Case discussion: How would you treat this patient? [17 April]

This week’s case discussion is another learning opportunity with a simple, real life and everyday scenario from Dr Slavko Doslo. An 81-year-old patient presented with concerns for a spot on the forearm.

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

Update 1:

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

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

  1. This is a lesion ? newly appeared on a 81 y/o male, solitary, more than 5mm size maybe upto 1cm, no no features of a nevus or seb K, blotches of pigmentation with multiple colors, chaotic lesion with white lines on polarisation, looks like an Invasive melanoma given the white lines with dermoscopic grey in the center of lesion and pink on upper region. Needs wide excision for histopath and proceed.Clinically it isnt a worrisome lesion, only dermoscopy proves it isnt

  2. Clinically: a Solitary brownish pigmented lesion 6-8mm in mid R forearm dorsally.
    Dermoscopically: Chaos in Colour (3 or 4 ) and Structure. Clues: 1/Eccentric structure-less area with white lines centrally, 2/ slightly grey area ( R hand side 3′ o clock), 3/ tiny grey dots (bottom 6′ o clock), 4/ polymorph vessels throughout, 5/ polygonal (top 12′ o clock and also indistinctly L hand side near central. This polygonal clue seems to be not widely consenus as not mentioned in other dermoscopy except Australia as clue number 9. In Dermnetnz, clues are only number 1 to 8, w/out polygonal.

    Next step: excisional biopsy with 2-3mm margin given the above chaos and clues, and then go from there.

  3. grey area, subtle white lines, faint vessels, and a square like PSL that is new mandate a cut to exclude MM.

  4. Tricky case isn’t it! For me, the clinical view is the most compelling. It is a stand out / lonely / ugly duckling. So, what it is? I can’t tell clinically or dermoscopically. That is, I can’t name it. So, that means I need to biopsy it. For me it is flat and relatively small, so is perfect for a “shave excision biopsy”. Thoughts?

  5. re. “shave excision biopsy”.
    Not a big deal 2mm excisional biopsy vs shaved biopsy in this particular case. If over sensitive area s/a face, definitely I would go with shaved biopsy.

  6. Bit late to reply . Yes does appear like a solitary ugly duckling . New appearance. Has choatic colour of pigment. Also blue grey spots and lines, blood vessels at rt side .Asymmetry of pigment and structure .Looks suspicious so best to excise with 2mm margin.

  7. According to Joyce et al Plast Reconstr Surg Glob Open. 2015 Feb; 3(2): e301, we should be looking to achieve histological margins of at least 3mm for MIS – so re-excision seems to be warranted.

  8. If not 5 mm clinical margin originally, it should be re-excised with 5mm margin as per guideline for level I. Pathological reported margin was 28x9x4mm. Dermoscopically lesion size looked 8x9mm. We do know excised skin can shrinkage however in this particular case, re-excision is warranted in view of transverse margin .

  9. Folks – remember that the margins that matter are the CLINICAL margins (what you measure on the skin), NOT the histological margins. So, for in situ melanoma you draw a 5mm margin and cut there.

  10. I agree with most of the folks but not convinced on seeing white lines. The grey area and peripheral grey dots are the clues which would convince me to biopsy.
    With respect to in situ lesions do the pathologist not mention the actual breslow depth – is it not measurable?
    Could anyone comment.
    Thank you