Newly diagnosed: "vast majority of malignant melanoma is in situ"

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3/8/2012 12:28am
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Replies: 6

I have had a suspisious mole on my forearm for about the last year.  I called several dermatologists' offices in the last six months, but all of them have told me that they are either not accepting new patients, or their earliest appointment would be in 6-12 months.  In desperation, I went to a plastic surgeon and had the mole removed.  My pathology just came back, but unfortunately my doctor is on vacation for the next week.  The nurse told me not to worry because I have "malignant melanoma" is in-situ, but I was concerned after reading the following pathology:

"Diagnosis: Malignant melanoma.  The vast majority of this lesion is in situ.  Only focal focal superficial invasion is noted (depth of 0.3mm, level II).  Ulceration, regression, or vascular invasion is not seen.  An associated melanocitic nevus is focally seen.  An asymmetric proliferation of atypical melanocytes is present in the epidermis and focally in the superficial dermis. The melanocytes are arranged in irregular, varibly-sized nests and single cells.  Upward migration of single melanocytes is observed.  Adnexal extension is focally noted.  The melanocytes exhibit conspicuous nucleolus, irregular nuclear membrane, and moderately abundant cytoplasm.  Dermal mitotic activity is not seen.  A small area in the dermis shows nevocellular melanocytes with bland cytogenic features consistent with a melanocytic nevus.  Variable basal keratinocyte pigmentation and focal pigment incontinence are observed."

I have a follow up appointment, and the nurse told me that I would have a wide local excision, but other than that, my only follow up would be to see a dermatologist (if I can get in).  I was very concerned when I read the pathology, but all my friends say I'm making a big deal out of it, and that it's nothing I should worry about. 

Is there anything I should be concerned about in the pathology?  What does "the vast majority of this lesion is in situ" mean?  Is it "in situ" or not?  Should I also schedule an appointment with an oncologist, or should I just have the plastic surgeon do the wide local excision and then follow up with a dermatologist?  Do I have a high risk for recurrance?

This lesion is a stage IA lesion.  While the majority of the lesion may be in situ, you did have one invasive area to a depth of .3mm and Clark Level II.  You have no regression, no ulceration and no mitosis.  This is a very low risk lesion.  All the secondary factors are what you'd hope to see (if you can hope for anything with melanoma).  The nurse was correct.  The standard procedure would be to have the WLE (wide local excision) where they take 1cm margins.  Then periodic followups with a dermatologist is standard.  I'd probably just have the plastic surgeon do the WLE.  They do surgery well and they cut a chunk out to get the correct margins.  Then I'd call around again looking for a dermatologist saying you need a doctor to follow you after your recent diagnosis.  An oncologist probably isn't needed.  They tend to deal with active disease and you won't have any after your surgery is complete.

Watch the scar area for any pigment regrowth.  Watch your other for CHANGE.   Sorry you had to join us here, but stage IA is a good place to be.

Best wishes,

Janner

It sounds like a melanoma with a thickness of .3 mm. This should have a very high cure rate 95-100%, and yes, a wide excision and monitoring would be the only treatment. But......as I usually suggest, unless your surgeon is a bona fide melanoma expert working with a melanoma group, I would get a second opinion at a melanoma clinic at a major medical center. A Surgical Oncologist who specializes in melanoma would review your situation and if there were any questions about the pathology, he would have it redone by his pathologist. In my opinion, it is worth this extra step, since this is a deadly disease and any mistakes at this point can be fatal.

I agree with what's already been said. As Don says, with most melanoma, it's best to use a surgical oncologist who is familiar with melanoma, but that is not always possible, depending on where you live. I had 3 wide excisions done by a  plastic surgeon, and he did great. Your lesion IS low risk.

 

It should be easier for you to find a dermatologist now, and you'll need one for regular folow up visits now. Your surgeon might be a good starting point, as s/he might know a good derm who sees melanoma patients. This is important because your risk of another melanoma is now higher than those in the general population. You should also learn to follow precautions to protect your skin, including shade seeking, avoiding the most dangerous times in the sun, using sunscreen and protective clothing, and use these procedures for your children as well (if/when you have them)

 

And..even though we, with a combined VAST KNOWLEDGE of melanoma, are telling you not to worry, don't let your 'friends' tell you that you are making a big deal of it. Melanoma is a DEADLY disease, there's hardly a way you can make a bigger deal of it than it is. Most of the general population is woefully ignorant about it, and your friends are probably right in that number, thinking it is a little skin issue that can be easily cut out every time. That is NOT the case. And while you are lucky enough this time to have gotten this lesion early, that doesn't mean it's not serious. It's cancer. And, though you should not spend your life worrying about it, you should always be on the look out for it from now on. But mostly, that's going to mean being vigilant about skin protection and watching current moles for change, and watching for new ones. And.. learn the other signs of cancer, so ..don't go ignoring things like swollen lymph nodes.

 

Once you do make it to that derm, don't be surprised if they look over your skin and decide to cut a few more off and have them tested. I can't even tell you how many moles I've had taken off and tested in the 29 yrs since my first melanoma. Derms are especially likely to do this when you are a new diagnosis. So if you have any other suspicious looking moles, they are gonna go too.

 

Finally, I'd like to congratulate you on your fine instincts. MANY people ignore these moles that look bad for years, and many would have been put off by being unable to get a timely appointment. You had an instinct about that mole that made you go the extra step to seek out your surgeon. This is something you should remember for the future. MOST people find their own melanomas before a doctor notices them, and the fact that you are in tune to your own body to that extent bodes well for you. Never ignore it.

