› Forums › General Melanoma Community › First Pathology report says Melanoma Insitu and Second Review says no Melanoma
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BillMFl.
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- May 1, 2011 at 12:41 pm
I had a place taken off my cheek a month ago by a shave biopsy and 2 weeks later the biopsy results came back and then said it was Melanoma Insitu Clark Level 1 which said it was superficial and only on the outer layer of the epidermis. I went and picked up my report and after looking at it was confused because it had the doctors name that reviewed it (dermapathologist) but my doctor had signed for him and they also mentioned on the report that I had a history of melanoma. Why would they need to state that on the pathology report? The first review from him stated Aty
I had a place taken off my cheek a month ago by a shave biopsy and 2 weeks later the biopsy results came back and then said it was Melanoma Insitu Clark Level 1 which said it was superficial and only on the outer layer of the epidermis. I went and picked up my report and after looking at it was confused because it had the doctors name that reviewed it (dermapathologist) but my doctor had signed for him and they also mentioned on the report that I had a history of melanoma. Why would they need to state that on the pathology report? The first review from him stated Atypia and then the final review was melanoma Insitu. Anyways, I requested my slides from the dermatologist office and picked them up before my appointment with the plastic surgeon at Vanderbilt this past Thursday. After looking at my report he also thought it looked a little strange. I told him that I had my slides and would like someone at Vanderbilt to review them and he said oh good so he sent them down while I was there. He went over 2 options to take care of this which were…..if he did the excision he would take .5cm all the way around. He also told me about Moh's which he said may be the better option for me since they check the tissue as they go and can make a smaller scar. I told him that would probably be the option that I would go with. On Friday I get a call from the Moh's people at Vanderbilt that he had referred me to saying they had received my pathology report and no where on there did it state I had melanoma just Atypia. She said they were going to send the report back to the plastic surgeon that I saw on Thurday. She said you may not have to have anything done. I said well since he did a shave he left me with a hole in my skin which I would like to have corrected. They told me that it would fill in but I don't think so. We are going on 5 weeks and it hasn't yet. So now I'm waiting on the plastic surgeons office to call me tomorrow to let me know what they think. My question is if he goes back in to fix this hole and pull the skin together so I have a line that would look much better couldn't he test a little bit of tissue again to make sure it comes back ok? Has anyone every experienced this? I'm just so confused and stressed out and don't know what to do. I don't want to be left with a bigger scar if its not necessary. Any replies would be greatly appreciated. Thanks!
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- May 1, 2011 at 1:18 pm
First: This is the off-topic board, so not many people may see your post.
Deciding whether a mole is merely atypical or melanoma in situ can be very difficult. Pathologists often use additional information like patient age or history to make a decision.
I don't have answers to your other questions. You should probably repost to the main board ( http://www.melanoma.org/community/mpip-melanoma-patients-information-page ) so that more people see your questions.
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- May 1, 2011 at 1:18 pm
First: This is the off-topic board, so not many people may see your post.
Deciding whether a mole is merely atypical or melanoma in situ can be very difficult. Pathologists often use additional information like patient age or history to make a decision.
I don't have answers to your other questions. You should probably repost to the main board ( http://www.melanoma.org/community/mpip-melanoma-patients-information-page ) so that more people see your questions.
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- May 1, 2011 at 2:54 pm
Yes, they could take another sample. However, in order to close the new wound, it would make it larger. The shave biopsy (crater) will fill in over time (months, not weeks), but you can talk to the plastic surgeon to get more info there. It is not that unusual to have a more experienced dermatopathologist say something isn't melanoma, just atypical. If they have more experience reviewing melanoma, they are a better judge. Making the distinction between atypical and melanoma in situ is as much an art as it is a science. They evaluate a lot of factors and then decide how atypical they all are. If too many are "going bad", you get a melanoma in situ diagnosis. If only a few are looking weird, you might get a mildly atypical diagnosis. I would ask for a copy of the pathology report from Vanderbilt, too, for your own records. In general, something "mildly" atypical can be left as is if you have clean margins. Something moderately atypical should have at least clean margins. And something severely atypical should have 5mm margins. So depending on what the new pathology says would determine if your wound reallly needs more removed or not. And depending on the margins already taken, you may or may not want to have more taken. If you already have clean margins on the path report, there may be no reason to take more if the lesion is not severely atypical.
Best wishes,
Janner
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- May 1, 2011 at 3:09 pm
Thank you so much for your reply. The sample that was taken was .5cm X .5cm and on the first pathology report it said "poorly circumscribed asymmetrical poliferation of melanocytes with severe cytologic atypia arranged in irregular nests and as single cells at the basal layer of the epidermis. Atypical melanocytes are identified at higher levels of the epidermis. The poliferation does not appear to extend into the underlying dermis. Anti-S100, -HMB45, -MART1, and -MiTF atibodies all label the atypical melanocytes."
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- May 1, 2011 at 3:11 pm
I will have to wait until tomorrow before I can see exactly what the second report says.
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- May 1, 2011 at 3:11 pm
I will have to wait until tomorrow before I can see exactly what the second report says.
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- May 2, 2011 at 7:39 pm
My two cents. Severe atypia clustered in nests with distribution into the higher levels of the epidermis is a classic description of mm insitu and should be treated as such. Key word: severe. Second key factor: distribution rising upwards from the D/E junction. Third key factor: no extension beneath the D/E junction down into the dermis. Below the D/E junction and it wouldn't be in situ. As Janner said, it can be difficult to split hairs over the degree of atypical. Most Derms nowadays would play it safe if there is any doubt. As far as the scar goes, it all depends on the depth of the scoop. I have had many shaves. Some fill in and are virtually invisible. Some leave a slightly pink indention. Others leave a whiteish indention. If I were you, I would ask for an excision with adequate but conservative margins just to be sure.
