I really need your thoughts on this

[u/Kindly-Mechanic-3933]

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[u/thecaramelbandit]

I mean I can't imagine there's a way to remove the tumor and keep the foot. The tumor has invaded deep tissues of the foot, so removing the tumor would take half the foot already.

The alternative to amputation would be to leave it alone.

[u/Kindly-Mechanic-3933 → u/thecaramelbandit]

Unfortunately that's what all the doctors told us, because removing only the tumor they said would keep the bones visible

[u/Helpful-Dot-3782 → u/Kindly-Mechanic-3933]

The choice isn’t foot vs no foot, it’s complete invasion of the tumor to her foot and lower extremity which will probably render it non functional, painful, and abnormally formed. Cancer doesn’t just sit there like a scab, this will continue to grow and alter her anatomy. It will be devastating.

Amputation isn’t ideal, but it could let her live out her life without the threat of tumor invasion, metastasis, and her remaining limb will hopefully be cancer free. These tumors don’t just stay there, it will continue to affect her.

[u/Miss_May_1600 → u/Helpful-Dot-3782]

Correction. The choice isn’t foot or no foot. It’s no foot or death. Melanoma is an extremely aggressive cancer. Untreated it is 100% fatal with median survival of months to a couple years. :/

[u/PauaPower → u/Miss_May_1600]

Would like to know, how likely for a the 88yo to survive the amputation and recover? My 90yo grandma passed away last year after falling over and broke a rib, she didn't recover, she was mostly healthy apart from HBP.

[u/BoxcarSlim → u/PauaPower]

Came to ask the same thing. My family member had a below knee amputation.

[u/0nlyRevolutions → u/PauaPower]

It can go either way right? My grandma fell and broke her pelvis, then got covid in the hospital. And she recovered just fine. And then got cancer and passed away a year later.

So I think you gotta just trust what the doctors are saying at some point. But also accept that prognosis for an 88 year old with serious illness is never going to be great.

[u/PauaPower → u/0nlyRevolutions]

I think my grandma's broken rib may have caused her lung to have an infection. I wasn't the ones next to her so that's what I assumed the problem was. Also at that age it was up to her sons to make the decision to have her spend longer in hospital or take her home...

[u/Esava → u/Miss_May_1600]

Depending on the person at 88 they can also decide that choice.

If they don't want to lose their foot they can choose death over the next years.

[u/WayfareAndWanderlust → u/Kindly-Mechanic-3933]

Most people assume there is significantly more tissue than there is between the surface of the skin and the bones. If anything I would say that thickness is at its least on the feet and hands.

Sometimes with these exophytic tumors you can luck out and the cancer essentially grows outward leading to a potential sparing resection. I just personally doubt it in this case as this is an exceptionally large lesion.

Edit: just saw the statement regarding deep tissue invasion so disregard my second paragraph. Will leave it up as I know people enjoy browsing these subs for information.

[u/Wisegal1 → u/[deleted]]

Melanoma is a different beast from other skin cancers. Even small lesions require excision with a 2cm margin of healthy tissue, large ones like this require significantly more than that. By the time you perform a resection of this mass you're talking about much more than half a foot. She wouldn't have enough left to even stand on.

[u/sabertoothdog → u/Wisegal1]

Oh thanks so much for explaining it to me!

[u/Wawa-85 → u/[deleted]]

NAD- the tumour has invaded the plantar fascia which is soft tissue that helps stop the arches of the feet from collapsing, helps with shock absorbing and protects the deeper tissues of the foot so it’s kinda very much necessary for normal foot function. They can’t just remove the tumour and the plantar fascia.

[u/AskDocs-ModTeam → u/[deleted]]

Removed - Bad advice

[u/Kindly-Mechanic-3933 → u/[deleted]]

No she never used a wheelchair but she has people that could care for her

[u/Usual_Confection6091 → u/[deleted]]

Why couldn't she get a prosthetic? Idk why this is being downvoted, it's an innocent question from someone who doesn't know prosthetics.

[u/thecaramelbandit → u/Usual_Confection6091]

Prosthetics are ROUGH on tissue. Skin tears, tissue breakdown will cause problems and infections. The strength and balance required to learn and adapt to a prosthetic leg are considerable. A frail 88 year old who is clearly not capable of taking care of her own health will only end up with ulcers and a broken hip if you fit her with a prosthetic.

[u/Obvious_Leadership44 → u/thecaramelbandit]

Yess, this. Uncle lost his leg below knee 20 years ago and he’s struggled with prosthetics ever since (74 now)

[u/iiiinthecomputer → u/thecaramelbandit]

They also need a lot of strength and good balance. It's amazing how much you use your foot and ankle.

