Dream team spares surgeon’s thumb – and career – from aggressive melanoma
April 26, 2023 | Jill Clendening
G. Lee Bryant Jr., MD, remembers when he first noticed something odd about his right thumb. In December 2016, a streak of redness appeared under his thumbnail, and splitting at the nail’s end never seemed to resolve.
That concern – and the path it put him on – ultimately led Bryant to create a blog to share his experiences as a surgeon turned patient. His blog posts, totaling more than 25,000 words, have now had more than 10,000 views by readers from all over the world. And some of those readers have received life-preserving medical diagnoses as a result of his candor.
Bryant was worried his thumb issues might be a sign of subungual acral melanoma, a rare but aggressive skin cancer that appears under the nails of the toes or fingers. Subungual means “under the nail.” Acral means it relates to peripheral body parts such as fingers and toes. This form of melanoma is challenging to spot and can stealthily metastasize to other parts of the body.
Subungual melanomas make up an estimated 0.7% to 3.5% of all melanomas. In contrast to cutaneous melanoma, this type of cancer is more common in individuals with more highly pigmented skin, such as persons of African American and Asian descent.
Bryant knew the first course of treatment for such a melanoma would likely be the amputation of his thumb. As a right-handed surgeon at Allergy & ENT Associates of Middle Tennessee, a surgery to save his life might also end his career.
Bryant went to a dermatologist who biopsied his nail. He was caring for his own patients when he received word a few days later that the tissue was negative for melanoma. After learning the good news, Bryant ducked into an empty exam room and cried.
But that’s nowhere near the end of the story. His thumbnail never quite grew back normally. It was irregularly shaped with some discoloration, though it still lacked the dark or black hue often present with melanoma. Over the next five years, Bryant consulted several medical professionals who offered benign explanations for the nail’s chronic inflammation. He often heard the unnerving reassurance that because of how long the changes in his thumbnail had been present, if it was melanoma, he most likely wouldn’t still be alive.
So, he kept living. Bryant was enjoying a thriving surgical practice of more than two decades, and he was celebrating milestones with his wife, Kellee, their two adult children and their young families. He took time for his favorite pastimes of golf, horseback riding, working on the family farm and fishing. He was even training for a triathlon.
Then, one day — specifically, July 16, 2021 — he got a nudge that might very well have been divine.
“I still felt like something was wrong,” Bryant said. “After all the patients had left the clinic, I don’t know if it was God, but I just had an overwhelming urge to biopsy this. Working alone and one-handed, I removed part of my nail, took a biopsy and then cauterized my own finger. I put the tissue in a specimen vial, labeled it and left it on my nurse’s desk. That’s the true story.”
Less than a week later, Bryant was again completing surgical cases when a pathologist called. This time, melanoma was clearly present. In fact, the entire specimen was tumor, with evidence of high mitotic activity or cell division.
Overwhelmed and numb with shock, Bryant knew he needed to act quickly. He had attended Vanderbilt University School of Medicine, then completed a general surgery internship and an otolaryngology/head and neck surgery residency at Vanderbilt University Medical Center. He knew where to find the experts.
Call for Help
One of his first calls was to Doug Weikert, MD, chief of the Division of Hand & Upper Extremity in the Department of Orthopaedic Surgery. The men were colleagues, friends, and even neighbors, and through the years they often met on the bleachers at their children’s athletic games. Bryant also shared the tough news with one of his mentors, James Netterville, MD, a co-founder of VUMC’s Department of Otolaryngology and the Mark C. Smith Professor of Neck Surgery.
Weikert specializes in surgeries to help patients retain or regain function after an injury or a life-preserving surgery to remove cancer. A team approach to surgery was needed for this case, so Weikert quickly connected Bryant with Ginger Holt, MD, chief of Orthopaedic Surgery’s Division of Musculoskeletal Oncology. Holt specializes in removing cancerous tissue with the primary goal of reducing the risk of recurrence while preserving as much function as is prudent.
