› Forums › General Melanoma Community › Where to begin … ??
- This topic has 33 replies, 4 voices, and was last updated 13 years, 4 months ago by
laheasley.
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- September 25, 2012 at 5:31 am
I found a spot on my side near my left breast/bra line that looked like a blood blister. This was about a year ago. I picked at it with tweezers and a lance thinking it would drain and was no big deal. By the time I was done, I had basically removed the "blood blister" (which by then I knew was not a blood blister, obviously). Some time went by before I realized that it had grown back – this time larger. It was 3/4 the size of a pencil eraser. I wasn't immediately concerned and let it sit on the back burner for a while as life took over
I found a spot on my side near my left breast/bra line that looked like a blood blister. This was about a year ago. I picked at it with tweezers and a lance thinking it would drain and was no big deal. By the time I was done, I had basically removed the "blood blister" (which by then I knew was not a blood blister, obviously). Some time went by before I realized that it had grown back – this time larger. It was 3/4 the size of a pencil eraser. I wasn't immediately concerned and let it sit on the back burner for a while as life took over. About a month ago, I finally got around to scheduling an appointment with my dermatologist. Her first available appointment was last Tuesday, September 18. On Friday, September 24, I got the results. Melanoma – 0.42 depth – not the best news, but certainly could have been worse! I am scheduled to have it removed next Monday, October 1, unless they have a cancellation this week. I have so many questions and very little information. First and foremost – how can they know that the depth is 0.42 when the dr. took a shave biopsy. I have observed two spots (my husband calls them "roots") in the remaining tissue/scab area that are dark/black and coincide with the location of the original "blood blister" and the first area where it reappeared. If there is still melanoma remaining, is there any way to find out the actual true depth of the original melanoma? Does it matter? Does that make a difference in treatment? Next question: My dermatologist told me that she would excise a 1 cm area around the melanoma. Is that 1 cm radius from the central point or from the edge or 1 cm total width? I'm wondering how big the incision will be and what to expect as far as recovery/scarring. Third question: What are the chances that they will find more melanoma under the surface that was not removed by the initial shave biopsy. I spoke with the nurse today and she said that the normal shave/scraping removes the tumor and the excision is just to be sure that there is no further growth. This seems questionable to me though because I can still see those two dark spots I mentioned already – the "roots". Fourth question: How likely is it that a second (or third or fourth) surgery will be performed to remove additional tissue. Both my brother and a friend had to return for additional/second surgeries. When I spoke to the nurse, she seemed to believe that a second procedure would be very unlikely. Now I'm uncertain what to expect. Question five: Will the first surgery involve removal and testing of lymph nodes based upon the 0.42 reported depth or is that unlikely? Six: How is the pain? Is ibuprofen/acetominophen effective at managing it or would it be a good idea to ask for something stronger than OTC? Seventh and final question: I bruise terribly and make really unattractive scars. Would that have anything to do with the melanoma or are the two unrelated? I have worried for some time about the bruising especially. I will wake up with multiple bruises with no idea where they came from. It just makes me think something more could be going on here. Well, ladies and gentlemen, thank you so much for reading this long laundry list of questions and for any advice you can share. I felt confident that everything was fine when she first told me my diagnosis, but over the weekend, I have started to feel very uneasy … I can't explain it. I just have a bad feeling about all this. Any advice for me??
P.S. My brother has had a serious melanoma removed with no further treatment required. My uncle died from melanoma. My mom thinks that my dad has had a few melanomas removed from his ears but she is not certain if they were melanomas or squamous cell carcinoma. Pretty strong family history … 🙁
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- September 25, 2012 at 6:19 am
Any advice is appreciated! I know this is a long laundry list of questions and uncertainty, and I apologize for that. If you have advice for even just part of one question, that would be so awesome! I hope I am getting worked up over nothing!!
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- September 25, 2012 at 6:19 am
Any advice is appreciated! I know this is a long laundry list of questions and uncertainty, and I apologize for that. If you have advice for even just part of one question, that would be so awesome! I hope I am getting worked up over nothing!!
