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?

      

Update:

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).

Macroscopic:

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.

Microscopic:

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.

Summary:

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.


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8 comments on “Case discussion: How would you treat this patient? [22 May]

  1. Single outstanding pigmented spot with several polygons throughout the lesion and central gray lines.
    Lentigenous Melanoma to me.
    2mm excisional Bx.

    Thanks for sharing.

  2. very regressed lesion with greyish annular granularity, close proximity to a melanoma excision , chaotic and more than a cm in size, needs to have shave biopsy done for excluding Superficial spreading melanoma level 1

  3. Asymmetric pigmented lesion, size >10mm, medial to previous scar of L upper back. Unfortunately majority part of dermoscopy is light grey colour, Lentiginous with not much clues. However lower part of Dermoscopic pic 1 and upper part of dermocsopic pic 2 ( the latter looks upside-down of previous pic) revealed reddish brown and grey/bluish pigmentation that might be a concerning part for sinister. Or that part could be artificial effect from light?

    In view of size and flat, Shaved biopsy with little deep dermal (ensuring those concerned part included) or whole 2-3mm margin excisional biopsy and go from there. I felt we need to mark concerning part properly for pathologist.

  4. Recent history of melanoma and lesion appearing on one edge of the scar.
    Chaos, eccentric structureless areas although quite small relative to the lesion.
    I do see some thick brown lines forming polygons. Not sure about grey areas.
    It would be interesting to check the histology report of the recent melanoma excision to assess margins and whether they were adequate, especially at around the 3 o clock area. Also would be prudent to check what breslow level the melanoma was. nevertheless this lesion needs to be excised with a 5mm margin if we suspecting melanoma.

  5. so, the results support everyone’s comments above – how would you proceed now?

  6. There is polygons with some whitish clearing. Certainly it needs to be excised with a safe margin.

  7. L mid scapula spine – Lentigo Maligna (MMis type). The white scar like lesion to the left of this MMis has not yet been identified. I would also have sent off a punch biopsy (at least 3mm) of this scar as it is in the surgical area (so when I shaved the SPL I would have punched the central or thickest palpated part of the scar-like lesion) if I was not confident with the history of how this previous MM was ‘treated’ or why it does not look like a surgical scar to me?? I would be concerned that it too may be MMinv (non pigmented), or is it recurrent MM or is it ?BCC or other pathology (no dermoscopy given nor history of if previous MM treated). Once all histopath returns I would book pt for a formal excision pending results. If the scar-like lesion is just a scar…. I would measure at least 5mm surgical margins dermoscopically from the original lesion, and excise using a primary ellipse most likely (or consider A-T or O-Z flap if needed). It may also be useful to discuss with the patient the idea of actually including the old scar into the excision (because I really cannot imagine how her ‘previous MM’ has been treated and left a circle that looks like it has just been cryo’ed or curette and cauterised) so, I need more info here. She has very solar damaged skin so, the concept of field cancerisation could be discussed and I believe there is some evidence for using Aldara (off label) after all has healed to attempt to treat any further atypical melanocytes.
    ISSUES:
    1) MMis diagnosed now next to a scar supposedly a previously treated MM
    2) How was the previous MM treated and what was it’s Breslow depth and when diagnosed?
    2) Solar damaged skin at high risk of MM and other skin cancers, consider Aldara off label (some evidence for post surgery). Encourage daily sunscreen use etc ++++
    3) Is the old scar now something else (?MM recurrent or,BCC) as it does not look like a surgical scar so I am suspicious. Would also check for axillary lymphadenopathy, just in case (again, due to sus white scar).
    4) Excision in this area of both lesions will be best closed with a flap. Discuss surgical options with patient.
    5) Book to review surgical scar and full skin check in 3/12, will need close followup over time.