› Forums › General Melanoma Community › PC Pathology or Pathological?
- This topic has 24 replies, 4 voices, and was last updated 11 years, 9 months ago by
Bob B..
- Post
-
- March 20, 2012 at 11:31 pm
The bright, young pathologist who did my lab work following last week's superficially spreading melanoma encision (SSM) shared some candid remarks with me. He explained why "completely excised" does not necessarily mean, well, completely. Why his clinical clients' legal exposure and the commercial necessity to keep them happy encourages absolutist pathology results rather than insights. Why a completely excised tumor may well need to be re-excised (as in my case).
The bright, young pathologist who did my lab work following last week's superficially spreading melanoma encision (SSM) shared some candid remarks with me. He explained why "completely excised" does not necessarily mean, well, completely. Why his clinical clients' legal exposure and the commercial necessity to keep them happy encourages absolutist pathology results rather than insights. Why a completely excised tumor may well need to be re-excised (as in my case). And why histological reality can be more "grey" than "black & white". Interesting.
I put my foot in my mouth with my first post "Overtreatment?" The fact that I have the luxury until now of only a second primary, both Stage 1, contributed to hubristic insensitivity. I will try not to make the same mistake again.
But if someone is interested in a superficial take on the reality check the pathologist gave me regarding my particular case, let me know. I found it fascinating. Others will not find it either interesting or particularly PC.
- Replies
-
-
- March 21, 2012 at 12:15 am
I thought you post regarding Overtreatment brought up an interesting debate. Oh well, I suppose some people were offended. Personally, I learned some things from it. Anyway, still willing to learn more. You can email me if you don't feel comfortable posting pothologists remarks.
Thanks,
Mary
Stage 3
-
- March 21, 2012 at 12:15 am
I thought you post regarding Overtreatment brought up an interesting debate. Oh well, I suppose some people were offended. Personally, I learned some things from it. Anyway, still willing to learn more. You can email me if you don't feel comfortable posting pothologists remarks.
Thanks,
Mary
Stage 3
-
- March 21, 2012 at 12:15 am
I thought you post regarding Overtreatment brought up an interesting debate. Oh well, I suppose some people were offended. Personally, I learned some things from it. Anyway, still willing to learn more. You can email me if you don't feel comfortable posting pothologists remarks.
Thanks,
Mary
Stage 3
-
- March 21, 2012 at 12:43 pm
He is right. There is always a chance that a single stray cell may be beyond the margins. That is all it takes.
-
- March 21, 2012 at 2:08 pm
Exactly. That's why "completely excised" on my pathology report cannot be credited. I will have a re-excision for this reason. But as mentioned, the following is irrelevant for our purposes because the distortions (#2-3, below) tend toward adequate treatment.
But if not cautionary in any way, I find the following issues instructive about the health industry. And a little amusing, too. Of course they reflect only my extremely limited experience. They may be anomalies that are in no way reflective of practice elsewhere….
1. Pathology labs depend on doctors, not patients, to survive in business.
2. "Complete excision" is an absolute statement, the sort doctors demand from pathology labs. In such a litigious society like the USA, doctors want black & white statements that will backstop their treatment decisions in case someone decides to sue them.
3. But both pathologists and doctors know better. By demanding absolute statements, the doctor passes the 'buck' (legal risk) to the pathology lab. As a result, the pathology lab and pathologists feel legally exposed. They then attempt to cover themselves with the sort of odd, parenthetical and unquantified statements I found repeated in my report: "narrowly excised… very close to the lateral edges… very narrow".
Which, from a scientific point of view, means nothing at all. Instead, they are a kind of 'code'. The pathologist hopes to protect himself legally, in case the doctor fails to prescribe adequate treatment based on the pathologist's official, "completely excised" results. The doctor, in turn, knows he should ignore the absolutist results and proceed with treatment, anyway.
Any more informed comments on the relationship between pathology labs and clinicians, exposure to lawsuits, and where the patient fits in- would be welcome.