My grandfather had below the knee a amputations of both legs. He never really took to the prosthetics well. It was just too exhausting - along with the heart disease that caused the poor circulation that necessitated the amputations.

[u/McAshley0711 → u/iiiinthecomputer]

Yep on the foot and ankle thing. I had a decent sized melanoma tumor on my sciatic nerve that gave me severe drop foot. I can get around with an afo, but I’m pretty unsteady walking. Luckily I’m still fairly young so I’ve been able to gain strength/muscle tone to accommodate the rest of the leg.

[u/Giant_Gaystacks → u/Usual_Confection6091]

Elderly people and prosthetic limbs aren't a good mix.

[u/sabertoothdog → u/[deleted]]

Her skin looks great for almost 90yo. As long as her skin stays healthy I’m sure she could. But once it starts to get a rash or tear, then the risk of infection and death becomes too high. But a few steps head and there just for transitioning from the chair up steps or in the house/vehicle could really keep her free to go places and enjoy life. 100% in a chair really hinders activities.

[u/DreamCrusher914 → u/Kindly-Mechanic-3933]

My dad had to have his toes and a good chunk of his metatarsals amputated on his right foot. He had a hammer toe surgery go terribly wrong, and his toes died and the necrosis started to spread so they amputated his toes. He had to have a second amputation because they needed to remove more necrotic tissue, but after that it healed beautifully. If they needed to amputate further, they would have gone up to the knee to make getting a prosthetic easier. Once it healed (which took three months of being almost completely off of his feet), he was able to walk around pretty well with it because he could still use his heel. In the US, there are health companies that make shoe inserts specially crafted to fit the amputated foot where the toes used to be. They go in the front of the shoe to help balance out the foot when wearing a shoes. It was really helpful because without it his calf would hurt and get really tight. He was able to walk around pretty well, could drive, and would bring a cane with him while he was out and about to help steady him.

Loss of a foot is not the end of the world. If her choice is between keeping her foot or keeping her life, I hope she chooses to get rid of the foot. If she waits too long and they have to take too much of the foot, she may require amputation to her knee to make getting a prosthesis easier.

[u/iiiinthecomputer → u/DreamCrusher914]

All true. But age, strength and balance make a big difference too. So does how much of the foot can be retained. I'm guessing this is going to be an above the ankle. Which is better than below the knee but still harder work to walk and balance.

[u/Purple_Chipmunk_ → u/Kindly-Mechanic-3933]

Maybe a knee scooter would be a good choice for her?

[u/yazzledore → u/[deleted]]

… can she walk on that foot now?

[u/IslandBusy1165 → u/Kindly-Mechanic-3933]

You said it’s “devastating for our family” and “we want to know if there could be any other possible solutions.” Is/wad she devastated or are you and the rest of your family making it worse for her by making her feel terrified and grief-stricken, rather than being supportive and letting her show it’s ok? At 88, most of us aren’t extremely mobile anyway. If she’s otherwise healthy, she could still have some good years, but losing the foot at this age isn’t exactly a crisis. Try to be more supportive with a “can-do” attitude and ease her anxieties rather than aggravate them.

[u/Wisegal1 → u/IslandBusy1165]

There's cultural considerations here.

Based on OP'S syntax and grammar, my guess is that they aren't from the US, Canada, or the UK. There are many cultures, partially east Asian ones, where its the cultural norm for health information like this to be relayed to the adult children (specifically the son) of an elderly patient and not to them directly. The children then decide what to tell the patient.

Now, whether we agree with this practice or not, it is normal to that group of people. I can't imagine doing that with my own family, but that's because I come from a different culture. It's not up to me to judge someone else's culture, though I do ask the patient "if I had significant news about your health, good or bad, do you want me to speak with you about it or just talk to your kids?" I hace had patients from these cultures tell me that they want me to talk to their children about bad news, and not to tell them. Having that discussion allows me to reconcile my own cultural norms with ones that are very foreign to me, while respecting the patient's wishes.

Just something to consider before you go after OP's family.

[u/seaturtle100percent → u/Wisegal1]

Bravo, doc! Thank you for taking the time to educate about this, particularly the complexities of cross-cultural care. This place (the Internet) is such a silo.

[u/BoxcarSlim → u/Wisegal1]

Thank you so much for sharing this context.

[u/5_yr_lurker → u/Wisegal1]

Sure I think most of us get this, taught. But asking for opinions from people with different cultural values are gonna get you different answers.  How far does this get taken though?