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- September 26, 2012 at 10:55 pm
Dermatopathology Report
Diagnosis:
Malignant melanoma
Breslow's Thickness – 0.46mm
Clark's Level – III
Ulceration – Absent
Regression – Not Observed
Mitotic Rate – zero per square mm
Host Lymphocytic Response – Non-brisk
Associated Lesion – Possible small vestige of intradermal nevus (172.5)
Clinical Information:
Clinical History: atypical
Specimen Data:
Specimen Type/Location: Breast, Left
Gross Description: Received in formalin is an irregular piece of skin measuring 0.8 cm in greatest dimension. The specimen is entirely submitted.
Microscopic Examination: Sections demonstrate skin with a confluent atypical melanocytic proliferation at the dermal-epidermal junction, composed as irregular nests and single units. Some areas display confluent single cell growth. The cells are intermediate to large in size with abundant dusty amphophilic cytoplasm and nuclear atypia characterized by hyperchromasia, pleomorphism and conspicuous nucleoli. There is marked pagetoid extension of single cells and small dyscohesive nests. Exceptionally rare mitotic figures are present. The process extends into and focally fills the papillary dermis to a depth of 0.46 mm. There is a very small focus in the dermal component where the cells tend to nest more, display much less atypica and mild changes of maturation. Elsewhere, the deepest components display cytoplasmic evidence of melanogenesiis and minimal maturation.
I am scheduled to have a Wide Local Excision at 8 a.m. in the morning. I was not too worried when I initially got the news, but as it gets closer, I am starting to have bad/worrisome feelings. I have the report but I don't understand what any of it means. I think it looks pretty good – at least the parts I can figure out! But there are parts that concern me … specifically "possible small vestige of intradermal nevus" and basically the whole paragraph after "microscopic examination" …
Any advice???
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- September 27, 2012 at 2:18 am
Basically, this is a stage IA lesion with a very good prognosis. There are no negative factors and it appears that the entire lesion was removed in the biopsy. All good.
As for your questions, the 'possible small vestige….' just means that the original source was a mole. Sometimes, that is not the case. There is a remnant of the original lesion present. It's just a description and means nothing prognositcally.
Now on to microscopic description. There is no real value in evaluating this line by line. Basically, the pathologist is describing the lesion and justifying his final diagnosis. He's describing the particular characteristics of your lesion that are atypical in nature – hence the final diagnosis. There is nothing described that changes the prognosis of a stage IA lesion.
The key from here is to be vigilant, but not paranoid. This is a very low risk lesion. Not no risk, but low risk. Watch your other moles for change. Just be more aware of your body and pay attention to things that change – aren't normal for YOU! Good luck on the WLE.
Janner
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- September 27, 2012 at 2:18 am
Basically, this is a stage IA lesion with a very good prognosis. There are no negative factors and it appears that the entire lesion was removed in the biopsy. All good.
As for your questions, the 'possible small vestige….' just means that the original source was a mole. Sometimes, that is not the case. There is a remnant of the original lesion present. It's just a description and means nothing prognositcally.
Now on to microscopic description. There is no real value in evaluating this line by line. Basically, the pathologist is describing the lesion and justifying his final diagnosis. He's describing the particular characteristics of your lesion that are atypical in nature – hence the final diagnosis. There is nothing described that changes the prognosis of a stage IA lesion.
The key from here is to be vigilant, but not paranoid. This is a very low risk lesion. Not no risk, but low risk. Watch your other moles for change. Just be more aware of your body and pay attention to things that change – aren't normal for YOU! Good luck on the WLE.
Janner
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- September 27, 2012 at 2:18 am
Basically, this is a stage IA lesion with a very good prognosis. There are no negative factors and it appears that the entire lesion was removed in the biopsy. All good.
As for your questions, the 'possible small vestige….' just means that the original source was a mole. Sometimes, that is not the case. There is a remnant of the original lesion present. It's just a description and means nothing prognositcally.
Now on to microscopic description. There is no real value in evaluating this line by line. Basically, the pathologist is describing the lesion and justifying his final diagnosis. He's describing the particular characteristics of your lesion that are atypical in nature – hence the final diagnosis. There is nothing described that changes the prognosis of a stage IA lesion.
The key from here is to be vigilant, but not paranoid. This is a very low risk lesion. Not no risk, but low risk. Watch your other moles for change. Just be more aware of your body and pay attention to things that change – aren't normal for YOU! Good luck on the WLE.
