Case discussion: How would you treat this patient? [24 October]

Another great case from Dr David Smith. An 80-year-old gentleman gave a history of a “mole” being present as long as he could remember but becoming more raised and irregular as an adolescent. The recent change was noticed by the patient’s wife and hairdresser.

What do you make of the history and the clinical image?


Case submitted by Dr David Smith


Now, what is your assessment?

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

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19 comments on “Case discussion: How would you treat this patient? [24 October]

  1. I agree that this lesion prompts me towards an excision biopsy with a 3mm border for which it’s comfortably positioned. Assess also clinically for regional nodes

  2. Any history of change is a red flag. A pink growing nodule another. Need dermoscopic image to make decision re: how to biopsy it.

  3. Would be nice to have a chance for dermoscopic image. However based vaailable info,

    I. What do you make of the history and the clinical image?- Hx- recently evolving, aged 80. Image: looking like raised/nodular erythema though saying “mole” . Irregular > Chaos +
    II. How would you treat? If inclined to NMSC> shaved biopsy first. However as saying mole, I would favoured excision with 2-3mm margin to appreciate Beslow thickness. Shaved biopsy may not answer thickness adequately.

  4. Agree: any change reported warrants further investigation. Would be good to have the dermoscopic pictures to this irreg shaped erythematous nodule/plaque. Would help in determining the type of biopsy. In addition any previous history of any skin cancers or other cancers. Any immunocomprimised status?

  5. Considering his elderly age and a lesion/mole with recent change and appearing as nodular and pinkish, I would do excision biopsy to rule out Melanoma.

  6. Need to know past personal or family history of melanoma, personal history of NMSC; sunexposure in the past (photo looks as if he has qite a bit of solar elastosis). Is it itchy, does it get bumped/irritated when combing hair; any bleeding?
    Would like to look with dermatoscope (however, might not be helpful if nodular melanoma)..
    Would offer excision biopsy

  7. Agreed. Good point from Sabine- Dermocsope might not be helpful in nodular lesion. Hx and Clinical exam (eye sight) will be more useful in evaluation.

  8. Linear; dot bv; irreg globules on a pink background raises concern
    In addition h/o recent change
    Would proceed to an excision biopsy for histological diagnosis: pdx: melnoma

  9. I suggest that in an 80 year old, with a history of recent change (of anything) biopsy is mandatory. This is (really) non pigmented, so I would do a nice big punch here, to know what I am dealing with, before moving to treatment (likely to be excision). Sound OK?

  10. I think dermoscopically the Ddx would be
    1. Pigmented BCC
    2. Malignant Melanoma ( possibly naevoid)
    I would like to do an excision biopsy taking 3mm margins

  11. Based on dermocsopic, 1/ Eccentric structureless pink (left upper), 2/ polymorph v/s (in central), 3/ one blue clod (R median), 4/ a few grey/brown dots but not strongly favouring for Dx.
    D/Dx would be in order 1/ Pigmented nodular BCC, 2/ Melanoma, or 3/ mixed BCC and Melanoma.
    Mx: already commented at the above.