Nope - not a keratosis

Posted By
9/12/2018 4:08am
View other posts by
Replies: 18

I'm pretty shaken up.  I had what I suspected was a basal cell CA on my right forearm.  I first noticed it just over a year ago, around the time that a recurrent basal cell was excised from my left forearm.  The dermatologist said it was a keratosis.  Two visits and one year later, even though he still thought it was a keratosis, he decided to take a closer look.  He did a shave biopsy and then decided to do a curettage.  As he scraped away the tissues, he kept reaffirming that it was coming off like a keratosis.  When he was done, I had a "crater" on my arm a little larger than the diameter of a nickel.  Over the past month, new tissue has slowly grown in to mostly fill the "crater".

Imagine my surprise (and his too, I guess), when the path report came back as melanoma, superficial spreading type, "at least Level II".   The dermatologist said this was "in situ", but if it's into the dermis, that isn't correct, is it?   He also referred me to a surgical oncologist for a wide local excision (1 cm).

According to the path report, the margins of the shave biopsy (including the base) were all positive.   Since it was a shave biopsy, the dermatopathologist couldn't determine the depth.  We just know that the melanoma is deeper than the shave biopsy and is into the dermis.  Plus, there is no lesion on my skin surface now, just the newly formed skin tissue.  So - how will the surgeon know how much to remove?  Will the 1 cm margins be measured from the edges of the "crater"?  

I know I can (and will) ask the surgeon about this.  My appointment isn't for ten more days, which seems like forever.  Does anyone have any experience with something like this?

Anonymous - (9/12/2018 - 9:29am)

I am sorry about your diagnosis. If you post your pathology report, we would have mo information to comment on.

How did your lesion look like since it was misdiagnosed as keratosis?

Grifsy - (9/12/2018 - 5:59pm)

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.

mrsaxde - (9/12/2018 - 9:55am)

I also had my melanoma originally diagnosed as a keratosis, but that was by my PCP, not a dermatologist. I think I'd find another dermatologist.


doragsda - (9/12/2018 - 10:41am)

The surgeon will go deep and wide on the excision, then send the excised tissue to the pathologist, who will evaluate the margins.   If the 1cm is achieved, good deal.   If it's less than 1cm, he'll likely excise again to achieve the margin.   If you didn't have a clear margin vertically on the biopsy, I think you're correct that he can't call it in situ based on what is currently known.  Unfortunately, the dermatologist may be trying to cover himself from his first mistake and is making another one in the process.   Hopefully you have also been referred to an oncologist who is a melanoma specialist at this point.

Grifsy - (9/12/2018 - 10:12pm)

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

Anonymous - (9/12/2018 - 10:50am)

Since you don't know the real depth, I'd make sure the surgeon does a SLNB.  It needs to be done before you do the WLE.

RichInLife2 - (9/12/2018 - 11:36am)

I hadn't heard that. In my case the SNLB was done at the same time as the WLE. What is the reasoning for doing the SLNB first?

Anonymous - (9/12/2018 - 11:39am)

Usually they are done in the same setting.  But the SLNB has to be done first.  It's purpose is to follow the lymph drainage from the original tumor to the first "sentinel" node.  If you remove a lot of skin first (WLE), there is no guarantee that the drainage paths haven't been altered.  You may still do the procedure, but no one can guarantee that you will have the same sentinel node after the WLE that you would have had prior to the WLE. 

RichInLife2 - (9/12/2018 - 11:41am)

OK, thanks for clarifying that. I thought you meant that they had to be done on different days, which didn't make sense to me.


Grifsy - (9/12/2018 - 10:18pm)

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.  :-(

MelanomaMike - (9/12/2018 - 12:05pm)

Ya! In Like Nov 2016 I think that was the name of what my original biopsy report came back as, Keratosis (couldnt remember the name) a non melanoma right? Then it grew back just like before (like a wart monster) they did another biopsy like 3 or so months later only to come back as Melanoma, another month or so after that CT scan revealed 2 tumors in each lung, go figure, all that time & "travel" it went to my lungs i believe! Ahhhh!

Im Melanoma and my host is Mike..

Grifsy - (9/12/2018 - 10:51pm)

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.
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.

Anonymous - (9/13/2018 - 11:21am)

Thank you for posting your report.
Although it is not in situ, it is very likely that your lesion will stay at les than 1 mm depth after WLE, which most l;ikely would make you Stage 1 with great prognosis (fingers crossed). You should discuss with your oncologist the need of SNLB, but I doubt that he would offer it at 0.15 mm initial depth. Good luck and stay strong! 

Grifsy - (9/14/2018 - 2:38am)

That's very encouraging!  Thank you!

casagrayson - (9/14/2018 - 1:27pm)

Someone with more experience might correct me here, but because the lesion was bisected in a shave biopsy there is no way to determine depth.  For that reason, I might push for a SLNB.  Once you have the wide local excision the SLNB wouldn't be an option.  

Strength and Courage,


Grifsy - (9/14/2018 - 2:41pm)

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.  

casagrayson - (9/14/2018 - 3:51pm)

Oh, my dear, that is one thing you will learn to do -- to be assertive when it comes to you or your loved ones' health.  I've fired more doctors than I can count.  You are paying their salary, they work for you -- at the very least you deserve to be a partner with an equal voice.  And yes, this is certainly a critical question in my opinion, so be prepared to ask until you feel satisfied with the answer.

Strength and Courage,


MelanomaMike - (9/15/2018 - 11:46am)

Well said Susan! Thank god iv had my very same team since initial diagnosis in 2008! Dermatologist, Oncology/Gen.Surgeon, my lovely Oncologist, Endocrinologist, Oncological Pharmacists & the newest on my team my Cardiothoracic Surgeon! Wich I havnt used yet, surgery was cancled due to desease progression...and all my lovely Nurses who are the meat & potatoes behind the lucky...(and this is Kaiser in Panorama City, Los Angeles)...Mike

Im Melanoma and my host is Mike..