Adequate Margins?

Thank you.  I understand that to perform EXCISION of a Stage 1 tumor, the recommendation is 1 cm margins for Stage 1.

Rather than excision guidlines my question refers to pathology results AFTER excision:   

If pathology report shows the tumor has been "completely excised" but the margin is "very narrow"- what margin IS adequate?

Unless a biopsy has been done, the surgeon performing the excision has little more to go on to provide adequate EXCISION margins than a superficial observation of the tumor and presumed healthy tissue margin surrounding it.   Depending on presumed thickness, as you say for Stage 1 the doctor establishes either a .5cm or 1.0cm margin.

However, the pathology report is no doubt far more accurate than the naked eye.   And (just guessing), it may well show- as in my case- a margin of healthy tissue significantly reduced from the excision margin the surgeon employed.

So the question is:   What are recommended margins for a Stage 1 tumor based on the pathology report AFTER the excision has been made?    Despite the difficulty the surgeon has in predicting adequate margins compared with the pathology report, it seems likely margins apparent after a microscopic evaluation would be reduced from those the surgeon used to make the excision.

I've looked everywhere online, called several national melanoma hotlines, but have so far not found a reply.   All I know is that "very narrow margins" and "completely excised- although narrowly" seems vague to determine the need for re excision.

Thanks for your help.

Thanks very much for your reply.   Very interesting. 

On your first point, neither of the two Brazilian pathology reports on my lentigo maligna melanoma excision of two years ago mentioned "margins".   The San Diego pathology report on my current, superficially spreading melanoma also does not.   Unless we can call "very close to the lateral margin… excised completely albeit with very narrow margins."-  scientific.  Maybe you can interpret what this means, I cannot.   Does "completely excised" preclude the existence of diseased cells within the "very narrow margins" or in fact beyond?   Who the hell knows?

These pathology phrases are so vague, I have no idea whether to have another excision before the sutures of the first excision are removed.   Seems to me we need some "numbers".    Do you agree? 

As far as I can tell the dermatologist chose 5mm margins because she had no biopsy beforehand to stage the tumor and imagined for some reason it was "in situ".    Instead of the 10mm (1cm) margins recommended for the epidermal and "dermis filled and expanded" spreading melanoma it turned out to be.   Although the surgeon based margins on the naked eye, I specifically asked that encision margins be made very generous.   I even tried to reassure the surgeon that aesthetics were unimportant.   Either she didn't believe me or for some reason believed the growing tumor I tracked for eight months was an "in situ".    Or both.   In contrast with my controversial post "Overtreatment?", perhaps a case of "Undertreatment"?   That's a laugh, but I can tell you I'm not happy.

Your last paragraph on pathology differences between biopsies and excisions much appreciated.   As mentioned, the pathology reported "completely excised".    Not sure what your reference to "8mm of tissue" refers to, sorry.  

The surgeon has already advised she'd like to do a second encision.   Instead, I have asked for quantification of histologic margins before considering this.   Your comments on shrinkage, etc may come in handy.        

Thanks very much for your comments.   Anything else you'd like to add would be most welcome.

Thanks very much for your reply.   Very interesting. 

On your first point, neither of the two Brazilian pathology reports on my lentigo maligna melanoma excision of two years ago mentioned "margins".   The San Diego pathology report on my current, superficially spreading melanoma also does not.   Unless we can call "very close to the lateral margin… excised completely albeit with very narrow margins."-  scientific.  Maybe you can interpret what this means, I cannot.   Does "completely excised" preclude the existence of diseased cells within the "very narrow margins" or in fact beyond?   Who the hell knows?

These pathology phrases are so vague, I have no idea whether to have another excision before the sutures of the first excision are removed.   Seems to me we need some "numbers".    Do you agree? 

As far as I can tell the dermatologist chose 5mm margins because she had no biopsy beforehand to stage the tumor and imagined for some reason it was "in situ".    Instead of the 10mm (1cm) margins recommended for the epidermal and "dermis filled and expanded" spreading melanoma it turned out to be.   Although the surgeon based margins on the naked eye, I specifically asked that encision margins be made very generous.   I even tried to reassure the surgeon that aesthetics were unimportant.   Either she didn't believe me or for some reason believed the growing tumor I tracked for eight months was an "in situ".    Or both.   In contrast with my controversial post "Overtreatment?", perhaps a case of "Undertreatment"?   That's a laugh, but I can tell you I'm not happy.

Your last paragraph on pathology differences between biopsies and excisions much appreciated.   As mentioned, the pathology reported "completely excised".    Not sure what your reference to "8mm of tissue" refers to, sorry.  

The surgeon has already advised she'd like to do a second encision.   Instead, I have asked for quantification of histologic margins before considering this.   Your comments on shrinkage, etc may come in handy.        

Thanks very much for your comments.   Anything else you'd like to add would be most welcome.

Thanks very much for your reply.   Very interesting. 

