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A Diagnosis of Melanoma
diagnosis of melanoma

A Diagnosis of Melanoma

If you get the dreaded phone call that your biopsy results are positive for melanoma, it is important to know the next steps. You are your own best advocate. You will want to get a copy of your original pathology report. By clearly understanding these findings, you'll be able to effectively participate in treatment decisions. Further tests might be necessary before treatment begins. The following are some terms you should see on your pathology report.

Breslow's Level. This is the thickness of the cancer. The thickness is the measurement from the surface of the skin to the deepest point where the tumor invades. These measurements are divided into categories according to the likelihood that the tumor has or will spread. The Breslow level is measured in millimeters (mm)

  1. In situ: Melanoma that is just in the epidermis
  2. Less than 1.0 mm in thickness: Very thin
  3. Between 1.01 and 2.0 mm in thickness: Thin
  4. Between 2.01 and 4.0 mm in thickness: Intermediate
  5. 4.00 mm in thickness, or more: Thick

Ulceration.The loss of the surface layers of the epidermis when viewed under the microscope is an important piece of information for staging. The presence of ulceration may alter the stage classification of a melanoma. Ulceration is thought to reflect rapid tumor growth, leading to the death of cells in the center of the melanoma. If the surface of the melanoma is ulcerated then the Breslow level may give a false picture of the severity of the tumor; the tumor may have been thicker and the risk of the tumor spreading greater. For this reason, ulcerated tumors are usually treated more aggressively than melanomas that are the same thickness, but do not have ulceration.

Clark's level. (Do not confuse the Clark's level with the Stage of melanoma) This uses a scale of I to V to describe a melanoma's depth of invasion. Clark level is not based on a measurement, but on the number of layers of skin that the tumor has penetrated. This, like the Breslow's level, is determined by the pathologist from the biopsy slide. The levels are numbered with Roman numerals.

  1. Clark's level I: The melanoma is only in the epidermis (in situ).
  2. Clark's level II: The tumor invades into the superficial layers of the dermis.
  3. Clark's level III: The tumor fills the superficial layers of the dermis and invades into the middle layers.
  4. Clark's level IV: The tumor invades into the deepest layers of the dermis.
  5. Clark's level V: The tumor invades into the subcutaneous fat, the fat layer just below the skin.

The thickness of the skin varies between different areas of the body: the skin of the eyelid is only about 2 mm thick, and the skin of the back may be a centimeter (cm) thick. Because of this, a thin melanoma on the eyelid may be less than a millimeter and still invade into the deep layers of the skin.

Other terms on the pathology report that you might see are:

Radial Growth Phase (RGP). The melanoma lesion is described as either having RGP present or absent. If present, RGP indicates that the melanoma is growing horizontally, or radially, within a single plane of skin layer.

Vertical Growth Phase (VGP). The melanoma is described as either having VGP present or absent. If present, it is an indication that the melanoma is growing vertically, or deeper, into the tissues.

Tumor-Infiltrating Lymphocytes (TILs). TILs describes the patient's immune response to the melanoma. When the pathologist examines the melanoma under the microscope, he/she looks for the number of lymphocytes within the lesion. This response, or TILs, is usually described as brisk, non-brisk, or absent, although occasionally can be described as mild or moderate. TILs indicate the immune system's ability to recognize the melanoma cells as abnormal.

Regression. Regression is described as being present or absent. If it is present, the extent of regression is identified. Regression describes an area within the melanoma where there is absence of melanocytic growth. When regression is present, the total size of the melanoma is hard to characterize.

Mitotic Rate. This term describes the frequency of division within the melanoma. Higher mitotic rates are associated with more rapidly dividing cells, and therefore larger lesions with greater potential for metastasis.

Satellites. Satellite lesions are nodules of tumor/melanoma located more than 0.05 mm from the primary lesion. Satellites are described as being present or absent.

Blood Vessel/Lymphatic Invasion. Blood vessel invasion, a/k/a angioinvasion, as well as lymphatic invasion are described as being present or absent. If present, it means that the melanoma has invaded the blood or lymph system, respectively.

You'll have questions that you will want to ask your dermatologist or oncologist. Make a list of these questions. Depending on the depth of your lesion (if it is greater than 0.76mm), a Clark Level IV or greater, or if your lesion is ulcerated, a SNB (sentinel node biopsy) might be recommended prior to your WLE (wide local excision). Never assume that your dermatologist would be aware of this. Some dermatologist do not treat many patients with melanoma. There have been patients that have had a WLE done at the dermatologist's office and then referred to an oncologist who recommends a SNB. The lymphatic mapping pathways have probably been altered.

Information on this page has been cited from the Melanoma Research Foundation (www.melanoma.org) - 2011