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Had Insitu melanoma on scalp. Mohs surgery done. Migraine found. Biopsy done. What does the report say?

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Hello,
I am a 46 year old female. May of 2010 I had Insitu melanoma on my scalp. Mohs surgery was done and clear margins were found. My oncologist said I would "live to be an old women" and that this was not going to cause any more trouble. 2 years later (June 2012) a new bump on my scalp appeared. It was a raised bump, pinkish in color and a little more than 2 cm distance from my original melanoma.

The biopsy was a scrap and I can send you the report. I had surgery to remove the melanoma, with 2 cm around the tumor. (Wide Excision). I am frustrated because my oncologist has been very hesitant to stage my cancer. I am confused as to the definitions I have heard from my report, my surgeon, my oncologist.
Metastatic melanoma, recurrent, in-transit, satalite.

I am confused which one is the primary and the secondary and why does that matter? My pathology report from my recurrence reads "at least 1.82 mm with a XXXXXXX level IV - "if this is a primary melanoma without epidermal involvement".

I had a SLN and the results were negative. I am still concerned because the cancer is on my scalp and as the surgeon says it is "in-transit mat". Can you help with reading my pathology reports?
Thank you
XXXXXX
Posted Mon, 27 Aug 2012 in Blood Cancer(Leukemia)
 
 
Answered by Dr. Indranil Ghosh 1 hour later
Hi XXXXXXX
Thanks for writing in.
What I see from your reports that 2 years back you had an in-situ melanoma which was taken care of appropriately. Now you have another lesion which is near to but still separate from the original site and this time it is invasive melanoma. It has also been treated appropriately.

Now, to answer your question that whether this lesion is related to the previous one, I feel that it is a separate lesion developing in adjacent skin rather than in-transit mets. Melanoma-in situ is localized to the topmost lining of the skin and by definition, does not metastasize. Your pathologist has mentioned that you had a history of malignant melanoma and he has interpreted the findings in the light of this history. But you did not have truly 'malignant' melanoma earlier; it was in-situ.

This is most probably a new primary and has developed in adjacent skin as obviously your entire scalp has been exposed to the same risk factors (like UV radiation). Developing new melanomas in one's lifetime is not uncommon and hence patients are advised lifelong follow-up.

Hope I have answered your query. I will be happy to answer any follow-up queries.
Best Wishes,
Above answer was peer-reviewed by
 
Follow-up: Had Insitu melanoma on scalp. Mohs surgery done. Migraine found. Biopsy done. What does the report say? 18 hours later
Dr. XXXXXXX

Thank you for your quick response. I have uploaded two reports, the most important being the pathology from the derm appointment and initial biopsy. This is on the "recurring" lesion, which was later excised as I mentioned above.

It appears that there must be a determination of which is primary/secondary for there to be a reasonable guess as to myself having "intransit met" or not.

From my perspective this is rather critical information, since it will put me at a IIb or a IIIb. And yet, we do not understand how this determination of "primary, secondary, or local recurrance is made.

Also, The 4cm wide excision is just outside of the original moh's scar, which is why we assume that this path report dated 6/18/2012 says "metastatic melanoma is favored XXXXXXX Are there other reasons why "metatstatic" is noted?

Thanks again, XXXXXXX
 
 
Answered by Dr. Indranil Ghosh 6 hours later
Hi

Thanks for follow-up.

As I said, recurrence of in situ melanoma is not common. However, if the second lesion is beneath the scar of previous excision then definitely a recurrence can be thought of. However, if it is outside the area then diagnosing it as an in-transit mets may not be appropriate.

This obviously upstages it. Unless any adjuvant therapy is contemplated based on this upstaging then it does not change anything.

In clinical practice many a times some questions are left unanswered. These are limitations of modern day medicine and little can be done in these circumstances. I am sure your treating team has explored all possibilities before labelling something.

Take care.
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Follow-up: Had Insitu melanoma on scalp. Mohs surgery done. Migraine found. Biopsy done. What does the report say? 1 hour later
Dr XXXXXXX

Thank you for your follow up. Can I ask you to look at the 6-13-12 path report and along with the surgery path report (clean lymph node) and do your best to stage my cancer in 2 ways?

1. This 2012 is a primary (not related to the Insitu in 2012)
2. This 2012 is in-transit met and a recurrence from the original 2010 Insitu.

Also - can you clarify what you meant when you said "This obviously upstages it. Unless any adjuvant therapy is contemplated based on this upstaging then it does not change anything"

Do you recommend Interphuron? What is your opinion on that?

Thank you, XXXXXXX
 
 
Answered by Dr. Indranil Ghosh 22 hours later
Hi

If it is a new lesion, then it is most likely stage IIA
If this is recurrence (in transit) then it is stage IIIB

In stage IIIB many people would recommend high-dose interferon but data is inconclusive. It is category 2B in NCCN recommendation (ie,not an uniform consensus) as it decreases recurrences but does not improve survival. We don't recommend interferon routinely. That is why I said that it would probably not change anything.

Regards.
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Follow-up: Had Insitu melanoma on scalp. Mohs surgery done. Migraine found. Biopsy done. What does the report say? 9 hours later
Thank you Dr. XXXXXXX

With my scalp melanoma stage IIIb - is chemo or radiation an option? I am trying to understand my treatment options (besides the interferon)

Regards,
XXXXXX
 
 
Answered by Dr. Indranil Ghosh 1 hour later
Dear XXXXXXX

Chemo or radiation has not been shown to be beneficial in stage III disease which has been completely resected. In any case, melanoma is not a particularly chemo or radio-sensitive cancer.

Hence I do not recommend chemo or radiation for you.

Regards,
Dr Indranil Ghosh
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