› Forums › Cutaneous Melanoma Community › Unclear diagnosis – pending further results
- This topic has 8 replies, 3 voices, and was last updated 6 years, 9 months ago by
Blond and fair.
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- August 29, 2018 at 4:47 am
I had a mole on my leg for a decade or more that suddenly started changing. I went to the dermatologist and she did a punch removal and biopsy two weeks ago. I went back for stitches removal and results today. The results were, as of yet, quite grey. Basically, the initial pathology report indicated further testing was needed. The dr is telling me it is "likely" somewhere between a benign mole and a melanoma, but closer to the melanoma end of the spectrum and that the pathologist sent it for further testing, including "molecular analysis" and looking for genetic markers.
I have the full preliminary report in front of me, and will type it below, but after looking online and trying to understand this, I am now even more confused. Am I correct in concluding it is NOT melanoma, but something that could lead to melanoma if not fully excised? or am I still potentially looking at a melanoma diagnosis? Also, I've read many studies now stating that atypical dysplastic nevus but NOT necessarily melanoma do not necessarily have to be re-excised and that the outlook tends generally to be the same whether those people with such a diagnosis stick with the initial biopsy removal or go back for a full re-excise. If this initial report is the pathologist's conclusion regarding melanoma v. not melanoma (so, it's NOT melanoma…) then what is this molecular analysis going to show?
Report says:
At the dermoepidermal junction, there is a proliferation of melanocytes arranged mostly in nests which focally tend to coalesce. Nests and solitary melanocytes in the epidermis extend past the intradermal component. the epidermis is hyperplastic and focally, there is fibroplasia surrounding rete ridges. Nevus cells are present in the dermis centrally. Some of the junctional melanocytes have larger nuclei, are more epithelioid, and are present in horizontally arranged nests. There is extensive melanocytic confluence and upward spread of melanocytes. A multplex immunohistochemical stair for Mart-1 and Ki-67 with appropriately staining controls highlights the melanocytic proliferation and shows no significant co-staining in the dermal component, confirming a low proliferation index. HMB-45 highlights the cells comprising the proliferation. the lesion extends to one lateral margin.
DIAGNOSIS: compound dysplastic nevus with severe atypia and spitzoid features
Comments: this lesion has been sent for molecular analysis. an addendum report will follow.
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- August 29, 2018 at 8:42 pm
Many diagnoses fall into that indeterminate area. My lesion was similar. After the derm pathologists at Emory were unable to call it one way or the other, they sent my specimen to Dr. Barnhill at UCLA which also came back indeterminate. Given the depth (1.2mm) and mitotic rate of 3, we decided t do a SLNB – bingo….two nodes with micromets. The additional analysis seems quite prudent, so looks like you're in good hands. By the way, my journey started in October of 2011 and I've been NED since my CLND. Hang in there and good luck!
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- August 29, 2018 at 11:12 pm
Thank you. That's interesting to hear you went with an SLNB. I'll be curious to see if that's something they discuss with me depending on the final findings. My sense is that even with the final molecular study there won't be a 100% certainty. once they did the SLNB, were you staged? Or was it just deemed very early and you caught it in whole by doing the CLND? Also, in deciding whether to do the SLNB, did you have any genetic testing (as the next poster mentioned)?
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- August 30, 2018 at 11:48 am
At the time, I think it was standard of care to recommend a SLNB for any lesion greater than 1mm. I was staged at that point, 3A, due to the two positive lymph nodes. After the SLNB, I transferred to Sloan Kettering for my care. I discussed the CLND with my surgeon, Dr. Coit who reviewed the procedure versus “watch and wait”, I opted for the,procedure with no additional positive nodes. The only other testing was for BRAF as I recall.
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- August 31, 2018 at 7:39 am
Can't thank you enough for this information. I feel much better equipped with at least some basic knowledge now. I don't want to find myself sitting in a dermatologist's exam room and being told to just do something without any understanding of what my actual options are or what to ask. I will come back and post when I find out more information. I really appreciate the input here!