On your first point, neither of the two Brazilian pathology reports on my lentigo maligna melanoma excision of two years ago mentioned "margins".   The San Diego pathology report on my current, superficially spreading melanoma also does not.   Unless we can call "very close to the lateral margin… excised completely albeit with very narrow margins."-  scientific.  Maybe you can interpret what this means, I cannot.   Does "completely excised" preclude the existence of diseased cells within the "very narrow margins" or in fact beyond?   Who the hell knows?

These pathology phrases are so vague, I have no idea whether to have another excision before the sutures of the first excision are removed.   Seems to me we need some "numbers".    Do you agree? 

As far as I can tell the dermatologist chose 5mm margins because she had no biopsy beforehand to stage the tumor and imagined for some reason it was "in situ".    Instead of the 10mm (1cm) margins recommended for the epidermal and "dermis filled and expanded" spreading melanoma it turned out to be.   Although the surgeon based margins on the naked eye, I specifically asked that encision margins be made very generous.   I even tried to reassure the surgeon that aesthetics were unimportant.   Either she didn't believe me or for some reason believed the growing tumor I tracked for eight months was an "in situ".    Or both.   In contrast with my controversial post "Overtreatment?", perhaps a case of "Undertreatment"?   That's a laugh, but I can tell you I'm not happy.

Your last paragraph on pathology differences between biopsies and excisions much appreciated.   As mentioned, the pathology reported "completely excised".    Not sure what your reference to "8mm of tissue" refers to, sorry.  

The surgeon has already advised she'd like to do a second encision.   Instead, I have asked for quantification of histologic margins before considering this.   Your comments on shrinkage, etc may come in handy.        

Thanks very much for your comments.   Anything else you'd like to add would be most welcome.

Replied, but lost again…

Replied, but lost again…

Second "Reply":  The first was somehow 'lost' when posting.   Recap, briefly to avoid rewriting >>>

Very interesting, thanks.    With such information and direct experience so kindly shared, this is truly a wonderful venue.

Guesswork:   I understand.  It's something we have to live with.   As my doctor in Rio put it:   "Medicine is Art + Science.  Mostly Art."   That is, insight, which is often (not always) gained through experience.   I am just beginning to learn about melanoma, yet I spotted the first, Lentigo Maligna Melanoma 2 years ago.   As well as this one, which just, well, "looked like" what it turned out to be.   After tracking its (apparently) slow growth 8 months, a Superficially Spreading Melanoma.   Irregular, diffuse edges of varying color density.

Allowances for guesswork are important.   But still, it is hard to understand why a dermatologist-surgeon would choose 0.5mm margins appropriate to an "in situ" Stage 0.   Instead of 1.0cm margins used with Stage 1 ≤1.0 Breslow thickness.  Besides,  I made a point of requesting generous margins- precisely in the attempt to avoid any doubt.

I am sure you are right that excision with adequate margins is fundamental.   This is why the report's "very narrow margins" suggests its assertion the melanoma "has been completely excised" lacks credibility.   With this and your comments on the usefulness of wide, rather than narrow margins, have you a comment on the margin ambivalence results of this study of IIA-C patients?    I gather this subject has been trending upward in oncology circles.   Of course the study focused on 2 vs 4cm margins (a 1cm vs 2 cm study is planned), so it is certainly not conclusive for ≤1.0mm tumors.  Still, with "Medicine as Art" in mind, what do you think?

http://www.cancer.gov/clinicaltrials/results/summary/2011/smaller-margin1211

Prior to excision, I asked for two independent pathology reports.   My request is likely a moot issue now, due to inadeqaute margins and the report's consequent ambiguity.   Also, there is the inevitable tissue disturbance and initial lab work tissue shrinking that you described.   

Thanks for sharing your father's story.  This is truly daunting.    Besides, most of us would have chosen exactly the same course of action.   Please wish him well.   You mention SNLBs' were unavailable with your first melanoma.   Yet another issue that since those days has become 'controversial'?    They are not apparently not "therapeutic", useful strictly for Staging and prognosis.   The concern is they are overprescribed or prescribed too early for most thin melanomas.  Studies show SNLB's offer no survivability advantage.

I forget what else I posted before it was lost, so…

Chances are I will take your advice and have it re-excised to increase margins, stop my grumbling and just get on with it.   Oncology is changing so very quickly.   The problem, of course, is that melanoma changes very quickly, as well.   

Second "Reply":  The first was somehow 'lost' when posting.   Recap, briefly to avoid rewriting >>>

Very interesting, thanks.    With such information and direct experience so kindly shared, this is truly a wonderful venue.

Guesswork:   I understand.  It's something we have to live with.   As my doctor in Rio put it:   "Medicine is Art + Science.  Mostly Art."   That is, insight, which is often (not always) gained through experience.   I am just beginning to learn about melanoma, yet I spotted the first, Lentigo Maligna Melanoma 2 years ago.   As well as this one, which just, well, "looked like" what it turned out to be.   After tracking its (apparently) slow growth 8 months, a Superficially Spreading Melanoma.   Irregular, diffuse edges of varying color density.

