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January 21, 2019 at 8:33 pm #23456
Hi — I recently had an atypical mole removed (“excisional biopsy”) from my back. The doctor recommends a second excision to increase the margins. I am trying to decide whether to proceed (or at least better understand the rationale for doing so), and how urgently to do so.
Highlights of the pathology report:
“Diagnosis: ATYPICAL LENTIGINOUS JUNCTIONAL NEVUS”
“Comment: The degree of atypia is considered moderate to severe… The lesion closely approaches to within 1.2 mm of the 12 o’clock peripheral edge margin and to within 0.9 mm of the 6 o’clock peripheral edge margin. A reexcision of the lesion/lesion site to ensure negative margins is recommended.”
Does anyone know the recommended margin for this diagnosis?
My doctor has told me “this is very low risk and reexcision purely prophylactic as we had narrowly clear margins already.”
My line of thinking:
Q1. Did they get it all already? (if so, there’s no benefit to doing the second procedure, right?)
Q2. If they did NOT get it all already, what’s the risk that it grows into something dangerous?
—a- If it was correctly diagnosed (not melanoma), it would have to turn into melanoma or something dangerous.
—b- If it was NOT diagnosed correctly (i.e., it IS or WAS actually melanoma), then it is (or was) already dangerous.
Q3. If something remains AND it grows into something dangerous, what’s the risk it would grow or spread before being diagnosed and removed? (could it grow or spread undetected under the skin?)
I welcome any suggestions, insights, or recommended reference sources. I sure wish they had just taken a bigger margin the first time around.
Thank you.January 22, 2019 at 12:48 pm #70854Catherine PooleKeymaster
Welcome to our forum. There is a very old dogma or conservative theory that after the melanoma is excised for pathology that the doctor go back for a wider excision to make sure all of the “cells” are removed. Now that is for melanoma. Often with low risk melanomas the proper biopsy takes the “whole” lesion. Yours is not melanoma if I understand the report correctly. It is a precursor to lentiginous melanoma and benign. I can”t see the benefit of going back to excise more of what was benign. But I would discuss with your doctor and possibly get a second opinion. Possibly just a second opinion on the pathology might be wise. Did a dermatopathologist do the pathology?January 22, 2019 at 6:06 pm #70855 That makes a lot of sense to me Catherine. Thank you so much. I will ask my doctor about their confidence in the diagnosis and a second opinion on the pathology.
I’ve been doing research. I’ve seen references that diagnosis by biopsy is not necessarily exact, and that in some cases “doctors may split 50/50 as to whether a mole is melanoma or benign.” It says that if the pathologist uses word like “severely dysplastic” or “atypical” or offers “a long descriptive narrative, it means he really is concerned about melanoma, but does not want to call it that.”
I’ve seen other studies reporting false negative rates (diagnosed as benign but actually malignant) between 10-50%.
If there’s a risk that this is/was really melanoma, I would want much larger margins than the ones I’ve got now. It looks to me like 9mm margins would provide the right safety factor.
I will let you know what my doctor says, and if I learn anything more. Thank you again for your help and for this site! Hopefully my links above will be helpful to others.January 23, 2019 at 1:44 am #70856
Here is another reference that I found informative.
“Are We Overtreating Severely Dysplastic Nevi?”
- Agreement among dermatopathologists regarding degree of atypia is surprisingly low
- The 2015 guideline recommends observation for mild to moderately atypical moles and re-excision for severely atypical moles
- However, in a more recent study, zero of the patients with severely atypical moles who did NOT have re-excisions developed melanoma over an average of almost 12 years
- Patients with negative margins were much less likely to have re-excisions
January 23, 2019 at 12:54 pm #70857Catherine PooleKeymaster
If you had a deep excision for the biopsy there should not be any residual cells. But good luck with the discussion with your doctor. You may know more than they do. There is a tendency to overdo reexcisions and if you have many dysplastic nevi too many biopsies. If you do have a lot of dysplastic nevi (atypical moles) be sure to have whole body photography to follow them.
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