› Forums › General Melanoma Community › Hello all…I’m new to this board. Goin to derm next week for suspcious mole
- This topic has 27 replies, 5 voices, and was last updated 9 years, 8 months ago by
jennunicorn.
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- March 28, 2016 at 2:39 am
Hi,
I was reading some older posts on the board about shave vs. punch biopsies.
I found this article that warns AGAINST punch biopsies.
I am guessing that means that an excisional biopsy is best. At least in the case of a suspected melanoma.
So frustrating to reach conflicting literature. A prior article I read mentioned that punch biopsy was the way to go. But a punch biopsy makes me wonder about seeding? Couldn't the punch force cells down further than they already are, since the depth can only truly be known with WLE?
Seems like one could go to 10 different derms and end up with 10 different recommendations!
So frustrating!!
p.s. I am also learning about nodular melanoma since that is what my new mole resembles.
The link below will take you to the full article, as I just posted the abstract.
http://escholarship.org/uc/
item/4vb8x54s Punch biopsies of melanoma: A diagnostic peril
Giovanni D Lorusso MD, Deba P Sarma MD, and Syeda F Sarwar MD
Dermatology Online Journal 11 (1): 7Department of Pathology, Veterans Affairs Medical Center and Louisiana State University Health Sciences Center. glorus@lsuhsc.edu
Abstract
Excisional or incisional biopsies of melanoma are used to determine depth of tumor invasion and to plan subsequent treatment. Accurate determination of depth of melanoma invasion is critical for treatment decisions and prognosis. Incisional or punch biopsies can be perilous for histopathologic determination of invasion, and both over- and underestimation of invasion can occur when using incisional methods. Likewise, histologic factors can lead to over- and underestimation of invasion. Prognosis and treatment of melanoma are primarily determined by depth of tumor invasion. We discuss several scenarios that can lead to over- and underestimation of depth of invasion in incisional biopsy specimens. We therefore discourage incisional or punch biopsies of suspected melanoma and recommend that depth of invasion not be reported on these types of specimens.
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- March 28, 2016 at 3:07 am
Most punch biopsies get about 4mm of depth – and staging doesn't change if a lesion is beyond 4mm. A punch won't push cells down, it's like a cookie cutter that removes a core of tissue. I know MANY institutions who use punches regularly. Same with shave biopsies, but shaves are MUCH MORE LIKELY not to get the full depth. That happens quite regularly on this board, but I can't remember someone having a punch not get enough depth. As for over/under estimation, I can't comment. It isn't something I've ever seen discussed outside of this one research paper.
As for which you should have, this is up for discussion with your derm. Different lesions might make sense to have different types of biopsies. Large lesions won't fit in punches so in that case, not the best choice. The goal is always to remove the entire lesion if possible, but for very large lesions – that could be disfiguring and why remove an entire lesion without knowing it is melanoma first. Shaves must be deep shaves, and even then, they still can bisect a lesion. Excisional is great, but honestly, it isn't all that realistic for every biopsy. Excisional becomes surgery, not biopsy in terms of level of effort. People who have biopsies all the time really could be cut up if every biopsy was excisional. Your doc deals with this all the time and it is good to discuss but your lesion and circumstances may lend themself to one biopsy type over another. Shallow shaves are the most likely to NOT return good data. One thing about biopsy types, they can ALL identify melanoma. Initial staging is important, but the melanoma diagnosis itself is the most important. Getting any biopsy is better than none. BTW, for lesions deeper than 1mm, prognosis and treatment would be determined by a SNB, not the biopsy itself.
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- March 28, 2016 at 10:34 pm
This discussion brings up a different question in my mind: Since melanoma can develop in previously "normal" moles, wouldn't it be important to ensure the entire mole is removed even if the pathology is normal? I'm thinking of the case of a shave biopsy that comes back as "atypical" but not melanoma but the shave doesn't have clear margins. Couldn't that heal over leaving small bits of atypical mole beneath the surface that could later become melanoma? I often wonder if that happened to me since I have had several moles removed, none of them diagnosed as melanoma, and now I am stage IV with unknown primary.