Allowances for guesswork are important.   But still, it is hard to understand why a dermatologist-surgeon would choose 0.5mm margins appropriate to an "in situ" Stage 0.   Instead of 1.0cm margins used with Stage 1 ≤1.0 Breslow thickness.  Besides,  I made a point of requesting generous margins- precisely in the attempt to avoid any doubt.

I am sure you are right that excision with adequate margins is fundamental.   This is why the report's "very narrow margins" suggests its assertion the melanoma "has been completely excised" lacks credibility.   With this and your comments on the usefulness of wide, rather than narrow margins, have you a comment on the margin ambivalence results of this study of IIA-C patients?    I gather this subject has been trending upward in oncology circles.   Of course the study focused on 2 vs 4cm margins (a 1cm vs 2 cm study is planned), so it is certainly not conclusive for ≤1.0mm tumors.  Still, with "Medicine as Art" in mind, what do you think?

http://www.cancer.gov/clinicaltrials/results/summary/2011/smaller-margin1211

Prior to excision, I asked for two independent pathology reports.   My request is likely a moot issue now, due to inadeqaute margins and the report's consequent ambiguity.   Also, there is the inevitable tissue disturbance and initial lab work tissue shrinking that you described.   

Thanks for sharing your father's story.  This is truly daunting.    Besides, most of us would have chosen exactly the same course of action.   Please wish him well.   You mention SNLBs' were unavailable with your first melanoma.   Yet another issue that since those days has become 'controversial'?    They are not apparently not "therapeutic", useful strictly for Staging and prognosis.   The concern is they are overprescribed or prescribed too early for most thin melanomas.  Studies show SNLB's offer no survivability advantage.

I forget what else I posted before it was lost, so…

Chances are I will take your advice and have it re-excised to increase margins, stop my grumbling and just get on with it.   Oncology is changing so very quickly.   The problem, of course, is that melanoma changes very quickly, as well.   

Second "Reply":  The first was somehow 'lost' when posting.   Recap, briefly to avoid rewriting >>>

Very interesting, thanks.    With such information and direct experience so kindly shared, this is truly a wonderful venue.

Guesswork:   I understand.  It's something we have to live with.   As my doctor in Rio put it:   "Medicine is Art + Science.  Mostly Art."   That is, insight, which is often (not always) gained through experience.   I am just beginning to learn about melanoma, yet I spotted the first, Lentigo Maligna Melanoma 2 years ago.   As well as this one, which just, well, "looked like" what it turned out to be.   After tracking its (apparently) slow growth 8 months, a Superficially Spreading Melanoma.   Irregular, diffuse edges of varying color density.

Allowances for guesswork are important.   But still, it is hard to understand why a dermatologist-surgeon would choose 0.5mm margins appropriate to an "in situ" Stage 0.   Instead of 1.0cm margins used with Stage 1 ≤1.0 Breslow thickness.  Besides,  I made a point of requesting generous margins- precisely in the attempt to avoid any doubt.

I am sure you are right that excision with adequate margins is fundamental.   This is why the report's "very narrow margins" suggests its assertion the melanoma "has been completely excised" lacks credibility.   With this and your comments on the usefulness of wide, rather than narrow margins, have you a comment on the margin ambivalence results of this study of IIA-C patients?    I gather this subject has been trending upward in oncology circles.   Of course the study focused on 2 vs 4cm margins (a 1cm vs 2 cm study is planned), so it is certainly not conclusive for ≤1.0mm tumors.  Still, with "Medicine as Art" in mind, what do you think?

http://www.cancer.gov/clinicaltrials/results/summary/2011/smaller-margin1211

Prior to excision, I asked for two independent pathology reports.   My request is likely a moot issue now, due to inadeqaute margins and the report's consequent ambiguity.   Also, there is the inevitable tissue disturbance and initial lab work tissue shrinking that you described.   

Thanks for sharing your father's story.  This is truly daunting.    Besides, most of us would have chosen exactly the same course of action.   Please wish him well.   You mention SNLBs' were unavailable with your first melanoma.   Yet another issue that since those days has become 'controversial'?    They are not apparently not "therapeutic", useful strictly for Staging and prognosis.   The concern is they are overprescribed or prescribed too early for most thin melanomas.  Studies show SNLB's offer no survivability advantage.

I forget what else I posted before it was lost, so…

Chances are I will take your advice and have it re-excised to increase margins, stop my grumbling and just get on with it.   Oncology is changing so very quickly.   The problem, of course, is that melanoma changes very quickly, as well.   

Replied, but lost again…

This 2005 Study concluded no recurrence nor survivability advantages to wider margins @ tumor thickness ≤2.0mm.   

Study discusses histological vs clinical margins, as well.  Interesting.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1356919/

This 2005 Study concluded no recurrence nor survivability advantages to wider margins @ tumor thickness ≤2.0mm.   

Study discusses histological vs clinical margins, as well.  Interesting.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1356919/

This 2005 Study concluded no recurrence nor survivability advantages to wider margins @ tumor thickness ≤2.0mm.   