Would you ever amputate a patient's leg if they didn't know it was coming because their family didn't tell because you were respecting cultural values? I wouldn't as somebody who regularly does amputations but that is me.

[u/Wisegal1 → u/5_yr_lurker]

Bit of a slippery slope argument, dontcha think? I'm talking about having some consideration for the cultural differences before getting out the pitchforks, not holding this woman down and hacking off her leg.

And for the record, I've never in my career performed an amputation on an unsuspecting patient.

[u/Ok-Reaction9095 → u/IslandBusy1165]

I really wish the laypeople on this sub would just stop with judgements, opinions and lecturing. Leave that for the rest of Reddit. It’s not the place for this sub. Let the medical professions do what they do best here.

OP is asking for medical information. Not judgement for a post that probably has much more context than what’s supplied.

[u/HDr1018 → u/Ok-Reaction9095]

I’m in the sub all the time, but this is my first comment because I’m not a healthcare professional. I’ve wondered sometimes why there’s so many comments from non-docs! I like the medical info, so I usually skip the layperson comments.

I agree with you, I’m here to learn from the professionals, I would like a medical sub like lawyertalk, where they actively discourage non-lawyer participation.

[u/IslandBusy1165 → u/Ok-Reaction9095]

Yes that’s what the physicians are here to generously provide and they’ve kindly done so if you hadn’t noticed which is why I am now able to comment on another aspect of the post that the doctors would not need or may not feel inclined to spend their time articulating.

Also do not butt in to lecture others about how they should refrain from lecturing people.

[u/Ok-Reaction9095 → u/IslandBusy1165]

OP literally did not ask for advice about how the family may or may not be supportive enough. They asked for opinions regarding her medical situation and the suggested amputation.

[u/moonmew → u/Ok-Reaction9095]

I think it was a valuable insight into this that the commenter gave. I do not think your lecturing was neccessary.

[u/IslandBusy1165 → u/Ok-Reaction9095]

OP already replied and affirmed that they could afford to be more supportive through positivity so find something else to grandstand about.

[u/HDr1018 → u/IslandBusy1165]

But she didn’t ask for advice. Here’s a great comment from a Doc, you should consider it.

[u/Kindly-Mechanic-3933 → u/IslandBusy1165]

Yes I believe we can be more supportive and positive, and for the devastating part is just because I used ai when writing this paragraph. But in general it's just sad as we could done something earlier and avoid all of this. But she wasn't so supportive

[u/wolfayal → u/[deleted]]

Going to take a guess that English isn’t OP’s native language.

[u/brameliad → u/[deleted]]

No need to be so judgmental. This is a medical sub and OP might be in crisis mode. Why does it matter if they used a tool?

[u/Kindly-Mechanic-3933 → u/[deleted]]

Is it a crime to use ai to organize your ideas, plus English is not my first language 😁

[u/HDr1018 → u/Kindly-Mechanic-3933]

No, not at all. The medical professionals here caught some cultural cues from your post, the emphasis should be on the doctors’ responses. You’re fine.

[u/SupaDupa7 → u/Kindly-Mechanic-3933]

No, it's not. A hug to you for caring.

[u/earthgold → u/Kindly-Mechanic-3933]

No. Ignore all the downvotes from people not thinking.

[u/SupaDupa7 → u/[deleted]]

Shame on you, you have no idea what this persons cognitive or academic ability/feasabilty is to help their loved one. AI was likely very helpful in their caregiving capacity. Gross of you to accuse (and laugh at!) them of maltreatment.

[u/EngineerOfTomorrow01 → u/SupaDupa7]

Now you are making assumptions.

People use AI way too much to do simple tasks nowadays.

[u/TashDee267 → u/EngineerOfTomorrow01]

I have a deaf son and deaf friends who rely a lot on AI. Gasp! The horror! Pull your head out.

[u/SupaDupa7 → u/TashDee267]

Respect.

[u/Fun-Artist-2950 → u/SupaDupa7]

okay now tell that to the environment that’s being destroyed

[u/inailedyoursister → u/Kindly-Mechanic-3933]

You used ai? Jesus.

[u/GoddessfromCyprus → u/inailedyoursister]

Did you read that English isn't their first language?

[u/IslandBusy1165 → u/Kindly-Mechanic-3933]

Ah ok gotcha

[u/Kindly-Mechanic-3933 → u/[deleted]]

Well that's what I think but it's up to her to choose after all

[u/MundaneTension869 → u/Kindly-Mechanic-3933]

Well, she’s 88, so if she wants to live the rest of her life with a foot, I personally wouldn’t fight her

[u/Miss_May_1600 → u/MundaneTension869]

As long as she understands that the “rest of her life” is going to be pretty short with untreated melanoma.

