Case discussion: How would you treat this patient? [27 March]

This week we have another case discussion from Dr Slavko Doslo. An 86-year-old patient presented with a chest infection. When examined, noticed a large mole on his back.

Please describe what you see from the clinical and dermoscopy images. Is it Seb K or melanoma? Why?

Case submitted by Dr Slavko Doslo

Update:

What is your interpretation and what would you do next, in light of this result?

  

Here is the final report. Any comments?

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


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17 comments on “Case discussion: How would you treat this patient? [27 March]

  1. A completely chaotic lesion which is more than 1 cm diameter,white lines on polarisation, Blue white veil occupying more than 50 percent of the lesion, regression, polygons, multiple colours, radial streaming. This is an Invasive melanoma of thickness more 5mm which would need wide local excision for histo and proceed

  2. Chaos in the lesion, with blue white and grey clods and radial pigmented lines at the periphery more than 6mm /Melanoma in situ which may be invasive probably level 2 or 3 melanoma . Needs excision of 5mm all around and deep /.may need follow up with ct scan depending on histopath and referrel .

  3. Dermocsopically: Absolute Chaos especially in colour . Scattered Whitish, greyish, blusih, and darkish with some pseudopods, and black dots/clods especially (1′ o clock position) + polygons >suggestive of Melanoma.
    If Seb K: not that extensive chaos in colour, and usually lack network. They are usually elevated and rough texture. This could be a sinister melanoma developed from Seb K.
    Thus excision 3mm margin and go from there.

  4. Definity a chaotic PSL that shows blue veil, white lines, upper pole thick line reticular, ? polygons, dark clods/ dots? MM…Excise.

  5. Macroscopic: irreg shaped shades of brown pig patch
    Dermoscopic: asymmetry of colour and structure. Multi component : multi focal areas of regression, brown irrigation blotches with overlying blue grey, atypical network

    Manage to: 2 mm clinical clearance excision biopsy to confirm a Melanoma with view to setineal node biopsy depending on the grade and further wider excision.
    May need referral depending on the grade of melanoma

  6. Clinically a pigmented lesion at least 20×15 mm on the back. It shows asymmetry in shape and colour. There are multi colours and a striking blue white veil. There is also irregular depigmentation suggestive of regression. Only a few milia spots. There is some radial streaming. Suspect an invasive malignant melanoma. Advise an excision biopsy with 5mm margins.

  7. Chaos in shape, colour and network.
    Clues in grey / white lines, grey / blue structures, black dots / clods, eccentric structureless area.
    Likely a melanoma.
    Lacks the usual milia like cysts and crypts of a simple seb K.

    Proceed with a standard excisional biopsy with 2mm margins to confirm diagnosis and thickness, then plan from there.

  8. I agree with the above however use the 1 point elephant approach. The lesion is chaotic, asymmetrical, multiple colours. Melanoma. Need excisional biopsy. Don’t forget good photographs.

  9. Agree with the abode comments however will use the elephant 1 Point approach. The lesion is chaotic, asymmetrical, multiple colours.
    Melanoma.
    Needs excisional biopsies.
    Take good photographs.

  10. what would you do next, in light of this result? >

    1/ Given invasive and clark level IV with mitoses present although completely excised, referral to next level for sentinel node, and to look for +/- metastases.

    2/ However given age, plus the lesions has been completely excised (with ellipse 60x30x 6mm, ie. clinically excised margin larger than this) with superficial spreading type, absence of lymphocyte infiltration and perineural invasion, I wonder just f/u with primary care practitioner (GP).

    Dr Soslo, Could you kindly tell us with pictures excision drawing lines and post-healed status (just for my learning). No doubt a huge excision and great congratulation.

  11. what would you do next, in light of this result? >

    1/ Given invasive and clark level IV with mitoses present although completely excised, referral to next level for sentinel node, and to look for +/- metastases.

    2/ However given age, plus the lesions has been completely excised (with ellipse 60x30x 6mm, ie. clinically excised margin larger than this) with superficial spreading type, absence of lymphocyte infiltration and perineural invasion, I wonder just f/u with primary care practitioner (GP).

    Dr Doslo, Could you kindly tell us with pictures excision drawing lines and post-healed status (just for my learning). No doubt a huge excision and great congratulation.

    1. If you mean excision orientation, that was horizontal with deep Maxon stitches as well, healed perfectly , but I had to to wider excision to be 1 cm , that excision healed well ,( patient had to stop warfarinfor surgery) , I did not send for sentinel node biopsy, patient still well and alive,
      Thanks

  12. Lesion is “ugly duckling”
    Asymmetry in structure and colour
    Multi-component global pattern
    White, grey and blue structures
    More than 5 colours
    Atypical network
    Diagnosis is melanoma
    Treatment, excision biopsy with 2mm safety margin
    After confirming the diagnosis with histopathology — definitive excision with 10mm safety margin
    To bring the patient back for full skin and general check including his glands
    To inform the patient to tell his siblings and children to get full skin check