Study discusses histological vs clinical margins, as well.  Interesting.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1356919/

I was unable to receive quantification of histologic margins for the primary superficially spreading melanoma (SSM) I had excised 3 weeks ago using 0.5cm surgical margins.    Same response:  "very narrow margins".   But thanks to you and the very bright young pathologist with whom I spoke, I understand the problem better now.   Judgement and intuition-  not just objective criteria-  in cases like mine can play a major role.  

I returned last week for a second WLE, this time with 1cm margins on top of the first excisions's 0.5mm margins.  

The second WLE pathology report received today states "completely excised" (again), but without the "very narrow margins" comment of the first.   Strangely, though, no prognostic factors are given-  all of which were quantitifed in the first:   Breslow thickness, mitotic rate, Clark level, etc    Given the vague histologic margins achieved by the first excision, it seems odd the second also does not mention them, much less quantify them.

Question:   Does a wider excision on top of a prior one result in tissue deformation which makes prognostic factors no longer possible?   The pathologist mentioned the 'scar line' from the first excision showed clearly this time.   But importantly, a few questionable melanocytes did appear over the line into the second, presumably healthymargin area.  

So, good thing I returned for a second WLE- as you, the pathologist and surgeon all strongly recommended.  Thanks!

The only question remaining is:   Is it normal that no prognostic factors or histologic margins are mentioned?  Thanks again for your insights.   

Please ignore my last post.  Stupid.   Of course there won't be prognostic factors with a re-excision (Breslow, mitotic rate, Clark, etc).    The first excision removed the tumor.    I would have liked to see updated histologic ('achieved') margins.  But it may not have been possible.  

Please ignore my last post.  Stupid.   Of course there won't be prognostic factors with a re-excision (Breslow, mitotic rate, Clark, etc).    The first excision removed the tumor.    I would have liked to see updated histologic ('achieved') margins.  But it may not have been possible.  

Please ignore my last post.  Stupid.   Of course there won't be prognostic factors with a re-excision (Breslow, mitotic rate, Clark, etc).    The first excision removed the tumor.    I would have liked to see updated histologic ('achieved') margins.  But it may not have been possible.  

Thanks for that.   The superficially spreading melanoma (SSM) doubled in 8 months to the size of a penny.  The WLE I had, expanded the second time, is about 6 inches (long 'tips') to facilitate healing.   Impressive.   I'm sure you're right, the tumor gets the attention.   I assume the question is whether the lymphatic drain field is distorted by a WLE- and potentially problematic in case a later SLNB is required.    But as far as I can tell, excision is still the real deal for early stage melanoma.    

I would guess you are right.  I think your comment is important.   Is the lymph drainage network- that a few surgeons avoid distorting by rejecting a WLE and going straight to a SLNB- how closely has it been studied?   You would think it important to stage metastasis from the primary tumor presumably to the nearest lymph node basin.   Must be complex.

Funny, but I'm not glad to have it over.   For one thing, it's our responsibility to continue to check for lesions for the rest of our lives.   For another, kind of anticlimatic.   I know it sounds strange, but just when I was enjoying the turn of events, it was over.   Not that I actually want to have more problems, but…

Thanks for the tips on cocoa butter.   The second one pulled alright.   Might try in on some biopsies today.. 

I would guess you are right.  I think your comment is important.   Is the lymph drainage network- that a few surgeons avoid distorting by rejecting a WLE and going straight to a SLNB- how closely has it been studied?   You would think it important to stage metastasis from the primary tumor presumably to the nearest lymph node basin.   Must be complex.

Funny, but I'm not glad to have it over.   For one thing, it's our responsibility to continue to check for lesions for the rest of our lives.   For another, kind of anticlimatic.   I know it sounds strange, but just when I was enjoying the turn of events, it was over.   Not that I actually want to have more problems, but…

Thanks for the tips on cocoa butter.   The second one pulled alright.   Might try in on some biopsies today.. 

I would guess you are right.  I think your comment is important.   Is the lymph drainage network- that a few surgeons avoid distorting by rejecting a WLE and going straight to a SLNB- how closely has it been studied?   You would think it important to stage metastasis from the primary tumor presumably to the nearest lymph node basin.   Must be complex.

Funny, but I'm not glad to have it over.   For one thing, it's our responsibility to continue to check for lesions for the rest of our lives.   For another, kind of anticlimatic.   I know it sounds strange, but just when I was enjoying the turn of events, it was over.   Not that I actually want to have more problems, but…

Thanks for the tips on cocoa butter.   The second one pulled alright.   Might try in on some biopsies today.. 

Thanks for that.   The superficially spreading melanoma (SSM) doubled in 8 months to the size of a penny.  The WLE I had, expanded the second time, is about 6 inches (long 'tips') to facilitate healing.   Impressive.   I'm sure you're right, the tumor gets the attention.   I assume the question is whether the lymphatic drain field is distorted by a WLE- and potentially problematic in case a later SLNB is required.    But as far as I can tell, excision is still the real deal for early stage melanoma.    

Thanks for that.   The superficially spreading melanoma (SSM) doubled in 8 months to the size of a penny.  The WLE I had, expanded the second time, is about 6 inches (long 'tips') to facilitate healing.   Impressive.   I'm sure you're right, the tumor gets the attention.   I assume the question is whether the lymphatic drain field is distorted by a WLE- and potentially problematic in case a later SLNB is required.    But as far as I can tell, excision is still the real deal for early stage melanoma.    

