Case discussion: How would you treat this patient? [18 April]

Brian, 82 year old retired accountant presents for routine skin exam. No lesion of patient concern. Only had recreational sun exposure or when boating. Unremarkable dermatological and family history. Scattered seb Ks and solar damaged skin over upper back. One lesion on upper left trapezius was noted to be flat and irregular in pigment pattern compared to scattered seb K’s.

Clinical 1

Question:
Do you see any suspicious lesion?

UPDATE

Clinical 2

Question:
Now do you see any suspicious lesion?

 

UPDATE

Clinical macro

Dermoscopy image

Questions

Does the Dermoscopy image help you at all?

How would you biopsy this lesion? Why?

 

UPDATE

This image shows the shaved site after bleeding arrested with Monsel’s solution (Ferric Subsulphate) Broad deep shave. Opsite dressing applied for 3 days.

Treatment

Pathology report

Clinical Notes: Shave biopsy Left T2 – excl ?MMis.

Macroscopic:
Left T2: The specimen consists of an irregularly shaped portion of skin measuring 21x15x1mm. Examination of the skin surface reveals a discoloured scaly roughened patch measuring 13x9mm. Blocking Details: 3ts A, 4ts B.

Microscopic:
Sections show pityriasis versicolor with an overgrowth of pityriasiform yeast, hyphal and yeast forms, within the keratin layer. There is otherwise focal mild basal pigmentation (solar lentigo-like), a focal small junctional lentiginous naevus with no significant atypia and focal excoriation.

Summary:
SKIN SHAVE, LEFT T2: – PITYRIASIS VERSICOLOR.

 

Please share your thoughts in the comment section below. Professor David Wilkinson will provide his opinion and advice.


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17 comments on “Case discussion: How would you treat this patient? [18 April]

  1. I see 2 lesions that look darker than the rest- the left upper trapezius and medial border of rt scapula. Honestly though, it’s hard to say if they’re suspicious based on this sole picture, a dermoscopic image would help. The one on the left upper trapezius has irregular borders and has different shades of brown making it bit suspicious clinically.

  2. He also has a pink ?nodule?papule just right of the upper spine, with a darker area of pigment, which is suspicious for a BCC, and nodular melanoma needs eliminating. He also has a reddish ?ulcer?scab towards the right shoulder, which I would like to check. The pigmented lesions need checking, but I suspect they are seb ks. None are ugly ducklings.

  3. r medial border scapulae and high left traps area., both stand out pal
    also reddish nodule superior o pal r med scapulae border

    1. looking at dermoscopy there are polygons , with chaos and regression , hence shave biopsy.
      But alas , one’s suspicions were unfounded!
      after looking at the result

  4. There are a couple of larger darker lesions that immediately take your attention but I would be going over his whole back carefully with the dermoscope. I guess the flat irregular lesion is the left trapezius lesion.
    These can be difficult examinations because there are many sebKs and lentigines it would be easy to overlook the banal-looking lentigo that turns out to be the lentiginous melanoma.

  5. Great comments so far. It would be fair to say that this man has “field change” across his whole back. That is, chronic and severe solar damage. So we might expect to see any or all of the solar-associated cancers. Nothing really jumps out from the first picture, although there are a few lesions that might justify closer look. The second picture shows an indistinct, fairly large, pigmented lesion. Having seen this with the naked eye and the magnifier, next step is to view with the dermoscope. We will put that picture up next.

  6. The lesion in the macro shot looks to be poorly circumscribed with some variation in colour. Lentiginous melanomas can be quite large with various shades of brown and difficult to distinguish within a field of other lentigines. I’d like a look through the dermoscope.

  7. Chaotic with polygons.
    I would shave the lesion as a whole.
    I would expect somewhere between lentiginous melanoma which would, most probably be , in situ to moderately atypical junctional naevus.
    Either way the excision does not need to be deep but it would be necessary to see the whole lesion, including shoulders histologically.
    Id love to see a slide of the histopathology. How about putting that up before giving the diagnosis to judge clinico-pathological correlation.

  8. David – great analysis – thanks. We don’t have histology slides for this one, but we want to present some for future cases. I’ll respond tomorrow with more comments, once others have chipped in.

  9. The analysis of this dermoscopy image is tricky. For the beginner, using the 3 Point Checklist, you would probably agree that it is ‘asymmetrical’ and has multiple types of network, and certainly has blue/grey. So you might score this at least 2, or even 3. This would support your plan to biopsy! For the more advanced folks you might spot the polygons, which hint at lentiginous melanoma. This is a lesion very suitable for a nice, deep-enough, and complete shave biopsy. The whole lesion is removed because it is pigmented and we are worried it might be a melanoma. Next we will show you images of the dermoscopy that display the polygons, and we will show you the post shave image. Any bets on what the histology showed?

  10. I would expect a reasonably normal architectural pattern of the dermoepidermal junction with preservation of the rete.
    A basically lentiginous, single cell growth pattern but focal patches of melanocytic proliferation producing confluence, junctional nests and single celled pagetoid spread.
    Melanocytes would be only moderately atypical with mild enlargement and slightly darker staining nuclei.

  11. OK, I was on the wrong track but it just goes to show how important it is to correlate the clinical picture with the histology.
    I noticed in the histology a small focus of junctional lentiginous naevus. Would you say that was uncommon in an 82 year old? I appreciate that there was no atypia seen but I would be scanning it closely knowing that the atypical lentiginous junctional nevi of the elderly, Kossard naevus?, which was once considered premalignant but now would probably be classified as melanoma. Further reason to take the whole lesion in a shave.

    1. David, Agree with your comments. Conclusion here, for me, is:
      – atypical clinical / naked eye appearance (always a worry)
      – dermoscopy confirms concern, and indeed heightens it; the polygons make me think ‘melanoma’
      – full excision biopsy (this time done by full, deep enough shave as the lesion is flat and thin
      – histology shows no evidence of malignancy, lesion fully removed by the deep shave
      = job is done.

      1. Thanks for the interesting case Prof. Wilkinson.
        My last 8 years as a GP were spent at Rainbow beach (SE QLD) and I saw a lot of patients with backs like this. Extreme UV exposure. Also melanoma of various sorts but a large proportion of lentiginous melanoma, but also lentigo maligna, pathological diagnosis of Kossard naevus and a variety of other melanocytic proliferations.
        This stimulated my interest in histopathology and skin cancer medicine in general. I now work in a skin cancer practice. I have enjoyed the change to a sub specialisation and the ongoing academic stimulation towards the end of my medical life.

    1. Pete – you raise a very very important issue here: does the pathology report make sense, considering the whole situation. It is very important for us as GP’s to not see pathology as the “gold standard” or the “full and final answer”. It is not. The gold standard is “the whole picture – history, examination and pathology” and it is we, as GPs who have that “whole picture”. So, how to deal with this situation? Certainly, raise doubts about whether there was a specimen mix up. You can always ask the pathologist to do more sections and check more of the specimen. In this case, there is no doubt that the slides were not mixed up. And, as the whole lesion was removed, not further treatment was necessary. If you still had doubts you should certainly keep chasing the issue!!

  12. Amazing the report came up as TV as the dermatoscope image shows pigmented skin lesion with chaos and an area of brown and pink which is always a suspicion, and moreover it shows polygons and brown-black dots at top part, torturous vessels and an eccentric area of regression, all of which points to LM, but seems was only a TV…