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- May 2, 2011 at 11:45 pm
The second report says "junctional nevus with marked architectural and cytologic atypia, shave margins appear to be free of the junctional melanocytic proliferation. Looks like 3 pathologists checked this out before they signed off on this report. Still waiting on the doctor to call to see what needs to be done. I'm assuming they will want to go in and do an excision but I'm wondering how much they will take. The spot is only about 1/4 inch now. I guess we will see.
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- May 3, 2011 at 1:47 am
hmmm, that reads quite different from the other dx. Junctional nevus is a nuetral phrase simply indicating location. Many mature benign nevi are junctional. To me the big difference is the phrase "marked" vs "severe" atypia. Severe or wildly atypical are often used in defining an early mm. Marked atypia seems less of a threat but still not to be ignored. Based on two somewhat different reports I'd opt for an excision with appropriate margins just to be sure. Otherwise you will probably worry for a long time. Best to sacrifice a little flesh vs having it come back already penetrating the dermis (invasive). I spotted both of my own in situ's and insisted on removal even though both Derms thought they were "nothing to worry about". I am having two in situ sqamous cell (scc) that I spotted myself re-excised tomorrow afternoon. I've had dozens of bcc and scc skin cancers over the past 20 years and my current Derm introduces me to new staff as a very knowledgeable patient who almost always knows his own dx before coming in. This gives a brief moment of pleasure before they stick the needle and get down to business. haha I feel for ya. Tell what you want if they get wishy washy.
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- May 3, 2011 at 1:47 am
hmmm, that reads quite different from the other dx. Junctional nevus is a nuetral phrase simply indicating location. Many mature benign nevi are junctional. To me the big difference is the phrase "marked" vs "severe" atypia. Severe or wildly atypical are often used in defining an early mm. Marked atypia seems less of a threat but still not to be ignored. Based on two somewhat different reports I'd opt for an excision with appropriate margins just to be sure. Otherwise you will probably worry for a long time. Best to sacrifice a little flesh vs having it come back already penetrating the dermis (invasive). I spotted both of my own in situ's and insisted on removal even though both Derms thought they were "nothing to worry about". I am having two in situ sqamous cell (scc) that I spotted myself re-excised tomorrow afternoon. I've had dozens of bcc and scc skin cancers over the past 20 years and my current Derm introduces me to new staff as a very knowledgeable patient who almost always knows his own dx before coming in. This gives a brief moment of pleasure before they stick the needle and get down to business. haha I feel for ya. Tell what you want if they get wishy washy.
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- May 2, 2011 at 11:45 pm
The second report says "junctional nevus with marked architectural and cytologic atypia, shave margins appear to be free of the junctional melanocytic proliferation. Looks like 3 pathologists checked this out before they signed off on this report. Still waiting on the doctor to call to see what needs to be done. I'm assuming they will want to go in and do an excision but I'm wondering how much they will take. The spot is only about 1/4 inch now. I guess we will see.
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- May 2, 2011 at 7:39 pm
My two cents. Severe atypia clustered in nests with distribution into the higher levels of the epidermis is a classic description of mm insitu and should be treated as such. Key word: severe. Second key factor: distribution rising upwards from the D/E junction. Third key factor: no extension beneath the D/E junction down into the dermis. Below the D/E junction and it wouldn't be in situ. As Janner said, it can be difficult to split hairs over the degree of atypical. Most Derms nowadays would play it safe if there is any doubt. As far as the scar goes, it all depends on the depth of the scoop. I have had many shaves. Some fill in and are virtually invisible. Some leave a slightly pink indention. Others leave a whiteish indention. If I were you, I would ask for an excision with adequate but conservative margins just to be sure.
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- May 1, 2011 at 3:09 pm
Thank you so much for your reply. The sample that was taken was .5cm X .5cm and on the first pathology report it said "poorly circumscribed asymmetrical poliferation of melanocytes with severe cytologic atypia arranged in irregular nests and as single cells at the basal layer of the epidermis. Atypical melanocytes are identified at higher levels of the epidermis. The poliferation does not appear to extend into the underlying dermis. Anti-S100, -HMB45, -MART1, and -MiTF atibodies all label the atypical melanocytes."
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- May 1, 2011 at 2:54 pm
Yes, they could take another sample. However, in order to close the new wound, it would make it larger. The shave biopsy (crater) will fill in over time (months, not weeks), but you can talk to the plastic surgeon to get more info there. It is not that unusual to have a more experienced dermatopathologist say something isn't melanoma, just atypical. If they have more experience reviewing melanoma, they are a better judge. Making the distinction between atypical and melanoma in situ is as much an art as it is a science. They evaluate a lot of factors and then decide how atypical they all are. If too many are "going bad", you get a melanoma in situ diagnosis. If only a few are looking weird, you might get a mildly atypical diagnosis. I would ask for a copy of the pathology report from Vanderbilt, too, for your own records. In general, something "mildly" atypical can be left as is if you have clean margins. Something moderately atypical should have at least clean margins. And something severely atypical should have 5mm margins. So depending on what the new pathology says would determine if your wound reallly needs more removed or not. And depending on the margins already taken, you may or may not want to have more taken. If you already have clean margins on the path report, there may be no reason to take more if the lesion is not severely atypical.
Best wishes,
Janner
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