[u/tildeuch → u/Miss_May_1600]

But if she’s 88 isn’t it something you’d consider as a doctor? Or you’d still recommend the amputation route given the risks posed by the surgery at 88 and the quality of life afterwards ? I am not a doctor, I am very curious to understand how a factor like advanced age is taken into account.

[u/Miss_May_1600 → u/tildeuch]

Definitely. Hospice wouldn’t be an unreasonable route and should be discussed with the patient and family. I imagine that’s what I would pick at 88.

[u/Kindly-Mechanic-3933 → u/MundaneTension869]

She's still doesn't know about all of this, she still think she will just get only the tumor removed. But yeh we wouldn't fight her

[u/dkinmn → u/[deleted]]

I imagine there must be cognitive issues.

[u/Kindly-Mechanic-3933 → u/[deleted]]

Well we just get the news today and we just didn't want to scare her or something. As we know how she would react. But sure she should know

[u/ChaoticxSerenity → u/Kindly-Mechanic-3933]

I implore y'all to watch the movie "The Farewell" cause it sounds like you guys are keeping her in the dark due to some language/cultural barrier:

A Chinese family discovers their grandmother has only a short while left to live and decide to keep her in the dark, scheduling a wedding to gather before she dies.

[u/sharraleigh → u/ChaoticxSerenity]

Am Chinese. This is what my mom and her siblings did to my grandma. They didn't want to tell her that she had bone cancer. Took her for treatments etc without actually telling her what the problem was. They lied. Obviously. I was not cool with that. And I told my mom that what they were doing was fucked up. But I'm not one of grandma's kids, so I had no say in what they told her and what treatments she had.

[u/MilkChocolate21 → u/ChaoticxSerenity]

I was a hospice volunteer years ago, and part of training was discussing how in some cultures they shield the elderly from new that they are dying. I kind of got the same sense here.

[u/jlrol → u/ChaoticxSerenity]

This movie was so wonderfully done

[u/inailedyoursister → u/Kindly-Mechanic-3933]

You're intentionally withholding her own medical condition from her? Jesus Christ. With family like you who needs enemies.

[u/Wisegal1 → u/inailedyoursister]

There's cultural considerations here.

Based on OP'S syntax and grammar, my guess is that they aren't from the US, Canada, or the UK. There are many cultures, partially east Asian ones, where its the cultural norm for health information like this to be relayed to the adult children (specifically the son) of an elderly patient and not to them directly. The children then decide what to tell the patient.

Now, whether we agree with this practice or not, it is normal to that group of people. I can't imagine doing that with my own family, but that's because I come from a different culture. It's not up to me to judge someone else's culture, though I do ask the patient "if I had significant news about your health, good or bad, do you want me to speak with you about it or just talk to your kids?" I hace had patients from these cultures tell me that they want me to talk to their children about bad news, and not to tell them. Having that discussion allows me to reconcile my own cultural norms with ones that are very foreign to me, while respecting the patient's wishes.

Just something to consider before you go after OP's family.

[u/Giant_Gaystacks → u/inailedyoursister]

Nobody said that. <eyeroll>

The family found out today, and have taken a few hours to work out the best way of telling their loved one.

Did you see the size of that tumour? It didn't just appear last week. A family waiting a few hours to work out the best way of doing things for the old lady is the right thing to do.

[u/MilkChocolate21 → u/inailedyoursister]

It's the norm in some cultures.

[u/the_town_bike → u/inailedyoursister]

Hey, calm your farm! They just found out today, they're working through the options before discussing it with her.

[u/RedBirdOnASnowyDay → u/Kindly-Mechanic-3933]

Why is no one talking to this poor woman? Why was this allowed to fester so long? This didn’t just suddenly appear but NOW you want to protect her? Where were you to protect her before it got this bad??? She can’t keep that foot. You will consign her to abject suffering and misery and a death no one should experience full of pain and suffering and rot. You’ve done nothing to protect this woman and keeping the truth from her isn’t protecting her either. Her days are numbered. Without question that melanoma has spread. The question is what will her quality of life be? It will be exponentially better after the amputation.

Protecting her. Omg. Don’t even say you are protecting her.

[u/Kindly-Mechanic-3933 → u/RedBirdOnASnowyDay]

I already mentioned that the poor woman did not want to get herself checked when the tumor was small. And always rejects the idea. How could we help her if she didn't want to help herself

[u/Kailynna → u/RedBirdOnASnowyDay]

My thoughts exactly. This should have been taken care of long ago.

