Case discussion: How would you treat this patient? [26 February]

This week we have a new case discussion from Dr Tom Alwyn. A 67-year-old man with no prior skin cancer noted this lesion before 12 months and reports recent growth.

How would you evaluate this lesion?


Case submitted by Dr Tom Alwyn


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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16 comments on “Case discussion: How would you treat this patient? [26 February]

  1. This lesion shows chaos of structure: thickened trabecular network, central structureless area extending to periphery, black dots and grey structures – all pointing to malignancy. Suggest excision biopsy with 2mm margin expecting diagnosis of malignant melanoma

  2. OMG! very obvious features of Melanoma dermocsopically.
    Chaos + in term of structure and colors.
    Clues +++ 1/ darkgrey and bluish discolouration in central, top and left hand side; 2/ thick reticular lines with branching at number of places; 3/ a few black dots/clods peripherally.
    Plan: 2-3mm margin excisional biopsy and go from there.

  3. thick line reticular and grey area and slight chaos…If its a recent lesion, then excise for ruling out malignancy.

  4. On the limited field of skin shown this lesion clearly does not fit the pattern.
    Chaos evident in terms of irregular colour & border.
    Clues evident in thick lines reticular, eccentric structureless area, black dots and central grey discolouration.
    I would perform excisional biopsy with 2-3mm margins and await the histo report.

  5. I see top level of skin with mesh ( interrupted broken mesh) with missing parts, but on separate enlargement after downloading photo I can see gray bluish area in middle where is 6 mm ans 8 mm mark highly suspicious of melanoma,
    definitely excision and see

  6. This lesion is ugly duckling
    Asymmetry in colour and structure
    Multi component global pattern
    Atypical network
    Grey white structures
    Atypical pigments and globules peripheral
    Peripheral structureless area
    More than 5 colours
    Irregular blotches

    Excision with 2mm margin to exclude melanoma

  7. its a melanoma, size of upto 1cm, assymetric in geometry and structures present, thick reticular pattern in upper side of lesion with black dots at periphery and greyish blue regression in center

  8. Next?
    Very difficult to response if histology indicated “dysplastic junctional naevus with clear margin”. Who’s right? Dermoscopically was very strong for melanoma which is a bit subjective. Options are
    1/ to check with another dermatopathologist or
    2/ After discussion with patient, watchful follow-up 3-6/12ly or
    3/ re-excised with 5mm margin to ensure with peace of mind

    Can junctional naevus mimic like melanoma dermocsopically?

  9. I am a Primary Care Practitioner (GP) and is always learning. What would be best solution for this case from Professor David Wilkinson and Dr Tom Alwyn please! Or most of us are more or less right or wrong, thus not much to add! 🙂

  10. I have taken to asking the pathologist for a clearer diagnosis, please.
    I am getting a 2nd and much better report as a result.

    However my last one like this : “at least a DN” ??

    I err on the side of caution and after explaining it to the patient , excise as MM.
    Agree would value the experts opinion, here.

  11. Dermoscopically and macroscopically this looked pretty convincing for a melanoma. I would excise with 5mm margins, and phone up the pathologist and let him/her know I thought it would be a higher grade lesion. Could (s)he view another section and have a further opinion.? If they have a panel where they discuss cases could this be viewed by them.

  12. I agree with most responses that clinically and on dermoscopy this lesion was very suspicious. However the histology report came as moderately dysplastic Naevus. The diagnosis remained even after we asked for a second opinion. We still treated this as in situ melanoma which meant re-excision with 5mm margin.

  13. mild to moderately dysplastic naevi do not need 5mm margin re-excision
    if the lesion is reported severely dysplastic then re-excise with 5mm margins