Pathology Report

[rmcmss]

I'm 69----saw dermatologist for my periodic six month check he(1st time with him) noticed a small spot on right upper lip size of a pin head pale color and slightly dished in been there about a year.  I do remember a small puss filled pimple in that exact spot hung around for while & I think turned into what he was looking at.  At first he thought it was a scar---as did the previous dermatologist---then decided to do a "punch biopsy"  and send it to the Univ of Penn---the results of that were/are:

Specimen: Lip, right upper, (skin) Punch; Clinical Diagnosis: MAC VS Scar VS BCC; Scarred Area,

Gross Description:  cylindrical piece of skin and adipose tissue measuring 0.2 by 0.2 by 0.3 cm

Diagnosis:  Lip, right upper: Epithelial Proliferation with Adnexal Differentation and Atypia, See Note.

Microscopic description: Lip, right upper--NOTE: Initial and multiple deeper levels have been performed on this punch biopsy.  The epidermis is thickened and proliferative.  At the base of the epidermis thee are multiple small lobules of epithelium embedded in a fibro or desmoplastic stroma.  These epithelial islands show single cell necrosis and features of follicular differentation.  The proliferation is limited to the upper part of the reticular dermis.

This difficult case has been reviewed at the Dermatopathology Consensus Conference.  This is unusual epithelial proliferation in a desmoplastic stroma.  Histologically, the differential diagnosis includes an unusual follicular or hamartomatous lesion or possible a very early stage of microcystic adnexal carcinoma.  Additional sampling and/or complete removal of this lesion is recommended.

The Dermatologist(one who found it) is recommending---Complete Removal (skipping any further "stand alone" sampling) via---MOHs surgery(Univ of Penn) on the 20 Sep 06---and---- sampling is a part of the MOHs procedure, etc...I intend to take his recommendation----I have discussed with him the questions  that follow:


I think I understand the benefits of the MOHs approach/recommendation---i.e., the thing to do if "very early MAC"----but MAC while invasive seems to be labeled as quite rare---and according to the report a ----"possibly"------so:


With something as inconclusive as this---i.e., three possibilities are called out in the report---(1)follicular Lesion or (2)hamartomatous lesion or (3)very early MAC---why go directly to surgery?  

Why not another "stand alone" sampling to further pin it down?

Perhaps---another stand alone sampling will not remove the uncertainty ?

Or is it  "it does not belong there and needs to come out".

Or maybe this is as conclusive as they can get with such a small sample or even a larger one?

Any thoughts/comments you might have----would help me understand it better.

Thanks

[Alan Rockoff, MD]

This is clearly a difficult case.  The recommendation for Mohs surgery is to be sure that there is no sampling error, and that the whole lesion is removed and evaluated.  Because the changes the pathologist found were diffuse and not clearly defined, another biopsy wouldn't be conclusive--the question would still remain about whether another area nearby would show more serious changes.  Basically, the surgery is to be sure that, even if there's only a chance that you have a skin cancer, that it's all out.  If the Mohs procedure makes it clear that you don't have cancerous changes, then they'll have to remove less.

You have a small risk, but it's of a serious condition, and there's no way to completely clarify things in advance.  I think your doctors are showing good judgment.

Best.

Dr. Rockoff