The Question: I suspect I have acral melanoma on my foot and I want an excision biopsy done. Most family practitioners are unaware of what it is, and they simply did not know what it is. I waited for a long time and saw a dermatologist who wasn’t sure what it is either. He said it’s a birthmark even after telling him that I only had it for 1.5 years and it grew over the period of time. After reading some suggestions from melanoma survivors (who strongly think this doesn’t look good and need to be removed), I am trying to get an excision biopsy from a melanoma specialist, regardless of what it is for peace of mind.

The Answer: Right off the bat, doctors will tell you any new lesion is worrisome – especially one that is growing – and that it definitely needs to be seen. I like that you have reached out to melanoma survivors for advice and it sounds like they have been able to confirm for you that this mark on your foot looks suspicious.

The only part of your question that gives me pause is that two physicians have already seen and dismissed it – your family physician and a dermatologist, the latter of whom would be particularly well placed to spot a suspicious lesion. I do think you are correct to pursue a biopsy as you require a definitive answer only a biopsy can provide that to you. Your preference for a total removal of the lesion for “peace of mind” may be extreme, given that the growth is on the foot and if it’s large, it could involve a skin graft or a rotational flap to reconstruct the area, according to Frances Wright, a surgical oncologist at Sunnybrook, who specializes in melanoma.

“He needs to have someone look at it,” Dr. Wright said in an interview. “If it needs a biopsy, then it may need to be an incisional biopsy (removing the most suspicious area) rather than an excisional biopsy (removing the whole area) to minimize the morbidity of the reconstruction. Most general surgeons can biopsy the foot.”

There are four major types of melanoma: superficial spreading, which is the most common making up 70 per cent of all diagnosed cases, nodular, lentigo maligna and acral lentiginous, the latter of which accounts for about five per cent of all diagnosed melanomas. [Nodular melanoma accounts for 15 per cent of cases, while lentigo maligna represents 10 per cent of cases].

The type you wrote about – acral lentiginous melanoma – is a common form of melanoma in Asians and those with dark skin. It is sometimes referred to as a “hidden melanoma” because the lesions occur on parts of the body that are typically not easy to examine – or that even one necessarily thinks to examine. These melanomas present on the palms of the hands, soles of the feet and mucous membranes, including those that line the mouth, nose, female genitals, anus and underneath or near the toenails and fingernails.

In your case, the lesion has appeared on the sole of your foot. Typically, melanoma looks like a black spot. Sometimes people mistakenly believe the mark is due to bruising or a recent injury.

Doctors are taught the classic signs of a melanoma are asymmetric lesion, irregular borders, change in colour or multi-coloured, diameter >6mm or ulcerated/ bleeding.

“If it looks suspicious, you need to do a biopsy,” said Dr. Wright, associate professor of surgery at University of Toronto. “Something new that is changing can be worrisome. In the end it’s going to be a discussion between the physician and the patient on how worrisome it is.”

Sunnybrook’s Odette Cancer Centre is the only place in Canada that has a pigmented skin lesion clinic that runs every Monday. There, you can have your suspicious lesion looked at by a dermatologist and an oncologist, if need be. You can access it if you are referred by a family physician through our central referral fax number 416- 480-6179 or referral telephone number 416-480-4205.

“The majority – 70 per cent of melanomas, – present with a depth of less than 1 mm and have a very good outcome,” according to Dr. Wright. “There are a proportion of melanomas that do present deeper and can be life threatening.”

Another alternative is that you return to your family physician and ask to be referred to a general or plastic surgeon to do a biopsy and if necessary, have it removed. Many dermatologists perform these biopsies as well.

I agree you need to vigorously pursue this, get a biopsy and a definitive finding. The biopsy alone will likely give you that peace of mind you seek.

The post Suspicious Skin Lesions and Melanoma appeared first on Your Health Matters.

The Answer: Cancer treatment is an area where strict adherence to the rules is paramount if you want to ensure the best possible outcome – in this case, cure is the aim so we should ensure not failing our goal –. Radiation treatment after lumpectomy is not an option but part of a package. There is a risk of the cancer returning if you do not undergo it.

“Many patients ask, if they can choose receiving radiation or not,” said Jean-Philippe Pignol, a radiation oncologist at Sunnybrook and professor of radiation oncology at University of Toronto. And in this case, “cancer treatment is not like choosing options when you buy a car. It is more a black or white thing and not receiving the appropriate treatment is a serious decision.”

Cancer patients such as your friend – who have undergone breast-conserving surgery – require radiation treatment. That’s because no matter how good a surgeon is at removing the tumor and surrounding tissue, there is always chance a couple of cancer cells – invisible to the naked eye – were missed.

Perhaps the easiest way of looking at it is to look at how much risk your friend is willing to accept. Without radiation treatment, the risk of the breast cancer recurring in five years is up to 30 per cent. In other words, the odds are almost one in three that the cancer will return in five years if she does not undergo radiation. When breast cancer returns, it is metastatic half of the time, which means it has spread to surrounding tissue, organs or bones, making cure impossible. The goals of care at that point will be lengthening survival as long as possible.

