Case discussion: How would you treat this patient? [3 October]

This week we are looking at an elderly man who returned for removal of dressings. Dr Slavko Doslo noted a lesion on his back as shown in the photo below.

What is your thought based on the photo? (Please disregard redness, as this was caused by the dressing removed)

Lesion_Back_160926     Dermoscopy image_160926

Case submitted by Dr Slavko Doslo

UPDATE:

Here is the pathology result. Comments?

03102016-blog-post

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


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11 comments on “Case discussion: How would you treat this patient? [3 October]

  1. Sorry but we can’t see enlarged photo through dermoscope, photo do not get enlarged like macro shot
    thanks
    Dr Slavko Doslo

  2. The dermatoscope image is out of focus and not clear..I do see chaos and surface scales on a sun damaged skin…not sure if i am seeing rightly some blue clods as well… Anyway its suspicious and mandate excision as well as other skin lesions on his back on the right side and some other two to the left…..my PD is SCC well differentiated.

  3. It would be good to have some history here whether this lesion has been bleeding intermittently , or what were the dressings for?
    It is a pity dermatoscopic view cannot be enlarged
    My best guess on macroscopic view & limited dermatoscopic view is Pigmented BCC. I will take a punch biopsy to confirm the diagnosis & then plan further management

  4. nice pick Slavko
    If this melanoma has naevoid features I will be considering taking 10mm margin rather then 5 mm
    Naevoid malignant melanomas are rare variants of nodular melanoma with significant local recurrence & high mortality rate

  5. These cases scare me! How did you pick up that one tiny area of pigmentation on a large area of sun-damaged skin?!

    1. most likely because I like photography and I have good eye, I have more scary cases they will come soon,
      thanks

  6. Sorry for late participation.
    Another challenging with complexed case. Even in zooming of dermoscopic pic, not much pigmentation and not strongly suggestive of melanoma except eccentric structureless pale/pink. W/out histopathology report, easy to jump into conclusion of BCC (in view of vessels).

    Anyone (Dr Doslo, Prof Wilkinson, Dr D Smith, …) know?
    1/ which area of dermoscopic photo is Seb K?
    2/ white lines/stuff (R hand side, 2’o – 5’o clock), are they from plaster or pathologic feature (clue) of melanoma?
    3/ what is Naevoid? (please enlighten me).

    Thanks and Regards 🙂

    1. Hi Tim
      1. not sure if Seb K is in dermoscopic view, but there is a Seb K like lesion at 9o’clock in macro picture
      2. White areas are dermal fibrosis & areas of regression
      3. Naevoid MM represent 1% of MM. It is a histological diagnosis as histologically they mimmick ordinary compound or intradermal naevus
      Staining pattern with HMB-45 & MIB-1(for proliferation marker ki-67) distinguishes them from common benign melanocytic naevi
      In this patholgy report I think dermal pigment incontinence & lack of pagetoid spread are naevoid features

    2. Hi
      1. it is hard to see Seb ker on magnification but there is seb ker on other macroscopic picture as was partially gone and obscured from previous dressing in area ( which caused redness on skin) as he has one more seb ker further up protected before surgery due to catching on clothing and causing bleed
      2. what prompted me to remove this lesion as suspicious of melanoma lies in middle of photo in elongated direction 12 to 6 o’clock 10 x 5 mm , with features of like horse shoe lesion darker lines on 12 few clusters of dots in middle where hair is growing out , small cluster of darker spots further down to right, further down on left another cluster cloud melanocytes, and one more lesion right lower another cluster, so lesion is going zig zag,
      I am using program Picasa for view of my photos, fantastic program free of viruses and free of charge from internet and you can make collage photos , easy to operate and fiddle with photos
      with Picasa you will be able to see all those changes on 220% magnification

  7. Commenting on the pathology report: This sounds like what would once have been called a Kossard naevus, but I am pleased to see now recognised as melanoma in situ. Generally found on the backs of elderly men with chronic sun damage and difficult to distinguish in amongst a range of other lentigines.
    Typically, there is a lentiginous proliferation of mildly atypical melanocytes with some small nests and patches of confluence ( this is one reason why it is necessary to get the whole lesion in a biopsy). What Steve Kossard would have called nevoid lentigo maligna, perhaps.
    Pagetoid spread is not a feature of these lentiginous proliferations. A different pattern of genetic mutations, possibly involving c-KIT instead of BRAF, encourages melanocyte migration over proliferation. The melanocytes becoming spread across the DEJ and often with atypical melanocytes extending out beyond the shoulders of the lesion, producing poor circumscription and problems defining the edges of the lesion as in lentigo maligna, which it is closely related to. Regression is also often a feature. Growth of these lesions is very slow but they do have the potential to extend to vertical growth phase and become more invasive.