-
- March 21, 2012 at 2:08 pm
Exactly. That's why "completely excised" on my pathology report cannot be credited. I will have a re-excision for this reason. But as mentioned, the following is irrelevant for our purposes because the distortions (#2-3, below) tend toward adequate treatment.
But if not cautionary in any way, I find the following issues instructive about the health industry. And a little amusing, too. Of course they reflect only my extremely limited experience. They may be anomalies that are in no way reflective of practice elsewhere….
1. Pathology labs depend on doctors, not patients, to survive in business.
2. "Complete excision" is an absolute statement, the sort doctors demand from pathology labs. In such a litigious society like the USA, doctors want black & white statements that will backstop their treatment decisions in case someone decides to sue them.
3. But both pathologists and doctors know better. By demanding absolute statements, the doctor passes the 'buck' (legal risk) to the pathology lab. As a result, the pathology lab and pathologists feel legally exposed. They then attempt to cover themselves with the sort of odd, parenthetical and unquantified statements I found repeated in my report: "narrowly excised… very close to the lateral edges… very narrow".
Which, from a scientific point of view, means nothing at all. Instead, they are a kind of 'code'. The pathologist hopes to protect himself legally, in case the doctor fails to prescribe adequate treatment based on the pathologist's official, "completely excised" results. The doctor, in turn, knows he should ignore the absolutist results and proceed with treatment, anyway.
Any more informed comments on the relationship between pathology labs and clinicians, exposure to lawsuits, and where the patient fits in- would be welcome.
-
- March 21, 2012 at 2:08 pm
Exactly. That's why "completely excised" on my pathology report cannot be credited. I will have a re-excision for this reason. But as mentioned, the following is irrelevant for our purposes because the distortions (#2-3, below) tend toward adequate treatment.
But if not cautionary in any way, I find the following issues instructive about the health industry. And a little amusing, too. Of course they reflect only my extremely limited experience. They may be anomalies that are in no way reflective of practice elsewhere….
1. Pathology labs depend on doctors, not patients, to survive in business.
2. "Complete excision" is an absolute statement, the sort doctors demand from pathology labs. In such a litigious society like the USA, doctors want black & white statements that will backstop their treatment decisions in case someone decides to sue them.
3. But both pathologists and doctors know better. By demanding absolute statements, the doctor passes the 'buck' (legal risk) to the pathology lab. As a result, the pathology lab and pathologists feel legally exposed. They then attempt to cover themselves with the sort of odd, parenthetical and unquantified statements I found repeated in my report: "narrowly excised… very close to the lateral edges… very narrow".
Which, from a scientific point of view, means nothing at all. Instead, they are a kind of 'code'. The pathologist hopes to protect himself legally, in case the doctor fails to prescribe adequate treatment based on the pathologist's official, "completely excised" results. The doctor, in turn, knows he should ignore the absolutist results and proceed with treatment, anyway.
Any more informed comments on the relationship between pathology labs and clinicians, exposure to lawsuits, and where the patient fits in- would be welcome.
-
- March 21, 2012 at 3:23 pm
This is why pathology is considered as much an art as a science. Send the same slides to a different pathologist and you might not get the same diagnosis. Much depends on experience. That's why I also give very little attention to "clear margins" or no melanoma found on the WLE. The WLE tissue is not analyzed to the same degree as the biopsy – they are only sampling it. The whole picture isn't there. The margins are an important safeguard, but the WLE analysis is only as good as the samples they happened to see. One thing to note, though, melanoma cells do love to travel. As was stated before, it may only take one rogue cell that was outside the WLE zone or already in a lymph vessel to advance a person. Clear margins or "completely excised" is nice, but it is impossible to analyze every cell – hence the extra margins to make sure. The other basic types of skin cancer don't seem to have the rogue cell (we want to travel) mentality. Clear margins with those types of cancers are fine and no extra buffer is typically needed.