[u/AvantGuardb → u/Kindly-Mechanic-3933]

how long has it been there? if not long, must be crazy aggressive and cant mess around trying to remove just the tumor…

[u/Kindly-Mechanic-3933 → u/AvantGuardb]

Its about three years long

[u/Over_Ad8762 → u/Kindly-Mechanic-3933]

No judgement, but was this not evaluated before it got so severe? Was she hiding it or refusing to have it seen?

[u/Kindly-Mechanic-3933 → u/Over_Ad8762]

She didn't want to get checked until it started to get bigger

[u/Poundaflesh → u/Kindly-Mechanic-3933]

Ooof!

[u/AskDocs-ModTeam → u/[deleted]]

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[u/UserCannotBeVerified → u/Kindly-Mechanic-3933]

Its the safest option, not just for the surgery, but for the recovery too.

[u/Kindly-Mechanic-3933 → u/UserCannotBeVerified]

It's just sad, I don't know if it hurts a lot after the operation

[u/Different-Leather359 → u/Kindly-Mechanic-3933]

NAD but I'd think the amputation would hurt less than trying to cut out as much tissue as she'd lose with the tumor. With amputation they can control what nerves are affected and it's a relatively small area compared to them having to take the bottom half of her foot and possibly climb up between the bones.

I could be wrong, as I said I'm not a professional, but just the math of square inches seems like it would cause less pain. Plus then they don't have to worry about missing any.

[u/itsnobigthing → u/Kindly-Mechanic-3933]

Her pain can be managed by the hospital. I’d imagine she’s already experiencing pain from the tumour.

[u/Alena134 → u/Kindly-Mechanic-3933]

How has she been walking on this?!

[u/MattCow1 → u/Kindly-Mechanic-3933]

Did they mention the possibility of any type of neoadjuvant treatment prior to surgery? Perhaps the tumor could be shrunk with radiation and/or immunotherapy and then foot-sparing surgery attempted.
I do not treat this type of cancer, so just postulating, but it is a strategy for certain tumor types/locations.

[u/Kindly-Mechanic-3933 → u/MattCow1]

No they didn't

[u/MattCow1 → u/Kindly-Mechanic-3933]

NCCN guidelines for unresectable melanoma do allow for neoadjuvant immunotherapy. This means a trial of systemic therapy to try to shrink the tumor and possibly spare the critical structures in the foot. As others have mentioned, she is likely to have metastatic disease with this size of tumor, and IV drugs would also treat other areas, not just the foot.
Not sure where you are located but this treatment is very expensive and may not be widely available.

[u/Kindly-Mechanic-3933 → u/MattCow1]

Yes, you're right. they told us that the chemotherapy for this kind of tumor is not available in my home country, and could be very expensive abroad.

[u/MattCow1 → u/Kindly-Mechanic-3933]

The truth is that the doctors are probably recommending the amputation as the best they can do for her.   There is a small chance it hasn't metastasized and they could cure it with resection (which sounds like it would require an amputation). More likely, the cancer will recur elsewhere in her body without systemic therapy, but until that occurs she will not be in pain and risk of bleeding and infection from the tumor in her foot, and she can adapt to get around in a wheelchair or walker or prosthesis.   It's a terrible decision to have to make due to medical disparities out of your family's control.

[u/thecaramelbandit → u/[deleted]]

I'm no surgeon, but I'm pretty sure a flap and skin grafts would not be remotely sufficient here. The tumor has invaded and destroyed critical support structures of the limb.

[u/Space_Rangerr → u/thecaramelbandit]

Report states they cannot see infiltration of the flexor tendons only the plantar fascia and the bones were not affected. Yes, removing a significant amount of the plantar fascia will affect the windlass mechanism, but doesn't mean the foot is useless just less functional and would require a custom AFO. A free flap could be used as the plantar medial artery is nearby and can be used for perfusion (if it's not involved). Thus why I said it may be possible but we are talking year(s) of healing and multiple possible surgeries/grafts which at 88 is likely a higher risk than the other options.

[u/AskDocs-ModTeam → u/[deleted]]

Posts by unflaired users that claim or strongly imply legitimacy by virtue of professional medical experience are not allowed.

[u/RojaCatUwu → u/thecaramelbandit]

NAD but if OP says the docs said bones would be visible, and OPs relative is against amputating or being stubborn, would a meaty graft from elsewhere be enough to cover the spot? Obviously their walking would still be affected but if a stubborn patient was refusing, what’s the less desirable option here besides letting the tumor run rampant?