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- September 1, 2018 at 6:32 am
I got the results… unfortunately it is a malignant melanoma. Here is the path report…
Breslow depth: 5mm
histological subtype: spitzoid
clark level II
ulceration = not identified
dermal mitotic index (per 2mm) = 0
Tumor infiltrating lymphocytes: present, focally brisk
regression: not identified
vascular or lymphatic invasion: not identified
perineural invasion: not identified
microsatellites: not identified
predominant cell type: epithelioid
solar elastosis: present (mild)
nearest lateral margin to in situ component: 0
margins: melanoma in situ involves the lateral margins
pathalogic staging: pT1a pNx (AJCC 8th edition)
next step is a consult with a surgeon and a subsection is being sent for another test by Castle (testing company) called Decision Dx which is supposed to help figure out how aggressive it is which would inform whether or not a SLNB is needed in addition to the re-exision. Since it is on my shin, they may have to do skin grafting…
I'm also getting a second opinion at UCSD…well, hopefully. I want their cancer center to read the pathology too. it seems like there is a lot of subjectiveness involved.
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- August 29, 2018 at 9:08 pm
My daughter had an atypical spitzoid biopsied. Path came back much like yours….lots of explanation that non-medical folk don't quite understand. The last sentence of her path said…complete excission recommended and re-submit for further testing. In otherwords, we aren't quit sure. Spitzoid features are hard to evalulate and distinguish from melanomas from what I have read and from the information obtained from my derm and oncologist. My daughter's final path determined benign atypical spitzoid, but she is now on an every 6 month watch because it was (1) atypical and (2) I, her mother, had stage 1B melanoma in May.
My derm told me that if by chance my daughter's 2nd test came back positive for melanoma, it would be in situ – very early. So yes, there is still a chance it could be just like there is a chance it is not. I think the odds may slightly be in your favor since it didn't scream melanoma right off the bat. For further confirmation on my daughter's tumor, they checked her tumor for the P16 gene. It is a tumor suppressor gene, that when present, indicates a benign lesion. Maybe their "further testing" will inlcude that?
I do think your derm has a point. This mole may very well be in the "in between" stage. Dysplastic…spitzoid..severe atypia..nasty little characteristics. She very may well suggest full excission of the mole. When in doubt, take it out. A punch biopsy is not a full excission. I have had 34 punch biopsies since May 15, 2018 and 5 complete excissions of atypical or just funky moles with extra melanocytes. Anything "funky" or atypical they will remove from me because of my melanoma and I am perfectly fine with that.
Waiting is hard, but try to stay positive while you wait another 2 weeks for the 2nd testing. There is nothing you can do about it and worrying/anxiety will not help. As stated, even if it is not melanoma, you may be advised to fully excise the mole and small surrounding area. This type mole (atypical spitzoid) does have a higher chance of becoming melanoma. Doesn't mean it will, but I think it wise to remove it regardless. Peace of mind is very important.
Let us know what your follow up testing reveals and best of wishes to you!
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- August 29, 2018 at 11:04 pm
Thank you so much for the feedback and sharing your daughter's experience. That's really helpful. I think now I understand much more about the genetic testing piece. the tumor supressor gene makes complete sense. Yep, patience and just wait to find out more!
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- September 1, 2018 at 6:33 am
I got the results… unfortunately it is a malignant melanoma. Here is the path report…
Breslow depth: 5mm
histological subtype: spitzoid
clark level II
ulceration = not identified
dermal mitotic index (per 2mm) = 0
Tumor infiltrating lymphocytes: present, focally brisk
regression: not identified
vascular or lymphatic invasion: not identified
perineural invasion: not identified
microsatellites: not identified
predominant cell type: epithelioid
solar elastosis: present (mild)
nearest lateral margin to in situ component: 0
margins: melanoma in situ involves the lateral margins
pathalogic staging: pT1a pNx (AJCC 8th edition)
next step is a consult with a surgeon and a subsection is being sent for another test by Castle (testing company) called Decision Dx which is supposed to help figure out how aggressive it is which would inform whether or not a SLNB is needed in addition to the re-exision. Since it is on my shin, they may have to do skin grafting…
I'm also getting a second opinion at UCSD…well, hopefully. I want their cancer center to read the pathology too. it seems like there is a lot of subjectiveness involved.
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Tagged: cutaneous melanoma
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