Case discussion: How would you treat this patient? [8 January]

Starting the year with an interesting case discussion from Dr Slavko Doslo. A 67-year-old patient presented with cough. A chest examination revealed a suspicious lesion.

Please describe what you see from the clinical and dermoscopy images. How you would biopsy this lesion?

slavko_doslo_90117 slavko_doslo_90117_2

Case submitted by Dr Slavko Doslo

Update:

slavko_doslo_100117_1     slavko_doslo_100117_2

What would you do next, if anything?

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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? [8 January]

  1. Chaos with different shades and a red area, with white lines and brown clods, and grey area….all warrant for an excision to rule out malignancy…..

  2. Irreg pig macule: shades of brown with pink background
    Multi component: irreg areas of hypopig; irreg globules, blotch with overlying blue grey
    Asymmetry in Colour and structure
    Highly suspicious
    Warrants excision biopsy (2mm clinical clearance) and further investigation to the cough symptom

  3. Pigmented lesion showing chaos + clues to malignancy of blue/grey structures and white lines. Excise with 2mm margins.

  4. Thanks everyone – and happy new year. Elderly gentleman, ‘ugly ducking’ on clinical examination. Dermoscopy: using 3 point checklist, score is at least 2 (Asymmetrical, Blue). Definitely suspicious lesion, needs biopsy. Best approach would be biopsy excision with 2mm margins.

  5. Bit late with my reply,.
    Irregular pigmented lesion with chaos and blue grey colour / definitely malignant needing excision biopsy and yes would certainly do 2mm margin. What is the histopathology?

  6. looks like a melanoma. With three point checklist there are different pigment networks, irregularity and white areas – I wold score 3/3 and excise it with a 2mm margin as excision biopsy and refer on for consideration of further therapy if needed

  7. Looked suspicious. Chaotic lesion with clues go malignancy. Asymmetry, blue white areas and some structure less areas. Would completely excise and biopsy with 2mm margin.

  8. Happy new year everyone, the management plans for breslow 0.4 and Clark II would be good prognosis and no recurrence of 95 to 100 %… then 2 mm margin full excision is enough ..

  9. Breslow thickness :0.4 mm, ulceration 0. Mitotic<1. Regression present
    Proceed to 10mm clinical clearance excision. Risk of sentinel lymph node involvement <5%.
    Assumes no lymphadenopathy on clinical examination, and investigation of cough has been completed.
    Follow up would be regular skin (3 monthly)checks for first 2 years.
    Advice skin screening for 1st degree family members.

  10. Strange ……u mean this suspicious lesion came out in the report as clear of any malignancy. i would revise to ensure.

  11. folks, remember what the national guidelines recommend in cases like this. First, excision biopsy with 2mm margins. This means biopsy the lesion, to get a diagnosis, by removing all of it, with narrow margins. Second, with a diagnosis of melanoma confirmed (invasive 0.4mm Breslow) the next step is to do a 1cm margin excision – that is, excise the scar from the biopsy by excising 1cm all the way around it. That will give you the highest likelihood of cure

  12. Should we be worried that the width of the re excision is 9mm and there was a 2mm margin .
    Now I know there is a measurable shrinkage with specimens, but does that appear to 6.5mm ?
    And 4.5mm on the end . Thats allot of shrinkage?
    Is my thinking correct. ? should we consider different margins for each lesion?
    Its just I worry about how it may look down the track.
    I like to photograph my margins for documentation.
    I certainly sleep better if the melanoma has spread.

  13. Nameer: how deep do you go? national guidelines say you go as deep as you go wide, but only as deep as the deep fascia. And yes, a 1cm margin around the previous margins.
    Neil: in this case we don’t know what CLINICAL margins were used. This is not reported in the clinical notes. his makes it difficult to interpret the pathology results. This is why I recommend following the national guidelines.
    So, first remove the lesion that is suspicious of melanoma with 2mm margins to confirm diagnosis. Then (if melanoma is confirmed) re-excise with whatever the recommended margins are (1cm in this case). It is the clinical margin that counts, and not the pathology margins. If pathology results are clear, as in this case (final slide) then all is good.

    1. Thanks for that.
      It is my understanding the HIC are able to interpret size/ margins with a formulae to calculate shrinkage, My fear is that a lawyer will grab that formulae and retrospectively come for you, if the patient in unlucky enough to have spread, later on.
      Apologies if I sound a bit paranoid.

  14. Interesting Neil. I have never heard of, or come across that. Medico-legally, it is your clinical records that count. What you put in their counts. So, if you measure and make 1cm margins, and make a record of that, then that is what counts. This is how the margins were done in the clinical trials that led to the national guidelines. Of course you need to evaluate your pathology report carefully and if margins are involved, further excision is needed. You don’t need a pathology report to “confirm” 1cm margins. Hope that helps!

  15. Asymmetrical pigmented lesion
    Blue white areas
    possible melanoma exc biopsy with 2 mm margin and if proven to be melanoma for wider exc