question about biopsy results

[suntower]

Hi there,

I'm a 36-year old white male. About a week ago I noticed that a flat, brown mole on my leg (area that doesn't get much sun) had become raised and firm over about half of the mole. It didn't have much color in this raised portion, and in fact I thought it might be something I could squeeze away but all squeezing it did was turn it red the next day. I have no idea how long this mole had been this way, but I decided to get it checked out. I became very scared about nodular melanoma after doing internet research.

Since I couldn't get a quick appt. to a dermatologist I went to my GP and he didn't seem concerned, although his lack of concern seem based on the 'ABCDs of skin cancer' which I had read didn't really apply to nodular melanoma. He suggested we just keep an eye on it but I told him I wanted it off. He did a shave biopsy which removed the flat darker mole portion and the raised part too.

The next week waiting was tough. I worried that a shave biopsy might not catch nodular melanoma since it would grow down. I also watched the healing process and after 6 days it looks to be healing normally. Today I got the biopsy report and while the nurse said on the phone that it was benign, she also said I could make an appt to excise if I wanted. I didn't understand why I would need to excise a benign shaved off mole, so I had her fax me the results. Here's what they said:

(in bold):
Consistent with intradermal nevus, ulcerated, extending to base and periphery. See comment.

(not bold):
Comment: Due to the surface ulceration, it is difficult to evaluate if there is any junctional activity. Clinical correlation is recommended as the lesion is not fully evaluated.

I'm sure the ulceration is from my squeezing it, but overall I don't know what to think or whether to worry. There is no mention of 'benign', although I guess intradermal nevi are benign? I'm concerned that there may be melanoma deeper, under the shaved part and under the intradermal nevus, as it has not been 'fully evaluated'. Do you think it is safe to assume that if it had been nodular melanoma, the shaved biopsy part would have shown malignancy? Or do I now need to get a full excision and worry more? Also, do you think that the normal healing/scabbing process that is occurring is a good sign?

Thanks, and sorry for the long post...I'm just tired of being scared and was hoping this biopsy would put my mind more at ease.

-Kevin

[chellybeans]

lol. ironically guys tend to do better with those kinds of biopsies than gals....just think, the vaginal area stays damp!!

i foresee no worries, but down the road you'll have the peace of mind knowing that someone looked in those odd spots you can't see, and they knew WHAT they were looking at.

i would do the numbing for my doctor before they would get the biopsy done. it was always interesting to see guys turn white or green at the sight of that needle, then totally relax when the shot was over. it's funny to think back on, but i think little boys are the best shot takers :P

good luck  :D

[suntower]

I was thinking of doing that, actually. Although I am worried about having to deal with waiting for more biopsy results...even if they are purely conservative biopsies I'll still worry. If he biopsies my scrotum, though, I'll probably be passed out for the week while the results are analyzed anyway.

[chellybeans]

no problem. i am glad you found peace with it :)

now..just watch for any changes. if things change suddenly remember to err on the side of caution as well.

i suggest getting an appointment with a dermatologist any way, for a "skin check"
a good dermatologist will make you undress, examine every area of skin on your body, including between toes, around the scrotum and scalp. i mean EVERYWHERE. biopsy anything at all concerning, treat you for sun damage that looks like it has the ability to change down the road( actinic keratosis) and chart lesions on your body so there is a record if things change. this all falls under a normal office visit. just tell the appointment person what you need done, and you'll feel alot more at ease in your skin :)

remember, wear your sunscreen!

[suntower]

Thanks Chellybeans.

I was particularly worried about nodular melanoma in particular. From reading online, it is presented as basically a death sentence. But you are right, my tendency to research ALWAYS makes me more worried, so I need to stop!

I did manage to communicate with a pathologist through email, and described the report and situation in detail to her, and she, like you, put my mind at ease. Her opinion was that I'm clear...that it is very unlikely that a shave biopsy wouldn't have picked up at least some atypical cells. She made it clear that a pathologist will err on the side of caution. So I think I'm done with this...I don't think I'll excise it or anything.

Thanks again for your time!

-Kevin

[chellybeans]

hi kevin, no i am not a doctor. i spent many years assisting a wonderful group of doctors in a rather upscale dermatology practice. i traveled to assist my physicians in satellite offices in more rural areas as well. that's where my experience comes from.

junctional can simply mean from the biopsy to the skin left behind. at that junction.

melanoma usually starts at the surface, then burrows deeper. it is rarely seen below and not above.

the ulceration is when you cause vessels and cells to rupture. a scrape is an ulceration. if you think of what happens when you squeeze a bump..the cells rupture allowing the contents to rise to the surface.

as for the changes indicative of melanoma...have they been explained thoroughly to you?

a-assymettry, ie irregular shape, if divided sown the middle one side is bigger than the other etc.

b-border. not being rounded in general. having an edge that looks like a scrambled egg, etc.

