Case discussion: How would you treat this patient? [15 May]

This week we have an interesting case discussion from Dr Tim Aung. A mid-60s male had a suspicious pigmented lesion over his left mid-back during a consultation for other health problems.

Have a look at the images here and provide your evaluation and next steps.



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

Case discussion

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

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14 comments on “Case discussion: How would you treat this patient? [15 May]

  1. ugly duckling. Irreg shaped pig patch. Shades of brown
    Asymmetry colour and structure: multi component: areas of hypopig; irreg blotches and irreg pig network

    Suspicious of melanoma
    Excision biopsy with a 2 mm clinical clearance

  2. Chaos: assymetry of colour and structure, thickened pigmented network habhazzardly scattered through the lesion. Scattered Brown/black globules at periphery, grey hue at 6 O’clock.

    Melanoma till otherwise proven.

    Exision biopsy with 2mm border.

  3. this is a sole lesion on midback, ugly duckling rule applies. Chaotic lesion with broken network and some minor regression, could be a superficial spreading melanoma versus a highly regressed solar lentigo

  4. solo lesion “ugly duckling”
    clinically – asymmetric pattern, indistinct ragged border
    dermoscopically: thick reticulated lines ; grey veil 3-6 o’clock; eccentric structureless areas;

    suspicious of melanoma ? superficial spreading ?

  5. ügly duckling”, asymmetrical, irregular borders, thick broken retic lines, different shades of brown ; excise with 2-3 mm margins to rule out MM.

  6. I agree with the general sentiment expressed here – stand out, ugly lesion, cannot name it and so it needs excision biopsy

  7. Agree clinically stand out different appearance from other lesions in adult disputably asymmetric and not exactly definable so needs excision biopsy. But I wonder if the histological cutting has gone through the 7 o’clock area where the darker network reaches the margin with ?grey area and clod or at other end where network shows some thickening. Should this be reviewed by pathologist as margin here is not adequate if suspect any melanomanous features. Did the pathologist get the dermoscopic picture?
    These are the tricky ones and if in doubt cut it out rule applies.

    1. Thanks. Indeed, sent the pics incl dermoscopic as well as spoken to Pathologist to ensure, which you might have noticed in the clinical notes of patho report, “?melanoma with thick reticular lines (see photo email to you)”.

      My Impression was also MM (SSM) (in view of asymmetric shape and irregular border with impressive thick reticular lines (in zooming) + a few dense pigmented area (clods/globules) in network. My next D/Dx, if not MM, was “Ink spot Lentigo” (as it exactly look like a pic from Dermnetnz. Th lesion was adequately excised with 3mm margin clinically.

  8. Thick line reticular with some black blotch and gray area….and an emerging hair…..would excise anyway to rule out MM.

  9. Yes i suspected it might come merely nevus, however that subtle gray was suspicious.

    1. Can you enlighten me how choose lentigo? My next D/Dx, if not MM, was “Ink spot Lentigo” (as it exactly look like a pic from Dermnetnz. 🙂