Case discussion: How would you treat this patient? [6 June]

We have a slightly different case this week – for a a good reason as will become apparent.
First of all, here is a clinical image. Please view the image and report what you see – how suspicious are you?

Lesion

UPDATE:

We have no more images for this lesion. The history is simple – the husband of the woman with this skin lesion noticed “a change”. Her GP did a biopsy.

What type of biopsy technique would you use here and why?

UPDATE:

Here is the pathology result. This result is from the definitive excision. How would you interpret this result? What broad comments would you make about the results and this case?

Pathology report

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


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17 comments on “Case discussion: How would you treat this patient? [6 June]

  1. I can see pinkish structureless macule with hypopigmented partial halo on one end and brownish blotches on the other end. It looks asymmetrical in terms of color and structure, hence it looks suspicious to me. I would do a shave biopsy to rule out Melanoma.

  2. I am suspicious. There is a pigmented macule with a large eccentric structureless area as a part of it or adjacent.
    If this represents an area of regression in a pigmented lesion I would be concerned.
    As usual the dermoscopic view will make or break it.

  3. Pink dome shaped lesion with different shades and white halo. Would love to know history and any other skin cancer history. For sure needs shaving to rule out any malignancy,

  4. Irregular shaped papule with central pink colour with surrounding brown to one side and pale area to the other.
    Clinical history would be vital, followed by dermoscopic findings.
    This will determine the next stage in management of this suspicious lesion.

  5. It’s good to see that we all agree that this is suspicious. It does look a bit different from the rest of the skin doesn’t it, but the changes are not really that dramatic. This is true for so many skin cancers – they are different from the rest of the skin, usually but it is often subtle changes……..

  6. There was a recent study comparing the effectiveness of a short education in interpretation of dermoscopy and just being shown a large number of slides of lesions. The resultant diagnostic ability tuned out to be much the same.
    Algorithms can be taught but just looking at a large number of lesions can give you a feel for the abnormal lesion. Maybe this is more applicable to pigmented lesions, at least. Cliff Rosendahl says you need to look at all the normal naevi as well as the ones that look atypical. I can see his point of view.

  7. I need to know more about the lesion.
    Also the dermatoscopic picture isn’t clear.
    Despite of that,
    If it has been there for a while, shave biopsy will help.

  8. Hi all. A skin lesion that is changing in an adult (especially pigmented) needs a biopsy (exceptions). The patient and her husband deserve an answer. The ideal in this case is a shave biopsy ensuring the whole lesion is obtained with a 2mm margin. Since it is quite flat, a good volume of local anaesthetic will help with hydro dissection providing a helpful bulge. To ensure the whole intended specimen is obtained marking the actual lesion boundary and the 2mm surgical margin is important, otherwise when the local is injected the lesion’s borders may become difficult to visualise. I would try to stay just outside the marked surgical margin with the biopsy blade. It is important to frankly discuss with this couple possible outcomes and what happens next. At the initial assessment checking the lymph node basins draining that region is also important.

  9. There is an inadequate peripheral margin at 3 o’clock. All the other margins are generous.
    Re-excise it with at least a 5mm margin all round, then you can completely reassure the couple that there is a 97% 5 year survival rate, otherwise, you can’t give this guarantee.

  10. Thanks for all the comments. I would agree with the view of doing a shave biopsy here. The lesion is small and flat, and I would be confident of being able to remove the whole lesion for diagnostic purposes, by doing a shave. With an MIS diagnosed I would then do a 5mm formal excision. The discussion now, about whether the excision report is sufficient is interesting. For me I would not recommend further excision, even though the report shows that 1 margin is less than 5mm. Why? Well, because all the trials on melanoma margins refer to clinical margins not pathology margins. In other words, the margins are “my margins”. If I feel confident that I can see the lesion and its margins (using my dermoscope, I mark that margin out. I then measure 5mm all the way around, and that is my formal excision. All I want to know from the pathologist is whether the margins are clear or not – I don’t want to know any measurements from the pathologist. The other point t make here is that tissue contracts once excised and placed in a specimen pot, so the margins would have been bigger anyway. My view – this lesion is out. Thanks to all for a great discussion!

  11. I’m really pleased to hear your comment on the excision margins Prof. Wilkinson .
    My comment was, what I thought you would like to hear rather than what I do. Also a reaction to some of my melanoma in situ excisions that have given histological margins at slightly less than I intended. There was one patient here for a follow-up appointment after her melanoma excision on the day of the post and I was really considering a re-excision in view of my own comments.
    A real problem for me is the lentigo maligna where the histologic edge is often way beyond the clinical edge.
    I think there needs to be some more work on separating the UV affected atypical melanocytes from the malignant melanocytes of these lesions. For instance the unstable solar lentigo, what is that?
    This is fair enough for melanoma in situ but would you say the same for more invasive lesions?

  12. Thanks David. You make important observations. My position is based upon my knowledge of the literature, and interpretation of national and international guidelines. So, to try and summarise:

    1 Margins are ‘clinical’ margins, not ‘histological margins’. This means it is our job to measure, mark and cut the margins, whether they are 2,3,4,5,or10mm. Every time I measure, mark and cut.

    2 All that I want from the dermatopathologist is a report on what the lesion removed is, and whether the margins he/she can see are involved or not

    3 As we all know, the pathologist will usually only look at a tiny fraction of the margin of the lesion. So, in no way at all is he telling me “I have looked at the whole margin of the lesion you sent me and there is no tumour nearby”. What he is actually saying is “I looked at a tiny part of what you sent me and I can’t see any tumour. I have no idea what the rest of the lesion is like though”.

    4 So, for BCC, SCC and in situ melanoma it is easy I think. The margins are my margins, and if the pathology says “margins not involved” then the lesion is excised. My pathologist doesn’t report histologic margins!

    5 For invasive melanoma, I take the same approach. If I measured and cut the correct margins, and what the pathologist looks at is clear, then the lesion is out. And, importantly, this is how the randomised trials that tested the margins were done.

    6 It is tricky for lentigo melanoma – the margins are often indistinct. All we can do is remove what we can and follow up closely, right?

    7 Unstable solar lentigo is a fascinating topic – let’s keep that for a future blog post. If anyone has pictures of this lesion that would be great. I will dig out David Weedon’s paper on this lesion and post on it in next month’s research blog

  13. Oh dear I looked at the clinical picture and didnt really think it looked that suspicious.Fair sun damaged skin seems to have quite a lot of things that look like that on it. I guess the history of change is the suspicious thing and I would examine with the dermatoscope. Depending on what I thought of the three point checklist score – and there is assymetry and white area suggestive of regression giving it at least a two I would either do an excision biopsy or refer for same if the lesion was big or on a difficult site. If the three point checklist is abnormal and there is a history of change you really need to be mindful of melanoma and the white area is suggestive of regression