Try not to read too much dire stuff on the web about melanoma. You have done well catching this early, and likely will not have to deal with it ever again.

 

Good luck,

 

dian in spokane

Thanks for the replies. My wife initially thought the pathology report was great news since it said "in-situ", as she believed it was stage "0". After looking at the pathology, I had a feeling it was going to be I-A with the report stating "atypical melanocytes is present in the epidermis and focally in the superficial dermis" and with the Clark's level II.

What does "Adnexal extension is focally noted" mean?  Does this contribute to a higher rate of recurrence?

I would have had the mole removed sooner, as I was worried about it since last May, but it was frustrating not being able to get in to see any dermatologists.  I even told one receptionist that I suspected melanoma (the mole had ALL of the ABCDEs), that I had insurance, that I only wanted the doctor to look at my arm, and that it would only take 5 minutes.  The receptionist said it didn't matter, and that I would have to wait 8 months for an appointment.  If I had waited for a dermatologist, I wouldn't have had the mole removed for another 5-6 months, in which time it probably would have progressed beyond I-A.  If I had the mole removed last summer, it probably would have only been stage 0.

I was reading somewhere that Med schools only graduate a limited number of dermatologists, that 50% of derm patients are there for cosmetic reasons (botox, etc), that existing patients have priority, and that new patients (medical and cosmetic) are put on the same waiting list.  Is there any truth to this?  Knowing how serious melanoma is, I would think that dermatologists would make more of an effort to see medical patients who suspect melanoma.

I think a lot of my friends believe it's "no big deal" becasue they confuse melanoma with basal and squamous cell carcinoma.  I didn't even know how serious melanoma was until my wife's friend's husband was diagnosed three years ago (he's currently in Hospice).

What really scares me is reading stories about people who had a stage I - II mole removed and there is NED for 5+ years; then they find a swollen lymph node in their armpit, and they're dead a year later.  I'm more worried about a few cells being left behind and  metastasizing several years later than I am about a second primary tumor, although I will make it a priority to see a dermatologist every 6 months. 

Should I have a surgical oncologist who specializes in melanoma do the second excision rather than the plastic surgeon?  Should I conside treating the scar with Imiquimod, or is that not warranted for I-A?

 

Stage 1A is pretty close to in situ in terms of survival numbers - high 90's.  Analyzing your path report inch by inch doesn't tell you anything.  This is how the doctor is justifying melanoma but it doesn't mean it's higher risk.   I already pointed out the most telling prognostic factors.  If they were bad, you wouldn't be stage IA.  Depth is #1 and mitosis, ulceration, regression - these are usually the things we scan to see if a lesion is higher risk.  Stage IA has 0 mitosis by definition.  No ulceration or regression makes this about as low a risk lesion as you can get.  Truthfully, your risk for getting another primary is higher than your risk for recurrence from this lesion.  Imiquimod is not indicated for your lesion - that is more typically for very large lesions and typically Lentigo Maligna Melanoma (high local recurrence rate and typically a difficult type to get adequate margins).  It is rarely used on a primary WLE removal unless margins cannot be achieved.

You can't compare yourself to people on the internet - you never truly know their situation.  I've seen people say they had an in situ lesion or stage I or whatever who really weren't in that category.  Not everyone really understands all the details.  (Just like the people who think melanoma is just "skin cancer").  The second thing is - you see the "exceptions" here.  Why would you be seeing the 97% of stage IA patients reporting that they are still alive and well after 5 or 10 years?  They've moved on and are out living their lives and not letting melanoma ruin it.  The good stories have no reason to post on the internet - it's the small minority who come back here with problems.

Often times, these lesions (superficial spreading melanoma) can take YEARS to change.   A few months here or there were unlikely to change your staging.  That doesn't apply to all types of melanoma, but SSM which comprises 70% of melanoma is typically considered a slow growing type.  Stage IA has great survival numbers.  And you are at the low end (Breslow Depth) of ALL the stage I survivors making your odds of having a recurrence even more remote.  As far as who to do the surgery, I don't think it matters much as long as they get the required margins.  You just want the margins taken.  Plastic surgeons can do this.  Heck, dermatologists can do this.  I've had several dermatologists do my wide excisions.  I don't really think who cuts it out matters much.  But maybe finding a dermatologist for followup who sees cancer more than they do botox would be a wise choice.

Best wishes,

Janner

Stage IB since 1992, 3 melanoma primaries 

Apologies if I'm a little late to this thread. I would definitely have the WLE and then press hard to establish a regular, ongoing relationship with a dermatologist. Preferably you want one who is properly equipped to do excisions in the office, and who will take the time to explain all the data in your pathology report. This makes a huge difference in your outlook and interpretation of your diagnosis.

Like you, I was just diagnosed IA (Breslow .54mm, Clark II, no mitosis, clear margins, no ulceration) and will be getting a WLE as pro forma. These lesions are considered, in the words of my derm, "very early, very thin, very low risk." She really went out of her way to explain every detail, what she thought was most important (mitotic activity per square mm - that's how fast cells are reproducing) and what she thought was less (Clark level). 

The most important thing for you is to take ownership of your treatment. Any diagnosis of early melanoma should be taken seriously -- not to the point of panic, but certainly more than "don't worry about it." You'll want to do regular checkups, at least every 6 months (and perhaps every three for the first year) with a derm you trust and knows your history. That way, any little speck that even hints at recurrence will be swiftly handled.

And with all respect -- your friends are misinformed. This is a great opportunity to educate them on the essentials of regular body screenings. The diagnosis for you and me is unsettling, but we should be thankful that we've caught it at such an early stage.

Hope this helps.