Melanoma: Key Questions on Diagnosis and Treatment Options

The user continues to ask?

Dear Dr.
Yang,
Thank you for taking the time to respond amidst your busy schedule.
During a recent discussion about my condition with my attending physician, Dr.
Ma from Taipei Veterans General Hospital, it was mentioned that the thickness identified in the first biopsy was in the epidermis and the upper dermis, classified as Stage II (0.76-1.5mm).
Undifferentiated melanocytes were observed, and there was one cancerous characteristic noted (however, no other evidence was found).
Consequently, a surgical excision with a 3 cm margin was performed.
During the procedure, a frozen section was taken from the underlying tissue, and no disseminated cells were found.
Currently, lymph node observation, bone scans, and chest X-rays have not revealed any abnormalities.
In the second tissue sample, only a large aggregation of immune cells was found at the site of the first biopsy, and despite various methods, no malignant cells could be detected.
As a result, the opinions among the pathologists have split into two factions (pro-war and pro-peace).
The attending physician has also mentioned consulting with doctors from other hospitals, but it remains undetermined whether the cells in the first biopsy can be classified as cancer cells (the pathology report indicates a high suspicion but cannot confirm), while the second tissue sample does not provide any conclusive evidence.
Therefore, the decision on whether to remove the lymph nodes has become a matter of choice.
The attending physician has requested that our family discuss this further before deciding on lymph node removal and encouraged us to seek additional opinions from other doctors to fully understand the treatment process moving forward.
Could you please clarify whether the lymphatic metastasis rate and the 10-year survival rate data you mentioned pertain to survival rates after lymph node removal or before? Additionally, the doctor has repeatedly emphasized that only one cancerous characteristic was found and that a determination cannot be made.
Is it necessary to have multiple cancer cell characteristics for a definitive diagnosis? (At this point, can melanocytes metastasize?)
I sincerely appreciate your willingness to address my lengthy questions despite your busy schedule, and I apologize for any inconvenience caused by my continued inquiries.
Thank you.

Xu Yifan, 20~29 year old female. Ask Date: 2001/07/03

Dr. Yang Youhua reply Oncology

Dear Mr.
Hsu,
In your last letter, you did not provide very detailed information.
If I understand correctly, it seems that after the lesion on your foot was excised and sent for pathology, some "suspicious" cells were found, raising concerns about malignant melanoma.
A subsequent wide excision was performed, and the second pathology report showed no evidence of any "suspicious" cells.
The accumulation of lymphocytes is merely a response to repair the initial wound.
The pathologist did not reach a definitive conclusion, and the diagnosis could only be stated as "suspected," as certain cancer diagnoses require meeting specific "criteria" for confirmation.
The statistics regarding lymph node metastasis, 10-year survival rates, and invasion depth that I provided previously are based on data from a cancer center in the United States and are for reference only; different centers may yield different results.
Since a definitive diagnosis cannot be established and the depth of invasion is between 0.76 and 1.49 mm, which is considered low risk, there is some debate about whether lymph nodes should be removed.
Relying solely on this information may lead to a higher chance of overtreatment.

Of course, you should understand that the physician's comments leave some room for interpretation.
This ultimately depends on your attitude towards risk.
If you feel significantly troubled, experience heavy psychological stress, have nightmares, and believe you can manage the potential complications of lymph node removal, then leaning towards excision may be appropriate.
However, if you can remain calm and leave everything to fate, it may be wise to avoid unnecessary risks and simply monitor the situation, as the second wide excision of 3 cm should be sufficient.

Reply Date: 2001/07/03

More Info

Understanding melanoma is crucial for patients diagnosed with this condition, as it can significantly impact treatment decisions and prognosis. In your case, the initial biopsy indicated a thickness of 0.76-1.5 mm, which places it in the intermediate risk category. This classification is important because the depth of invasion is a key factor in determining the likelihood of metastasis and the overall prognosis.

Melanoma is staged based on several criteria, including the thickness of the tumor, whether it has spread to nearby lymph nodes, and if there are any distant metastases. The AJCC (American Joint Committee on Cancer) staging system is commonly used, and it categorizes melanoma into stages I through IV. For instance, Stage I melanoma is localized and has not spread, while Stage IV indicates widespread metastasis.

In your situation, the presence of "undifferentiated melanocytes" and the fact that only one cancerous feature was identified raises concerns. The determination of malignancy in melanoma typically relies on multiple histological features, including the presence of atypical mitotic figures, invasion patterns, and the overall architecture of the tumor. If only one feature is present, it may lead to uncertainty in diagnosis, as you have experienced.

Regarding lymph node involvement, the decision to perform a lymphadenectomy (removal of lymph nodes) is often based on the risk of metastasis. If there is a significant chance that the melanoma has spread, removing the lymph nodes can help in staging and potentially improving outcomes. However, if the pathology is inconclusive, as in your case, the decision becomes more complex. The lymph node dissection can provide more definitive information about the presence of cancer cells, but it also carries risks, including complications such as lymphedema, which is swelling due to lymph fluid buildup.

The survival rates you mentioned are typically based on the stage of melanoma at diagnosis and whether lymph node involvement is present. For example, the 10-year survival rate for melanoma that is less than 0.75 mm thick is quite high, around 97%, while for thicknesses between 0.76 mm and 1.5 mm, the rate drops to about 87%. These statistics are generally derived from large cohorts of patients and can vary based on individual circumstances.

In terms of treatment options, if the melanoma is confirmed, the standard approach may include surgical excision of the primary tumor and possibly the affected lymph nodes. Adjuvant therapies, such as immunotherapy or targeted therapy, may also be considered, especially if there are signs of metastasis or high-risk features.

Given the complexity of your case and the uncertainty surrounding the diagnosis, it is advisable to seek a second opinion from another pathologist or oncologist. They can review the pathology slides and provide additional insights. Furthermore, discussing your concerns and treatment options with your healthcare team is essential to make informed decisions that align with your preferences and values.

In summary, understanding melanoma involves recognizing its staging, the implications of biopsy results, and the potential treatment pathways. Engaging in open discussions with your medical team and seeking additional opinions can empower you to navigate this challenging diagnosis effectively.

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