Janner
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- September 26, 2012 at 10:55 pm
Dermatopathology Report
Diagnosis:
Malignant melanoma
Breslow's Thickness – 0.46mm
Clark's Level – III
Ulceration – Absent
Regression – Not Observed
Mitotic Rate – zero per square mm
Host Lymphocytic Response – Non-brisk
Associated Lesion – Possible small vestige of intradermal nevus (172.5)
Clinical Information:
Clinical History: atypical
Specimen Data:
Specimen Type/Location: Breast, Left
Gross Description: Received in formalin is an irregular piece of skin measuring 0.8 cm in greatest dimension. The specimen is entirely submitted.
Microscopic Examination: Sections demonstrate skin with a confluent atypical melanocytic proliferation at the dermal-epidermal junction, composed as irregular nests and single units. Some areas display confluent single cell growth. The cells are intermediate to large in size with abundant dusty amphophilic cytoplasm and nuclear atypia characterized by hyperchromasia, pleomorphism and conspicuous nucleoli. There is marked pagetoid extension of single cells and small dyscohesive nests. Exceptionally rare mitotic figures are present. The process extends into and focally fills the papillary dermis to a depth of 0.46 mm. There is a very small focus in the dermal component where the cells tend to nest more, display much less atypica and mild changes of maturation. Elsewhere, the deepest components display cytoplasmic evidence of melanogenesiis and minimal maturation.
I am scheduled to have a Wide Local Excision at 8 a.m. in the morning. I was not too worried when I initially got the news, but as it gets closer, I am starting to have bad/worrisome feelings. I have the report but I don't understand what any of it means. I think it looks pretty good – at least the parts I can figure out! But there are parts that concern me … specifically "possible small vestige of intradermal nevus" and basically the whole paragraph after "microscopic examination" …
Any advice???
-
- September 26, 2012 at 10:55 pm
Dermatopathology Report
Diagnosis:
Malignant melanoma
Breslow's Thickness – 0.46mm
Clark's Level – III
Ulceration – Absent
Regression – Not Observed
Mitotic Rate – zero per square mm
Host Lymphocytic Response – Non-brisk
Associated Lesion – Possible small vestige of intradermal nevus (172.5)
Clinical Information:
Clinical History: atypical
Specimen Data:
Specimen Type/Location: Breast, Left
Gross Description: Received in formalin is an irregular piece of skin measuring 0.8 cm in greatest dimension. The specimen is entirely submitted.
Microscopic Examination: Sections demonstrate skin with a confluent atypical melanocytic proliferation at the dermal-epidermal junction, composed as irregular nests and single units. Some areas display confluent single cell growth. The cells are intermediate to large in size with abundant dusty amphophilic cytoplasm and nuclear atypia characterized by hyperchromasia, pleomorphism and conspicuous nucleoli. There is marked pagetoid extension of single cells and small dyscohesive nests. Exceptionally rare mitotic figures are present. The process extends into and focally fills the papillary dermis to a depth of 0.46 mm. There is a very small focus in the dermal component where the cells tend to nest more, display much less atypica and mild changes of maturation. Elsewhere, the deepest components display cytoplasmic evidence of melanogenesiis and minimal maturation.
I am scheduled to have a Wide Local Excision at 8 a.m. in the morning. I was not too worried when I initially got the news, but as it gets closer, I am starting to have bad/worrisome feelings. I have the report but I don't understand what any of it means. I think it looks pretty good – at least the parts I can figure out! But there are parts that concern me … specifically "possible small vestige of intradermal nevus" and basically the whole paragraph after "microscopic examination" …
Any advice???
-
- September 25, 2012 at 6:19 am
Any advice is appreciated! I know this is a long laundry list of questions and uncertainty, and I apologize for that. If you have advice for even just part of one question, that would be so awesome! I hope I am getting worked up over nothing!!
-
- September 25, 2012 at 12:52 pm
I would advise a second opinion before any further surgery takes place. You need a melanoma specialist at this point, not the dermatologist. Find a melanoma center at a major medical facility, where they will review your situation, redo the pathology and make sure that what's being done is the best path. Speculating on the chances of this or that is not important right now. Getting the right treatment is.