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- March 28, 2016 at 10:34 pm
This discussion brings up a different question in my mind: Since melanoma can develop in previously "normal" moles, wouldn't it be important to ensure the entire mole is removed even if the pathology is normal? I'm thinking of the case of a shave biopsy that comes back as "atypical" but not melanoma but the shave doesn't have clear margins. Couldn't that heal over leaving small bits of atypical mole beneath the surface that could later become melanoma? I often wonder if that happened to me since I have had several moles removed, none of them diagnosed as melanoma, and now I am stage IV with unknown primary.
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- March 29, 2016 at 12:40 am
I've often worried about this.. I've had over 20 moles removed (a lot of those were removed because they got caught on buttons, zips and sat around bra straps etc… All of them were benign (aside from the 1 melanoma I have had)… I wonder about the pathology reports for all of those other moles though and if they removed all the roots etc – and if they can turn cancerous if there was anything left?
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- March 29, 2016 at 12:40 am
I've often worried about this.. I've had over 20 moles removed (a lot of those were removed because they got caught on buttons, zips and sat around bra straps etc… All of them were benign (aside from the 1 melanoma I have had)… I wonder about the pathology reports for all of those other moles though and if they removed all the roots etc – and if they can turn cancerous if there was anything left?
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- March 29, 2016 at 12:40 am
I've often worried about this.. I've had over 20 moles removed (a lot of those were removed because they got caught on buttons, zips and sat around bra straps etc… All of them were benign (aside from the 1 melanoma I have had)… I wonder about the pathology reports for all of those other moles though and if they removed all the roots etc – and if they can turn cancerous if there was anything left?
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- March 29, 2016 at 12:45 am
There is not a universal strategy on this one. I know my onc derm requires at least clean margins on ANY atypical lesion – he won't leave anything behind. He does believe that trauma may, in rare cases, cause future trouble if cells are left behind. However, that is not a universal feeling and some derms are fine with leaving mildly and even moderately atypical lesion cells behind. Severely atypical lesions are typically treated like melanoma in situ with 5mm margins. I know I tell anyone who has a biopsy if there is ANY pigment regrowth, get it checked out again. In your case, I'm sure it is possible. However, it is also possible there was some other lesion unseen by you that spread the seed elsewhere. Unfortunately, it will always be some type of a guess.
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- March 29, 2016 at 12:45 am
There is not a universal strategy on this one. I know my onc derm requires at least clean margins on ANY atypical lesion – he won't leave anything behind. He does believe that trauma may, in rare cases, cause future trouble if cells are left behind. However, that is not a universal feeling and some derms are fine with leaving mildly and even moderately atypical lesion cells behind. Severely atypical lesions are typically treated like melanoma in situ with 5mm margins. I know I tell anyone who has a biopsy if there is ANY pigment regrowth, get it checked out again. In your case, I'm sure it is possible. However, it is also possible there was some other lesion unseen by you that spread the seed elsewhere. Unfortunately, it will always be some type of a guess.
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- March 29, 2016 at 12:45 am
There is not a universal strategy on this one. I know my onc derm requires at least clean margins on ANY atypical lesion – he won't leave anything behind. He does believe that trauma may, in rare cases, cause future trouble if cells are left behind. However, that is not a universal feeling and some derms are fine with leaving mildly and even moderately atypical lesion cells behind. Severely atypical lesions are typically treated like melanoma in situ with 5mm margins. I know I tell anyone who has a biopsy if there is ANY pigment regrowth, get it checked out again. In your case, I'm sure it is possible. However, it is also possible there was some other lesion unseen by you that spread the seed elsewhere. Unfortunately, it will always be some type of a guess.
