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    Hi again,

    All went well with the delivery of my new baby girl – thanks again for all the support and information. My SNB is scheduled for Monday morning, so I’m keeping my fingers crossed that all will be clear. After reading my pathology report again, I wanted to post it in full so that someone experienced in reading these can give me some feedback, as it seems contradictory:

    Page 1 – Pathologic diagnosis:

    A. Skin, left upper arm, punch excision

    – Malignant melanoma, Spitzoid type, non ulcerated, Clark 4, Breslow depth 1.1mm, inked margins are uninvolved

    B. Skin, left breast, punch biopsy

    – In-situ melanoma, superficial spreading type, nonulcerated, extending to side edge

    Comment: Specimen A, deisgnated from the left upper arm, shows an atypical dermal melanocytic prolfieration with Spitzoid features. There is an overlying junctional melanocytic component. The atypicla dermal melanocytic proliferation has Spitzoid epithelioid morphology with markedly atypical nuclei. Prominent psuedo-nuclear inclusions are noted. Maturation is not observed. The MART-1 and HMB 45 highlights the melanocytic proliferation. MIB-proliferative marker was performed. A host response is not seen.

    Page 2

    Specimen Laterality: Left

    Multiple primary sites: Addl. primary sites present

    Macroscopic Satellite Nodule: Not identified

    Macroscopic Pigmentation: Present, diffuse


    Histologic type: Spitzoid Melanoma


    Tumor size – Dimensions: 0.5×0.4

    Maximum tumor thickness – specify: 1.1mm

    Anatomic level: IV (Melanoma invades reticular dermis)

    Ulceration: Not identified


    Peripheral margins

    Invasive: Uninvolved by invasive melanoma

    Distance of invasive melanoma from closest peripheral margin: 0.17 cm

    In-situ: Uninvolved by melanoma in-situ

    distance of mel in-situ from closest margin: 0.15 cm

    Deep margin: Uninvolved by invasive melanoma

    Distance of invasive melanoma from margin: 0.15 cm

    Accessory findings

    Mitotic rate: none identified

    Microsatellitosis: not identified

    Lymph-vascular invasion: not identifed

    Perineural Invasion: not identified

    Tumor-Infiltrating Lymphocytes: Not identified

    Tumor regression: not identified

    Growth phase: vertical

    Lymph nodes: lymph nodes are not present in specimen

    Stage (pTNM)

    TNM descriptors: not applicable

    Primary tumor (pT): pT1a: Melanoma 1.0 mm or less in thickness, no ulceration, <1 mitoses/mm2 (this is where I am confused - I thought it was 1.1mm - wouldn't I be a pT1b???)

    Regional lymph nodes: pNX regional lymph nodes cannot be assessed

    Distant Metastasis: Not applicable

    Addl. pathologic findings: Other (specify) – Spitzoid melanoma

    Gross description:

    A. The container is labeled “upper left arm”. The specimen is received in formalin and consists or a single skin punch biopsy which measures 0.7×0.7, cut to a depth of 0.4. On the skin surface there is an irregular flat deep brown lesion which measures 0.5×0.4, and the distance to the nearest margin of excision is less than 0.1 cm. The surgical margin is inked black. The specimen is bisected. Sections submitted.

    Can anyone provide some feedback on the 1.1 “maximum tumor thickness” and the primary tumor findings on the second page? It seems to completely contradictory. Sorry for the long post, and repeated threads, but I figured the more info I can provide, the better someone who is well-versed in reading these things might be able to notice anything I may be reading wrong. Since this initial report, I have had the WLE, and the nurse called to report the good news of all the margins being completely clear. Does anyone have some feedback on my chance of a positive lymph node biospy based on the info provided? I know it’s almost impossible to give “odds”, but just wondering what to expect. Thanks again for all the support and feedback as my husband and I are extremely worried. Thanks again!



    Congratulations on your baby girl! Hopefully all this melanoma stuff will be in the past soon, and you’ll just have follow-ups.

    It looks to me as if everything on page 2 of your report deals only with the lesion on your arm. Where it mentions in-situ on page 2, it is referring to the in-situ portion of that lesion: the thinnest part that occurs around its edge. The report indicates that the biopsy removed the lesion entirely. That’s a good thing!

    The 1.1mm is the maximum thickness of the lesion, and the .5x.4mm were its surface dimensions.

    I’m not sure about the staging question – perhaps Catherine can help with this?

    I know the odds are very favourable of having clear nodes with such a thin lesion, but I also know you’ll still worry until the SLNB is done. Try to clear your mind and enjoy your baby. Most people don’t have such a delightful distraction! :)

    Best wishes,


    (Stage 1a removed 2010)


    Thanks Wendy!

    I guess my question really concerns the wording “maximum thickness”. I’m wondering if this is the actual definitively measured thickness, or if it could theoretically be less thick than 1.1. Possibly a patholoigists way of “overestimating” on purpose rather than underestimating the depth? I ask because where under the stage section – it references a T1a tumor with a thickness of <1mm. I have the SNB scheduled for tomorrow which I want to get done regardless, but with being so close to to 1mm cutoff I'm just wondering. Sorry for all the questions - I just noticed this today and likely won't be able to get ahold of the patholigist prior to the surgery. Not that it would change the decision to proceed with the SNB, but just wondering if anyone you see makes any difference in terms of SNB positivity probability.