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- September 25, 2012 at 12:52 pm
I would advise a second opinion before any further surgery takes place. You need a melanoma specialist at this point, not the dermatologist. Find a melanoma center at a major medical facility, where they will review your situation, redo the pathology and make sure that what's being done is the best path. Speculating on the chances of this or that is not important right now. Getting the right treatment is.
-
- September 25, 2012 at 12:52 pm
I would advise a second opinion before any further surgery takes place. You need a melanoma specialist at this point, not the dermatologist. Find a melanoma center at a major medical facility, where they will review your situation, redo the pathology and make sure that what's being done is the best path. Speculating on the chances of this or that is not important right now. Getting the right treatment is.
-
- September 25, 2012 at 1:55 pm
First and foremost – how can they know that the depth is 0.42 when the dr. took a shave biopsy. I have observed two spots (my husband calls them "roots") in the remaining tissue/scab area that are dark/black and coincide with the location of the original "blood blister" and the first area where it reappeared. If there is still melanoma remaining, is there any way to find out the actual true depth of the original melanoma? Does it matter? Does that make a difference in treatment?
The "roots" may just be scabs or blood vessels. A shave biopsy does have the ability to get clean margins below it. That is the key. If you have a copy of the pathology report, you can find out whether or not the deep margins are clear. If they are, the depth is correct. If the margin is not clear, then you will never know the true depth.
Next question: My dermatologist told me that she would excise a 1 cm area around the melanoma. Is that 1 cm radius from the central point or from the edge or 1 cm total width? I'm wondering how big the incision will be and what to expect as far as recovery/scarring.
1cm from the central point. So 2cm wide and probably at least 6cm long. They have to make an elliptical excision so they can close the wound. In general, an excision length is about 3x the wide in order to pull the skin together. This figure can vary based on anatomy, however. This is called a wide local excision (WLE).
Third question: What are the chances that they will find more melanoma under the surface that was not removed by the initial shave biopsy. I spoke with the nurse today and she said that the normal shave/scraping removes the tumor and the excision is just to be sure that there is no further growth. This seems questionable to me though because I can still see those two dark spots I mentioned already – the "roots".
In general, they don't often find more melanoma in the WLE. If you had clear margins from the biopsy (again, pathology report is needed), then the chances are very good no melanoma will be found in the extra margins.
Fourth question: How likely is it that a second (or third or fourth) surgery will be performed to remove additional tissue. Both my brother and a friend had to return for additional/second surgeries. When I spoke to the nurse, she seemed to believe that a second procedure would be very unlikely. Now I'm uncertain what to expect.
Unlikely. Multiple surgeries is more often the case for the other cancers where they are trying to obtain clear margins, not extra margins. Melanoma tries to get extra margins and therefore a WLE is pretty much "the plan". Yes, there are times when the margins after the WLE may not be big enough, but that is not the norm.
Question five: Will the first surgery involve removal and testing of lymph nodes based upon the 0.42 reported depth or is that unlikely?
If you don't have an appointment with a surgeon, they are not planning on testing the lymph nodes (Sentinel Node Biopsy (SNB)). This is usually done with general anesthesia, not in a doctor's office. If the deep margins were clear, there is no real need to test the lymph nodes. That is typically done for lesions greater than 1mm. If the deep margins are not clear, it is more of a judgement call. Most WLE tissue does not show melanoma so the depth is probably accurate but you don't know until the tissue is analyzed. Just a note, the lymph node testing needs to be done PRIOR to the WLE. So if this is something you are considering, you need to talk to a surgeon first.
Six: How is the pain? Is ibuprofen/acetominophen effective at managing it or would it be a good idea to ask for something stronger than OTC?
I've had 7 WLE and I've never taken more than ibuprofin. I consider it an incovenience. Not comfortable, but something I just have to work around. Others have taken stronger pain medication. Much depends on the person. I might use a little ice on the day of the surgery, but not much else. I have gone back to work on the day of surgery several times. Others treat this like major surgery. I've had what I consider major surgery and this doesn't compare in my book.
Seventh and final question: I bruise terribly and make really unattractive scars. Would that have anything to do with the melanoma or are the two unrelated? I have worried for some time about the bruising especially. I will wake up with multiple bruises with no idea where they came from. It just makes me think something more could be going on here.
No relation with melanoma that I've ever heard.