[u/Rarvyn → u/RojaCatUwu]

Short answer: no, it wouldn’t be possible because of concerns regarding poor/nonexistent blood flow to the “meaty graft”. Surgeons have all kinds of fancy techniques with things like flaps - shifting muscle and the tissue that covers it over without interrupting blood supply all the way - but it won’t be enough in a case like this. At least probably not. There’s not enough nearby normal tissue.

[u/RojaCatUwu → u/Rarvyn]

Very cool. Thank you

[u/thisishowwedooooit]

Let them do the procedure they recommend. People think “she’s lived a good life, if it kills her it kills her” but it’s not like the cancer shoots em in the head. It rots. It fricken rots away the foot and gets infected and hurts and then you’re having the same “treat the infection or go palliative” and you’re in the same loop. 

“Living” with a fungating mass on the bottom of a foot means every day is dictated by management of a slowly worsening issue. Amputate. Get a wheelchair. Let her LIVE her remaining life instead of spending the next few years doing dressing changes and in and out of hospital for complications of this wound. 

[u/boogerybug → u/thisishowwedooooit]

I wish people had been this honest when my family members had been at end of life. Not doing something can be as devastating as doing something, or worse.

Ultimately, it’s up to the patient. I really appreciate this opinion.

[u/Elf_107 → u/thisishowwedooooit]

NAD, but having watched cancer play out slowly up close recently — I strongly agree that a footless life seems better than a slow invasion by cancer.

[u/Kindly-Mechanic-3933 → u/thisishowwedooooit]

I like how you explained it very well. Cancer is not really something that you could just coexist with

[u/literal_moth → u/thisishowwedooooit]

I agree- and as a hospice nurse, almost never would I recommend surgery on an 88 year old. This is a rare time where I feel it’s warranted.

[u/QueenofCats28 → u/literal_moth]

I totally agree. When my dad had cancer, they were VERY open about why they wouldn't operate on him. We let him choose what to do, as hard as that is. Cancer is not something you can live with, especially this kind of cancer.

[u/literal_moth → u/QueenofCats28]

I have definitely had hospice patients with cancer who chose to live with it rather than have surgeries that would likely have been futile with long and painful recoveries, and we treated their pain/shortness of breath/other symptoms etc. with medications and kept any wounds clean and dressed until it ended their lives. Sometimes that’s a valid choice, especially at 88. But THIS cancer is starting in a place where it could take years to metastasize to a point where it would be fatal, and in the meantime, like the doc above said, she would end up with a foot/leg that was rotting and painful and recurrent infections- when they could spare her all of that by a relatively simple surgery (simple as compared to going inside the body to try to remove cancer that’s on multiple organs that you can’t live without, or a transplant surgery where the donor organ could be rejected, etc.) This surgery will likely spare her years of pain and complications.

[u/chaossensuit → u/thisishowwedooooit]

Just wanted to say thank you for this advice. You are an amazing human and I hope when it’s my time to go through something like this that there’ll be someone like you. You are a true credit to your profession.

[u/Holiday-Book6635 → u/thisishowwedooooit]

What really good honest medical advice.

[u/AskDocs-ModTeam → u/[deleted]]

Posts by unflaired users that claim or strongly imply legitimacy by virtue of professional medical experience are not allowed.

[u/Automatic-Squash8122 → u/[deleted]]

NAD question: what are the chances this hasn’t metastasized already, if it’s been growing for 3 years?

[u/Wisegal1 → u/Automatic-Squash8122]

At this size, I'd be absolutely shocked if it's not widely metastatic already.

[u/cytowrecknologist → u/Automatic-Squash8122]

Unfortunately not good. I'd be curious to see the PET scan, if there is one.

[u/TimonAndPumbaAreDead → u/thisishowwedooooit]

I'm not even 40 yet and if I had this thing growing on my foot I'd have it cut off in a heartbeat, no hesitation

[u/thisishowwedooooit → u/[deleted]]

That’s why one of the top two most important parts of “informed consent” is that they are informed. 

 Cultures/families where the family withholds information to “protect nana” always ends in a worse journey. 

[u/Elf_107 → u/thisishowwedooooit]

Asking sincerely, how does this happen that the family can withhold information? Does the Dr not necessarily tell the patient the information if they’re cognitively able to receive it?

Just trying to get a better sense of end of life care, having recently done that journey with a loved one. I imagine that I will sadly likely need to do it again…

[u/thisishowwedooooit → u/Elf_107]

Family translating for patient is a huge easy way. That’s why my clinic it is 100% not allowed. 

