Case discussion: How would you treat this patient? [17 October]

A 70-year-old woman presents for a full skin check to Dr Deon Hoffman. She presents with multiple Seb Ks on her back and a 2.5×2.5cm macule situated mid-scapular. Also, history of previous NMSC’s and recently completed chemotherapy for breast cancer, seemingly in remission.

How would you approach this lesion?

What is your differential diagnosis?

deon-hoffman-case dermoscopic-image_171016

Case submitted by Dr Deon Hoffman


2 punch biopsies were taken and the report was in situ melanoma. What would you do next?

Histology report:

histology-report_1710_1     histology-report_1710_2     histology-report_1710_3

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

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12 comments on “Case discussion: How would you treat this patient? [17 October]

  1. Photographs are great, but lack the final dimension depth. Having said that this picture gives the impression of a rolled edge and a crater in the centre. I would remove it on the basis that it is an SCC (more prone to them follow chemotherapy and a reduce immune system) I presume the lines drawn were a planned biopsy and I think would look neat.

  2. To me the appearance is rather consistent with a BCC on the basis that there is some pigment about the periphery and on the lower half, what appears to be dilated vessels. Different components of this lesion are difficult to see clearly in the presented picture. The lesion is clearly different from the surrounding SKs. The excision just about to go ahead is a good idea. I would perhaps make the clear margins a bit wider.

  3. Surface scales would made me think of SCC well differentiated. and those pigmentation around, would fit the sun damage skin i would presume.

  4. How would you approach this lesion? and What is your differential diagnosis?

    It is a erythema with some scaly suggesting Sol K, SCC or least BCC. It looked Dr Hoffman is going to excise after obtaining punch biopsy report (noticed 2 stitches). Would be nice if available for Dermocsopic pic incl pigmentation (Left top 11 o’ clock and inferior 6 o’ clock). If chaos and clues Dermoscopically, shaved or wide bore punched incl pigmentation part. Would be extremely challenging If amelanotic melanoma/merely melanoma. I love the line of excision.
    Sorry for Post-mortem comment.

  5. If the Blog has the copy of Dermoscopy image it may be worth posting. To be honest it did not help me much to come to come to a diagnosis hence the punch biopsies noted by Tim. Macroscopically this lesion was a flat macule without any palpable [rolled] edges. My first thoughts were towards a superficial BCC.

  6. Looking at the macroscopic picture only my Ddx would be
    1. Bowen disease
    2. SCC
    3. BCC superficial spreading
    The fact that Deon has decided to excise the lesion after the punch biopsy Bowen or SCC looks more likely

  7. Dermoscopic view shows polymorhic pink dot & a few coiled vessels with white lines
    Dermoscopically the two Ddx would be melanoma in-situ or bowen’s

  8. I appreciate everyone comments, thanking all participants.

    This is how this case further unfolded.

    The punch biopsies diagnosed the lesion as being a Melanoma-in-Situ. I proceeded in excising the lesion with a 5mm border to the level of muscle. I soon received a call from the Pathologist enquiring if the patient has a history of Breast Ca as the preliminary stains indicate towards metastatic breast cancer in the deep section of the specimen. This I confirmed as she just recently completed her Chemotherapy and being in remission. The Pathologist’s final report however soon followed confirming that the presumed Breast Ca metastasis proved actually to be Melanoma.

    The status of the lesion was therefore adjusted to that of Clark V Malignant Melanoma with infiltration to a Breslow depth of 8.0mm.

    Further scrutiny of the Dermoscopy of this lesion brought the ‘reticular white lines’ and ‘pin point polymorphic vessels’ into better ‘focus’. The lesion was nestled amongst several Seb K’s and in collision with one or two of them as can clearly be seen on the Dermoscopic image. The final diagnoses brought the question to mind of the best method in obtaining a diagnosis of such a lesion.

    Had I originally picked it as a possible Melanoma-in-situ and opted for the more appropriate shave biopsy, how would it have effected further histology, having shaved through a Clark V Melanoma?

    The patient was promptly referred on the Newcastle Melanoma Clinic who has gladly taken over further management.

    [thanks to the Blog for the opportunity of sharing this case with Colleagues]

  9. if you were thinking melanoma you would probably be thinking invasive not insitu and done an excisional biopsy

  10. Hi Deon

    “the presumed Breast Ca metastasis proved actually to be Melanoma.—- Clark V Malignant Melanoma—”

    Let me say- OMG! Well done and great job. I can’t imagine. 🙂 🙂 🙂