I've given you general answers based on the info you've given us. We always recommend getting a copy of the pathology report for your own files. That info lets you know more specifically what is going on with your lesion. There are other factors that can be prognostic indicators and should be called out in the report. Without knowing the margin status or other factors, we can't recommend or not recommend doing the SNB. Again, if this is something you are considering, it must be done PRIOR to the scheduled surgery for wide margins.
Best wishes,
Janner
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- September 25, 2012 at 1:55 pm
First and foremost – how can they know that the depth is 0.42 when the dr. took a shave biopsy. I have observed two spots (my husband calls them "roots") in the remaining tissue/scab area that are dark/black and coincide with the location of the original "blood blister" and the first area where it reappeared. If there is still melanoma remaining, is there any way to find out the actual true depth of the original melanoma? Does it matter? Does that make a difference in treatment?
The "roots" may just be scabs or blood vessels. A shave biopsy does have the ability to get clean margins below it. That is the key. If you have a copy of the pathology report, you can find out whether or not the deep margins are clear. If they are, the depth is correct. If the margin is not clear, then you will never know the true depth.
Next question: My dermatologist told me that she would excise a 1 cm area around the melanoma. Is that 1 cm radius from the central point or from the edge or 1 cm total width? I'm wondering how big the incision will be and what to expect as far as recovery/scarring.
1cm from the central point. So 2cm wide and probably at least 6cm long. They have to make an elliptical excision so they can close the wound. In general, an excision length is about 3x the wide in order to pull the skin together. This figure can vary based on anatomy, however. This is called a wide local excision (WLE).
Third question: What are the chances that they will find more melanoma under the surface that was not removed by the initial shave biopsy. I spoke with the nurse today and she said that the normal shave/scraping removes the tumor and the excision is just to be sure that there is no further growth. This seems questionable to me though because I can still see those two dark spots I mentioned already – the "roots".
In general, they don't often find more melanoma in the WLE. If you had clear margins from the biopsy (again, pathology report is needed), then the chances are very good no melanoma will be found in the extra margins.
Fourth question: How likely is it that a second (or third or fourth) surgery will be performed to remove additional tissue. Both my brother and a friend had to return for additional/second surgeries. When I spoke to the nurse, she seemed to believe that a second procedure would be very unlikely. Now I'm uncertain what to expect.
Unlikely. Multiple surgeries is more often the case for the other cancers where they are trying to obtain clear margins, not extra margins. Melanoma tries to get extra margins and therefore a WLE is pretty much "the plan". Yes, there are times when the margins after the WLE may not be big enough, but that is not the norm.
Question five: Will the first surgery involve removal and testing of lymph nodes based upon the 0.42 reported depth or is that unlikely?
If you don't have an appointment with a surgeon, they are not planning on testing the lymph nodes (Sentinel Node Biopsy (SNB)). This is usually done with general anesthesia, not in a doctor's office. If the deep margins were clear, there is no real need to test the lymph nodes. That is typically done for lesions greater than 1mm. If the deep margins are not clear, it is more of a judgement call. Most WLE tissue does not show melanoma so the depth is probably accurate but you don't know until the tissue is analyzed. Just a note, the lymph node testing needs to be done PRIOR to the WLE. So if this is something you are considering, you need to talk to a surgeon first.
Six: How is the pain? Is ibuprofen/acetominophen effective at managing it or would it be a good idea to ask for something stronger than OTC?
I've had 7 WLE and I've never taken more than ibuprofin. I consider it an incovenience. Not comfortable, but something I just have to work around. Others have taken stronger pain medication. Much depends on the person. I might use a little ice on the day of the surgery, but not much else. I have gone back to work on the day of surgery several times. Others treat this like major surgery. I've had what I consider major surgery and this doesn't compare in my book.
Seventh and final question: I bruise terribly and make really unattractive scars. Would that have anything to do with the melanoma or are the two unrelated? I have worried for some time about the bruising especially. I will wake up with multiple bruises with no idea where they came from. It just makes me think something more could be going on here.
No relation with melanoma that I've ever heard.
I've given you general answers based on the info you've given us. We always recommend getting a copy of the pathology report for your own files. That info lets you know more specifically what is going on with your lesion. There are other factors that can be prognostic indicators and should be called out in the report. Without knowing the margin status or other factors, we can't recommend or not recommend doing the SNB. Again, if this is something you are considering, it must be done PRIOR to the scheduled surgery for wide margins.
