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February 20, 2013 at 12:59 am #21035Mike24Participant
Hi everyone, whoa where to begin.
I’m a 22 year old attending Rutgers. Back in November, I noticed a pimple like bump on my right shoulder. I’m accustomed to getting pimples there so I thought nothing of it. After a while, it simply didn’t go away so I went to my local dermatologist to get it checked out in December. She said it was just a wart and nothing to worry about, but just to be safe she did a shave biopsy.
Two weeks later I get a call back saying that it actually came back as a “sort of unusual mole” to her surprise. It was considered an Atypical Spitz Nevus. She said she would send it to a 2nd pathologist for another opinion. Two weeks later I get yet another call, this time saying this other pathologist, an expert at Columbia University, said while he did not believe the tumor to be cancerous, he could not rule out a melanoma. This was corroborated with 2 other Columbia pathologists. My path report stated it had a depth of 2 mm and occasional mitotic figures with cells lacking maturation with depth. No ulceration was present and the lesion displayed a small size and good symmetry. Once again it was considered an Atypical Spitz. Now my dermatologist wanted to refer me to Dr. Wang of Sloan Kettering to get another opinion.
Today I went in and to my dismay was diagnosed with Spitzoid Melanoma. With that being said, there was still a significant amount of confusion as to what the lesion showed and its malignant potential. Here’s their path report:
Tumor Type: Melanoma
Histological Type: Spitzoid
Breslow Thickness: 1.7 mm thick, focally transected
Ulceration: Not identified
Mitotic Index: 3/mm2
Clark Level: IV
Surgical Margins: Transected at the deep margin
Inflitrating Lymphocytes: Non-Brisk
Regression: Not Identified
Lymphovascular Invasion: Identified
Perineural Invasion: Not Identified
Microscopic Saellite: Not applicable
Solar Elastosis: Absent
Associated Melanocytic Nevus: Not Identified
Note: Submitted immunostains reveal that the cells are staining focally for HMB45 and MIB1
I asked Dr. Wang what they saw that made them make the diagnosis and he said it was that the cells seemed to be heading towards the lymphatic channels. I then mentioned that Atypical Spitzes frequently have Lymph node deposits and mitotic rates like that, to which he agreed. So the course of action was to treat it as a melanoma, with at the minimum a WLE of 1 cm margins.
What do you guys think? I’m just confused and rattled, I don’t know what to expect. I don’t understand why the pathologists at Columbia did not mention the lymph invasion at all in their report. This was all done off the same slides too. For what it’s worth the slides were reviewed by Melissa Pulitzer at MSKFebruary 20, 2013 at 1:10 pm #59241Catherine PooleKeymaster
I would ask that Boris Bastian at Sloan Kettering looks at the slides. He is a spitz nevus expert! One more opinion is worth it. It does sound like a benign spitz nevus and if they truly thought it to be melanoma, they would be doing a sentinel node biopsy. But get Dr. Bastian’s opinion, he’s right there and a brilliant dermatopathologist.February 20, 2013 at 1:52 pm #59242cohanjaParticipant Are Bastian and Mihm equally expert/brilliant?February 20, 2013 at 4:05 pm #59243Catherine PooleKeymaster Yes, but Bastian is known for his expertise in the Spitz Nevus category of lesions.February 20, 2013 at 6:24 pm #59244Mike24Participant I will do just that, thanks! Also, my concern to which my doctor did not have an answer for was how the other pathologists did not pick up on the LVI. That is a huge factor, and I’m curious as to how they missed it.
That being said, is it possible MSK incorrectly stated there was LVI?
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