Cautionary narrative.   Really.  Thanks for sharing, I'm sure you are right.   An ounce of prevention is worth a pound of cure.  Getting it early with adequate margins is key.   If the two excisions I've had in the last couple months have really done the job, I suppose but I dunno.  If so, it's despite the absurd nonchalance with which I watched it spread for 8 months.   Stupidity and a complete lack of paranoia is my perennial problem.   I'll try to do better next time, as I assume there will be one.   A whole lot quicker off the mark.   Bottom line is, it's largely up to us.   Thanks again.   

Cautionary narrative.   Really.  Thanks for sharing, I'm sure you are right.   An ounce of prevention is worth a pound of cure.  Getting it early with adequate margins is key.   If the two excisions I've had in the last couple months have really done the job, I suppose but I dunno.  If so, it's despite the absurd nonchalance with which I watched it spread for 8 months.   Stupidity and a complete lack of paranoia is my perennial problem.   I'll try to do better next time, as I assume there will be one.   A whole lot quicker off the mark.   Bottom line is, it's largely up to us.   Thanks again.   

Cautionary narrative.   Really.  Thanks for sharing, I'm sure you are right.   An ounce of prevention is worth a pound of cure.  Getting it early with adequate margins is key.   If the two excisions I've had in the last couple months have really done the job, I suppose but I dunno.  If so, it's despite the absurd nonchalance with which I watched it spread for 8 months.   Stupidity and a complete lack of paranoia is my perennial problem.   I'll try to do better next time, as I assume there will be one.   A whole lot quicker off the mark.   Bottom line is, it's largely up to us.   Thanks again.   

I was unable to receive quantification of histologic margins for the primary superficially spreading melanoma (SSM) I had excised 3 weeks ago using 0.5cm surgical margins.    Same response:  "very narrow margins".   But thanks to you and the very bright young pathologist with whom I spoke, I understand the problem better now.   Judgement and intuition-  not just objective criteria-  in cases like mine can play a major role.  

I returned last week for a second WLE, this time with 1cm margins on top of the first excisions's 0.5mm margins.  

The second WLE pathology report received today states "completely excised" (again), but without the "very narrow margins" comment of the first.   Strangely, though, no prognostic factors are given-  all of which were quantitifed in the first:   Breslow thickness, mitotic rate, Clark level, etc    Given the vague histologic margins achieved by the first excision, it seems odd the second also does not mention them, much less quantify them.

Question:   Does a wider excision on top of a prior one result in tissue deformation which makes prognostic factors no longer possible?   The pathologist mentioned the 'scar line' from the first excision showed clearly this time.   But importantly, a few questionable melanocytes did appear over the line into the second, presumably healthymargin area.  

So, good thing I returned for a second WLE- as you, the pathologist and surgeon all strongly recommended.  Thanks!

The only question remaining is:   Is it normal that no prognostic factors or histologic margins are mentioned?  Thanks again for your insights.   

I was unable to receive quantification of histologic margins for the primary superficially spreading melanoma (SSM) I had excised 3 weeks ago using 0.5cm surgical margins.    Same response:  "very narrow margins".   But thanks to you and the very bright young pathologist with whom I spoke, I understand the problem better now.   Judgement and intuition-  not just objective criteria-  in cases like mine can play a major role.  

I returned last week for a second WLE, this time with 1cm margins on top of the first excisions's 0.5mm margins.  

The second WLE pathology report received today states "completely excised" (again), but without the "very narrow margins" comment of the first.   Strangely, though, no prognostic factors are given-  all of which were quantitifed in the first:   Breslow thickness, mitotic rate, Clark level, etc    Given the vague histologic margins achieved by the first excision, it seems odd the second also does not mention them, much less quantify them.

Question:   Does a wider excision on top of a prior one result in tissue deformation which makes prognostic factors no longer possible?   The pathologist mentioned the 'scar line' from the first excision showed clearly this time.   But importantly, a few questionable melanocytes did appear over the line into the second, presumably healthymargin area.  

So, good thing I returned for a second WLE- as you, the pathologist and surgeon all strongly recommended.  Thanks!

The only question remaining is:   Is it normal that no prognostic factors or histologic margins are mentioned?  Thanks again for your insights.   

I'd be interested in your thoughts on new post today, "PC Pathology or Pathological?"   To understand what I took from my conversation with the pathologist, I would need to provide details of his description of commercial exigencies and litigation protection expediencies that exist between clinician and pathologist.    Useful subject?   On the other hand, it may be entirely irrelevant to our mission to recover good health.   Afterall, the end result supports adequate rather than inadequate treatment.  

It seems good can in fact come from illogic.

I'd be interested in your thoughts on new post today, "PC Pathology or Pathological?"   To understand what I took from my conversation with the pathologist, I would need to provide details of his description of commercial exigencies and litigation protection expediencies that exist between clinician and pathologist.    Useful subject?   On the other hand, it may be entirely irrelevant to our mission to recover good health.   Afterall, the end result supports adequate rather than inadequate treatment.  

