Case discussion: How would you treat this patient? [10 April]

This week we have another interesting case discussion from Dr Slavko Doslo. A 69-year-old female presented with a chest infection. During the examination, the doctor noted a lesion on her back.

What is your evaluation, clinically and dermoscopically? What are your next steps?


Case submitted by Dr Slavko Doslo

Update 1:

Here is the pathology result. What would you do next?

Update 2:

Here is the final result. Any comments?

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? [10 April]

  1. Solitary pigmented lesion with eccentric black dots and clods.
    Excision also biopsy with 2mm margins to rule out MIS.

    Clinically: looking slightly raised reddish-brown papular.
    Dermoscopically: not much impressive clues except a few peripheral dots/clods which is one of clues in algorithm of Australasia. Latest article of JAMA, March 29, 2017 indicated that the presence of the blue-black sign, pigment network, pseudopods or streaks, and/or blue-white veil, despite the presence of other SebK features, allows the correct diagnosis of most of the difficult melanoma cases. Those 4 are not here to my eye.
    Skin cancer council guideline indicated “biopsy if suspicious, not to use word of follow up”. Thus I will go with 2mm margin excisional biopsy and go from there.
    Cheers 🙂

  3. Irregular pigmented lesion with black dots at the top rt hand and ?? radial lines at the left hand corner . Not typical features of mealnoma nor seb k . Would excise it with a 2mm margin

  4. square like PSL showing at the top part pseudopods and irregular clods, and some vessels. Excise to rule out MM.

  5. Square type lesion with no features of a benign mole, solitary lesion on the back on an elderly raising suspicion, black dots in periphery with regression in the center and some black dots in center, hypopigmented macule with leaf like areas on the left upper periphery which could be in line with a superfical BCC, needs excision with narrow margins for histopath confirmation and proceed. Most likely a BCC- Superficial

  6. Great comments so far – thanks! We all agree that this is suspicious clinically – it is a real stand out lesion. So, we should be thinking that it is suspicious and look with our dermoscope. On dermoscopy it is NOT obviously benign, therefore it needs biopsy.

    Now, if we look more closely: 1) there are no pseudopods here, 2) there are no “leaf-like areas”. There are dots and clods at 1 o’clock and along the right hand border. What do they imply?

  7. Pigmented lesion that draws the attention due to its size

    Dermascopically shows chaos of colour. Clues are peripheral dots, radial lines segmental on [L]. White lines reticular at 12 0’Clock. I favour a diagnosis of MM and suggest an excision biopsy of 2-3mm to confirm.

  8. when I first saw this I was thinking it was a lesion which certainly stood out on the back as an ugly duckling lesion, and there are peripheral dots and some colour irregularity – so I was leaning toward a possible pigmented BCC with the need to exclude MM – so excision / biopsy 3mm margins. The peripheral dots would usually indicate an actively growing lesion.

  9. dots and clods, … What do they imply?
    They are generally localised pigmentation and can be benign if central. However likely malignant (melanoma) if peripherally, which is one of clues for suspiciousness for MM in algorithm (peripheral dot, clods, globules with network).

    1. To elaborate more, dots and clods can also been seen in Seb K but usually orange or white with sharp demarcated border. To confirm, check other Seb K features- Milia-like cysts, crypts, Fissures/ridges, Cerebriform, waxy ……

  10. peripheral clods or globules are a sign of growth- and you will often see them in nevi in young people arranged around the full periphery of a nevus. That pattern is normal. Here, they are asymmetrically distributed, and are in a pigmented lesion of an elderly person. That implies melanoma.

    So, biopsy removing the whole lesion (2mm margins) is needed

  11. Asymmetrical skin lesion, @ 2 o’clock abnormal network , grey structures noted

    Excision biopsy with 2 mm margins

  12. MIS with histological margins of 2mm – my understanding is that in MIS histogical margins 3mm …….. so re-excision seems required.

  13. MIS with histological margins of 2mm – my understanding is that in MIS histological margins 3mm …….. so re-excision seems required.

  14. MIS with histological margins of 2mm – my understanding is that in MIS histological margins 3mm carries a risk recurrence of 0.5% …….. so re-excision seems required.

  15. MIS with histological margins of 2mm – my understanding is that in MIS histological margins of 3mm carries a risk recurrence of 0.5% …….. so re-excision seems required.

  16. So, we have an in situ melanoma diagnosed. Next step is excision with 5mm margins – clinical margins, measured on the skin. This is irrespective of the clinical or pathology margins from the excision biopsy. Remember that the pathologist only looks at a tiny fraction of the circumference of the excised lesion. So, the reported margin (reported as 2mm here) is irrelevant