Your arguments also play a role in the diagnosis of melanoma in situ – the fastest growing category of melanoma diagnosed. Some think that melanoma in situ is "over diagnosed" in the same CYA (cover your butt) mentality. If they diagnose it as in situ and the doctor fails to take the required margins, the pathologist is covered. The difference between a melanoma in situ lesion and a severely atypical/dysplastic lesion is a matter of degrees. Because so many factors have to be analyzed – and no two melanomas are exactly the same – there is a certain level of judgement made by a pathologist in the categorization of a lesion. Again, experience most likely plays a role in this type of diagnosis, too. I will say I do appreciate going to an institution that does their pathology in house. I think the doctors develop a rapport with the pathologists and you may see less CYA diagnoses because the pathologist KNOWS the doctor will take extra margins and the doctor KNOWS the pathologist isn't intentionally overdiagnosising. I have an odd scenario where my cutaneous oncologist/Mohs surgeron does the biopsy, and his wife – also a dermatologist and a dermatopathologist – might read the slides. There are several dermatopathologists at my institution so no biopsy gets just one reading. All path reports have at least two signatures.
In the end, the bottom line for me is: surgery and margins at the outset are the best hope of not advancing. So obtaining a few extra millimeters "just in case" is money well spent. If anywhere, this is where I think overtreatment is warranted.
Janner
-
- March 22, 2012 at 4:56 am
Cigarette ad from the 60's: "A Silly Millimeter More". Or five.
I strongly agree that ample surgery is the best bet. But largely for intuitive reasons ("just get the sucker out, will you!"). Not for technical reasons, about which opinions vary. "Less is more" is a good mantra, but I never worry about what I don't know and can't find out, e.g. the potential for WLE distortion of the lymphatic drain field. Up to a point, more is more secure.
Will get a second excision, and treat the first like a biopsy.You mention a fundamental difference between the more precise histology performed on a biopsy, compare with that performed on a WLE. I guess you mean more sections are taken and studied with a biopsy. In general, the more sections and the finer those sections the more accurate the results. Results employing @1mm sections are excellent, although impossibly laborious to do. Results decrease rapidly the wider the section.In the case of my not-so-WLE with clinical margins of 0.5cm, the pathologist took sections every 3mm. According to the pathologist, the end "tails" or "football" shape taken to facilitate suturing and cosmetics, the area was absolutely clear. According to the pathologist. (Obviously gratified at the chance, he said he performed several hundred analyses per year, but "only got to talk to 2 or 3 per year".) But along one of the laterals the margin was close. As you say, only a cell or two outside the sample could be enough. In addition, if I understood correctly, melanocytes have a tendency to "play games", mutate to a point where it's hard to tell which ones are diseased and which are not.As the difference between "in situ" and Stage i is a matter of degree, it appears the same with melanocytes.. Judgement and experience are everything. And in the last instance it is on the pathologist's insights and experience that the surgeon depends. "Art + Science. Mostly Art." -
- March 22, 2012 at 4:56 am
Cigarette ad from the 60's: "A Silly Millimeter More". Or five.
I strongly agree that ample surgery is the best bet. But largely for intuitive reasons ("just get the sucker out, will you!"). Not for technical reasons, about which opinions vary. "Less is more" is a good mantra, but I never worry about what I don't know and can't find out, e.g. the potential for WLE distortion of the lymphatic drain field. Up to a point, more is more secure.