Holt had also learned about Bryant from Netterville, who gave her the heads-up that a member of Vanderbilt’s surgery family needed assistance. Because of Bryant’s history with the angry nail and the troubling initial pathology report, Holt felt fairly certain she would at least remove his thumb down to the first joint.
“As hard as it is to tell someone ‘Hey, we’re going to remove part of your hand,’ it does take time and experience on the part of a surgeon to say, ‘Let’s be definitive and do a really strong surgery to get you out of this mess,’” she said.
Before surgery, Bryant met with another key member of his medical team, his oncologist, Douglas Johnson, MD, MSCI, associate professor of Medicine, holder of the Susan and Luke Simons Directorship, and director of Precision Oncology at Vanderbilt-Ingram Cancer Center. Johnson’s specialty is melanoma, specifically developing and understanding biomarkers for immune and targeted therapeutics and developing clinical trials for melanoma patients. Johnson counseled Bryant on the best evidence-based path ahead, and they discussed how treatment decisions would be made moving forward.
“Of course, it’s a very big deal when surgeons have to think about taking part of a patient’s finger off, and so we talked a little bit about that,” Johnson said. “There have been studies that suggest that trying to do some sort of digit-sparing operation could theoretically be feasible, but there is concern that doing so is associated with bad outcomes — with higher rates of recurrence.”
Johnson ordered an MRI of Bryant’s brain as well as a full body PET/CT scan. Because Bryant had been having issues with his thumb for many years, there was reasonable concern that the scans would reveal other areas of cancer. If so, the melanoma would be classified at a higher stage, which typically means a bleaker prognosis. Bryant remembers praying continually throughout the hours he lay in perfect stillness as the machines took detailed images of every inch of his body.
“At that point, I knew I was going to lose all or part of my right thumb, and I knew that there was a high chance that I had stage 4 disease, which has a high mortality rate,” Bryant said. “All of those things were running through my mind.”
In his blog, Bryant wrote: “I found myself back at the large academic medical center in town where I had trained for 10 years (four years of medical school and six years as a resident physician). But now, instead of being a caregiver, I was the patient. Becoming the patient was a somewhat humbling experience!
“After answering the medical questionnaires and filling out all the demographic information, I was asked to remove my clothing and put on a hospital gown. Before meeting with the first surgeon, I was escorted down the hall by a nurse to get a plain film (X-ray) of my thumb. I sat in a little waiting area with two other patients who also were wearing the same attire: hospital gown, underwear and socks. It seemed surreal that just a few days ago I had been treating my own patients.”
The X-ray showed that the distal phalanx of the thumb, or the bone farthest from the palm, had no evidence of tumor involvement, and the MRI and PET/CT scans came back clear. These results helped surgeons better plan what would happen in the operating room.
VUMC surgical oncologist Mary Hooks, MD, MBA, who has since retired, met with Bryant as she would be performing a sentinel lymph node biopsy under his right arm which would also help guide decision making. If melanoma cells are found in the excised sentinel node during an immediate analysis by a pathologist, additional lymph nodes are evaluated to determine if they also contain melanoma cells. If no melanoma cells are found, then surgery is not extended to a greater area.
“Dr. Hooks, Dr. Weikert and Dr. Holt all made me feel extremely comfortable in the room,” Bryant remembered. “I was a person to them, not just a melanoma. Dr. Hooks touched me, she looked me in the eye and said, ‘You’re going to be OK.’ Those three surgeons are all very compassionate and empathetic. They are really the ‘whole physician.’ I was blessed to have that crew.”
Weikert said knowing he was operating on a fellow surgeon with a challenging diagnosis impacting his dominant operating hand was tough, but he stressed that a functional surgeon’s job is to perform the surgery to preserve function once the oncological surgeon has removed the cancerous tissue, no matter who the patient might be.
“When it comes right down to it, you have to focus on the problem at hand and not worry about all the social noise around it,” Weikert said. “What I tell people is, if I’m going to build a hand, I’m going to start with a thumb because the thumb is about half of what the hand’s worth. If you think about what the hand does, it mostly pinches and grips, and you have to have a thumb to do both of those things. Maybe not the entire length of the thumb, but every millimeter counts.”
