Case discussion: How would you treat this patient? [11 July]

Today we have another case submission by Dr David Smith.

A 25-year-old female patient with a lesion on the flank. The history here is vague. This lesion has been present for “some years, I think” and “it may have changed a bit recently”.

Lesion 1
Lesion 2

Please evaluate the photos provided and consider what actions you might take.

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

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16 comments on “Case discussion: How would you treat this patient? [11 July]

  1. The lesion appears asymmetrical, with multicomponent features, irregular borders,variable colors of brown, blue grey, hypopigmented, regression areas, dots and globules on one periphery, eccentric structureless area on the other end. Clinically, also appears as the “ugly duckling/pattern breaker”. Will need to rule out Melanoma by excision biopsy.

  2. Asymmetrical with ?radial streaming on inferior border (bit fuzzy but ? pseudopods) Polymorphic structure, blue/white veil plus blue/grey globules visible over inferior section of the lesion. Excisional biopsy would be prudent to exclude melanoma.

  3. Those blue grey amorphous areas demand an excision biopsy I would think because lesion looks very suspicious of MM.

  4. Ugly duckling on inspection
    Irreg in shape with asymmetry of both colour and structure
    Irreg brown dots with an irreg central blotch with overlying blue grey veil.
    Worrisome findings and therefore favour an excision biopsy for a histopathological diagnosis

  5. Multiple colours including brown, blue, white and grey with ? pseudopods inferiorly. Also looks like blue-white veil inferiorly. Irregular shape and pigmentation – I would excise this lesion.

  6. Chaos with different colours of grey and brown and unspecific net work…certainly mandate excision…However it might be a merely nevi as in many instance patients are not sure if recently changed.

  7. Lesion is asymmetrical in colour & pattern + white blue veil — for excision biopsy with 2mm safety margin — ? Melanoma

  8. Given looking ugly duckling pattern with asymmetry in color and shape + some clues (grayish/ bluish discoloration and dots), it warrants biopsy. Shaved biopsy would be 1st choice for small size (5mm) rather than excisional biopsy with 2-3mm margin. Then go accordingly from report.

    1. To add “why I favour Shaved than Excisional” in this particular case, size and location:
      1/Shaved with little deep dermal would almost provide fairly adequate amount of tissue like excisional for analysis for pathologist.
      2/ Shaved would heal with primary union and can achieve to almost like normal skin or mildly hypopigmented area. In contrast, Excisional with 2-3mm margin would involve suture leaving some degree of scar.
      3/ In this case, patient is a girl/lady, and would not like scar in flank with Bikini if not melanoma.

      In some areas/location I would go with excisional biopsy if depth is greatly concerned. Anyway no one is greatly wrong as its dermocsopic features are leading to suspicious with “Chaos and Clues”

  9. Thanks to everyone for the comments. I share much of the perspective provided. To me, on the clinical this is an “ugly duckling” or “pattern breaker”. Even in a young woman, this worries me. I can’t name it – don’t know what it is, clinically. Dermoscopy does not make it benign. Indeed I am more worried – blue and asymmetrical. So, it needs to come off. As it is small (5mm max) I would take a 6 or 7mm punch biopsy tool and remove the whole lesion, await the histology and go from there. This approach is very quick and easy and safe, and accurate.

  10. This was a relatively small macular lesion so most biopsy techniques could be considered appropriate. I agree with you Tim, that there are a lot of advantages to shave biopsy of macular lesions and lesions unlikely to be invasive. I did an excisional biopsy with 2 mm margins because I expected this lesion to be malignant in a relatively young patient. There are definitely 2 distinct architectural patterns here with signs of deeper melanocytes but the lesion was benign. A combined naevus with “ordinary intradermal melanocytic naevus, and a component of pigmented epithelioid cells beneath this. There are associated melanophages but no significant atypia.”

  11. Many thanks David for great and variation learning, as ended up Benign although much looking like and favoring malignant dermoscopically.