Will get a second excision, and treat the first like a biopsy.You mention a fundamental difference between the more precise histology performed on a biopsy, compare with that performed on a WLE. I guess you mean more sections are taken and studied with a biopsy. In general, the more sections and the finer those sections the more accurate the results. Results employing @1mm sections are excellent, although impossibly laborious to do. Results decrease rapidly the wider the section.In the case of my not-so-WLE with clinical margins of 0.5cm, the pathologist took sections every 3mm. According to the pathologist, the end "tails" or "football" shape taken to facilitate suturing and cosmetics, the area was absolutely clear. According to the pathologist. (Obviously gratified at the chance, he said he performed several hundred analyses per year, but "only got to talk to 2 or 3 per year".) But along one of the laterals the margin was close. As you say, only a cell or two outside the sample could be enough. In addition, if I understood correctly, melanocytes have a tendency to "play games", mutate to a point where it's hard to tell which ones are diseased and which are not.As the difference between "in situ" and Stage i is a matter of degree, it appears the same with melanocytes.. Judgement and experience are everything. And in the last instance it is on the pathologist's insights and experience that the surgeon depends. "Art + Science. Mostly Art." -
- May 4, 2012 at 6:00 am
Re: The Art of Pathology Reports
After a second excision of a second primary melanoma, had two shave biopsies. One on my left temple I've noticed for the last 10-15 years, very occasional bleeding, rough but unimpressive. Turned out to be a basal cell carcinoma. The other is an odd one on my chest I've watched slowly change shape over the last two years. Two weeks after taking the biopsy the pathologists still can't figure out what it is. They have sent it on to a second laboratory more specialized in dermopathology.
But I reckon it's a melanoma alright. I have no doubt. And I'm getting used to the drill: ambivalent pathology results. No problem. Ambivalency is- to me- more reassuring than dogma. But I'm interested to hear what they finally come up with. Probably need another wide excision, but I can spare the excess flesh. About time I'm having these things taken care of, I'm sure anyone would agree.
-
- May 4, 2012 at 6:00 am
Re: The Art of Pathology Reports
After a second excision of a second primary melanoma, had two shave biopsies. One on my left temple I've noticed for the last 10-15 years, very occasional bleeding, rough but unimpressive. Turned out to be a basal cell carcinoma. The other is an odd one on my chest I've watched slowly change shape over the last two years. Two weeks after taking the biopsy the pathologists still can't figure out what it is. They have sent it on to a second laboratory more specialized in dermopathology.
But I reckon it's a melanoma alright. I have no doubt. And I'm getting used to the drill: ambivalent pathology results. No problem. Ambivalency is- to me- more reassuring than dogma. But I'm interested to hear what they finally come up with. Probably need another wide excision, but I can spare the excess flesh. About time I'm having these things taken care of, I'm sure anyone would agree.
-
- May 4, 2012 at 6:00 am
Re: The Art of Pathology Reports
After a second excision of a second primary melanoma, had two shave biopsies. One on my left temple I've noticed for the last 10-15 years, very occasional bleeding, rough but unimpressive. Turned out to be a basal cell carcinoma. The other is an odd one on my chest I've watched slowly change shape over the last two years. Two weeks after taking the biopsy the pathologists still can't figure out what it is. They have sent it on to a second laboratory more specialized in dermopathology.
But I reckon it's a melanoma alright. I have no doubt. And I'm getting used to the drill: ambivalent pathology results. No problem. Ambivalency is- to me- more reassuring than dogma. But I'm interested to hear what they finally come up with. Probably need another wide excision, but I can spare the excess flesh. About time I'm having these things taken care of, I'm sure anyone would agree.
-
- March 22, 2012 at 4:56 am
Cigarette ad from the 60's: "A Silly Millimeter More". Or five.
I strongly agree that ample surgery is the best bet. But largely for intuitive reasons ("just get the sucker out, will you!"). Not for technical reasons, about which opinions vary. "Less is more" is a good mantra, but I never worry about what I don't know and can't find out, e.g. the potential for WLE distortion of the lymphatic drain field. Up to a point, more is more secure.
