Help with path reports please

[Rojam]

Hi everyone,

My name is jane and I live in the Uk. I’ve been lurking in the background for quite a while!

Firstly I would like to thank everyone (especially Catherine) for helping me become as knowledgeable as I now am.

I am finally in a good place with my melanoma,although this took a long time mainly due to several months delay between biopsy and wle and of course the original diagnosis.

I am listing my path reports (same melanoma) just for your comments really.

The first puts me at 1b shows regression, mitosis and does it say that it DIDN’T arise from a pre existing mole?

The second puts me at a 1a

I appreciate the outcome between the two readings is the same in that its a Very thin lesion and my outlook is very good and I was lucky to catch this early.

I’m guessing I’m asking Catherine to comment on my melanoma specifically, if possible, please. The sun has just come out in England for summer and I’m having a tiny little wobble!

First done at a local but large hospital; sorry it’s very long so please pull up a chair!

Histopathology report

Clinical details

?benign naevi

Specimen

Skin biopsy, back

Macroscopy

A skin eclipse measuring 20 x 8mm across x 8mm in depth. There is a distinct hyperpigmented macule on the surface measuring 5×4 mm across. The margins are regular. The is an ill defined hyperpigmented lesion towards the superior aspect of the specimen. This lesion measures 3×2 mm across and appears to be associated with the main lesion rather then a instinct second one.

Microscopy

The excision biopsy shows a melanocytic lesion which displays prominent cytological and architectural atypia in the junctional component. The atypical changes are best appreciated in the sections sampled from the superior aspect (block a2) where there is lentiginous proliferation and foci of pagetoid activity in the form of individual melanocytes. The degree of cytological atypia is also severe and more than random in the junctional component and hence qualifies for an in-situ melanoma. A minor dermal component is also recognised in the form of small numbers of occasional melanocytic cell nests (blocks a2, a3) in the superficial papillary dermis. These cell nest whilst much smaller then those of the junctional nests, display a degree of cytological atypia identical to those recognised in the overlying junctional component. They also appear as individual large atypical cells spilling into the superficial papillary dermis which would represent invasion. In this instance the invasion would represent radial growth phase in melanoma with clarks level 2 invasion and a maximum breslows thickness of 0.25mm. There is also pigmentary incontinence, fibrosis and telangiectasia of the vessels with effacement of the melanoma which constitutes regression. The depth of regression measures more of less the same as the invasive component (0.25mm).

The constellation of histological features in this biopsy would represent a superficial spreading malignant melanoma with features of regression. The is no surface ulceration or discernible lymphovascular invasion recognised. The mitoric activity is <2/sq.mm. A pre-existing naevus component is not present.

The excision of this melanoma is denoted in the table below

In-situ. Invasive

A1 inferior 5mm. At least 5mm

A2 superior. 3mm. At least 5mm

A3 lateral. 2mm. 4mm

A3 medial. 2.5mm. 5mm

A3 deep. N/a. >10mm

In summary the excision biopsy shows a clarks level 2 breslows thickness 0.25mm superficial spreading malignant melanoma which is excised by a closest peripheral margin clearance of 2mm with respect to the junctional component (lateral/outer margin). There is regression present in the melanoma.

The second reading was by Addenbrookes hospital cambridge (a large teaching, university hospital);

Microscopy findings

There is a severely dysplastic naevus in which there is early progression to melanoma. Most of this is in situ but there is focal dermal invasion of a few cells without evidence of vertical growth phase. The dermis also contains residual dysplastic naevus which shows cytological atypia but shows maturation with depth and lacks mitoric figures. There is focal chronic inflammation but no evidence of established fibrotic regression

Hist type. Superficial spreading RGP

Breslow depth. 0.25mm

Clarks level 2 papillary dermis

Ulceration. No

Lymphovascular inv. no

Perineural inv. no

Mitoric index. 0 per square mm

Established dermal regression. No

Microsatallites. No

Coexistent naevus. Yes dysplastic

TNM PT 1a <1.0mm clark 2,3

Per marg. 1.0mm

Deep marg. 5.5 mm

So, do I just disregard the first report and go with the second making me a 1a?

I have also had six other moles biopsied all but one dysplastic (mild) and have no further nhs checks just photos to help me.

Thankyou for taking the time to read and comment.

Wishing you well in your individual journies

Jane

X

[Worrywart]

Sounds like a very early low risk lesion with early invasion, and the path report confirms this. I would see the regression as positive in this case since the main downfall of regression is that when it is deeper than the lesion it could signal that he lesion was deeper previously. Your regression was same as depth so it’s not ‘extensive’ and therefore just means your body recognized the cancer and was attacking it, which is good. Radial growth phase means the cancer cells hadn’t reached that stage where they could really invade. They were heading in that direction, but not quite powerful enough to do any major damage.

This interpretation is from a melanoma patient with no medical training – I just spent hours reading and taught myself. My lesion had many of the same characteristics as yours.

[Rojam]

Thanks worrywart.

Guess I just find it odd to have two differing path reports. Seems strange that I had mitosis on such a thin melanoma so I’m thinking maybe the first one thought my melanoma was more 0.5 taking the regression into account. Doesn’t alter anything, I know, just curious really x

[Catherine Poole]

Happily looks very low risk! Good idea to get more than one opinion for sure. Rest easy.

[Rojam]

Thanks Catherine x

[Worrywart]

Maybe the fact that the first institution listed it as less than 2 was because that is their standard response for anything less than or equal to 2? If it were me, I would simply call the pathologist and ask – not sure you can do that in UK? The second report says 0 mitosis so I’d go with that.

[Rojam]

Thanks worrywart,

I’ll give them a ring. If that was their practise though would that then not put all the 1a patients automatically at a 1b due to the mitosis? Or would it have to state the mitoric rate as a number if its seen?

Just wondering as 1bs get followed for five years in the uk whereas 1as only a year, obviously due to the higher risk.

I will go with the second report as i feel its from a better hospital and is of course more favourable.

Guess I want to be a 1a but want to be allowed 5 years follow up due to my dysplastic mole syndrome. Wouldn’t want to go every three months as that caused lots of stress but maybe once every six months. Need to find someone privately I think.

Thanks

X

[Worrywart]

Maybe a 3rd opinion would help ease your mind? And hopefully it concurs with 0 mitosis?

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