Case discussion: How would you treat this patient? [22 May]
This week our case discussion is another great learning opportunity with a real-life scenario from Dr Colin Armstrong. This elderly lady had recently had a melanoma excised (you can see the scar). At a routine skin check, the below pigmented lesion was observed.
What is your evaluation and next steps?
What is your interpretation and what would you do next, in light of this result?
Clinical Notes: Left mid scapula spine – ? atypical naevus (recent level 1 melanoma).
The specimen container is labelled ‘L mid scapula spine‘. The specimen consists of an irregularly shaped portion of an orientated shave of skin and subjacent tissues measuring 25x8x1 mm. Examination of the skin surface reveals a focally pigmented, tan/brown macular lesion measuring 23 x 8 mm. There is a suture present on one tip, indicating 12 o’clock. The 3 o’clock margin is inked green and the 9 o’clock margin is inked black.
Blocking Details: 1A 4TS 2LS 12 o’clock; 1B 4TS; 1C 2TS 2LS 6 o’clock.
Sections are of skin to mid dermis. There is an irregular increase in melanocytes along the junction, largely single cells with very focal small nest formation. Cytological atypia is moderate, including a mild-moderate increase in pale eosinophillic cytoplasm. No dermal involvement is identified.
The features are in keeping with lentigo maligna (subtype of melanoma in-situ). In the planes of section, margins are narrow: 0.1mm from 9 o’clock transverse margin, 1mm from 3 o’clock transverse margin, 1.5mm from 12 o’clock longitudinal end marked with suture, apparent 4mm clearance from 6 o’clock. Wide excision recommended.
SKIN SHAVE, L MID SCAPULA SPINE:
– LENTIGO MALIGNA (SUBTYPE MELANOMA IN SITU) – 0.1MM MARGIN CLEARANCE
– WIDE EXCISION RECOMMENDED.
Please share your thoughts in the comment section below. Professor David Wilkinson will provide his opinion and advice.