Case discussion: How would you treat this patient? [20 June]

Another case kindly submitted by Dr David Smith.

Male patient, mid-60s, lesion noted on skin check as being a slightly different in size and colour from surrounding nevi. The pink lesion is presumed clinically to be a haemangioma.

Two dermoscopic images are provided – the first is polarised and the second in non-polarised.

 

Non-polar

Polarised

Please describe what you see, and make comment on any differences between the 2 images.

What next?

 

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


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14 comments on “Case discussion: How would you treat this patient? [20 June]

  1. pigmented skin lesion with lower pink area, showing Chaos with different shades and unspecific network.. score 2 of 3…..would excise to rule out any malignancy.

  2. Chaotic lesion with polarising specific white lines. Excise whole lesion or deep shave biopsy of whole lesion, including the pink area.

  3. This lesion has chaos and clues- different colours and clues – thick lines and ? eccentric structureless area.The first photo is not polarised shows the grey and blue much better. It needs an excisional biopsy with 2mm margin to rule out melanoma

  4. Changed lesion in adult needs excision as suspect of mm. This is a pigmented lesion with 2colours brown reticular and pink ? Vascular polymorphic vessels also has Malignancy clues of asymmetric structureless areas with grey on polarised light. Also white area suggestive of regression. I can see polygons in pigmented area and maybe a couple of radial lines/pseudopods peripheral in two places. This is a malignant melanoma probably of spreading type. Is it on the face? If so grey means immediate excision possibly wide and deep shave. If on body grey plus other features enough for mm and immediate excision with boundaries at least 0.5cm to enable histopathological evaluation and simple closure with need for revision, wider excision and possible referral depending on histology.

  5. Thanks of the comments so far. There a couple of key points here. First, as mentioned in the notes, this lesion caught David’s eye and that led him to photograph it. If a lesion catches your eye in this way, trust your instincts – and biopsy it. Your eye and brain is telling you that this is unusual – don’t try and talk yourself out of doing something! In the first image you can clearly see blue / grey (the lesion was on the clavicle). the blue / grey is always a sign of concern. “Blue or grey is not OK”. This is a small and flat lesion, so I would do a shave biopsy there in the consulting rooms, with the intent of getting a diagnosis. I would be suspicious of melanoma. Personally I never go from “suspicion” to “treatment”; I always aim for a diagnosis first. Then I go onto a definitive treatment.

  6. Hi All, this lesion is clearly chaotic, has blue grey areas and on the 2 o’clock edge position; one formation with some imagination looks like a pseudopod. There is asymmetry of structure. The deep pink sector on the left could be angioma or fresh scar from an attempted biopsy or trauma, difficult to say. The white sector on the zenith position possible regression. I would shave biopsy that lesion. Making sure I obtain it entirely including the pink area on its left. I agree that regardless of all theorising gut feeling is important and I rarely ignore it. Further action depends of histopathology. (Anyone who does not believe in gut feelings should read a book called: Blink, The Power of Thinking Without Thinking by Malcom Gladwell; Pinguin Books).

      1. Hi: Zenith point or position is the exact vertical position in a quadrant or celestial sphere above any other point; equivalent to the 12 o’clock position of your wall clock. I use it to describe some feature that is the uppermost position in a roughly round structure. Thank you for your question hoping it clarifies what I mean. Best wishes J. A. Gerzenstein

  7. Histopathology- Melanoma in situ with nested and lentiginous growth of melanocytes showing confluent atypia.
    I appreciate that algorithms need to be used to teach diagnostic methods but I agree with Jorge that there a degree of gut feeling that can come into play, not just in dermoscopy, but right through medicine. Of course, he backs it up with good dermoscopic assessment.

  8. Yes, for me, gut feeling / blink / instinct is very important. (Blink is a terrific book). For me, in clinical practice it includes being willing to almost “let your mind loose” and allow your eyes to roam. You will settle on the ugly ducking or the pattern-breaking lesion. I think this is what happened in David’s case here. Trust these feelings, trust the instinct, and act! Great case.

  9. Just for curiosity towards supervisor/manger for this blog re. “the first is polarized and the second in non-polarised”. Are you sure in this matter?? Because the second pic looked polarised and vice versa for the first!
    Regards