham continued the monthly treatments for two years.

“That information helped us successfully navigate him through the pneumonitis,” Dr. Eton said.

Bingham also developed vitiligo, patches of white skin together with white eyelashes and eyebrows – all reflecting that one of the targets of the immune response against his melanoma was likely a target in the pigment (melanin) pathway.

Scans taken in December 2020 showed not only that the tumors had each shrunk significantly, but that no new cancer had appeared. Yet the residual masses remained sizeable, approximately the size of a quarter and a dime respectively (they were the size of a baseball at baseline).  The multispecialty  team, with the blessing of colleagues at Memorial Sloan Kettering, opted to remove both.

Katigbak performed a wedge resection, removing the lung mass  in January 2021, and the histology  revealed no residual cancer, just a lot of scar tissue. Dr. Stephen Shichman, Physician-in-Chief of Hartford HealthCare’s Tallwood Urology & Kidney Institute, then removed  the  adrenal mass  laparoscopically in March 2021. Again, no residual melanoma was found, just scar tissue.

“This immunotherapy treatment allowed his own immune system to kill the cancer,” Eton said. “Ipilimumab and nivolumab eradicated the tumors completely.”

Bingham, now 76, is returning to normal life and will, of course, be monitored by his primary care doctor, a dermatologist, and his cancer team.

“They saved my life,” he said.