    I guess nit picking over a .1mm difference is pointless. At the end of the day I just have to get the SNB done and let the chips fall where they may. Thanks again for all the help and advice!


    I meant SNB scheduled for Monday and cutoff so close to a stage Ib lesion. I’m assuming I am currently stage Ib pending the SNB, even though the report references a T1a lesion? Thanks again – this forum is such an awesome resource!


    Congrats on your baby girl! What is her name?

    1. Don’t worry about the in situ.

    2. You have a spitzoid lesion, these are very difficult to diagnose pathologically. You need an expert second opinion if you have not already gotten one. Have your derm send your slides to one of the experts in spitzoid melanomas.

    3. Maximum thickness is just basic path report jargon. Don’t worry about whether or not you are 1b or 1a, both are fairly low risk. Always remember, life is full of risks. We do not go around thinking about our odds of dying in a car wreck on our way to the store, or of having a heart attack, etc. Just know that a stage 1 lesion is LOW risk – whether a or b.

    Good luck with SNB! Thinking of you!


    Congrats on the birth of your daughter. I wish you luck with your next step in treatment


    Thank you all very much for the good wishes and congratulations! Her name is Ava Caitlin and she’s doing great – her parents are a little sleep deprived however =).

    I’d like to send my slides for a 2nd opinion after the SNB. If anyone knows a good doctor who specializes in spitzoid melanoma in the Chicagoland area, please let me know. I guess my question would be – what is commonly misdiagnosed as far as spitzoid type is concerned? Should I be worried that my current doctor missed something critically important as a result of it being hard to diagnose? I am hoping that its at least not “worse” than indicated from the pathologist. Thank you all again for the advice and sorry for all the questions.


    I’m also in Chicago area, but you can send your slides anywhere for another opinion. Local there is Dr Pedram Gerami at Northwestern, Dr Thomas Krausz University of Chicago. .

    but you can always send to Dr Mihm for another opinion: Contact them first before sending your slides, though, I think there is a form to also fill out with demographics, billing info, etc…

    Martin C. Mihm Jr., M.D., F.A.C.P.


    One Broadway

    Suite 14

    Cambridge, MA 02142


    Catherine Poole

    Congrats on your new baby! Here is a link to staging info: http://www.cancer.gov/cancertopics/pdq/treatment/melanoma/Patient/page2

    Just want to add that melanoma is a scary thing to both docs and patients, but mix in pregnancy (as you and I did) and the overcautiousness seems to double. I do worry that this was just a spitzoid nevus that is most likely benign. For second opinion, shipping slides is relatively easy. I agree with the others to give that a shot. You can’t get more expert than Dr. Mihm.

    Hope you can get some rest with all of this going on. We’ll keep you in our thoughts during these challenging days ahead.



    Thanks for the information – I am definitely going to have the slides sent for a second opinion. I was thinking about doing so initially, however with how fast everything was happening and the shock of first hearing the news with the pregnancy, I didn’t end up taking the steps needed to send them off for a 2nd look. Does anyone know “generally” what the cost of a 2nd opinion is? I have a PPO, so it’s kind of a process to get referrrals etc….but if the cost is relatively low, I would just obviously pay out of pocket for it.

    Catherine – Is there anything specifically in the pathology report that raises red flags for you? Or, do you suggest a second opinion simply for the fact that Spitzoid, by nature, is notoriously hard to diagnose? I am extremely inexperienced here, so please forgive the endless questions – but do benign lesions also grow invasively vertically?

    I’m assuming that this was “most likely” diagnosed correctly and the SNB I’m having done tomorrow is still a good idea. Unfortunately, I decided to take a closer look at the pathology report the weekend before the surgery was scheduled. I wish I had sent the slides out when this was initially diagnosed. Thanks for all the good wishes! I am hoping that even if it was correctly diagnosed, that it’s still relatively low risk for having spread into the lymph nodes. Thanks again!


    I also have a PPO. . I thought with PPO you don’t need referrals (just with HMOs). .anyway, I didn’t even ask, I just sent my slides for couple different opinions and insurance paid everytime (I had my copay, etc..). . I think if I had paid out of pocket it would have been around couple hundred dollars approximately. .


    Yes – sorry – I meant to type I have an HMO. Thank your the info, I was hoping it wasn’t thousands of dollars or anything to get an additional pathology report!

    Lisa P

    Congratulations on the birth of your new baby girl! I, too, would be interested in hearing an approximate cost for obtaining a second optinion on a pathology report from Dr. Mihm, just to have an idea. In the meantime, take care and enjoy your new bundle of joy! Lisa


    I believe the amount billed (to insurance) was $193.00. (obviously insurance only covers part and then patient is responsible for part, etc. . .but if you’re using provider in your insurance plan’s network the benefits are better)

    Lisa P

    That’s helpful. Thanks, Cohanja. By the way, how are you doing? It’s been a rough go for you lately…

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