Case discussion: How would you treat this patient? [19 September]

This week we have another case by Dr David Smith. While performing a skin check on an elderly person, David noticed a pigmented skin lesion on the ankle.

How would you biopsy?

Pigmented lesion on ankle_160919

Case submitted by Dr David Smith

UPDATE:

Here is the pathology report – “Nested and focally lentiginous proliferation of cytologically atypical melanocytes in the epidermis.”

What is your interpretation and what would you do next (if anything)?

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? [19 September]

  1. How biopsy suspicious pigmented lesion on the ankle?
    May I know size and exact location of ankle (eg. over malleolus or anterior ankle, …).

    1. No doubt, I. Chaos in terms of size/symmetry, and colour;
      II. Clues (dots in different colour + dot/thick line; thick reticular and polygons are not apparent; scaly across central ?pointing to Seb K or Sol K or mixed melanoma & one of non melanoma).

      Anyway it warrants biopsy over all. But the question was how to biopsy?
      My response would be depending upon size and location over ankle in view of elderly with think skin area! >
      Excisional with 2-3mm margin or shaved ( if over malleolus/think skin), or wide bore punched (if thick skin area).
      Then go from report.

  2. Very weird lesion.
    It is definitely chaotic.
    I could see pink 5 O’clock (If you see pink, stop and think).
    I could see negative network 11 O’clock.
    I would shave the lesion (deep saucerization)

  3. brown clods , grey areas , not very asymmetrical though
    some suspicious features
    will do excision biopsy with 2 mm margin

  4. Sorry my comment for appearing as a reply to someone’s comment (Daniel). The intention was a separate comment. We would deeply appreciate if Admin of this blog kindly allow us to be able to edit or delete at times in the future. So far no such option exist.
    Kindest Regards
    Tim

  5. I agree narrow margin excision, report than most likely more as looks like melanoma, or badly displastic nevus, 5 o’clock no structure, 4 colors, 7 o’clock grey area, 11 o’clock plenty of dotted concentrated melanin , no real structural mesh, uneven boarders , few pseudo-pods 2 o’clock
    === melanoma until proved otherwise

  6. thanks for all the comments – a split view on biopsy technique here, between shave and excision biopsy; this is a relatively small lesion (no ruler, sorry but clearly small) and is a great site for a simple shave with dressing

  7. Dermpath report says that there are nests & lentiginous spread of atypical melanocytes in the epidermis.
    This is Melanoma in situ & requires 5mm margin.
    I will take another 3mm margin of the scar as I took 2mm margins with the excision biopsy initially.