It seems good can in fact come from illogic.

I'd be interested in your thoughts on new post today, "PC Pathology or Pathological?"   To understand what I took from my conversation with the pathologist, I would need to provide details of his description of commercial exigencies and litigation protection expediencies that exist between clinician and pathologist.    Useful subject?   On the other hand, it may be entirely irrelevant to our mission to recover good health.   Afterall, the end result supports adequate rather than inadequate treatment.  

It seems good can in fact come from illogic.

Thank you.  I understand that to perform EXCISION of a Stage 1 tumor, the recommendation is 1 cm margins for Stage 1.

Rather than excision guidlines my question refers to pathology results AFTER excision:   

If pathology report shows the tumor has been "completely excised" but the margin is "very narrow"- what margin IS adequate?

Unless a biopsy has been done, the surgeon performing the excision has little more to go on to provide adequate EXCISION margins than a superficial observation of the tumor and presumed healthy tissue margin surrounding it.   Depending on presumed thickness, as you say for Stage 1 the doctor establishes either a .5cm or 1.0cm margin.

However, the pathology report is no doubt far more accurate than the naked eye.   And (just guessing), it may well show- as in my case- a margin of healthy tissue significantly reduced from the excision margin the surgeon employed.

So the question is:   What are recommended margins for a Stage 1 tumor based on the pathology report AFTER the excision has been made?    Despite the difficulty the surgeon has in predicting adequate margins compared with the pathology report, it seems likely margins apparent after a microscopic evaluation would be reduced from those the surgeon used to make the excision.

I've looked everywhere online, called several national melanoma hotlines, but have so far not found a reply.   All I know is that "very narrow margins" and "completely excised- although narrowly" seems vague to determine the need for re excision.

Thanks for your help.

Thank you.  I understand that to perform EXCISION of a Stage 1 tumor, the recommendation is 1 cm margins for Stage 1.

Rather than excision guidlines my question refers to pathology results AFTER excision:   

If pathology report shows the tumor has been "completely excised" but the margin is "very narrow"- what margin IS adequate?

Unless a biopsy has been done, the surgeon performing the excision has little more to go on to provide adequate EXCISION margins than a superficial observation of the tumor and presumed healthy tissue margin surrounding it.   Depending on presumed thickness, as you say for Stage 1 the doctor establishes either a .5cm or 1.0cm margin.

However, the pathology report is no doubt far more accurate than the naked eye.   And (just guessing), it may well show- as in my case- a margin of healthy tissue significantly reduced from the excision margin the surgeon employed.

So the question is:   What are recommended margins for a Stage 1 tumor based on the pathology report AFTER the excision has been made?    Despite the difficulty the surgeon has in predicting adequate margins compared with the pathology report, it seems likely margins apparent after a microscopic evaluation would be reduced from those the surgeon used to make the excision.

I've looked everywhere online, called several national melanoma hotlines, but have so far not found a reply.   All I know is that "very narrow margins" and "completely excised- although narrowly" seems vague to determine the need for re excision.

Thanks for your help.

Hello Paula,

Thanks very much for that.   I am also glad I had it removed.   Just that I was "gladder" before, when I imagined adequate margins would produce an unambiguous pathology report.  

 I'm trying to get them to provide a number for "very narrow", but I am not expecting much.   If they could have quantified "achieved margins" before, I suppose they would have.  Lack of biopsy or not, I will have to lean on the dermatologist-surgeon about use of Stage 0 "in situ" margins for something that, at least to me, appeared to be Stage 1 or more, requiring double the margins.   I won't lean too hard, she's the one with the scalpel.  🙂

I'm also wondering about about the traditional 'breadloaf' technique they, and many other labs also, use.   False negatives, do you know about this?    But you're probably right.  The SSM was probably below the skin, while the doubtful area was limited to "12 o'clock to 6 o'clock" on the lateral edge.   The guesswork issue Janner mentioned earlier that we just have to live with.

I'm not too concerned about the re-encision as such.   Just bored at the idea and dislike doing things over- not to mention the additional cost.

Thanks again- Persistence!

Bob   

Hello Paula,

Thanks very much for that.   I am also glad I had it removed.   Just that I was "gladder" before, when I imagined adequate margins would produce an unambiguous pathology report.  

 I'm trying to get them to provide a number for "very narrow", but I am not expecting much.   If they could have quantified "achieved margins" before, I suppose they would have.  Lack of biopsy or not, I will have to lean on the dermatologist-surgeon about use of Stage 0 "in situ" margins for something that, at least to me, appeared to be Stage 1 or more, requiring double the margins.   I won't lean too hard, she's the one with the scalpel.  🙂

I'm also wondering about about the traditional 'breadloaf' technique they, and many other labs also, use.   False negatives, do you know about this?    But you're probably right.  The SSM was probably below the skin, while the doubtful area was limited to "12 o'clock to 6 o'clock" on the lateral edge.   The guesswork issue Janner mentioned earlier that we just have to live with.