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- March 30, 2016 at 3:43 am
Omg, and a few years before my son was diagnosed my now 24 yr old son had a "highly atypical" mole removed! He is estranged from the family but 3 of these 4 kids….amazing I have not thought about that. So focused on trying to keep Jake going I can't focus on everything else! Geez.
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- March 30, 2016 at 3:43 am
Omg, and a few years before my son was diagnosed my now 24 yr old son had a "highly atypical" mole removed! He is estranged from the family but 3 of these 4 kids….amazing I have not thought about that. So focused on trying to keep Jake going I can't focus on everything else! Geez.
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- March 30, 2016 at 4:11 am
Atypical moles do run in families. Not all derms will go back for clear margins on atypical moles but most will for severely atypical. With melanoma being very much in the family, when your other kids get moles removed that come back as atypical of any kind, they might want to make sure they get clear margins, just to be safe, it's really up to them though. I can't even imagine the stress you're under, not just with Jake but also with your whole family. You're one tough momma.
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- March 30, 2016 at 4:11 am
Atypical moles do run in families. Not all derms will go back for clear margins on atypical moles but most will for severely atypical. With melanoma being very much in the family, when your other kids get moles removed that come back as atypical of any kind, they might want to make sure they get clear margins, just to be safe, it's really up to them though. I can't even imagine the stress you're under, not just with Jake but also with your whole family. You're one tough momma.
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- March 30, 2016 at 11:31 am
Woke up with my other kids on my brain. Gonna get after that today:) Thanks for the calm, rational thoughts. Just gotta be vigilant. Nothing else you can do. Thinking I had a gene clash with my husband. This melanoma roller coaster messes with your sanity. You have to be careful, control your thoughts and stay very peaceful. It's the only way I can fully breathe.
Today, life is good. Digging in on labs and skin checks for the 3 other grown kids:) And pushing Jske just a little to get started on the next treatment. Hoping Mek/Taf combo!
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- March 30, 2016 at 11:31 am
Woke up with my other kids on my brain. Gonna get after that today:) Thanks for the calm, rational thoughts. Just gotta be vigilant. Nothing else you can do. Thinking I had a gene clash with my husband. This melanoma roller coaster messes with your sanity. You have to be careful, control your thoughts and stay very peaceful. It's the only way I can fully breathe.
Today, life is good. Digging in on labs and skin checks for the 3 other grown kids:) And pushing Jske just a little to get started on the next treatment. Hoping Mek/Taf combo!
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- March 30, 2016 at 3:53 pm
Sanity is something we all struggle to keep under control sometimes. Being human isn't easy 🙂
Hoping Jake chooses that combo too!
Keeping you and your family in my thoughts.
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- March 30, 2016 at 3:53 pm
Sanity is something we all struggle to keep under control sometimes. Being human isn't easy 🙂
Hoping Jake chooses that combo too!
Keeping you and your family in my thoughts.
-
- March 30, 2016 at 3:53 pm
Sanity is something we all struggle to keep under control sometimes. Being human isn't easy 🙂
Hoping Jake chooses that combo too!
Keeping you and your family in my thoughts.
-
- March 30, 2016 at 11:31 am
Woke up with my other kids on my brain. Gonna get after that today:) Thanks for the calm, rational thoughts. Just gotta be vigilant. Nothing else you can do. Thinking I had a gene clash with my husband. This melanoma roller coaster messes with your sanity. You have to be careful, control your thoughts and stay very peaceful. It's the only way I can fully breathe.
Today, life is good. Digging in on labs and skin checks for the 3 other grown kids:) And pushing Jske just a little to get started on the next treatment. Hoping Mek/Taf combo!
-
- March 30, 2016 at 4:11 am
Atypical moles do run in families. Not all derms will go back for clear margins on atypical moles but most will for severely atypical. With melanoma being very much in the family, when your other kids get moles removed that come back as atypical of any kind, they might want to make sure they get clear margins, just to be safe, it's really up to them though. I can't even imagine the stress you're under, not just with Jake but also with your whole family. You're one tough momma.
