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1800 867 1390Case discussion: How would you treat this patient? [24 April]
This week we have another engaging case discussion from Dr Slavko Doslo. A 69-year-old patient presented with a cough. During chest examination, Dr Doslo noticed a mole on his back and excised the next day.
What do you think of this clinical image? What is your impression?
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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1300 856 695
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1800 867 1390
clinical image looks more of a Seb K pattern
Dermoscopic view are more in line with regression occupying less than 50% of lesion, reticular network overral, some black dots. looks more like a regressed compound melanocytic nevus or a Sclerosing Nevus
Chaotic lesion on undamaged skin.
Irregular pigmented network, structureless area.
Excised 2mm margin
Clinical Image: 6mmx8mm slightly raised pigmented lesion with ?a few scaly on top which grossly lead to Seb K.
However Dermoscopically was concerning with Chaos in colour and structure. Clues: 1/ pale-pinkish prominently in lower central (eccentric structureless) with tiny pinkish dots, 2/ large Black clods/globules (large clod) in both Left and Right hand side with pigmented network peripherally, which make me to suspect a sinister MM, thus with 2-3mm margin excisional biopsy.
Recent article of dermatology of JAMA 2017 (C Carrera, et al) indicated that if presence of 4 clue signs (Blueblack, Bluewhite veil, Pseudopods or streaks, Pigment networks), then MM can be differentiated from Seb K. This lesion fit into 3 out of 4 (except pseudopods). If Seb K- Fingerprintlike, Fissures and ridges, Multiple orange and white clods, thick curved lines, sharply demarcated border.
Overall my impression are:
1/ MM
2/ pigmented Seb K
3/ pigmented Bowen disease.
Irreg shaped, shades of brown pig macule
Mulicomponent pattern: atypical reticular network- thickened in areas, central irreg shaped area of hypopigmentation with blue grey and dot bv, mulifocal blotches
Asymmetry of colour and structure
Suspicious of melanoma
As per guidelines: 2mm clinical clearance excision biopsy
Relevance of a cough in the history???
Chaos of colour and structure
eccentric structureless
black clods in periphery
excisional biopsy w 2 mm border
Chaotic pigmented lesion.
Dermoscopically 3/3 on three point system.
Suspicious of Melanoma for excision with 2 mm margin.
Chaos with segmental thick line reticular and white area of regression and area of red dots all of which mandate excision to rule out MM.
it is great to see that we all agree that this is a suspicious lesion, clinically and dermoscopically. I think it mandates biopsy simply on clinical appearance – lonely lesion. Dermoscopy certainly does not give a benign diagnosis, and I score it 3/3 on 3 point check list. So, yes, time for a 2mm margin excision biopsy
I agree it is a suspicious lesion.
A biopsy is the right way to proceed.
Again the most matter is clinical margin. If has already excised 5mm clinical margin originally for level 1 , no need to re-excise. Just f/u periodically and regular skin check.
I agree. The excision biopsy margins for excisional biopsy are 2mm as per guidelines, but in this case an excisional clinical margins of 5 mm is warranted – as per guidelines.
My advice is to “ignore” the pathology reported margins. If the pathologist only checks <1% of the margins, how does any number help you? What matters is 1) did you measure and make note of the 5mm margins clinically, from the real edge of the lesion (as you see it) and 2) there is no involved margin reported by the pathologist
Thanks for that clarification, and as pointed out clinical margins of excision are the important parameter rather than the margins reported by the pathologist.
Thanks for the information
I feel that the lesion has been dealt with adequately but the presenting complaint of the cough should be investigated to make sure that there at e no connections