Will get a second excision, and treat the first like a biopsy.You mention a fundamental difference between the more precise histology performed on a biopsy, compare with that performed on a WLE. I guess you mean more sections are taken and studied with a biopsy. In general, the more sections and the finer those sections the more accurate the results. Results employing @1mm sections are excellent, although impossibly laborious to do. Results decrease rapidly the wider the section.In the case of my not-so-WLE with clinical margins of 0.5cm, the pathologist took sections every 3mm. According to the pathologist, the end "tails" or "football" shape taken to facilitate suturing and cosmetics, the area was absolutely clear. According to the pathologist. (Obviously gratified at the chance, he said he performed several hundred analyses per year, but "only got to talk to 2 or 3 per year".) But along one of the laterals the margin was close. As you say, only a cell or two outside the sample could be enough. In addition, if I understood correctly, melanocytes have a tendency to "play games", mutate to a point where it's hard to tell which ones are diseased and which are not.As the difference between "in situ" and Stage i is a matter of degree, it appears the same with melanocytes.. Judgement and experience are everything. And in the last instance it is on the pathologist's insights and experience that the surgeon depends. "Art + Science. Mostly Art." -
- July 16, 2012 at 3:50 pm
Janner,
Do we attract that which we think? An example or two…. If we are fearful, bad things are more likely happen. If confrontational, we generate confrontations. And, as you are aware I am more concerned with 'overtreatment' than most, it looks like overtreatment is what I get, as well.
I was successful in my wish to avoid biopsies and go directly to Wide Lesion Excisions (WLE) with Primary #1 (LMM, 2 1/2 years ago) and Primary #2 (SSM, 4 months ago after tracking its growth 8 months, excised twice). However, with Primary #3 (SSM, 2 months ago after tracking its growth 2 1/2 years)- best practice, standard health insurance protocols, the health industry, etc wore me down. It all combined to coerce me into a shave biopsy I did not want of a lesion that, for the third time in a row, turned out as expected: Melanoma.
After waiting two weeks, what I found to be an ambivalent, rudimentary pathology report claimed diseased tissue "at the margin". According to the also delayed "addendum", the shave had presumably "transected the lesion" at .94mm depth. Obviously there was no way to know how deeply the lesion had gone. (Maybe "1.5mm?", one doctor speculated, imagined…). Due to the depth (over .75/recent staging) and our lack of knowledge of "actual depth", a SLNB was strongly encouraged. I again declined- as I had with Primary #1 and Primary #2.
Here is maybe where it gets interesting re: "overtreatment"? See what you think….
Post-WLE pathology showed absolutely no residual disease! Hey, what about the "transected lesion" biopsy? What about diseased tissue "at the margin"? This time, the pathologist who had signed the biopsy pathology simply avoided me. After weeks of persistence, the pathologist who signed the post-WLE report with which I had no problem, talked it over. The credibility of his opinion seems key:
According to him, it is quite common for a WLE to be "clear" after the shave biopsy showed disease "at the margin". the question, of course: IS this true? Of course doctors, pathologists, friends, family… everyone asks, "Why, aren't you content to learn the thing was completely excised?"
Sorry, I am NOT content. A WLE under general anesthetic was performed that came up 100% healthy, based on (it would appear) potentially spurious biopsy results.
What about a "transected" biopsy that turns out to have completely removed the lesion- PRIOR to a WLE? Would much appreciate your opinion.
-
- July 16, 2012 at 3:50 pm
Janner,
Do we attract that which we think? An example or two…. If we are fearful, bad things are more likely happen. If confrontational, we generate confrontations. And, as you are aware I am more concerned with 'overtreatment' than most, it looks like overtreatment is what I get, as well.
I was successful in my wish to avoid biopsies and go directly to Wide Lesion Excisions (WLE) with Primary #1 (LMM, 2 1/2 years ago) and Primary #2 (SSM, 4 months ago after tracking its growth 8 months, excised twice). However, with Primary #3 (SSM, 2 months ago after tracking its growth 2 1/2 years)- best practice, standard health insurance protocols, the health industry, etc wore me down. It all combined to coerce me into a shave biopsy I did not want of a lesion that, for the third time in a row, turned out as expected: Melanoma.