Best wishes,
Janner
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- September 25, 2012 at 1:55 pm
First and foremost – how can they know that the depth is 0.42 when the dr. took a shave biopsy. I have observed two spots (my husband calls them "roots") in the remaining tissue/scab area that are dark/black and coincide with the location of the original "blood blister" and the first area where it reappeared. If there is still melanoma remaining, is there any way to find out the actual true depth of the original melanoma? Does it matter? Does that make a difference in treatment?
The "roots" may just be scabs or blood vessels. A shave biopsy does have the ability to get clean margins below it. That is the key. If you have a copy of the pathology report, you can find out whether or not the deep margins are clear. If they are, the depth is correct. If the margin is not clear, then you will never know the true depth.
Next question: My dermatologist told me that she would excise a 1 cm area around the melanoma. Is that 1 cm radius from the central point or from the edge or 1 cm total width? I'm wondering how big the incision will be and what to expect as far as recovery/scarring.
1cm from the central point. So 2cm wide and probably at least 6cm long. They have to make an elliptical excision so they can close the wound. In general, an excision length is about 3x the wide in order to pull the skin together. This figure can vary based on anatomy, however. This is called a wide local excision (WLE).
Third question: What are the chances that they will find more melanoma under the surface that was not removed by the initial shave biopsy. I spoke with the nurse today and she said that the normal shave/scraping removes the tumor and the excision is just to be sure that there is no further growth. This seems questionable to me though because I can still see those two dark spots I mentioned already – the "roots".
In general, they don't often find more melanoma in the WLE. If you had clear margins from the biopsy (again, pathology report is needed), then the chances are very good no melanoma will be found in the extra margins.
Fourth question: How likely is it that a second (or third or fourth) surgery will be performed to remove additional tissue. Both my brother and a friend had to return for additional/second surgeries. When I spoke to the nurse, she seemed to believe that a second procedure would be very unlikely. Now I'm uncertain what to expect.
Unlikely. Multiple surgeries is more often the case for the other cancers where they are trying to obtain clear margins, not extra margins. Melanoma tries to get extra margins and therefore a WLE is pretty much "the plan". Yes, there are times when the margins after the WLE may not be big enough, but that is not the norm.
Question five: Will the first surgery involve removal and testing of lymph nodes based upon the 0.42 reported depth or is that unlikely?
If you don't have an appointment with a surgeon, they are not planning on testing the lymph nodes (Sentinel Node Biopsy (SNB)). This is usually done with general anesthesia, not in a doctor's office. If the deep margins were clear, there is no real need to test the lymph nodes. That is typically done for lesions greater than 1mm. If the deep margins are not clear, it is more of a judgement call. Most WLE tissue does not show melanoma so the depth is probably accurate but you don't know until the tissue is analyzed. Just a note, the lymph node testing needs to be done PRIOR to the WLE. So if this is something you are considering, you need to talk to a surgeon first.
Six: How is the pain? Is ibuprofen/acetominophen effective at managing it or would it be a good idea to ask for something stronger than OTC?
I've had 7 WLE and I've never taken more than ibuprofin. I consider it an incovenience. Not comfortable, but something I just have to work around. Others have taken stronger pain medication. Much depends on the person. I might use a little ice on the day of the surgery, but not much else. I have gone back to work on the day of surgery several times. Others treat this like major surgery. I've had what I consider major surgery and this doesn't compare in my book.
Seventh and final question: I bruise terribly and make really unattractive scars. Would that have anything to do with the melanoma or are the two unrelated? I have worried for some time about the bruising especially. I will wake up with multiple bruises with no idea where they came from. It just makes me think something more could be going on here.
No relation with melanoma that I've ever heard.
I've given you general answers based on the info you've given us. We always recommend getting a copy of the pathology report for your own files. That info lets you know more specifically what is going on with your lesion. There are other factors that can be prognostic indicators and should be called out in the report. Without knowing the margin status or other factors, we can't recommend or not recommend doing the SNB. Again, if this is something you are considering, it must be done PRIOR to the scheduled surgery for wide margins.
Best wishes,
Janner
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