Case discussion: How would you treat this patient? [4 July]

Fantastic case today from Dr Rana Atmaran

A 24-year-old woman with a mole near her left labia minora presents for a skin check. The patient thought the mole to be present since birth, and is unaware of any changes. Please see the polarised dermoscopic picture below.

How do you assess special sites such as this? How would you evaluate the dermoscopic picture shown?

Rana Atmaran case

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? [4 July]

  1. Very suspicious lesion for malignancy, (displastic nevus or melanoma in city) . Congratulation on picking up ( I advise all my patients to look in private areas at home and report any spots before mole check, as that area is ” not standard part” of examination). Lesion need biopsy (excision with close margin)

  2. I guess there are 3 possibilities with an isolated melanotic macule on the labia minora.
    melanosis, naevus or melanoma.
    Melanosis generally has a pattern of parallel lines. A naevus would be the most likely diagnosis in this age group, with globular or mixed pattern predominating. This lesion fits with the mixed pattern. Blue-white discolouration or irregular dots would suggest melanoma.
    There is enough doubt about the mixed pattern in this case to warren biopsy.
    The lesion has been present since childhood, suggesting a congenital naevus and this may account for the patchy bluish discolouration representing melanocytes in the deeper dermis and distribution in a non sun exposed site.

  3. Melanotic macule on the labia minora which is somehow out of focus abit, however it shows mild chaos, with polarised white lines, white clods, brown to grey clods in faint globular pattern at lower part, and some unspecific brown net work at top part (maybe be line reticular but not clear though). I think with history of long time, we might observe and wont surprise if it comes a nevi, However the white line mandate close observation. if planned to shave it, wont that be painful and put the lady in agony.

  4. In my humble opinion:
    1/ Suspicious: in view of clues: dots (grey & black), disparity of color with bluish, pinkish component,…
    2/ How to assess: along with female nurse chaperon, that particular + other parts
    3/ Dermocsopic evaluation: as in number one.
    4/ how to manage: Presuming small size (<5mm), I would favour shaved biopsy rather than excisional biopsy in which the latter require stitching with inferior cosmetic outcome in comparison with shaved procedure. If biopsy result revealed as melanoma, to excise as per guidelines with margin by primary care GP or specialist. The bottom line is to get correct diagnosis and management accordingly with maintaining normal cosmetic structure as much as possible.

  5. Apart from making a diagnosis I find genital examination problematic. I usually get patients to undress to their underwear and then ask if there are any lesions under underwear that they would like me to examine.
    In this case it is a lesion that the patient is aware of and may have asked to have examined.
    There are obviously going to be anogenital lesions that the patients are not aware of with malignant potential.
    I’d appreciate your opinion on dealing with this sort of examination Prof. wilkinson.

  6. Assessment: patient led, but make patient aware the need to self review regularly highlighting the risk of lesions in hidden areas.
    Examination : consented and with chaperone
    Asymmetry of colour and structure
    Irreg brown dots with areas of hypo pigmentation – irreg and a blue white blotch
    Clinically concerned to lead to a histopathological excision biopsy- usually a 2 mm clinical clearance excision biopsy.

  7. Thank you for all of your insightful comments and dermoscopic points. She is regular patient of mine, she revealed this lesion herself after 3rd skin examination during follow up of her scalp mole which was benign. Obviously chaperone and patient consent to picture is a must. I’ve documented this picture in her file to monitor after a month but really I am a bit unsure of how to approach especially its so near to her labia minora. Perhaps I might send her to the specialist after discussion of several issues but cost may be deterrent factor.

  8. It is a tricky case isn’t it. I will share my thoughts. First, about genital examination as part of a skin check. My practice, and medico-legally defensible, is to keep bra and pants on in women, and pants on in men. I always specifically offer to examination skin covered by underwear, and specifically ask if they have noticed anything that needs to be checked. My experience is that most patients are aware of their skin and don’t want me to check it. Some ask me to check, and I will, offering women a female nurse to be present with me. I always document this in my clinical notes. Second – this lesion is very difficult to assess. The history and age are reassuring – long standing nevus in a young person, with no clear history of change. The dermoscopy is not very reassuring, but there are no specific clues to malignancy. If the patient had any concerns I would offer excision. Is the patient was happy to leave the lesion in place I would review in 6 months and 12 months and if no change then it is clearly benign. If I was to excise this lesion I would actually use a large punch tool to capture the whole lesion. Gentle infiltration of anaesthetic is important of course. If you are very gentle and careful this would be an easy procedure. Thoughts?

  9. You obviously feel that there is not going to be significant clinical/dermoscopic change in a melanotic macule in under 6 months. Is this applying to genital lesions or melanotic lesions in general? I find that patients description of change in a melanoma is often over a couple of months and this is just macroscopic.

    1. My this particular query is towards experts- Dr David Smith, Professor David Wilkinson and Dr Rana Atmaran, as I am a novice practitioner who recently joined this group. Sorry if not make sense

      In the given picture, Is there any clues dermocsopically for suspicion /sinisters:
      1/ dots of various size (grey & black) mostly in central.
      2/ disparity of color component- with bluish and gray (L hand side and top part); pinkish (pale) (top and R hand side). very mixed pattern!

      I wished attached the pic with my exact arrow pointing but no option here.

      Best Regards

      Qld, Australia

      1. Thanks Tim, but I am not yet an expert. However, I think we would all agree there are atypical dermoscopic features with this lesion.
        A good starting point is the chaos and clues algorithm. I you feel the lesion is chaotic then you need to consider whether these features are clues to malignancy.
        In relation to the black dots, if they were peripheral then this would be considered a clue. Central black dots are not uncommon in naevi, and probably represented nested nevi cells.
        Grey and blue, on the other hand, are definitely a clue, but as I said earlier, I would consider this as possibly a congenital naevus and as such, histologically, you could expect deeper dermal melanocytes.
        There are always going to be lesions that don’t allow a definitive macroscopic diagnosis. I don’t think anyone would be critical of a decision to biopsy this lesion.

        1. My approach in this type of situation is: “if in doubt, cut it out”. There is nothing “safe” about leaving a lesion you are uncertain about on a patient. And, we all have a different threshold based on our experience and expertise. In my view, “punch excision biopsy” is easy here. If the patient or doctor has any doubt or concern, I would advocate this procedure. To my eye, this lesion is benign – dermoscopic assessment is tricky because this is a mucosal surface / boundary. Overall, I do not advocate monitoring lesions – as I teach in my course, it is best to make a decision on the day. In some situations there is a “grey zone”. So, if this patient was not worried by this lesion (young, long standing lesion) I would be happy to leave it, with clear instruction to return if it changes at all, and I would want to review the lesion 6m later). Hope this makes sense.

  10. A recent study in the US looked at the features and incidence of perianal melanocytic naevi.
    surprisingly, The incidence was 48.9%, with 22% on the anal margin, 36% gluteal and 3% perineal.
    They were usually flat and lightly pigmented, 40%>2mm diameter and 5% >5mm.
    The strongest association was with a history of removal of an atypical naevus.
    This suggests to me that this examination should be offered to patients with a history of dysplastic naevi.
    Ref: The US preventive services task force recommendation statement Published online July 2016 JAMA. dos: 10.1001/JAMA.2016.8465

    1. That is a surprise – such a high incidence of naval. Do take your point in offering the examination at the time of consultation and the association in patients with dysplastic navaei