After waiting two weeks, what I found to be an ambivalent, rudimentary pathology report claimed diseased tissue "at the margin". According to the also delayed "addendum", the shave had presumably "transected the lesion" at .94mm depth. Obviously there was no way to know how deeply the lesion had gone. (Maybe "1.5mm?", one doctor speculated, imagined…). Due to the depth (over .75/recent staging) and our lack of knowledge of "actual depth", a SLNB was strongly encouraged. I again declined- as I had with Primary #1 and Primary #2.
Here is maybe where it gets interesting re: "overtreatment"? See what you think….
Post-WLE pathology showed absolutely no residual disease! Hey, what about the "transected lesion" biopsy? What about diseased tissue "at the margin"? This time, the pathologist who had signed the biopsy pathology simply avoided me. After weeks of persistence, the pathologist who signed the post-WLE report with which I had no problem, talked it over. The credibility of his opinion seems key:
According to him, it is quite common for a WLE to be "clear" after the shave biopsy showed disease "at the margin". the question, of course: IS this true? Of course doctors, pathologists, friends, family… everyone asks, "Why, aren't you content to learn the thing was completely excised?"
Sorry, I am NOT content. A WLE under general anesthetic was performed that came up 100% healthy, based on (it would appear) potentially spurious biopsy results.
What about a "transected" biopsy that turns out to have completely removed the lesion- PRIOR to a WLE? Would much appreciate your opinion.
-
- July 16, 2012 at 3:50 pm
Janner,
Do we attract that which we think? An example or two…. If we are fearful, bad things are more likely happen. If confrontational, we generate confrontations. And, as you are aware I am more concerned with 'overtreatment' than most, it looks like overtreatment is what I get, as well.
I was successful in my wish to avoid biopsies and go directly to Wide Lesion Excisions (WLE) with Primary #1 (LMM, 2 1/2 years ago) and Primary #2 (SSM, 4 months ago after tracking its growth 8 months, excised twice). However, with Primary #3 (SSM, 2 months ago after tracking its growth 2 1/2 years)- best practice, standard health insurance protocols, the health industry, etc wore me down. It all combined to coerce me into a shave biopsy I did not want of a lesion that, for the third time in a row, turned out as expected: Melanoma.
After waiting two weeks, what I found to be an ambivalent, rudimentary pathology report claimed diseased tissue "at the margin". According to the also delayed "addendum", the shave had presumably "transected the lesion" at .94mm depth. Obviously there was no way to know how deeply the lesion had gone. (Maybe "1.5mm?", one doctor speculated, imagined…). Due to the depth (over .75/recent staging) and our lack of knowledge of "actual depth", a SLNB was strongly encouraged. I again declined- as I had with Primary #1 and Primary #2.
Here is maybe where it gets interesting re: "overtreatment"? See what you think….
Post-WLE pathology showed absolutely no residual disease! Hey, what about the "transected lesion" biopsy? What about diseased tissue "at the margin"? This time, the pathologist who had signed the biopsy pathology simply avoided me. After weeks of persistence, the pathologist who signed the post-WLE report with which I had no problem, talked it over. The credibility of his opinion seems key:
According to him, it is quite common for a WLE to be "clear" after the shave biopsy showed disease "at the margin". the question, of course: IS this true? Of course doctors, pathologists, friends, family… everyone asks, "Why, aren't you content to learn the thing was completely excised?"
Sorry, I am NOT content. A WLE under general anesthetic was performed that came up 100% healthy, based on (it would appear) potentially spurious biopsy results.
What about a "transected" biopsy that turns out to have completely removed the lesion- PRIOR to a WLE? Would much appreciate your opinion.
-
- March 21, 2012 at 3:23 pm
This is why pathology is considered as much an art as a science. Send the same slides to a different pathologist and you might not get the same diagnosis. Much depends on experience. That's why I also give very little attention to "clear margins" or no melanoma found on the WLE. The WLE tissue is not analyzed to the same degree as the biopsy – they are only sampling it. The whole picture isn't there. The margins are an important safeguard, but the WLE analysis is only as good as the samples they happened to see. One thing to note, though, melanoma cells do love to travel. As was stated before, it may only take one rogue cell that was outside the WLE zone or already in a lymph vessel to advance a person. Clear margins or "completely excised" is nice, but it is impossible to analyze every cell – hence the extra margins to make sure. The other basic types of skin cancer don't seem to have the rogue cell (we want to travel) mentality. Clear margins with those types of cancers are fine and no extra buffer is typically needed.
