New Dx

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6/3/2014 12:21pm
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Replies: 5

Good Afternoon,

 

I'm newly dx and just needed help understanind path report.  My Derm said that I should be ok with just a WLE since the thickness is 0.86MM.   It's the should that worries me, I ask if we could have an oncologist give a 2nd opioion on SNB.  She indicated that most insurance companies will not pay for SNB unless MM is 1MM or more.

The following is what my path report indicates.  I would really appreciate feedback, am I just being over the top or should I push for something more then a WLE.

 

Lower Back:  Shave method, Neoplasm of uncertain behavior vs. Melanoma

Gross Description:

1/4 10x8x2 mm 1 Slide.  Micro Description typed by MAK

Diagnois:

Skin (Lower Back Shave Method)

Malignant Melanoma, Invaise, 0.86 MM in thickness, non ulcerated, see comment:

 

Comment:  This is a diffcule case to evaluate.  There is compound melanocytic proliferation with areas showing definite change of benign nevus.  There are large areas composed of cellular nests or atypical melanocytes with mitotic figures within the papillary dermis.  Other lare areas are composed of atypical melanocytes with mitotic figures.  There is apparent maturation.

I favor the diagnosis of nevoid melanoma arising in a compound nevus.  The area of melanoma appears completely excised in the planes of section.  The changes of nevus are present at one lateral margin of the specimen.

Appropriate reexcisionis necessary.

 

 

 

Janner - (6/3/2014 - 1:41pm)

It is hard to tell from the pathology report if this is a stage IA or stage IB lesion.  It doesn't call out mitosis directly but mentions it in conjunction with benign areas as well.  I'd want clarification.

As for the SNB, your doc may be right.  Staging has changed since the end of 2010.  Prior to that, this would have been a stage IA lesion and since it was less than 1mm, no SNB would be done.  (I had a very similar lesion (0.88mm) removed in 2001 with no SNB as it wasn't warranted).  However, new staging may or may not affect insurance companies.  They may pay if this was a stage IB lesion.  Hard to know.  Personally, I was fine NOT having the SNB.  It's not a guarantee of anything and it is additional surgery.  Obviously, I'm still stage I and the SNB would have been negative in my case -- as it is in the vast majority who have one.  But only you can make this decision for yourself.  Get a second opinion if you want it.  You might also consider getting a second opinion on just the pathology and see if they concur with the original diagnosis.  That might drive my decision on the SNB.  Was the pathology done at a major cancer center with an experienced dermatopathologist reading it? 

In the end, it's what makes YOU feel comfortable, not anyone else.

MattF - (6/6/2014 - 12:01am)

Hey there.

I agree with Janner I would want maybe 2nd Pathology 

and I also agree with 2nd opinion about insurance.

I am stage IV and started at stage 1 in 2012.

 

I did have a SNB with a .96mm malignant melanoma on my ear....it came back NEG.  Ultimately it was determined through the shave biopsy to be "over 1mm" on the final pathology report which kind of got them to do the SNB.

In the end it spread to lymph nodes...so they aren't gospel but I understand wanting accurate pathology and SNB. As well as a well done WLE of course.

 

PS not sure where you are but the screen name is interesting. Southern California here.

Matt

 

 

pasadenagirl - (6/8/2014 - 4:07pm)

Thank you both for your input.  

I contacted an oncology surgeon that specializes in Melanoma and met with him this past Friday.  He was able to get better clarification from the pathologist on my pathology.   He explained that normally a SNB would not be done on a .86mm melanoma, however the mitotic figures was a 3.  In addition the fact that it was difficult to dx, by the derma pathologist and presents as a nevoid with a bit of nodular tendencies it could be more aggressive then it appears.  Therefore the onc. feels there is a need  for a SNB along with the WLE.  He also did blood work and is checking the LDH level.

Is a mitotic rate of 3 bad?   The path report given to me did not include any of this information, however I saw the path report sent to the Onc and it had much more specific information.  Why would I not be given the same report?   It bothers me that my dermatologist would have had me just go to their surgery center and have a WLE and according to her I should be fine.

Thoughts?   Would love to here them.

 

P.S.  This Pasadena girl is from MD, would love to be in CA :)

Blessings to all.

Janner - (6/9/2014 - 2:42pm)

Ask for the other report.  As far as the SNB, it's a judgement call at the best of times.  There is no universal standard protocol for this particular decision... different institutions use different criteria and even then, there are more intangible factors that influence a decision.   It wouldn't have been "wrong" not to do it.  It isn't "right" to do it.  It's all about evaluating the facts and making the best decision you can. 

The SNB is NO GUARANTEE OF ANYTHING.  A negative SNB is great, but do not think that means it won't ever come back.  There are plenty of people on this site who had a negative SNB and later progression.  It's just a snapshot of this point in time.  Now, I'm not saying that to be negative because statistically, it's extremely likely that you will have a negative SNB and never deal with melanoma again.  But you do need to understand that the SNB is a staging tool only, nothing else. 

Mitosis of 3.  There really isn't much out there on mitosis when it comes to distinguishing 2, 5 or 8 or whatever number.  The ONLY distinction used at this moment is either ZERO or Greater than 0.  Zero mitosis is stage IA.  Greater than 0 mitosis is stage IB.  So is your prognosis worse because you had a mitosis of 3 than my last lesion (0.88mm) that had a mitosis of 1?  I honestly can't answer that.  Mitosis is a newer staging tool since the end of 2010.  And while it was very predictive if you had a mitosis of 0, it didn't make any other distinctions. 

LDH levels - basically useless (I feel) for early stages.  LDH can be significant if you are stage IV.  LDH is a measure of organ tissue breakdown which COULD happen with cancer.  But it isn't specific to melanoma and other things can affect the numbers.  You're unlikely to be stage IV with organ damage at this point, so the blood test is a little frivolous in my point of view.  There isn't a melanoma blood test out there right now that can tell you if your melanoma has spread.. 

Just another reminder to remember the source:  your onc surgeon CUTS for a living, so chances are he would recommend doing the SNB to almost anyone who walks in his door.  I'm not saying that's a bad thing, just consider the source of the information.  He's doing what he does best and unlikely to tell you to just leave.  He will justify surgery.   It's not a criticism, it's just a reality. 

It's hard when you are adjusting to a diagnosis, a new medical language and all the rest.  Much easier for someone like me who's been at this ages to step back and take a more critical view.  Right now, you just need to do what feels right for you!  YOU call the shots, no one else.

pasadenagirl - (6/24/2014 - 11:58am)

Good afternoon:

Well I had my SNB and WLE yesterday.   The dye injected traveled to two different locations, groin and under my arm.   They removed lymph nodes from both area's, only have drain in for under my arm and really that is the only spot that is uncomfortable at the moment.

While doing the WLE the doctor saw another spot that was to the left of the original spot that he called "very suspicious"  He performed a WLE on that area as well to avoid having me have to do this all over again.   My question is if this new spot is melanoma is it a satellite lesion and how bad is that?    This spot was a mole that has been there like the first spot, however I did just in the last week notice that it was sticking up off my skin more and a little itchy however I thought I was just being paranoid and a little over zealous when it came to examining every spot I could find.   

The Doctor told my husband results would take about 5-7 days and did not indicate one way or another on possible outcome.

As always I appreciate any insight to help better prepare me for whatever comes my way.

Thanks