Holt removed the end of Bryant’s thumb up to the first joint, working meticulously to achieve clear margins or no cancer cells at the outer edge of the removed tissue. She then took the tissue to the nearby pathology suite so it could be analyzed immediately. An innovative method of creating a three-dimensional model of the specimen allowed pathologists and Holt to also examine the excised tissue, with minimal degradation, in relation to its former location in the thumb.
“It’s a really big deal to be able to go to the pathologist immediately and look at it together under the microscope,” Holt said. “We tell the pathologist what we think the close margins might be, where there might be a concerning area. It just makes it much better because we’ve studied the scans, and we’ve been in the surgery. Then I go back into the operating room, and if there’s anything I’m still concerned about, we can take care of it.”
While Holt studied the tissue in pathology, Weikert stepped in to begin his portion of the surgery, the reconstruction.
“It’s nice to be together on the front end to know exactly what we’re both doing,” Holt said. “As I go look at the pathology, he can begin the process of putting the thumb back together again, covering and closing.”
Weikert’s goal was to maintain the longest possible thumb for Bryant and provide a smooth, soft-tissue padding over the thumb’s new end.
“Neuromas happen when nerves get cut in healthy people that can regenerate nerves,” he explained. “When we cut a nerve, we expect that nerve to try to sprout and grow. And if that sprouting nerve gets trapped in scar tissue, then it becomes sort of a lightning rod. Every bit of pressure, every pinch grip, fires off that nerve and causes it to hurt. So, a painful stump, regardless of the length, is not good enough, especially with what Lee needs to do with his thumb. It’s important to create a healthy, padded tip over whatever bone is left so the patient can maintain pinch strength and grip strength from then on.
“The end of the bone has to be contoured to a smooth surface, and then when we’re dissecting out nerves and handling tissue as we begin reconstruction — whether it’s a skin edge or a nerve ending or a blood vessel — we have to be delicate. That’s one of the things that separates hand surgeons from other subspecialties. Everything has to be relatively intact when you put the skin over and cover up the bone.”
To avoid tension on both the nerve and the skin, Weikert used a technique called a Moberg flap to gain additional skin length to better cover the bone’s end.
“When Dr. Weikert reconstructed my thumb, it was important that I would still have feeling in my thumb so I could use surgical instruments,” Bryant said. “If I didn’t, I couldn’t do my job. It was important that I have sensation but also that I didn’t develop phantom nerve pain.”
Typically, at six weeks following surgery, it is clear if a pain/nerve issue is developing, Weikert said. At that point, he begins telling patients to call upon their inner streak of OCD (obsessive-compulsive disorder) and begin regularly massaging the surgery site to stimulate nerves, break up scar tissue and eliminate stiffness.
“I tell patients you can put cocoa butter, vitamin D, or you can put peanut butter on there if you want, as long as you massage it,” he said. “There’s a certain amount of what I call pep talks that usually have to be given along the way. Lee didn’t need one.”
Because the melanoma was deep and there was high mitotic activity, Johnson recommended immunotherapy following surgery to reduce the risk of recurrence. A class of drugs called PD-1 inhibitors, which help restore the T cells of the immune system and prevent deactivation of T cells by tumor cells, are the best line of defense with melanoma.
“Melanomas that start on the hands and feet or the nail beds tend to be very aggressive,” Johnson said. “They tend to have a higher rate of recurrence, and that can be a local recurrence in the same general area, or it can come back in lymph nodes, or it can come back in organs. Dr. Bryant and I had a long discussion about whether any additional treatment might be useful. He ended up receiving immunotherapy for a full year, and he did very, very well and has done well so far.”
Bryant’s first five intravenous treatments with Keytruda (pembrolizumab) were scheduled three weeks apart and the last five treatments, six weeks apart, as long as he tolerated the therapy well. Ironically, Bryant had resumed training for a triathlon as a way to combat increasing fatigue caused by the therapy when a serious bicycling accident landed him in VUMC’s Trauma Intensive Care Unit. He had multiple injuries including broken ribs, a collapsed lung, bilateral pulmonary contusions and a mediastinal hemorrhage.