I'm not too concerned about the re-encision as such.   Just bored at the idea and dislike doing things over- not to mention the additional cost.

Thanks again- Persistence!

Bob   

Hello Paula,

Thanks very much for that.   I am also glad I had it removed.   Just that I was "gladder" before, when I imagined adequate margins would produce an unambiguous pathology report.  

 I'm trying to get them to provide a number for "very narrow", but I am not expecting much.   If they could have quantified "achieved margins" before, I suppose they would have.  Lack of biopsy or not, I will have to lean on the dermatologist-surgeon about use of Stage 0 "in situ" margins for something that, at least to me, appeared to be Stage 1 or more, requiring double the margins.   I won't lean too hard, she's the one with the scalpel.  🙂

I'm also wondering about about the traditional 'breadloaf' technique they, and many other labs also, use.   False negatives, do you know about this?    But you're probably right.  The SSM was probably below the skin, while the doubtful area was limited to "12 o'clock to 6 o'clock" on the lateral edge.   The guesswork issue Janner mentioned earlier that we just have to live with.

I'm not too concerned about the re-encision as such.   Just bored at the idea and dislike doing things over- not to mention the additional cost.

Thanks again- Persistence!

Bob   

I agree, why spend time thinking about false negatives.   

It sounds to me like you had very good treatment, particularly the close interface between pathology and your dermatologist.   I'd say that is very important.  

I'm curious to see how the pathologist reacts to my request to quantify "achieved histologic margins"- instead of the vague pathology report phrases "narrowly excised…. close to the lateral edge".   If I were he, my reply would be something like pathology margins were "too close to call".   Therefore, re excision, which is what the dermatologist wants.   Me too.  

What irks is that adequate surgical margins for Stage 1 or higher start at 1.0dm.    Not the 0.5cm suggested for "in situ".   The thing is I'd tracked the tumor's slow growth for 8 months, I requested "generous margins" and, to reinforce, further added that aesthetics were unimportant to me.   If the pathology is accurate that it was "completely excised", it seems clear that an additional 0.5cm would have obviated the need for re excision.  Grumble, grumble.

It's my own fault for not researching suggested margins before surgery.   Had I done so, I would have questioned the use of only 0.5cm.  I keep saying it's best to be informed.  Yet I broke my own rule!    Next time, I'll be better prepared.   

Thanks again for the input.   Let me know how things progress for you?

I agree, why spend time thinking about false negatives.   

It sounds to me like you had very good treatment, particularly the close interface between pathology and your dermatologist.   I'd say that is very important.  

I'm curious to see how the pathologist reacts to my request to quantify "achieved histologic margins"- instead of the vague pathology report phrases "narrowly excised…. close to the lateral edge".   If I were he, my reply would be something like pathology margins were "too close to call".   Therefore, re excision, which is what the dermatologist wants.   Me too.  

What irks is that adequate surgical margins for Stage 1 or higher start at 1.0dm.    Not the 0.5cm suggested for "in situ".   The thing is I'd tracked the tumor's slow growth for 8 months, I requested "generous margins" and, to reinforce, further added that aesthetics were unimportant to me.   If the pathology is accurate that it was "completely excised", it seems clear that an additional 0.5cm would have obviated the need for re excision.  Grumble, grumble.

It's my own fault for not researching suggested margins before surgery.   Had I done so, I would have questioned the use of only 0.5cm.  I keep saying it's best to be informed.  Yet I broke my own rule!    Next time, I'll be better prepared.   

Thanks again for the input.   Let me know how things progress for you?

I agree, why spend time thinking about false negatives.   

It sounds to me like you had very good treatment, particularly the close interface between pathology and your dermatologist.   I'd say that is very important.  

I'm curious to see how the pathologist reacts to my request to quantify "achieved histologic margins"- instead of the vague pathology report phrases "narrowly excised…. close to the lateral edge".   If I were he, my reply would be something like pathology margins were "too close to call".   Therefore, re excision, which is what the dermatologist wants.   Me too.  

What irks is that adequate surgical margins for Stage 1 or higher start at 1.0dm.    Not the 0.5cm suggested for "in situ".   The thing is I'd tracked the tumor's slow growth for 8 months, I requested "generous margins" and, to reinforce, further added that aesthetics were unimportant to me.   If the pathology is accurate that it was "completely excised", it seems clear that an additional 0.5cm would have obviated the need for re excision.  Grumble, grumble.

It's my own fault for not researching suggested margins before surgery.   Had I done so, I would have questioned the use of only 0.5cm.  I keep saying it's best to be informed.  Yet I broke my own rule!    Next time, I'll be better prepared.   

Thanks again for the input.   Let me know how things progress for you?

Thanks for that.   From your comment about 'wider margins', I guess it's to some degree 'hit or miss' whether the margins chosen will be adequate or not.   I agree, if a pathologist's respone is framed with numbers, phrases like "closely, very narrow" don't do the job.   I reckon his response to my query will be something like "too close to measure".  Interestingly, I could find no histological margin recommendations.   American Cancer Institute contact believes they must be "the same" as recommended surgical margins.  Which I take to mean, 'hit or miss' margins from superficial inspection (no prior biopsy) must mean re excision is quite common.   So if I I had had a biopsy prior to excision, more ample margins might have been indicated and I would not have to have the re excision.   A guess.

