New here, pathology report questions

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8/4/2010 12:47pm
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Replies: 15

Hi All,

I'm not too happy to be here, frankly, but very glad to know I'm not alone.  I was diagnosed with a melanoma on my arm, near my elbow.  The pathology report is this:

Left Arm
Malignant Melanoma
Note: Preliminary Depth: at least 1.6mm to base
Preliminary Level: at least Clark's Level IV, to base
Ulceration: Present
Regression: Not identified
Lymphovascular invasion: Not identified
Mitosis: 5-7mm(2)
Tumor infiltrating lymphocytes: Not identified
Margins: The deep margin is focally involved; the side/peripheral margins appear negative.

Clinical Impression: DF
Gross Description: 8x7x1 bisected

Microscopic Description:
Original and multiple deeper levels were prepared and reviewed at dermatopathology consensus conference. Sections shows a shave biopsy of skin with focally ulcerated epidermis in the center of the biopsy, covered by a scale crust. In the dermis there is a proliferation of large slightly pleomorphic cells with vesicular nuclei and abundant pale cytoplasm. In some areas these cells are arranged in nests whereas in other foci they form long fascicles. Focally, there are similar cells at the dermoepidermal junction. The cells do not mature with their descent into the dermis. Numerous mitotic figures are seen throughout the lesion including the deep portion of the lesion. A panel of immunohistochemical stains is performed. The cells are positive for S100, NGFR, and Vimentin. They are negative for Melan A, HMB-45, cytokeratin 116, CD10, and Desmin. MIB-1 labels numerous nuclei within the lesion.

So I go see a surgical oncologist in a few days but some questions.  From what I've been reading around the web, some things on this report look bad (like the high mitotic rate) and the fact that they are calling this a "shave biopsy" which, along with the mitotic figures in "the deep portion of the lesion" looks like I still have more to take out.

I'm thinking the best this could be would be Stage II at this point but obviously they'll have to try to get the rest of the cancer.  My question is does this pathology report indicate a sentinel node biopsy should be done?  And from what I'm reading, results are likely to be positive because of the high mitotic rate... so does that mean they automatically take out the whole cluster of lymph nodes?

I know I should (and will) be asking the specialist about all this but just wanted to be prepared. 

Thanks for any and all help and advice!!  I'm a bit worried but I am also a realist and a fighter... I like to know what I'm up against. :)

i'm not sure what all of it means but good luck.  make sure you see a very good cutaneous surgeon/oncologist.  these are the ones that specialize in melanoma.  best wishes

melanoma is a word...not a sentence

Thank you for answering, Vicki.  With all the views and no answers I was beginning to think the worst. lol  I am seeing Dr. Deepak Narayan at Yale-New Haven Hospital and he is a surgeon who specializes in melanoma.  We'll see what he says.  I know surgery is a given just not too sure what happens after that.

My understanding is that SNB is warranted when Breslow is 1.0 mm or greater.  At 1.6 (at least) I would expect your surgeon to offer it without you even needing to advocate for it.  As for the question about skipping the SNB and just doing a full lymph node dissection on the assumption there will be positive nodes, I don't know.  You should ask the surgeon that very question.

Good luck~let us know how things shake out.

KatyWI

Just keep going!

Thank you very much, Katy, I will.

Thank you very much, Katy, I will.

I would expect the idea of a sentinel node biopsy would be raised with you.  I doubt a surgeon would be willing to strip the entire section of lymph nodes without some evidence of disease in the lymph system.  The issue with shave biopsy is, as you noted, it can cut through the tumor.  This can make staging very difficult.  Really depends on the tumor and the surgeon.  You will probably know more after your next appointment, but in any event you may want to get a couple of opinions.  You have a couple of very good melanoma docs at Yale, and a very strong team at Sloan Kettering should you decide to take a drive into the city.

 

Tim

Thank you Tim, do you happen to know the names of those doctors at Yale?  Might be good to see them for a second opinion as you suggest. Thanks!!

Last I knew this Dr. Ariyan was the guy at Yale. I know he's very experienced.

http://www.ariyan.com/special_programs/melanoma_special.htm

I don't know who you are planing to see, but having a very experienced melanoma surgical oncologist is very important when you are first diagnosed. This is the time to head off the disease and often less experienced docs do not take the right steps.

The others gave you great advice so no reason to expand on that other than you need an SNB for sure. They only take out further nodes if the sentinel nodes are positive. If they are negative the snb will probably be the end of your treatment other than checkups. Good luck!

