Seeking Solutions in the Midst of Uncertainty

One by one, treatment options fell by the wayside. Reviewing images of Gayla Farrar’s tumor—a rare mucosal melanoma running through the nasopharynx—the nearly 20 physicians gathered at the Department of Otolaryngology, Head and Neck Surgery’s weekly Tuesday tumor conference quickly agreed on what they couldn’t do.

Surgical removal was out of the question, considering how perilously close the melanoma sat to the carotid artery. As for chemotherapy, the literature rated it a longshot at best in cases like Farrar’s. Other drug-treatment possibilities ranged from too new to too unproven to both. That left standard radiation therapy, which should slow such a tumor down but probably couldn’t deliver a full cure.

“This was a very unusual melanoma, one of those situations where it’s genuinely uncertain how best to proceed,” recalls Otolaryngology Chairman Charles Cummings, M.D. “Hopkins is a place where the unusual surfaces quite a bit, so we get a broad exposure to questions of management.”

In Cummings’ view, such cases are tailor-made for the multidisciplinary approach favored in otolaryngology, head and neck surgery and so many other Hospital departments. “When you get all the players in one room winnowing out the best thoughts, it makes a real difference,” he says.

Faced with an uncommon case, Farrar’s doctors eventually decided to try an uncommon treatment. They’d launch a double-barreled attack on the melanoma by first surgically implanting radiation seeds in strategic spots and then, while the seeds were sprouting, bombarding the tumor with a standard round of radiation.

For the patient, it would mean a rough few weeks, filled with painful side effects, uncomfortable treatments and overly long hospital visits. Cummings recalls Farrar as an “extraordinarily good soldier” during that period. “There’s going to be some substantial down times during a treatment like that,” he says, “but there can be good times at the end of the process. You have to pay your dues, but you can get better.”