BTW, I've heard commonly used "breadloafing" pathology produces its share of false negatives.   Is there an option, other than MOHS?)   Look forward to an eventual pathology-  from a more 'generous' excision next time.          

Thanks for that.   From your comment about 'wider margins', I guess it's to some degree 'hit or miss' whether the margins chosen will be adequate or not.   I agree, if a pathologist's respone is framed with numbers, phrases like "closely, very narrow" don't do the job.   I reckon his response to my query will be something like "too close to measure".  Interestingly, I could find no histological margin recommendations.   American Cancer Institute contact believes they must be "the same" as recommended surgical margins.  Which I take to mean, 'hit or miss' margins from superficial inspection (no prior biopsy) must mean re excision is quite common.   So if I I had had a biopsy prior to excision, more ample margins might have been indicated and I would not have to have the re excision.   A guess.

BTW, I've heard commonly used "breadloafing" pathology produces its share of false negatives.   Is there an option, other than MOHS?)   Look forward to an eventual pathology-  from a more 'generous' excision next time.          

Thanks for that.   From your comment about 'wider margins', I guess it's to some degree 'hit or miss' whether the margins chosen will be adequate or not.   I agree, if a pathologist's respone is framed with numbers, phrases like "closely, very narrow" don't do the job.   I reckon his response to my query will be something like "too close to measure".  Interestingly, I could find no histological margin recommendations.   American Cancer Institute contact believes they must be "the same" as recommended surgical margins.  Which I take to mean, 'hit or miss' margins from superficial inspection (no prior biopsy) must mean re excision is quite common.   So if I I had had a biopsy prior to excision, more ample margins might have been indicated and I would not have to have the re excision.   A guess.

BTW, I've heard commonly used "breadloafing" pathology produces its share of false negatives.   Is there an option, other than MOHS?)   Look forward to an eventual pathology-  from a more 'generous' excision next time.          

You are right:   I really have no idea of what you are talking about.

Why?   My "many statements"- as you characterize them-  are from my own, limited experience.   From no one else's.  I don't pretend to speak for everyone.  Do you?   We can learn from each other-  but only if we see each case is individual.  That "Stage 1's" do not have to 'pay their dues' to share opinions.   That we reject the censorship of lessons others have learned-  just because they do not conform to our own.   That we refuse to deny 'overtreatment' exists, insist there is only 'undertreatment'.   That there is more than one way- our way- to see things.  

So my error is one of hubris in that I imagined no one has some sort of personal medical history axe to grind, that personal opinions are allowed, that no one would feel like their toes had been trod on, that we are all here to learn something if we can.      

Drop the backbiting-  we share alot more than you think.   We have both had lentigo maligna melanoma.   I foolishly watched a spreading lesion for eight (8) months- before doing something about it.  You let a couple years go by, yourself.   

Be kind to yourself.   A good place to start is by being kind to other.   Agreed?

You are right:   I really have no idea of what you are talking about.

Why?   My "many statements"- as you characterize them-  are from my own, limited experience.   From no one else's.  I don't pretend to speak for everyone.  Do you?   We can learn from each other-  but only if we see each case is individual.  That "Stage 1's" do not have to 'pay their dues' to share opinions.   That we reject the censorship of lessons others have learned-  just because they do not conform to our own.   That we refuse to deny 'overtreatment' exists, insist there is only 'undertreatment'.   That there is more than one way- our way- to see things.  

So my error is one of hubris in that I imagined no one has some sort of personal medical history axe to grind, that personal opinions are allowed, that no one would feel like their toes had been trod on, that we are all here to learn something if we can.      

Drop the backbiting-  we share alot more than you think.   We have both had lentigo maligna melanoma.   I foolishly watched a spreading lesion for eight (8) months- before doing something about it.  You let a couple years go by, yourself.   

Be kind to yourself.   A good place to start is by being kind to other.   Agreed?

You are right:   I really have no idea of what you are talking about.

Why?   My "many statements"- as you characterize them-  are from my own, limited experience.   From no one else's.  I don't pretend to speak for everyone.  Do you?   We can learn from each other-  but only if we see each case is individual.  That "Stage 1's" do not have to 'pay their dues' to share opinions.   That we reject the censorship of lessons others have learned-  just because they do not conform to our own.   That we refuse to deny 'overtreatment' exists, insist there is only 'undertreatment'.   That there is more than one way- our way- to see things.  

So my error is one of hubris in that I imagined no one has some sort of personal medical history axe to grind, that personal opinions are allowed, that no one would feel like their toes had been trod on, that we are all here to learn something if we can.      

Drop the backbiting-  we share alot more than you think.   We have both had lentigo maligna melanoma.   I foolishly watched a spreading lesion for eight (8) months- before doing something about it.  You let a couple years go by, yourself.   

Be kind to yourself.   A good place to start is by being kind to other.   Agreed?