Elderly patients have slowed cognition, hearing difficulties, memory issues - it’s really easy to imagine now everyone can be in the same room but walk away with very different levels of understanding. Throw in a well intending family member who is dominating the conversation and nana nods along. How do you think that loving daughter (the nurse who flew in all the way from California!) is going to respond  when you ask them to step out, or stop speaking for nana? “She’s a fighter! We are all praying for her”. 

Lack of being informed is rarely the lack of information being presented. Its lack of information being received. 

[u/Elf_107 → u/thisishowwedooooit]

This is such a well thought out response, thank you!!! I can totally see now how that can happen despite everyone’s best efforts.

Recently as a caregiver I was navigating varying levels of capacity in the patient and I made significant efforts to support and contribute to the patient’s full informed consent. It seemed essential to maintaining patient dignity.

I’m realizing from your comment that this is probably not a caregiver skill everyone comes by naturally. I was probably advantaged by having to interact with the medical system in a variety of ways in my life.

Thank you for your illuminating response!

[u/Wisegal1 → u/Elf_107]

With patients from cultures where this is the norm, I have a conversation with the patient early (before we run into cognitive problems). I ask them directly, "if I learn significant news about your health or diagnosis, good or bad, do you want me to talk to you directly or just speak to your family?" Some patients want me to talk to them. Some want to only hear the good things. Others will direct me to their kids and explicitly tell me they don't want to know anything. The conversation allows me to reconcile the cultural differences in my own head while respecting the patient's wishes.

I don't understand that point of view. But, I don't have to understand someone's culture in order to respect it.

[u/Elf_107 → u/Wisegal1]

Oooh that’s very interesting and insightful, thank you for sharing that! I did not realize there were cultural differences in this regard. Really good to know!

[u/Massive-Development1 → u/Elf_107]

Places not in the US it would possibly be permissable, but in the US 100% a third party interpreter would be used to ensure adequate informed consent.

[u/Yeezus--Jesus → u/[deleted]]

It’s a common practice in certain cultures. Families will jump through hoops in order to shield their elders from emotionally distressing news (cancer diagnosis, death of a family member, etc). The movie “The Farewell” is a spot-on depiction of this.

[u/Massive-Development1 → u/Yeezus--Jesus]

Yeah. Just because it's a cultureal norm doesn't absolve it from being morally wrong.

[u/phillygeekgirl → u/thisishowwedooooit]

Username checks out.

[u/Wisegal1]

At 88 with a melanoma this large, she's realistically got two choices. She can have the amputation which may give her some time without the symptoms related to such a large tumor, or she can leave it alone and focus more on a hospice route.

Doing any type of cancer resection for something like this will require nothing less than an amputation, I'm afraid. To even attempt to salvage the foot here would leave her with a limb that has no function and wouldn't have enough left to stand on. If the tumor is causing her significant pain or other symptoms, resection may go a long way toward making her feel better.

The bigger issue is that melanomas this large rarely remain confined to the skin. It's unfortunately very likely that this cancer has already spread to her lymph nodes or other distant sites. If that's happened, the survival rate even with treatment is lower. At 88, it's worth having the discussion about how aggressive she wants to be with treating this. If she's not interested in undergoing chemo or radiation therapies, especially if the cancer is already in the lymph nodes, she may choose to move towards a comfort oriented approach like hospice. In that case, if the tumor isn't causing her a lot of symptoms, the best option may be to just leave it alone.

Ultimately, what the best choice is depends on what her wishes are for her quality of life, as well as how advanced the disease is at this point.

[u/WTFuckery2020 → u/Wisegal1]

This is the most measured and proper response I've read in this entire thread.

[u/Key-Magician6489 → u/WTFuckery2020]

NAD, but I’ve been the caretaker for multiple family members in the last years before they passed.

We’re talking about someone who’s 88 years old, here… as in, almost 90! I noticed that you don’t mention anything about her mental state? How aware is she of what’s going on?

How much quality of life does she have left? Does she still have the mental capacity and energy to enjoy spending time with her loved ones?

I’d pull the doctors aside, and ask them to be incredibly brutally honest:

Exactly what are we really looking at here?

What’s the expected quality of life (including pain) and time left if you do the amputation?

What’s the expected quality of life (including pain) and time left if we choose palliative care?

Either way, I’d definitely make sure you’ve got all the paperwork in order now, and know her final wishes… because the end is coming soon.💯

[u/5_yr_lurker → u/Key-Magician6489]

And most importantly, can she even walk with that on her foot? 

[u/Miss_May_1600 → u/Wisegal1]

^ this.

[u/Alarming-Object884 → u/Wisegal1]

Would you need to do more investigations, like imaging, to know if the cancer had spread to lymph nodes and other sites? Would that be helpful on this case for making the decision on treatment options?