Yes, I would definitely want an SNB with a depth of 1.6mm, ulceration, and a significant mitotic rate. Having said that, I want you to know that my husband's mel was nodular and at least 2.22mm with involved deep margins from a shave biopsy. His mitotic rate was 6/mm2. He had a WLE which found no additional mel cells and an SNB that was negative. He is now more than 3 1/2 years out and is NED (no evidence of disease). He is perfectly healthy and doing great. For the first two years or so, I was holding my breath just waiting for the other shoe to drop. But eventually you learn to deal with the uncertainty and get on with living. When I think about his "negative" factors (mitotic rate, nodular, etc.) it can still freak me out a bit--but I feel so much more prepared to deal with whatever happens after educating myself.

I would insist on an SNB and then take it from there. Hopefully it will be negative and you will eventually learn how to live a normal life again.

Best wishes,

Niki (Wife of Joe, Stage IIA and 3 1/2 years NED)

Thank you so much Niki and I'm so happy your husband is doing well.  I think I will be a lucky one too. I hope so anyway :)

Everyone has already pretty much covered what I would say but I wanted to add that there is plenty of room for hope even if more melanoma is removed during the wide excision and/or your sentinel node is positive. I also had a shave biopsy because miy nodular melanoma looked like it could be a blood blister. Mine was very deep (at least 6.9 mm breslow) and my sentinel node was positive. I also had an addition 2.8 mm removed during the wide excision. I am saying all of this because I haven't had any recurrences since my lymph node dissection in March of 2005. Hopefully you won't have any positive nodes but either way there is a lot of room for hope. I wouldn't read anything into there being more views than responses. People often read the posts but don't comment if they don't have any experience with the specifics of some situations.  Best of luck, Carver

"A closed mind is a wonderful thing to lose"

Thank you so much Carver, your story is very encouraging!  In fact everything I'm reading here makes me very hopeful and positive. 

Hello IntoTheWild, and welcome to the board.  Don't worry about the difference in views vs replies. Many people will red and decide they have nothing to offer in terms of advice, they might not have answers...or their answers might agree with others.

 

In your case, most will agree that yes, you are likely to be looking at a sentinal node biopsy, and a WLE ..wide local excision. They'll do both procedures on the same day. They'll inject you with the dye for the snb..put you under, do the snb and then the WLE then wake you up, and you'll have a much bigger scar.

The further LND (lymph node dissection) would depend on what the SNB shows, and who your doctor is. I've seen people here who ~automatically~ have a total dissection of the lymph node basin..and indeed that seems to be favored by most surgeons. I've known others though, who had selected lymph node removals. Where maybe a cluster of 10 or so nodes were removed, leaving others intact.

 

I am not sure about any evidence showing that one method is more effective than the other, but perhaps someone else here does and will offer up that info. You should definately ask your doctors about their feellings on this matter, and also ask about the consequences of total LND.

Also, you might be looking at scans, anything from xrays to PET/CT scans, especially if your SNB is positive.

 

There are a lot of knowledgable people here who have gone through all of these exact procedures. Good luck, and hang in there!

 

dian

I will confirm what the others are saying.  You'll probably have a wide local excision (WLE) since it looks like you had a shave biopsy.  You have 4 risk factor which will lead the surgeon to recommend a sentinel node biopsy(SNB).  Those are Breslow Depth > 1mm, Clark level of III or greater, high mitotic rate and ulceration.  This is a time to stay calm and learn about the condition.  Understand that only about 20% of patients who have a sentinel node biopsy will show melanoma in the regional lymph node.  That means you have an 80% chance of having clear nodes.  That is what I hope for you.  The morbidity (adverse side effects) of a complete lymph node dissection is significant.  Patients can sometimes suffer from lymphedema afterwards.  It is controversial even if the SNB is positive whether to have a complete lymph node excision of the regional nodes.

Stay strong.  Stay calm.  Hopefully things will not go beyond the SNB. It is a simple outpatient surgery that has very few complications

Kevin

Thank you Dian and Kevin and everybody.  I saw the surgeon today and it's exactly what you say.  I will have a WLE (whole new language, isn't it? :) and he'll do the SNB too.  (I'll have some cool new scars to add to my collection.)  Then we take it from there.  I also have to have a chest x-ray, blood work, and other stuff that I can't remember right now because my head is spinning a bit.  But it's a great relief to have a course of action! 

I recorded the whole visit (with my doctor's permission of course) so I can go over it again and take some notes.  But I guess this will all happen in the next couple of weeks. 

I asked the doctor how much time I could take off from work and he said "as much as you want".  So there are some plus sides to all this.