Grifsy

Here's the initial path report and the addendum, both from the dermatopathologist.  

Initial Report:
Skin, right forearm biopsy (shave biopsy)
Superficial Spreading Malignant Melanoma at least in situ, present at all edges

Microscopic Description:
The sections, at least the initial sections, are interpreted as showing the microscopic features of an atypical nevomelanocytic neoplasm consistent with a superficial spreading malignant melanoma, at least in situ.  I have utilized the term “at least in situ” since the lesion does extend to the lateral edges, appears to be focally transected at the deep edge, there are are a few foci where superficial invasion cannot be entirely excluded, and there is a lymphohistiocytic cell infiltrate present at the deep edge which could mask an invasive component. In addition, because of the prominent inflammatory infiltrate and focal nesting, I would not consider this as an early evolving in situ lesion.  Therefore I have requested deeper levels and an addendum will be sent.

The sections do exhibit epidermal atrophy and most importantly atypical nevomelanocytic cells within the epidermis, at the dermo-epidermal junction, and involving at least one eccrine sweat duct.  The atypical nevomelanocytic cells do exhibit considerable variation in nuclear size, shape and staining characteristics.  Although not entirely classical I would consider the intraepidermal growth component most consistent with the superficial spreading type which would go along as well with the overall cytological features.  There is melanin pigment within the nevomelanocytic cells free in the dermis and within melanophages.  There are a few foci where I cannot completely exclude superficial invasion, although at least in these initial sections, they probably communicate with a rete ridge.  The dermis exhibits prominent solar elastosis and as mentioned a focal dense band-like inflammatory cell infiltrate consisting primarily of lymphocytes and histiocytes.  The lesion does extend to all edges and should be completely and more widely excised.  For a lesion such as this I would recommend 10 mm margins since invasion cannot be excluded.  Margin size is, however, controversial and it is possible that the deeper sections or the lesion elsewhere may exhibit more obvious invasion.
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Addendum diagnosis:
Malignant Melanoma, Superficial Spreading type, at least Level II, at least 0.15 mm in depth, present at all edges.
Epidermal ulceration: none identified
Mitotic rate: cannot adequately evaluate
Surgical margins: positive

Addendum Pathological Report:

Multiple deeper levels were obtained and there is now a focus that I would consider to be at least superficially invasive measuring approximately 0.15 mm in depth.  The lesion is transected at the base and present at the lateral edges, hence deeper involvement elsewhere cannot be entirely excluded, but it is reasonable to consider the lesion at least superficially invasive.

Thank you, Susan.  That has been one big concern – that the path report describes the lesion with the term "at least".  That – and the fact that the dermatologist did a curettage to completely remove what he thought was a keratosis.  Now there is no visible lesion; instead I have a nickel+-sized area of healing skin where the "keratosis" was.  BUT I know that there are melanoma cells still down below the surface.  

I'm also concerned that the curettage has altered the lymphatic drainage already – so how would we know which was the original sentinal node?  Argh!

I'm trying to take comfort where I can.  I appreciate your posting, because it reaffirms my original concern.  I do have questions about the SLNB on my list of things to ask the surgical oncologist about.  I tend not to be very assertive, but I think this is a critical question.  

That's very encouraging!  Thank you!

I definitely need to do some reading before my appointment, re: SLNB.  I hadn't encountered that term yet, so thanks for bringing this up.    Because the dermatologist removed a large amount of tissue after doing the biopsy (thinking this was a keratosis), maybe the lymph drainage has already been altered.  🙁

Yes, the surgical oncologist does specialize in melanoma at our local university hospital's cancer center.

Thank you all for replying.  I thought it looked like every basal cell CA I've ever had – kind of red and scaly.  I do have a ton of actinic keratoses, even though I wasn't much of a sunbather.    Those look more tan and rough textured, not as "scaly" as this looked.  (All of my sibs and my dad have had multiple Mohs procedures for basal cell, but they were all in the sun much more than I was.  We are all very fair-skinned.  I'm the one who seems to have the most keratoses.)

I'll scan and post the path report after I pick up my granddaughter from preschool.  Thanks again.  I am glad I found this site.