Newly Diagnosed – help with the dermatopathology report
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Just got my report yesterday and would love some feedback. “Diagnosis: Melanoma in-situ with profound underlying dermal fibrosis, inflammation, features of regression, margins involved.
Microscopic Description: The specimen is a shave biopsy of skin present as multiple H&E stained sections on one slide. The primary pathologic process is that of malignant proliferation of melanocytes along the dermoepidermal junction. There is marked pagetoid extent. There are large irregular nests. There are nests entering the granular layer. There is underlying dermal fibrosis, inflammation and pigmentary incontinence but definitive evidence of dermal invasion is not identified, although adnexal extension is prominent. The lesion extends to the lateral surgical margin.
Using appropriate positive and negative controls, the following special stain(s) is/are performed:
HMB-45 (MMA): Demonstrates the pagetoid component. Highlights adnexal extension. Fails to demonstrate evidence of definitive dermal invasion. Highlights involvement of the surgical margin.
Ki67/Mart-I (combo): Confirms the melanocytic nature of the process. Highlights a markedly elevated proliferative index. Highlights involvement of the surgical margin.
Comments: The histopathologic findings are those of melanoma in-situ with profound and marked underlying dermal fibrosis, inflammation, and pigmentary incontinence. Even despite performance of immunohistochemical stains, we simply cannot identify definitive evidence of dermal invasion, yet we would consider the degree of dermal regression exceptional.
As the process extends to the lateral surgical margin, re-excision with histopathologic confirmation of complete removal is necessary, and will afford a second valuable opportunity to examine the entirety of the process, reclassifying or re-staging the process if necessary.
Also, given the extremely marked amount of regression in this case, a discussion of the prognostic and therapeutic implications of such features, including the possible use of wider surgical margins or even sentinel node sampling, may be worthwhile.”
Hi there, I am sorry you were dx with melanoma.
Your pathology is difficult, because your body started to attack the lesion, which makes it hard to confidently assess the depth. It is good your immune system attacked the lesion though – it is obviously doing its job. I would definitely have your slides sent to a pathologist who specializes in difficult cases for a second opinion. Dr Mihm would be good. You can google his info, then call your dr and have slides sent over. I would trust his opinion on whether or not an SNB is a good idea due to the extensive regression.
Thank you for your reply. It’s a bit unnerving the “extensive regression”. I will definitely be getting a second opinion, though this report is from the University of Colorado Dermatopathology Consultants. I had my slides read there too – I live in Colorado Springs. 
I would still send them to an expert. Univ of Colorado is great but due to regression I’d want just one more look.
I’m confused why they are suggesting a SLNB for an insitu lesion. There was no depth to this lesion, and therefore no worry of spread. This seems unwarranted, despite the regression. I agree that you get another opinion, and have your slides sent to http://www.drmihm.com or to UPENN, UCLA or another lab of excellence. Let us know how things turn out.It sounds like the thinking here is the regression might indicate the lesion was deeper at one time? Thank you so much for the great feedback. I think I will have the slide sent on to Dr. Mihm for a second opinion. It is so great to have this forum. Thank you! 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.
SKADA
One Broadway
Suite 14
Cambridge, MA 02142
Phone-617-401-2231
You might have better luck and a quicker response by sending an email directly to this person:
Rolanda Flammia
Assistant to Martin C. Mihm Jr., M.D.
Director, Melanoma Program
Department of Dermatology
Brigham and Women’s Hospital
41 Avenue Louis Pasteur
Alumnae Hall, Room 317
Boston, MA 02115
Phone-617-264-5910
Fax-617-264-3021
E-mail-
rflammia@partners.org Catherine Poole wrote:I’m confused why they are suggesting a SLNB for an insitu lesion. There was no depth to this lesion, and therefore no worry of spread. This seems unwarranted, despite the regression. I agree that you get another opinion, and have your slides sent to
http://www.drmihm.com or to UPENN, UCLA or another lab of excellence. Let us know how things turn out.Regression masks the depth of the original lesion. The in situ portion is all that is left because the body ate the rest of it. They don’t know how deep it was originally, hence the recommendation for SNB
According to Dr. Guerry: “Regression is an attribute that may be absent or present in the radial growth phase. Regression is evidence of destruction of some of the melanoma celss in the radial growth phase (by immune factors probably) Regression is a weakly negative factor.” Radial Growth Phase, it is unlikely that the lesion has metastasized. A second opinion is needed and I wish more docs would do an excisional biopsy to have better pathology results and determine radial and vertical growth phase
fyi, I had one pathologist say, “I personally do not comment on radial vs vertical growth (is subjective and not required)” Last week I had surgery to excise a larger area around the original area where the biopsy of the shave found a melanoma in-situ. This much larger and deeper excision gave them a much better sample to test. I received the results this week and they could find no evidence that the melanoma had spread. Thank you for everyone’s feedback and input. This is a wonderful place to be able to share and learn.
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