Case discussion: How would you treat this patient? [8 May]

This week we have another engaging case discussion from Dr Slavko Doslo.  The patient presented for mole check as he had a melanoma removed from the left temple.

Please find the first images showing a lesion over an 18 month period. what is your assessment?

   

   

Update:

Here is the excision report, what would you do next, in light of this result?

    

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


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7 comments on “Case discussion: How would you treat this patient? [8 May]

  1. The lesion shows irregular shape and pigment and white clods though no radial lines seen . with past hx melanoma excision have to think of melanoma

  2. this is a slowly enlarging lesion over several months, solitary lesion on the face on fitzpatrick skin type 1 patient with prior melanoma in the area where it was removed could be another melanoma formed de novo not because of mets but of increased predisposition for genetic tendency to form another denovo lesion

    dermoscopy shows annular granular pattern with grey around hair follicles, it is not a seb k or a solar lentigo, not an actinic keratosis, this could well be facial lentigo maligna melanoma

    that having said, if it did show changes in 4 months this should not have been left as long as 18 months for an excision, it should have been excised with 3mm margins promptly at 4 months on the first follow up

  3. The lesion as it has evolved over time show assymetry in colour and it has broadened. There is no great increase in size. It shows milia cysts favouring a seborrheic keratosis. However the fact that there is now new pigmentation at the 10 o clock position and in view of the past history of melanoma it now merits an excision biopsy with 2mm margins.

  4. The main pattern is tructureless brown interrupted by white clods. To me there is four white dots in square( rosettes). I can not see anything which points to lentigo maligna. ?? pigmented actinic keratosis

  5. This is a tricky case, but if we fall back to our first principles, that will help. So, we have a middle aged man, who had a melanoma removed and now has a growing pigmented skin lesion. This cannot be assumed to be benign, and must be considered suspicious – middle age, prior melanoma. For me, I suggest, that means – excise. The dermoscopy shows irregularity of pigmentation. There are no lesion specific features. All that dermoscopy does is confirm that this is not clearly a benign lesion – it is not an obvious Seb k or solar lentigo; there are no features of these lesions. Indeed there are no white clods here – what you see as white is hard follicles. So, need for excision is confirmed. Hope this helps!

  6. However i dont see any specific features, and its a but chaotic and provided a previous history of MM before would make me think to consider it carefully. there is white dots which represent hair follicle opening and not a white milia and some subtle dark dots.