Case discussion: How would you treat this patient? [9 May]

A 60 year old woman presents for routine skin exam.

Question:

Do you see any suspicious lesions on this woman’s back?

UPDATE

Suspicious lesion

Specific mid back lesion imaged 2

Question:

This lesion was considered suspicious and here is the dermoscopic image. How would you evaluate this, and what action would you take?

UPDATE

2 years later 3

4

Question:

No action was taken at this time, and here is the clinical image and dermoscopic image taken 2 years later (she missed her 12 months skin check). How do you evaluate the situation now?

Question:

How would you biopsy this lesion?

UPDATE

Here is the pathology result:

Excision. Upper back 12x10mm pink structureless macule with eccentric brown with lines reticular. Changed on digital review. ?Melanoma.

MICROSCOPIC EXAMINATION.

Sections show skin to subcutis. There is a nested, lentiginous and focally confluent proliferation of variably atypical melanocytes at the dermoepidermal junction. There is focal extension of atypical melanocytes along follicular structures and upward scatter of atypical melanocytes into the upper layers of the epidermis is seen focally. The superficial dermis shows  a mild to moderate chronic inflammatory cell infiltrate with melanin pigment incontinence and concentric eosinophilic fibroplasia. There is no evidence of invasive malignancy. Atypical melanocytes come to 2.1mm from the closest transverse margin. The lesion is well clear of deep margin. It is excised in the planes of sectioning.

CONCLUSION.

UPPER BACK – MELANOMA IN SITU, SUPERFICIAL SPREADING TYPE (CLARK LEVEL 1) WITH FEATURES OF REGRESSION, 2.1mm FROM THE CLOSEST TRANSVERSE MARGIN.

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


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13 comments on “Case discussion: How would you treat this patient? [9 May]

  1. There are on a macroscopic view a number of ugly ducklings I will await developments

  2. I was looking for an ugly duckling without magnification and I was suspicious about the large partially whitish lesion on the right side. On magnifying the picture I thought all of them look similar bicoloured moles but the one in the middle of the field just right to the spine seems to have more than two colours with some bluish/gray hue. I think we should look under the straps as well for any surprise. Next step would be dermoscopic examination. By the way what is that greenish colour at the right strap?

  3. I think there is chaos of structure and ?colour as well. There are some thick lines reticular in the upper triangular portion of the lesion versus two eccentric areas of structureless pattern on the bottom right and bottom left. I was suspicious clinically and I could see a grey area corresponding to the left bottom structureless area which is not so clear dermatoscopically. I think we need to use polarised dermoscpy as well. Anyhow for me I think SSM with areas of regression and I can not say for sure it is a benign naevus so I will go for excisional biopsy with 2mm margin. A dermatoscopic comparison with the neighbouring lesion might help better diagnosis.

  4. Interesting comments – thanks for contributing. I think it is fair to say that on the clinical image there is not much that jumps out. There is extensive solar damage, but no lesion that is dramatically different. The lesion that caught the eye of the clinician on close attention is now marked, and the dermoscopy provided. The comments about monitoring are interesting – I never monitor now. My view, and that shared by many, is that if there is “any suspicion” then action should be taken. So, in other words, if you plan to monitor, you are making the decision that the lesion is (in some way) suspicious. What do you think now that the update is provided?

    1. i feel now with the extensive regression , white lines and pm vessels we are dealing with a MIS at the very least and a shave excision would give an answer as there is no dermal element visible as yet.

  5. I think it is more clear now that there are wider structure-less areas and white lines with polymorphous vessels. I think excisional biopsy with 2mm margin has to be done by now. My suspicion of SSM is almost confirmed.

  6. I have the advantage of coming late. Now there is significant change in the lesion with a large pale structureless area adjacent with some peripheral vascularity. I would shave biopsy. The lesion is getting quite large now and if you did an excisions biopsy there is every likelihood of having to go back and do a wider excision. Either way would probably give a reliable diagnosis.
    I try to avoid monitoring but in this case I’m not so sure. I will almost always take photos of atypical pigmented macules, so at least I have record on review.
    I have only worked in a skin clinic this year and don’t, as yet, have a regular patient base and am not confident that patients will necessarily return. It make it more important to get it right first time.
    If there is doubt a shave biopsy is quick and easy to do at the time of consultation. Patients don’t generally take exception to removal of a benign lesion.

  7. Further excision for definitive treatment of SSM to secure 5mm margins is required. Follow up 6 monthly thereafter.

  8. Sorry for the delay in responding – I have been travelling and had website access problems, until today. Well, the image, taken 2 years later clearly shows changes doesn’t it. So, biopsy is mandatory now. It doesn’t matter what technique we use to biopsy, so long as we remove the whole (pigmented) lesion. I tend to use a deep shave biopsy myself, but only when the lesion is fairly small and definitely flat. I make sure I remove the whole lesion that way. As Albert says – definitive treatment is now 5mm margins (and same depth).

    A final word about monitoring. This case, I think shows, why “formal monitoring”, that is – making an explicit decision to not act on a “suspicious lesion” is risky. Patients often don’t come back. Of course, we must NEVER monitor a raised lesion – not might be a nodular melanoma. So, personally, I just don’t monitor – if I have doubts, I biopsy. Thanks for all the input. Great case!

  9. For me comparing between the first and the last dermatoscope, there is however changes, as it shows chaos with clues to polymorphic vessels and thick line reticular and a bit grey central area, some regression on the left side. I would be keen to know the biopsy reading.