Case discussion: How would you treat this patient? [27 June]

Another case submitted by Dr David Smith

A 38 year old man with some sun-damaged skin presents for a skin check. The small dark lesion on his right shoulder was noted clinically. The associated dermoscopic picture is shown.

What do you see? Please provide your interpretation and advise on biopsy technique.

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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? [27 June]

  1. As symmetrical chaotic pigmented lesion with areas of thickened pigment network, blobs and grey areas . Management is to excise lesion with 2 mm margins for histo. Exclude melanoma

    1. It fit into to suspicious melanoma with criteria-
      I. Chaos + (Asymmetry of shape & color)
      II. Clues +
      a. multiple Grey & Black dots, pods (centrally + peripherally)
      b. Thick line reticular
      c. Polygone

      How to manage:
      If unsure> Shaved biopsy with large area and go from there.
      If likely and confident enough> standard excision 2-3mm normal margin. If reported back with melanoma > wider excision as per guidelines. I would favor flap (Rhomboid) in view of location- shoulder.
      Cheers

      1. Tim, I’m still learning – why do you say shave biopsy if unsure? Why would you not do excision biopsy if unsure?

        1. Thanks. I am also learning. I might be wrong.
          1/ Shaved biopsy with deep dermis (not punched) also provide tissue amount satisfactorily for analysis for pathologist. If reported back with melanoma and tumor size is more than 5mm, Nice to excise with flap in view of location. Excision biopsy also yield similar, but standard excision elliptical with 2 or 3mm margin would be a bit difficult to proceed within a week for flap. Sorry I was a bit over-leaning and inclined for flap in this context with no size statement. In comparison, excision biopsy would require suture and leave scar if not melanoma. Regards.

  2. Irreg in shape with shades of brown macroscopic ally. Asymmetry of colour and structure: multi focal areas of hypo pigmentation, irreg brown blotch and irreg ret network leads red flags to a conclusion to an excision biopsy – preferably with a 2 mm clinical clearance margin. If not practice then a shave or an incisional biopsy.

  3. Definitely a chaotic pigmented skin lesion with different shades and structure, brown- grey clods/ dots, and central clearing/ white area, and at 6 i do see thick line reticular, however the network as a whole is unspecific, but lower pole show as line reticular and some side as pseudopods, though not that clear to emphasis. It needs to be removed to rule out malignancy either excision or shave.

  4. It is a pigmented skin lesion. Chaotic – colour and pattern. Colour of grey/blue and clues of black dots and thick lines
    Needs elliptic excision with 2mm margin

  5. Great to see so many comments so soon on this case. And thanks again to Dr Smith for submitting so many cases – anyone else is welcome to send cases in. This is how all learn. Here are some early thoughts from me:

    1 This is an ugly ducking or a pattern breaker, on clinical examination. That is – it stands out, it is different from everything else. That demands a good look with the dermoscope.

    2 Using the 3 point checklist, this lesion is 1) asymmetrical, and 2) has more than type of pigment network. Score of 2 = suspicious

    3 Now we need to do a biopsy. Always get a diagnosis before you consider treatment.

    4 In my humble opinion, the lesion is so small and flat that a nice, fairly deep shave excision biopsy is ideal here. The KEY factor is to remove the whole lesion (in depth and width). It is very quick and very easy to do this with a deepish shave.

    You will then get the pathology diagnosis and can plan definitive treatment, if needed. National guidelines, and good practice would recommend “get a diagnosis before you consider treatment”.

    Look forward to further comments. David

    1. Hi David, a slightly tangential question – if you do a shave you are left with a roundish area, so when you go back to do a formal excision how do you measure the margins; from the edge of the shaved area? (I have not done many shaves and recently did one and when I went back to excise it formally, the ellipse was quite big because the shaved area was quite wide. If I had done an excision biopsy I would have measured the margins from the linear scar so not as wide and therefore a smaller ellipse). I hope my question makes sense!

      1. Hi Leonora, Yes the question makes perfect sense. What I do is take my margins for the excision from the margins of the shave wound. So, for me, I do shaves on “small and flat” pigmented lesions – I am suspecting melanoma. I ensure that I shave the whole lesion with a small margin (approx 2mm). If the result is in situ melanoma, for example, I will then do a 5mm excision. The 5mm is all around the edge of the shave wound. This ensures complete excision of the in situ melanoma. If the melanoma is invasive then the margins are of course larger – 1cm.

        1. I agree with Prof. Wilkinson’s comments on shave biopsy. Another potential problem, however, is that the good cosmetic result can make it difficult to find the original biopsy site. Try to avoid a long delay before formal excision. I photograph most pigmented lesions, particularly if I suspect melanoma. This gives me some idea of the position and orientation of the original lesion. Path reports will give you the dimensions but generally there is only a small margin on the shave anyway.

  6. David – would you like to share the biopsy results with our colleagues. The result is interesting, is it not!