Case discussion: How would you treat this patient? [16 May]

Jack- 54 year old amateur triathlete presents for routine skin exam with no lesions of concern noted by him.

Do you see anything of note here?

Clinical image 1

UPDATE

Here is the suspicious lesion, noted on careful and close clinical examination.

Day 2 a

Here is a close up. What features do you observe?

Day 2 b

UPDATE

And here is the dermoscopy image. How would you evaluate this lesion using 3 point checklist, and / or other processes? How would you biopsy?

Day 3

UPDATE

Biopsy was shaved specimen- Level 3 Superficial Spreading Melanoma Breslow thickness=0.42mm (shave margin clear by 2.5mm).
Wide local excision with 10mm margins, 12mm to right lateral aspect so as to include a small reticular naevus in excisional specimen.

Day 4 a

Day 4 b

Day 4 c

Provide info to pathologist- picture worth a thousand words

Day 4 d

Excision down to fascia- marking suture in place BEFORE removal from patient.

Day 4 e

Day 4 f

 

Day 4 g

Day 4 h

Layered closure with Monosyn suture (skin with half buried horizontal mattress)

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


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18 comments on “Case discussion: How would you treat this patient? [16 May]

  1. I have heard of the ‘ugly duckling’ sign but as a novice, I’ll probably inspect almost all of the larger or more significant lesions. There are a few darker lesions at about T7(lower border of scapula) in the midline and one larger more diffusely pigmented lesion midmedial to his right scapula margin. Using a photo mapping system may make future check easier but I have doubts if a photo of his full back has the resolution to tell if a future new lesion of 1-2mm in diameter was not present previously.

  2. The 2 mid back central pigmented lesions warrant a closer look.
    There is a R inferior scapular ? BCC
    Love to see the dermoscopic view of those lesions…

  3. An overview picture would be handy for future checks.
    Check lesions individually as usual with dermatoscope.
    Lower lesion ~ T7 may be of interest.

  4. There are two spots next to each other that are darker than others and are surrounded by whitish irregular halos. The left one on the midline seems more suspicious as there is an eccentric whitish (?scar) area. I have to put my dermoscope on them for further analysis.

  5. As usual, there are plenty of spots to run the dermoscope over. What a fantastic piece of equipment they have turned out to be.
    There are a couple of lesions that take the eye. The central back lesion with a couple of colours and a paler lesion just medial to the right medial scapular margin.

  6. 2 pigmented lesions mid back ? melanoma or pigmented BCC need dermoscopic pics, also erythematous /plaques R scapula , L upper shoulder area and slightly paler area mid way down R back I will like pics on? BCC

  7. I do see two pigmented skin lesions, and it shows some white keratin like and pink area. I would examine with a dermatoscope to get some clues.

  8. The circled lesion shows asymmetry of colour and structure in the centre of the close up view there is an outline of blue white structure on a pink background. That close up view does not show enough detail of the central portion to decide whether there are vessels. In any case there is chaos and enough concern to excise that lesion which could be either a melanoma or a pigmented BCC. It seems too flat for a reliable shave biopsy. A second best option could be to photograph and review in about four weeks. However I would excise with at least 2 mm margin from the visible (dermoscopic) edge. I would just mention that the lesion to the right of the circled one deserves scrutiny and follow up.

  9. Dermoscopically: Chaos; reticular pattern top right + thick lines at 4 o’clock; colours brown, blue/gray and white: structureless pattern; pinkish background at 10 o’clock (?significance): lots of gray dots & clods at periphery.
    3 point checklist 3/3. Highly suspicious melanoma, possibly invasive. Excisional Biopsy 2mm margin.

  10. Dermatoscope shows a pigmented skin lesion,, with eccentric white structureless area, and two grayish area, and top right shows some thick line reticular, and top left a pink area though i cant see any vessels…some grayish dots, all of which are clues to malignancy and mandate excision and send for HP.

  11. dermoscopically, I would be suspicious of this lesion.
    There are two patterns at least with a variety of colours.
    The SW corner shows regression with peripheral spots of pigmentation and NE corner looks to be sebK, but I’m not totally convinced about that.
    Overall, I think that this is a seb K with lichenoid keratosis supervening. The black dots representing macrophages in the papillary dermis.
    There is enough chaos and doubt to justify biopsy. I would shave biopsy the lesion as a whole, with a DD of sebK, LPLK or melanoma in situ.

  12. I have just blown up the dermoscopic view and have a different opinion.
    What I thought was sebK is a reticular pattern. so partially a naevus with a variety of colours and eccentric structureless area in the the regressive part. Possibly vague polygon structures.
    I’m more convinced this is melanoma in situ.

  13. Some great discussion so far – many thanks for all the input. My approach here, in terms of clinical examination is to stand back and look for the ‘ugly duckling’ or the ‘pattern breaker’. To my eye there is not much to get excited about here, although the circled lesion does catch the eye a little. On closer inspection, with a magnifier, (image 3 above) it gets much more interesting – it looks asymmetric. On dermoscopy it scores 3 on the 3 point checklist, for me – asymmetric, blue, atypical network. This then leads us to do a biopsy. This is a small, flat lesion, which (for me) is perfect for a nice deep shave biopsy. (It is almost too small for an excision biopsy). My view is that for most GPs – who don’t become “expert” in dermoscopy, the 3 point checklist works well – it leads us to a confident decision to biopsy the lesion. Specific dermoscopic features are suggestive of melanoma.

  14. Just an inquiry please, would punch biopsy be more beneficial in small lesion like this to be able to get the whole diameter and thicker layer of specimen?

    1. Dr Tamayo – great question! The key issue here is to biopsy by taking the whole lesion. A shave will do this well, but a “big punch” that includes the whole visible lesion would also be fine. The key, with any pigmented lesion is to take the whole lesion – breadth and depth. Regards, David

  15. Given site and size of the lesion, I would think adequate excision biopsy is possible if you were even considering 15mm margins of clearance.