c- color. having multiple colors in one lesion. ie red, blue, brown, black, white etc...darker colors if uniform do NOT indicate anything

d- diameter. if a lesion is bigger than 2 mm, or a pencil eraser, it may need examination.

other things of note are changes in texture, ie once was smooth, now is scaly or pebbly.
pain at the site, itching at the site, bleeding from the lesion, any other sudden change not associated with trauma.

if you legitimately doubt the biopsy, i suggest another appointment. this time with a real dermatologist. call around, be willing to drive up to an hour if need be and put this to bed. they can do a punch biopsy if they deem it needed. that test requires the same style of numbing you would have received for the shave, then a circular instrument is used to take a plug of skin(similarily to a cookie cutter) then it would be stitched. looking at one to two stitches.  they can be removed in one to two weeks depending on the amount of stress on the area.

this is pretty much the most conclusive testing there could be for you.

you may also want to discuss the anxiety you are experiencing...skin cancer is NOT a life sentence 9/10 times. if you did have melanoma, believe me, you can be treated. usually it is as simple as an excision done while you are awake under local anesthesia(just like for the biopsy)

you'll find alot of scary stuff online. i would try to disengage from the research since it seems to be creating more anxiety than assuading your fears.

good luck :)

[suntower]

Chellybeans,

I really appreciate your responses. Are you a doctor? You seem pretty knowledgeable.
I must say though in my stupidity I did more internet research that is still scaring me...why I do this I don't know, as it always gets me scared. But maybe you could give me some input on these questions:

-so junctional doesn't mean junction between, say, epidermis and dermis?
-I've read that shave biopsies are bad ideas for melanomas...is this because they make it difficult to subsequently determine a melanoma's depth, or is it because melanomas occur deeper and can be missed overall? I am particularly worried about nodular melanoma, since mine was firm and, well, sort of nodular, and I thought that intradermal nevi weren't really that firm...and I am worrying now that perhaps the malignant cells wouldn't show up in the shave biopsy, and may in fact by lying deeper, under the 'base' or 'junction' or whatever the report terminology means, 'pushing up' and causing the bump that was shaved off.
-i didn't actually pick at it...i squeezed it and it turned reddish the next day. would this really cause deep 'ulceration'? and what is ulceration really anyway? It didn't look red or anything before I squeezed it but does that mean it may still have been ulcerated?

Sorry to pester you with questions, but it's hard to get a dermatologist to talk anytime soon. I guess my main concern is that despite the fact he shaved off the whole visible surface (which included a brownish flat mole that I believe had been there for a long time + a firm, somewhat colorless raised portion that I squeezed), that they missed deeper stuff or something, since I've now read that shave biopsies are bad ideas for melanoma, and because of the 'lesion has not been fully evaluated' comment. By the way, this raised area did seem to come from a mole that was previously flat, although I have no idea how long ago that actually happened, since I just discovered it.

Thank you so much,
Kevin

[chellybeans]

nooo, don't worry, by junctional activity they mean activity that crossed from the borders of the shave specimen to the still intact skin. in other words they weren't sure if there was anything overlapping from the biopsy to what was left behind.

basically you picked it, made a sore and that sore caused inflammation that extended beyond the edges of what was removed. (which is typical). a lab likes to have a complete specimen so they  can say without a doubt there was no activity, but unless the doctor just shaved a small sample from one side and not the general entire lesion i would think nothing of it.

before a melanoma forms they typically start out as what it known as a dysplastic nevus, or nevi. your biopsy absolutely did not even say that so i think it was just one of those odd little moles we all get from time to time.

[suntower]

thanks! that makes me feel better...yes I also worried that the ulceration could make it difficult to tell if it was malignant, but that doesn't really seem to make a whole lot of sense to me, since malignancy should be pretty clear regardless of ulceration I would think. I'm still not clear on what 'junctional activity' means...I guess I had assumed that meant 'junctional malignancy' and that is what scared me too. As you can see, I am easily scared...it comes with having 2 little kids; now my health has become so much more important.

[chellybeans]

it is benign. they mean clinical study should be done to correlate their findings since the margins are not clear.

what that means is that they shaved it and did not do a full excision. they took off the surface. if there were melanoma it would ahve shown up and in my experience with reading biopsy reports if it is any fom of skin cancer ie basal cell, squamous cell or melanoma they report will say that in no uncertain terms. it will also recommend further excision and re-testing to make sure the margins are clear of any remaining cells.

the ulceration is because you picked at it, but they should have still been able to deem it cancerous or not. if you are really concerned take the report to a dermatologist and ask them to evaluate it. unfortunately many general practitioners will gladly treat skin issues when they are definately not the right doctor for the job. dermatologist are far more accustomed and specialized in their training to know the minute indicators of skin cancer, pre cancer and typical nevi, or aging related lesions.

good luck :)