Compare that to patients who undergo radiation following breast cancer: their risk of recurrence over five years is about five per cent. In other words, they have a one in 20 chance of the cancer returning over five years. After five years, patients are often considered cured of the disease and if cancer returns after that period of time it is considered a new primary.

Theoretically, your friend is onto something: 70% of the patients may not recur after limited surgery there are likely breast cancer patients who do not require radiation whose survival would not be impacted but as of today, oncologists have no way of determining who these patients are.

“It’s rare that they would say maybe no radiation is necessary,” said Dr. Pignol.

There is no question radiation therapy represents a significant burden in terms of time and psychic energy: typically, patients are required to come every day, five days a week up to five weeks.

“Daily radiation is very disruptive,” said Dr. Pignol in an interview. “It has a great impact on patients’ lives and nobody is very pleased to go every day at a cancer center. It can be extremely draining, physically and psychologically.”

There are other side effects of radiation besides boredom, including burning on the skin – roughly 30 per cent of patients will experience it, but this side effect disappears typically after a week or two.

There have also been concerns that those who have radiation to the left breast may have a higher chance of coronary artery disease and myocardial infarction than those whose right breast is irradiated.

But according to Dr. Pignol, this seems untrue today as technological advances – in the form of CT scans – helps doctors better see what they are actually treating.

Though there is an additional radiation exposure, the chance of developing a secondary cancer due to the radiation treatment is almost undetectable.

Recognizing the arduous length of time for radiation treatment is a barrier to patients across Canada – especially those in remote areas who must travel to urban centers – doctors are studying ways to provide it in a compressed, shortened period of time. Even today, some patients can obtain radiation at certain Canadian centers over several weeks.

“We’re working on solutions,” said Dr. Pignol. “And since we cannot select who should receive radiation and those who should not, the best thing to do is to simplify the radiation treatment and make it more patient friendly.”

To that end, doctors are looking to see if they can compress that five-week radiation treatment, to shorter periods, including treatment in a single session using implanted radioactive seeds or delivery of radiation during surgery.

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It’s not the happiest news. Experts published in the most recent edition of the Journal of the American Medical Association suggest cancer is poised to become the leading cause of death worldwide. That’s despite major strides forward in cancer treatment and prevention.

That said, there is a lot you can do as an individual to reduce your risk. That includes things like healthy eating, staying active and being screened, when indicated. Cancer screening is something most of us will experience, and it simply means you’re being checked. If something suspicious is found, your doctor will likely order a biopsy, a sample of tissue taken for closer examination. And while you wait at home, worrying and wondering, what happens behind the scenes is something you simply have to see.

At Sunnybrook Health Sciences Centre, thousands of such tissue samples are sent to our state-of-the-art pathology lab every year. When I walked in for the first time, I was amazed by the process. It’s something patients usually never get to see. But if you click on my video link, I’ll walk you through every step and introduce you to our Chief of the Department of Anatomic Pathology, Dr. Mahmoud Khalifa.

Step one is receiving the sample, processing it into the system with a unique patient code number. A technician then sits at a table, cutting it into smaller pieces that will fit into a special color-coded cassette. The one-inch cassette is porous to allow different chemical solutions to pass through, the purpose being to dry out the tissue during overnight processing.

Once that’s complete, the sample moves on to a so-called embedding station, where it’s removed from the cassette and covered in liquid wax. The wax is then allowed to harden on a small black cold plate. You might wonder, why wax? The reason is that the wax suspends the tissue sample, allowing for the next step in this intricate process: cutting. Picture the meat slicer you find at the grocery store. Well, that’s what happens to the tissue suspended in wax: it’s sliced like salami so different depths of the sample can be examined. Then, these thin sheets of wax are placed to float in a small water bath, where the technologist can literally scoop up what they need onto a glass slide. These glass slides are labeled with the patient’s specific code to eliminate any mix-ups.

Once the section is on the slide, it needs to be stained so the pathologist can do their job. Pathologists are physicians who have specialized training and examine tissue, blood or other body fluids to help diagnose diseases, blood disorders and infections. The staining process takes about one hour, and the pink color allows for the cells to be viewed under the microscope to check for cancer. Sunnybrook has one of the most up-to-date staining systems in the country. By laying the glass slides flat, it virtually eliminates the risk that cells from one slide will contaminate another. In short, cutting the chance of receiving a false-positive result.

After staining, another technologist matches the slides with a pathology report before they are sent on. Sunnybrook is also a leader here, having teams of pathologists who specialize in each type of cancer. And that’s an added benefit to patients, especially in more complex cases.

Our hospital has one of the most robust quality assurance programs in Canada. And the bottom line for patients is simple: when they get a result, they can rest assured that every step has been taken to make sure it’s accurate.

I hope you’ll check out my video. It’s a story you won’t see anywhere else.

The post What happens to your biopsy? appeared first on Your Health Matters.