Your arguments also play a role in the diagnosis of melanoma in situ – the fastest growing category of melanoma diagnosed. Some think that melanoma in situ is "over diagnosed" in the same CYA (cover your butt) mentality. If they diagnose it as in situ and the doctor fails to take the required margins, the pathologist is covered. The difference between a melanoma in situ lesion and a severely atypical/dysplastic lesion is a matter of degrees. Because so many factors have to be analyzed – and no two melanomas are exactly the same – there is a certain level of judgement made by a pathologist in the categorization of a lesion. Again, experience most likely plays a role in this type of diagnosis, too. I will say I do appreciate going to an institution that does their pathology in house. I think the doctors develop a rapport with the pathologists and you may see less CYA diagnoses because the pathologist KNOWS the doctor will take extra margins and the doctor KNOWS the pathologist isn't intentionally overdiagnosising. I have an odd scenario where my cutaneous oncologist/Mohs surgeron does the biopsy, and his wife – also a dermatologist and a dermatopathologist – might read the slides. There are several dermatopathologists at my institution so no biopsy gets just one reading. All path reports have at least two signatures.
In the end, the bottom line for me is: surgery and margins at the outset are the best hope of not advancing. So obtaining a few extra millimeters "just in case" is money well spent. If anywhere, this is where I think overtreatment is warranted.
Janner
-
- March 21, 2012 at 3:23 pm
This is why pathology is considered as much an art as a science. Send the same slides to a different pathologist and you might not get the same diagnosis. Much depends on experience. That's why I also give very little attention to "clear margins" or no melanoma found on the WLE. The WLE tissue is not analyzed to the same degree as the biopsy – they are only sampling it. The whole picture isn't there. The margins are an important safeguard, but the WLE analysis is only as good as the samples they happened to see. One thing to note, though, melanoma cells do love to travel. As was stated before, it may only take one rogue cell that was outside the WLE zone or already in a lymph vessel to advance a person. Clear margins or "completely excised" is nice, but it is impossible to analyze every cell – hence the extra margins to make sure. The other basic types of skin cancer don't seem to have the rogue cell (we want to travel) mentality. Clear margins with those types of cancers are fine and no extra buffer is typically needed.
Your arguments also play a role in the diagnosis of melanoma in situ – the fastest growing category of melanoma diagnosed. Some think that melanoma in situ is "over diagnosed" in the same CYA (cover your butt) mentality. If they diagnose it as in situ and the doctor fails to take the required margins, the pathologist is covered. The difference between a melanoma in situ lesion and a severely atypical/dysplastic lesion is a matter of degrees. Because so many factors have to be analyzed – and no two melanomas are exactly the same – there is a certain level of judgement made by a pathologist in the categorization of a lesion. Again, experience most likely plays a role in this type of diagnosis, too. I will say I do appreciate going to an institution that does their pathology in house. I think the doctors develop a rapport with the pathologists and you may see less CYA diagnoses because the pathologist KNOWS the doctor will take extra margins and the doctor KNOWS the pathologist isn't intentionally overdiagnosising. I have an odd scenario where my cutaneous oncologist/Mohs surgeron does the biopsy, and his wife – also a dermatologist and a dermatopathologist – might read the slides. There are several dermatopathologists at my institution so no biopsy gets just one reading. All path reports have at least two signatures.
In the end, the bottom line for me is: surgery and margins at the outset are the best hope of not advancing. So obtaining a few extra millimeters "just in case" is money well spent. If anywhere, this is where I think overtreatment is warranted.
Janner
- You must be logged in to reply to this topic.