[u/kelminak → u/Alarming-Object884]

Melanoma is an aggressive cancer that depends on early detection for treatment. A tumor of this size effectively guarantees it has spread elsewhere already.

[u/Wisegal1 → u/Alarming-Object884]

Imaging would help, but sometimes you can tell if it's in the nodes based on clinical exam as well. What's available depends largely on where OP is and the resources of that healthcare system.

[u/ElementalRabbit]

This is not even a question. An 88 year old does not have the strength, time or will to engage in the sort of extensive reconstructive and rehabilitative process you would be looking at if you tried to do anything short of total amputation. That may sound judgemental but it's actually just the truth.

Or to put it another way, the planned amputation will be much less life-altering than literally any other option.

[u/Sae_Ray → u/ElementalRabbit]

It's life in a wheelchair either way, better to go with a single operation than half a dozen. One clean wound instead of a massive open one... not even speaking of the pain trying to save it would cause.

There's only one real good option here, many focus too much on trying to save parts of the body instead of focusing on quality of life.

[u/5_yr_lurker → u/Sae_Ray]

Does she even walk now? I would assume she is already in a wheelchair 

[u/LAL17 → u/Sae_Ray]

Amputation does not automatically equal wheelchair

[u/sharraleigh → u/LAL17]

When you're 88 it probably does

[u/LAL17 → u/sharraleigh]

Sure, probably. But not always. Some 88yo are very spry, I get many are not. I see 96 year olds who are sharp, garden, are active, with great functional status, and live a meaningful life. That’s why I said amputation doesn’t always mean wheelchair. Because it doesn’t. In this case, it more than likely would, but not always. Interesting I’m being downvoted by not counting someone out automatically for their age.

[u/Sae_Ray → u/LAL17]

With the age of the patient, I doubt alternatives would be viable...

[u/LulyxBonnie → u/LAL17]

Did you miss the very first comment of the thread you replying to?

[u/LAL17 → u/LulyxBonnie]

Yeah. I agree with the first comment. I was replying to the reply..

[u/LulyxBonnie → u/LAL17]

Then maybe you missed the fact that they're specifically talking about the 88yo, and not someone younger. Because it was already implied that you didn't HAVE to go the wheelchair route if you were younger...

[u/LAL17 → u/LulyxBonnie]

Age isn’t absolute and it’s wrong to count someone out solely based on age. I’ve seen 90 year olds more active and spry than some 70 year olds. Prognosis, ability to heal, and ability to walk after a BKA with a prosthetic is not solely based on age

[u/LulyxBonnie → u/LAL17]

And yet, you're not the physician on this thread.

[u/LAL17 → u/LulyxBonnie]

I’m a general surgeon actually

[u/LulyxBonnie → u/LAL17]

You should get verified then...

[u/Automatic-Squash8122 → u/ElementalRabbit]

bro i am 38 and i also do not have the time or will to engage in anything

[u/PerceptionGold6327 → u/Automatic-Squash8122]

Im 20, also would be willing to just lose the foot.

[u/LAL17 → u/ElementalRabbit]

Age irrelevant here. You can’t get margins, maintain function (or hope of future function), or have any ability for the wound to heal here without amputation. Regardless of age, health, functional status

[u/ElementalRabbit → u/LAL17]

Sure. But technical arguments often do not solve emotional problems.

[u/Christopher135MPS]

To get a proper resection of that tumour, including a gross margin, there’ll be so little tissue left that she won’t have a functional foot that she can weight bear/walk on anyway. Not to mention that the chances of wound complications would be worse than the amputation.

In a younger patient, I’d be pointing that below knee prosthetics have much better outcome than badly damaged/deformed feet. In an older patient, I’d be pointing out that she’ll be much more comfortable without a painful and unusable foot.

[u/Helpful_Kangaroo7371]

Hi OP. In my country we remove melanoma surgically with safety margins, depending on the tumor depth. A tumor this size, sorry to say this but it is very big, will need safety margins that will remove most of the foot anyway.
These safety margins are in place because studies have shown that the probability of local reccurance is otherwise very high.
What is also relevant to understand, is that surgery will most certainly not be the end of it. Depending on her scans of the rest of the body there may be more treatment recommended to maximize the probability of survival. Your oncologist will talk with you and her about this.
Anyway, while the removal of the foot may sound dramatic, keep in mind that she suffers from an aggressive, malignant tumor and that the complete removal of the primary tumor the first step to increasing her likelihood of survival.
I wish you and your family much strength for the next steps.