Case discussion: How would you treat this patient? [22 August]

This week we have a case from Dr Sue Guirguis. A 45-year-old female presented to check a “mole” on her lower 1/3 of anterior R thigh. She was worried as over the last 6/12 the mole has become palpable and has increased in size. The lesion has been there for few years.

There is a dermoscopy picture only. What is your evaluation and how would you biopsy (if you decide biopsy is needed)?

Skin-lesion-lower-third-of-extensor-R-thigh-

 

 

 

 

 

 

 

Case submitted by Dr Sue Guirguis

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


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8 comments on “Case discussion: How would you treat this patient? [22 August]

  1. History: change over the last 6 moths-palpable and increase in size, in an area that may have high level of sun exposure
    Clinically: irreg shaved pig patch with a very marked pink background
    Dermoscopic ally: irreg dots and blotches; irreg area of ? Regression ? Hypo pigmentation; polymorphic blood vessels. Asymmetry of colour and structure.
    Management : warrants histological confirmation: melanoma 2 mm clinical clearance excision biopsy, but if not then incisional biopsy over the area of maximum clinical change

  2. Asymmetric, regression areas, different colours, atypical pattern at one pole suggestive of melanoma.
    I will do excision biopsy with about 2mm margin for histology

  3. This lesion looks suspicious- chaotic with multiple colours ? polygons at left edge.
    If its palpable I would be doing an excisional biopsy with 2 mm margin.

  4. suspicious pigmented skin lesion as it has chaos structure, polymorphic vessels and a pink structureless area, and unspecific brown net work, and central scar like area…..excise with 5 mm.

  5. Agree ; pigmented lesion, asymmetrical, chaotic and regression.
    There is a very red area underneath.
    Little choice but to excisional biopsy , 2 mm.
    Only because I might be able to say I told you : It does look like the base of a Seb Keratosis where the the epidermal layers have been rubbed off, though

  6. Evaluation:
    1/ Chaos + = in view of asymmetrical in shape and colour.
    2/ Clues +, pattern breaker with mixed erythema/pink and brown pigmented colour peripherally (Clues= 1/ a few brown dots at 10′ o clock; 2/ eccentric structure-less pale pink area in the center; 3/ polymorph v/s pointing to BCC).

    How to Manage:
    In view of Dermoscopic features as above + Hx of recent evolving + size 6-8mm
    1/ Excisional biopsy with 2-3mm margin or
    2/ Shaved biopsy given palpable (elevated)

    Then go from histopathology report.

  7. Thanks for all the comments so far. This is a small (<1cm) pigmented lesion. To my eye it has no diagnostic features on dermoscopy. I would either do a large shave biopsy here (assuming it is flat) or a 2mm excision biopsy).

    Diagnosis was – pigmented superficial BCC. Unusual!

  8. Hi all; sorry to join late. It is always easy to be smart with the retrospectoscope. However to be honest I would relay on a thorough history of this (and any previous lesion/s) in this person. Any solid nodular skin lesion exhibiting change in an adult I would excise entirely as a primary procedure. A thorough physical examination is essential; checking for also inguinal adenopathies and any lesions in the surrounding skin especially signs (and history) of sunburns. Some dermoscopy features are concerning: like the erythematous background, some serpentine and dot vessels, and peripheral pigmented clods. IN SUMMARY MY APPROACH: excise with a 3mm margin from the visible lesion borders with depth to sub cutaneous fat & advise the patient that may require wider excision if histology proves that the lesion extends to any of the excision border/s.