Dermatopathology Expert Comments on Delayed Diagnosis of Malignant Melanoma

Case Overview

This case involves an elderly female patient and her diagnosis and subsequent treatment of malignant melanoma. The patient initially underwent a shave biopsy of a mole on her face under the care of her dermatologist, which indicated the presence of cancer cells. However, the lab that was used to obtain additional findings on the sample claimed to have seen no cancer cells, and instead submitted a diagnosis of a begin lesion. Despite these findings, the patient’s treating dermatologist was not convinced, and performed a deeper biopsy, attempting to use cyrotherapy to remove the mole entirely. This time, the lab returned results that indicated a highly advanced melanoma that had taken root in the patient’s facial musculature. In order to treat the advanced cancer, the patient underwent a deep resection of her facial tissue, leaving her disfigured. Despite treatment, the patient died from metastatic cancer some time after the procedure.

Questions to the Dermatology expert and their responses

Do you routinely treat patients similar to the one described in the case? Please explain.

I have made the diagnosis of desmoplastic melanoma on a number of occasions and am familiar with what the standard of care involves regarding their staining. Most clinicians I know, when they have a patient with that diagnosis, send them to surgical oncologists for resection, staging and the consideration of additional therapy. Follow up on these patients involves having a very high index of suspicion regarding subsequent lesions and the need for their biopsy. In this case, it was quite critical that the patient's prior history of left cheek pathology was looked into. It is quite routine. Before someone undergoes a surgical procedure based on pathology reports from outside institutions, the pathology slides are reviewed to be certain that, in fact, the patient has the tumor he/she are about to be treated for. Most institutions/hospitals have this policy in place.

When would it have been appropriate for stain utilization based on the brief case summary? How could this affect the patient's prognosis on this case?

Desmoplastic melanomas are well known to be HMB-45 and Mart-1/Melan-A negative. However, they are positive for S-100 and typically today a Sox-10 stain will do as this is a cleaner stain for diagnosing melanomas, particularly desmoplastic melanomas.

About the expert

This expert candidate is an elite dermatologist who has over 20 years of experience in the field. He is double board certified and licensed in two states. He is a member of the American Society of Dermatopathology, and frequently participates in medical mission trips.The expert is a reviewer for numerous journals including Journal of the American Academy of Dermatology, Journal of Cutaneous Pathology, American Journal of Dermatopathology, and American Journal of Medicine. He is also published numerous times on various skin diseases, such as melanoma and their treatments. This expert is a current Associate Professor and Physician of Dermatology and Pathology at a major university medical center.

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Specialties:

Dermatology