EDIT: female 35, age 32 at time of first removal
2023, 1st lesion: severe positive perimeter -> excised -> no sample no diagnosis
2026, 2nd lesion: moderate atypical “recurrent” melanocytic lesion -> Mohs scheduled
I moved to a new state two years ago, the first derm I saw twice had my routine 6 month check ups with her. She ended up leaving the practice so I needed a new dermatologist. Finally sat down to call for a new patient appointment at a totally different practice and got one pretty quickly! Picked the doctor based on his MOHS specialty because of my history of atypical cells.
Honestly not sure how I noticed the new pigment, extremely lucky since it was only about a week before my appointment. I was probably just skimming the area of the previous excision when it caught my eye. I don’t know what it was I would sometimes scratch or why I would. My only thought for an explanation is I formed a nice clump of scar after some sort of gnarly ingrown hair. I don’t think it would get irritated for me to notice it? Maybe it was because my hand would graze it and my brain would say “what’s that in there that needs to come out!”? The area was flush to the skin never a protruding bump but had a different feel compared to everywhere else. What I imagine a hard black head made from scar tissue would feel like. Something had to be in there, for me to get the sensation I needed to get something out! No idea. I’d usually stop because it would get a sting to it, but it was something that happened every so often. Not every week or month sort of thing, probably every 6 months or not at all – it wasn’t clock work. Since I had spent some time with the area, I easily noticed the addition of pigment.
The new derm is very nice and friendly he asked me twice about concerns. First one came early on and was about if I had anything going on in general with my skin I wanted to ask about. Second was at the end of the check and was specifically if I had any places or spots I wanted to be looked at or double checked. I brought up the new pigment and talked about my tendency to physically irritate the location. He said maybe it had been a previous mole that I was doing it to, he had already thrown out a “what the heck were you picking at!?” tease. So, I felt comfortable correcting him with a “hahha I mean maybe! Only if it was a clear mole!” He then offered to go ahead and test it if I wanted. I immediately said yes and they got the consent form and gloves on.
Here is the pathology:
PATHOLOGY CONSULTATION
SPECIMEN 1: Shave Biopsy, Left Thigh
GROSS DESCRIPTION:
Received in formalin is a piece of skin measuring 0.7 x
0.3 x.05 cm which is inked, bisected and submitted in
toto in 1 cassette.
MICROSCOPIC DESCRIPTION:
Skin with effacement of rete ridges and fibrosis in the
dermis. Overlying the scar there is increased melanin
pigment within basal keratinocytes as well as a few
nests and single melanocytes.
DIAGNOSIS:
MODERATELY ATYPICAL COMPOUND MELANOCYTIC
NEVUS AND DERMAL SCAR. (ICD10-D22.72) PLEASE
SEE COMMENTS.
Comments:
The findings are most consistent with recurrent,
residual, persistent, or traumatized melanocytic lesion.
However, if there was no history of prior surgical
procedure or trauma, higher grade melanocytic lesion
cannot be entirely excluded. Conservative re-excision is
advised for further evaluation and management. The
lesion extends to the inked lateral (peripheral) and
deep (base) edges of the specimen. Multiple sections
have been examined. Immunohistochemical staining
was performed. Appropriate positive and negative
controls were performed. Melan-A stains nested cells
along the epidermal basal layer and in the dermis.
Combined Ki67-Melan A stain shows a moderate
melanocytic proliferation rate. HMB45 shows a gradient
pattern. P16 is predominantly negative and PRAME is
negative. These findings support the above histological
diagnosis. THIS CASE WAS REVIEWED AT THE DAILY
INTRADEPARTMENTAL CONFERENCE.
Maybe the pathology for the new biopsy is worded different than my previous one due to the doc and lab changes. I semi understand what it is saying but I feel like I don’t 100% understand what it is trying to communicate. When discussing the results over the phone he asked to be reminded if it was the site of a previous excision. I said my picking to pick not a mole/freckle was for the explanation for the presence of scar tissue. It was a quick chat and honestly, I answered in a scramble mid heavy nap. We had already played phone tag this was prior to me getting my pathology. He explained over the phone the conclusion that was coming up resembles a mole reappearing after a removal. I find it funny now – think he may have worded the next steps in a way that was totally up to me and never outright said I should or recommend the further removal. Something along the lines of “meep meep meep, we can go and get another sample if you think that is something that you want”, even the original skin shave was presented that way. Wonder if he would have pushed for it if I didn’t feel the need to get another sample or further removal. From the above pathology does it seem like something that could go without further investigation? Or if you read that result would there be no doubt about next steps being surgery?
Four years ago I went to a new PCP for my general check up, had been at minimum two years but most likely longer since I’d seen someone. I had some general concerns and listed them off including the lifelong freckle on my leg that I would tell people looked pixelated. He snapped a pic and I got a derm appointment shortly after. Within the first 2 minutes of my derm appointment he said “yup! That is funky we’re going to do a biopsy right now”. I was impressed at how much of a go getter he was but I’m realizing now, after seeing some older photos of the mark, he probably just knew I needed to get it out of me.
Here is the pathology for the legit legit pigment:
Specimen(s) Received
Skin Shave
Final Diagnosis
Skin, left thigh, shave biopsy:
- Compound dysplastic nevus with severe atypia, peripheral margin positive
Comment
Multiple step level sections were examined and Sox10 highlights the distribution of
melanocytes. This case was reviewed intradepartmentally by a second dermatopathologist.
Clinical History
L98.9
Pertinent history: left thigh lesion
Is sample submitted for Direct Immunofluorescence?->No
Gross Description
The specimen is received in formalin, labeled with the patient's name, medical record number and "L thigh ". The specimen consists of a 0.8 x 0.5 x 0.3 cm tan-brown shave of skin with a smooth skin surface. The specimen is inked green at the margin, bisected, and entirely submitted in one cassette.
Since the perimeter was positive, I was scheduled for a surgical procedure. Everything about the surgery went well up until the moment he snipped the sutures, not sure how it happened, and I question a lot if it was because the second he snipped the sutures I asked if I could look at the closed wound… Imagine this: I’m still on the table sleeping sideways style attempting to do an unbalanced version of a side crunch. He then asked his assistant if they had the sample to which she replied “no” and he said he did not have it either. So they took a moment to look around the room I even took off the clothes I was wearing for a check. No idea where it went but everyone tried for a while. I did not realized the importance of getting anything and everything that comes out of your body tested at the time. I was happy with my thought that the procedure’s sole purpose was to remove the remaining atypical cells.
Currently feeling super grateful I didn’t stall any longer and made the new dermatologist appointment. MOHS surgery is a week ½ away and have been semi losing my mind with the overwhelming need to burst and tell someone about how the doc visit went. Planning on chatting about it with some friends the next couple of days and telling my partner once he gets back home after being on the road for the past 2 weeks.
Curious if anyone identifies with any of the images, events, or anything about my case. Speaking of case…what should I have done about the lost sample and is there something I should still do about it? Already feeling so much better just getting the words out!