-
- March 30, 2016 at 3:43 am
Omg, and a few years before my son was diagnosed my now 24 yr old son had a "highly atypical" mole removed! He is estranged from the family but 3 of these 4 kids….amazing I have not thought about that. So focused on trying to keep Jake going I can't focus on everything else! Geez.
-
- March 28, 2016 at 10:34 pm
This discussion brings up a different question in my mind: Since melanoma can develop in previously "normal" moles, wouldn't it be important to ensure the entire mole is removed even if the pathology is normal? I'm thinking of the case of a shave biopsy that comes back as "atypical" but not melanoma but the shave doesn't have clear margins. Couldn't that heal over leaving small bits of atypical mole beneath the surface that could later become melanoma? I often wonder if that happened to me since I have had several moles removed, none of them diagnosed as melanoma, and now I am stage IV with unknown primary.
-
- March 28, 2016 at 3:07 am
Most punch biopsies get about 4mm of depth – and staging doesn't change if a lesion is beyond 4mm. A punch won't push cells down, it's like a cookie cutter that removes a core of tissue. I know MANY institutions who use punches regularly. Same with shave biopsies, but shaves are MUCH MORE LIKELY not to get the full depth. That happens quite regularly on this board, but I can't remember someone having a punch not get enough depth. As for over/under estimation, I can't comment. It isn't something I've ever seen discussed outside of this one research paper.
As for which you should have, this is up for discussion with your derm. Different lesions might make sense to have different types of biopsies. Large lesions won't fit in punches so in that case, not the best choice. The goal is always to remove the entire lesion if possible, but for very large lesions – that could be disfiguring and why remove an entire lesion without knowing it is melanoma first. Shaves must be deep shaves, and even then, they still can bisect a lesion. Excisional is great, but honestly, it isn't all that realistic for every biopsy. Excisional becomes surgery, not biopsy in terms of level of effort. People who have biopsies all the time really could be cut up if every biopsy was excisional. Your doc deals with this all the time and it is good to discuss but your lesion and circumstances may lend themself to one biopsy type over another. Shallow shaves are the most likely to NOT return good data. One thing about biopsy types, they can ALL identify melanoma. Initial staging is important, but the melanoma diagnosis itself is the most important. Getting any biopsy is better than none. BTW, for lesions deeper than 1mm, prognosis and treatment would be determined by a SNB, not the biopsy itself.
-
- March 28, 2016 at 3:07 am
Most punch biopsies get about 4mm of depth – and staging doesn't change if a lesion is beyond 4mm. A punch won't push cells down, it's like a cookie cutter that removes a core of tissue. I know MANY institutions who use punches regularly. Same with shave biopsies, but shaves are MUCH MORE LIKELY not to get the full depth. That happens quite regularly on this board, but I can't remember someone having a punch not get enough depth. As for over/under estimation, I can't comment. It isn't something I've ever seen discussed outside of this one research paper.
As for which you should have, this is up for discussion with your derm. Different lesions might make sense to have different types of biopsies. Large lesions won't fit in punches so in that case, not the best choice. The goal is always to remove the entire lesion if possible, but for very large lesions – that could be disfiguring and why remove an entire lesion without knowing it is melanoma first. Shaves must be deep shaves, and even then, they still can bisect a lesion. Excisional is great, but honestly, it isn't all that realistic for every biopsy. Excisional becomes surgery, not biopsy in terms of level of effort. People who have biopsies all the time really could be cut up if every biopsy was excisional. Your doc deals with this all the time and it is good to discuss but your lesion and circumstances may lend themself to one biopsy type over another. Shallow shaves are the most likely to NOT return good data. One thing about biopsy types, they can ALL identify melanoma. Initial staging is important, but the melanoma diagnosis itself is the most important. Getting any biopsy is better than none. BTW, for lesions deeper than 1mm, prognosis and treatment would be determined by a SNB, not the biopsy itself.
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Tagged: cutaneous melanoma
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