Date of Procedure: 1 November 2024
Specimen/Specimen Type: Excisional biopsy of skin lesion from left forearm, 0.8 cm diameter.
Pathology Lab: City General Hospital Pathology Department
Requesting Consultant: Dr. Eleanor Vance, GP
Clinical Information: 45-year-old male with a darkly pigmented, irregularly shaped mole on his left forearm, noted to have changed in size and colour over the past 3 months. Suspected melanoma.
Macroscopic/Gross Description:
- Irregularly shaped, dark brown to black skin ellipse measuring 1.2 cm x 0.9 cm x 0.4 cm.
- Central raised area of 0.7 cm diameter with focal ulceration.
- Margins appear clear grossly.
Microscopic Description:
- Histological examination reveals an atypical melanocytic proliferation within the epidermis and dermis.
- Features consistent with superficial spreading melanoma, Breslow thickness 0.9 mm.
- Invasion noted into the papillary dermis.
- No evidence of lymphovascular invasion or perineural invasion.
- Surgical margins are clear; closest margin 0.2 cm at the deep aspect.
- Mitotic rate: 2 mitoses/mm².
Diagnosis:
Superficial Spreading Melanoma, left forearm. (ICD-10: C43.6)
Comments: Further discussion regarding sentinel lymph node biopsy is recommended given Breslow thickness.
Pathologist: Dr. Thomas Kelly, Consultant Histopathologist. IMC Registration: 12345
Date of Report: 1 November 2024
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