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May 2, 2014 at 9:54 am #21953
Hello! I’m not glad to be here, but I am glad to find what looks like a group of people who know their stuff about melanoma!
I was hoping I could get a little assistance interpreting my husband’s recent pathology report. I understand some things (like the 4mm breslow depth) but other parts of the description are throwing me off. (Psuedo-vascular spaces? The hair follicle issue?)
How bad is this? We have an appt at the cancer center on Monday where I’ve been told they’ll schedule the SNB… If that comes back clean then we’re in the clear? Will they do further scans? I’m terrified that the SNB will come back clear but it actually is in his lungs or something… The mole he had removed was one that had not changed in size width-wise much (hence us thinking it wasn’t a melanoma) but had grown much larger vertically and a pink nodule had appeared on top of it (which they say isn’t ulceration, but looks like it?). He already had it completely cut out, including some healthy flesh around it, which required cauterization and stitches, so is that the “WLE” or should we be expecting the cancer surgeon to want to do another?
Should we be trying to get an appointment elsewhere at a different hospital or is it okay to stay where we are until after the SNB? (We’re in Charlotte, NC)
We’re kicking ourselves, of course, for not having gone in a year ago when we first noticed it (I even took a picture because it looked funny! sigh)… but we have 4 children including a baby and have been so distracted. My husband is extremely squeamish and won’t do any reading on the topic so I’m trying to learn it all for both of us.
Thank you so much for your help.
A – RIGHT LOWER BACK;
MALIGNANT MELANOMA, SUPERFICIAL SPREADING WITH DOMINANT TUMORIGENIC
VERTICAL GROWTH PHASE
Breslow Depth: 4.0 MM
Inflammation: TUMOR INFILTRATING LYMPHOCYTES, MODERATE
Mitotic Index: AVERAGE 1 PER SQUARE MILLIMETER L
Lymphovascular invasion: NOT DETECTED (SEE DISCUSSION)
Ulceration: NONE SEEN (SEE DISCUSSION)
Margins: CLEAR IN THE PLANES OF SECTION EXAMINED
The lesion is composed predominantly of atypical melanocytes in the dermis, which exhibit moderate to severe nuclear atypia and do not mature with depth. Centrally, there are atypical melanocytes at the junction, both singly and in loosely cohesive nests. The epidermis above the lesion is thinned and stretched. Occasional melanocytes are seen above the junction. Lateral to the main portion of the tumor, in some sections, there are atypical melanocytes in loosely cohesive nests both at the tips of rete, along the sides of rete, and singly along the junction as well as single cells above the junction The main body of the tumor extends to 4.0 millimeters in depth in one section, the tumor extends to 5.0 millimeters in depth, however, this is a long a hair follicle which has been destroyed, and the remaining hair follicle above as well as polarizable hair in that portion of the tumor can be demonstrated. There for this could be considered as extending from a nest along the hair follicle and not qualify for measurement as per the Lever measurement protocol.
in the body of the tumor, there is an average of 1 mitosis per millimeter squared
Tumor infiltrating lymphocytes are seen, with a moderate intensity.
One focal area of epidermal loss is noted, however, this does not appear to be true ulceration. It appears more traumatic. Prominent pseudo-vascular spaces are noted. Although dilated lymphatics and capillaries are seen, it is difficult to determine any lymphovascular invasion on plain H&E studies. Additional studies will be deferred as the patient is being referred to The Levine Cancer Center, where additional studies may be performed.
Background history was obtained and the patient and wife state that the small amount of pigment lateral to the bulk of the tumor is new. However, previous photographs that the family provided shows surrounding pigment in photographs as far back as January of 2013. Thus, I interpret this as a superficial spreading melanoma with a dominant tumorigenic vertical growth phase.May 2, 2014 at 11:24 am #64277
The depth of the lesion (or Breslow) is the most important prognostic indicator. This is a deep lesion, but it does have a small mitotic number (a secondary prognostic variable). I missed where the lesion is on the body. The SLNB (please read more about it here: http://melanomainternational.org/melanoma-facts/sentinel-node-biopsy
will tell you if any malignant cells have migrated through the lymph system. There is not guarantee they haven’t gone into the bloodstream, but the lymph system is very good at catching these things. Any positive nodes will be removed and a further dissection may be needed to get the others. A baseline cat scan may be done too. There would be symptoms if the disease was in the lungs, etc, usually. None of this comes with absolute guarantees unfortunately. So you need to take it step by step and day by day and don’t jump ahead, or go to the past which is gone.
It sounds like you are in a good place, I have not hear of it, but second opinions are always a good idea. Be sure to look at our list of cancer centers, and other info on this site. We are here to support you.May 2, 2014 at 12:05 pm #64278
Thanks Catherine! It’s on his torso, lower right back. That’s one of the reasons it took him so long to finally go to the dermatologist, since it was in a location that he couldn’t see himself.May 3, 2014 at 11:19 am #64279 It is good to do skin exams together or with a mirror for those hard to spot places. I hope things go well for you.May 6, 2014 at 10:29 am #64280 Had the appt with the cancer doc, which went okay, all things considered… Will be getting a call from his scheduling person to set up the WLE and SNB.
He threw me for a loop though, when he suggested freezing my husbands sperm if we wanted to have more children. Does the radioactivity from the SNB really affect fertility that much? We have four kids, so we weren’t *planning* on any more… However I’m only 28 (he’s 36) and I don’t know that I’m ready to completely give up having the option? I always liked the thought that since I was young, we could choose to have a later-in-life baby down the road if we wanted.
I’ve google searched and haven’t found anything specifically regarding melanoma and fertility, especially if the SNB is clear and no further treatment is needed.
Also, should I be pushing for further scans like a PET scan? He said if the tumor had been 4.1mm they’d do those, but since it was 4.0 they don’t.
Thanks.May 6, 2014 at 12:18 pm #64281AnonymousGuest
Sorry you guys have to deal with this crappy disease but you have definately landed on the right forum for advice.
The WLE and SNB are the next step and will determine the steps after that including any scans. Some encouraging things in the path report, IMO, were that there appeared to be no ulceration and there where lymphocytes invading the lesion which means his immune system has taken notice and is responding.
Have your team do the lesion’s Braf/KITN/RAS testing and discuss with them sending a sample out for the new genetic testing that’s now available (though insurance may balk at that unless there is lymph node involvement). It’s nice to have that stuff in the bank.
You may really want to consider a second opinion on the biopsy as well. This is stuff you can do while waiting for the WLE and SNB.
I have NO idea what they’re talking about concerning frozen sperm. Sounds a bit wierd to me.
Also, try not to get too caught up in any “would have, should have, could have, maybe if we…” stuff. You guys have done well.
Now go out and enjoy the day.
JeffMay 6, 2014 at 9:51 pm #64282
The doctor may be anticipating systemic therapy since the lesion is deep. This could be the reason suggested freezing of sperm. I would ask though. The SLNB biopsy should not be a concern though. I hope the procedure goes well and you’ll stay in touch.
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