Case discussion: How would you treat this patient? [9 August]

This week we have an apparently simple case from Dr Ravanjit Singh. Like all our cases, this is a real life scenario. Here is a photograph of a nevus, on a patient’s back. There is no history, but the patient is middle aged.

This lesion looks different from all others – especially the dark area.

What do you think it is? What would you do?

IMG_1447

Case submitted by Dr Ravanjit Singh

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


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9 comments on “Case discussion: How would you treat this patient? [9 August]

  1. Single dark globule in the centre of a banal naevus. Is it macular?
    I don’t know what it is. So I’d shave biopsy, maybe marking the hyperpigmented area to make the histopathologist aware of it. I’d be surprised if its a melanoma but, like I say, I don’t know what it is.

  2. Benign looking PSL on the back.The photo is out of focus? It looks like a bruise. If the area is flat and is not indurated with features of ?haematoma dermoscopically, I will probably review in 2-3 weeks if the patient is reliable. Otherwise , will shave Bx. with note to the pathologist about my concerns.

  3. I dont see any chaos seriously and that dark middle blotch could imply a trauma or irritation. So i would review in 3 months time.

  4. So, shave biopsy was done, and the result is “severe dysplastic nevus” (I am trying to get the actual report). How do you interpret this? What would you do next?

  5. I’ll ask for a second pathologist opinion to check that it is not melanoma in-situ.
    I will treat it, as if, it is melanoma in-situ and perform an excision with 5mm margin around the lesion.
    But I’m not sure what item number to charge in this case, melanoma Item number or scar excision item number ?

  6. Severe dysplastic naevus should be treated as Melanoma in situ, excision with 5mm clinical margin.
    Rather than have different pathologists argue over the degree of architectural and cytological atypia they can give an opinion on the total excisional specimen.
    My histopathologist now avoids the term dysplastic altogether and prefers atypical. I appreciate the clarity.

  7. Here is the actual report!! Thoughts??

    The sections show a highly atypical compound melanocytic lesion as well as there being a superficial lymphocytic inflammatory infiltrate, consistent with a component of regression. The overall findings in this biopsy favour those of a compound dysplastic naevus exhibiting severe atypia, together with some features suspicious for a component of early melanoma in-situ. Complete conservative excision of this lesion is advisable in order to more fully assess this lesion and to ensure its complete removal.

    Comment: Biopsies of melanocytic lesions may no be representative of the entire lesion.

    Summary:

    PUNCHBIOPSYUPPERLEFTBACK:
    – AT LEAST COMPOUND DYSPLASTIC NAEVUS WITH SEVERE ATYPIA, SUSPICION FOR EARLY MELANOMA IN-SITU (SEE TEXT).

  8. I agree with the conservative approach of David Smith – excised to achieved 5mm margins to treat such lesions especially for a back lesion.