Case discussion: How would you treat this patient? [14 June]

Case submitted by Dr David Smith

A 65 year old female patient presents with a large pigmented lesion on the heel. She gives a history of it being present for years but she has noticed that it had recently grown. 20 x 10 mm

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First of all, let’s consider the question: Is this benign or suspicious” Assume the patient is reliable, and she does say it has been there for years. There is also a history of recent change.

 

UPDATE:

Assuming we all agree that this lesion is suspicious, clinically, what are the features on dermoscopy that help you become even more confident that this is a suspicious lesion?

UPDATE:

How would you biopsy this lesion?

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


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15 comments on “Case discussion: How would you treat this patient? [14 June]

  1. Hi, for me it is suspicious lesion as had pigment “under “flaky white dry skin , ( so is less likely that someone was treating with silver nitrate- which would be dark and black, superficial) on upper edges of magnifier photo there is still pattern of heal print dots ( like what we see in fingerprint) middle section is heavily disturbed in pattern and non recognizable, If patient has lesion for 3 years, might be in big trouble as melanoma is 99,9% on my list and has to excluded with biopsy and check regional lymph nodes
    Melanoma

  2. Chaotic big pigmented skin lesion on the heel for sure and its PRP…Its suspicious lesion and especially the lady stated a change noted.

  3. suspicious lesion, esp if recently changed, would worry about melanoma
    irregular border, various colours w/ regression, some inferior ?crusting (??has it bled)
    needs urgent (?incision) Bx

  4. I agree – clearly “suspicious”. No need to ‘over think’ this one – nothing like this on anyone’s foot is “normal”. And she tells us it has changed. Change of a pigmented lesion in an elderly person is highly suspicious. Dermoscopy of pigmented lesions on the feet is tricky, and I’ll make some more comment on this during the week. However, as a simple rule of thumb, for me, if a lesion on the foot looks “chaotic” I want to biopsy it.

  5. I agree that this lesion needs further attention. The recent changes noted by the patient I think would trump all other considerations for a biopsy. Apart from it being a PSL with chaotic features it presents on the an akral surface that in itself has a less than favourable prognosis. I note the lesion to be on the LEFT Foot, the seemingly favourable side for melanoma to present on the lower extremity in females.
    In my humble opinion the question here should rather be HOW are we to biopsy this lesion rather than IF it should be biopsied. Being a PSL the aim is always to remove ALL of the lesion leaving the options of excision or shave biopsy in this case. The size of the lesion and anatomical site of this PSL presents its own surgical challenges.

    1. You are absolutely right Deon. The question of how to biopsy the lesion was the problem, as I saw it. The lesion definitely looked chaotic and suspicious. I also thought that this picture may have been through bleeding into the stratum corneum, but less likely.
      Change in the lesion had been reported by the patient’s son. The patient, herself, seemed unaware of change. There was no local lymphadenopathy palpable.

  6. This is a chaotic lesion with parallel ridge pattern –> it is a melanoma.
    Excision biopsy with 2mm safety margin.

  7. I didn’t feel comfortable about the sort of wound I would create on the heel of this patient. The lesion was 20X10mm, a fairly large lesion in a sensitive area.
    Although, obvious now, I still wasn’t absolutely convinced that this was a melanoma.
    The excisions biopsy would have provided the correct diagnosis with a suitable Beslow, so I can’t argue with your choice of biopsy.

  8. This is a great case, as it demonstrates the “every day” challenges that we face. So, choice of biopsy here? The ideal of course, as we all know is to remove the whole lesion. This is because we suspect melanoma and want to confirm this diagnosis and get an accurate Breslow thickness to we can ensure complete excision. Excision biopsy here, with 2mm margins is a significant procedure because the lesion is large and the foot is tricky spot to operate on. A nice deep shave of part of the lesion and / or 1 or more large punches are all options. They are second best, but they would all likely confirm diagnosis of melanoma, but would not give you an accurate Breslow. Another, very good option, is to send the patient to your friendly local surgeon for the 2mm excision biopsy, and most likely subsequent wide local excision. What you should not do here, is just do a routine surgical referral – you would want to talk to the surgeon, explain what you are faced with and negotiate a prompt consultation and procedure. To my eye this is an invasive melanoma. Excision is easy. Closing the hole is the challenge – and so having a friendly surgeon to help is ideal. Bottom line for me – this IS a melanoma. It “has to be”. My job is to make sure it is diagnosed and then treated correctly.

  9. I provided both a shave and punch biopsy specimens for histology. This was a compromise because of the size and position of the lesion. This gave the melanoma diagnosis. The report suggested melanoma in situ. It really looked invasive and the final excision specimen demonstrated this with a Breslow of 1.45mm. Acral lentigenous melanoma. “Thick acral epidermis overlies invasive component and shows lentiginous in situ involvement.”
    I was able to speak to both the surgeon and the pathologist about this case, and I think that is important. The surgeon took a generous margin and the wound hasn’t required any revision.
    It’s easy sometimes, with the more difficult cases, to pass it on and then move on but having a discussion between the various players shares the burden and helps make it a more positive learning experience.

  10. Hi. Sorry to join a bit late with my contribution. The lesion is clearly chaotic with total loss of acral pattern; blue-white structures and white lines, so the confirmation of melanoma is no surprise. The yellow (coagulated plasma) clods in the central area are either ulcerations or site of punch biopsies that have NOT healed. The challenge here is regional & surgical. The medical history is paramount: diabetes, vascular disease. venous insufficiency, chronic oedema, SMOKING, inguinal lymphadenopathies if present are significant surgical and medico-legal risks. In my view this case is beyond what we can do in a surgery setting. Once confronted with that dermoscopic finding in a 65 Y.O. I would refer the case to either a plastic or vascular surgeon with expertise in operating and managing soft tissue lesions in lower limbs let them biopsy from start. The post operative phase may well be complex and protracted even after a shave biopsy.

  11. Q 1/ “benign or suspicious” : We all agree on highly suspicious in view of acral area (sole of foot), recently evolving. Statistically we also need to keep low threshold in suspicion in acral/distal extremities areas.

    Q 2/ Features on Dermoscopy:
    I. Chaos + {absolutely asymmetric pattern (color and shape,…)}. However needing to keep in mind “exception rule” in acral areas.
    II. Clues +++ (see below)
    (1) grey dots- not obvious (difficult to identify)
    (2) Eccentric structureless (grey, dark,..) +
    (3) Thick lines reticular +
    (4) Black dots- not obvious (difficult to identify)
    (5) Lines radial / pseodopods- No.
    (6) White lines ++ (very obvious)
    (7) Polymorph v/s- No.
    (8) Lines Parallel, ridges ++
    (9) Polygon ++

    Thus fit into highly suspicion into melanoma.

    Q 3/ How to biopsy: Taking into account of highly likely melanoma and large size with possible metastasis plus being a GP (primary care setting)-
    (1) Shaved biopsy with deep dermal incl whole pigmented surface (not punched) and then referral to specialist (if melanoma).
    (2) Not favored for standard excisonal biopsy with 1-2mm margin; Instead straight referral to next level. Because how would you close after cutting such large size 2cmx1cm in this sole/thick keratin area. Sural flap! better leave for specialist.

    Best Regards

    1. She would be also a candidate for Sentinel node study if melanoma, which would fall into specialist setting/room.

    2. Sorry. My comment was w/out looking at Prof D Smith whose is right. Thanks for stressing about Breslow thickness.