The bike wreck paused Bryant’s treatment schedule by a few weeks, and his medical team and family encouraged him to take it a tiny bit easier.
Treatment with a PD-1 inhibitor comes with the risk of serious side effects and toxicities, and it can cause the immune system to attack healthy tissue and organs. Some negative effects include interstitial pneumonitis, colitis, hepatitis, thyroiditis, skin reactions, low levels of platelets and white blood cells, inflammation of the brain or spinal cord, adverse neuromuscular events, myocarditis and cardiac insufficiency, acute adrenal insufficiency and nephritis. Common side effects include nausea, fatigue, muscle pain, bone pain and brain fog.
While he was undergoing treatment, two of Bryant’s own patients were hospitalized with serious complications from the same immunotherapy. He said becoming a patient himself with this lengthy treatment regime gave him a new level of empathy and compassion for others in similar circumstances. And he learned firsthand how exhausting and emotional navigating countless treatment and imaging appointments can be.
“I get emotional thinking about the patients for whom I have cared over the years,” he wrote in his blog. “For many years, I remember how I revealed various diagnoses to them; how I walked with them through valleys and mountaintops; how I was a part of helping many head and neck cancer patients achieve victory over their cancer; and how I have laughed, hugged and prayed over them. And I cannot express how supportive they have been to me, now returning the favor.
“Many patients follow this blog, and I have been hugged and prayed over too numerous times to count in my clinic since my diagnosis. The physician-patient relationship was transformed and deepened in many circumstances. It has been an interesting period of my life, in which I am a patient for a few days, then I regroup and become a physician again for a short time, and then repeat the process.”
Bryant began retraining himself to use his new “half-thumb.” At first it was achieving routine tasks like buttoning his shirt or holding a spoon. He used a training board with a silicone panel to mimic tissue so he could practice surgical sutures. He picked up the familiar tools of an otolaryngology/head and neck surgeon — scopes and surgical instruments — and retaught his hand the skills he had spent decades perfecting. He started back slowly, first seeing patients for in-office scopes and other minor procedures.
Still a Surgeon
“When I came into the OR for the first operation after being out for so long, I cried; the nurses cried,” Bryant said. “We all cried. I was back.”
When he was diagnosed with melanoma, Bryant told his co-workers they could let patients know he was out on medical leave. But he knew that vague statement would bring more questions and worry, especially for individuals and families he’d been seeing for years. A friend helped him set up his blog, and in September 2021 — unsure if he could find the words to adequately convey the experience of becoming a patient — he began writing.
“I didn’t know if it was professionally a good move or not, but I thought I would be completely transparent with a perspective of a physician turning patient and maybe educate some people as I was going through it,” Bryant said. “My patients were so concerned and were clamoring to know what was wrong with me. They were really happy they could follow along with my progress. So, I just did it.”
In September 2022, Bryant was honored with a Board of Governors Practitioner of Excellence Award presented by the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS). In a statement from the AAO-HNS, Bryant’s blog was recognized, and he was noted as being “an inspiration to all by refusing to give up and striving to overcome his physical obstacles while continuing to demand and deliver excellence in patient care.”
Today, Bryant returns to VUMC for routine scans to monitor for any cancer recurrence and office visits with Johnson. He plans to continue his blog to encourage others to maintain a balanced, healthy lifestyle, including regular physical activity and a healthy diet. He hopes by doing so he can help others reduce their risk of cancer and other illnesses. Bryant has also provided philanthropic support to the Melanoma/Skin Cancer Fund at Vanderbilt-Ingram to help advance research and ultimately lead to new therapies and treatments for patients. He admits there were some low points along his journey that made sharing his thoughts and feelings incredibly challenging. But he would do it all again.
“There have been several patients who sought care, and some have been diagnosed with melanoma as a result of reading my blog,” he said. “They’ve left comments like, ‘Going to get a biopsy.’ So that’s made it all worth it right there.”