Case discussion: How would you treat this patient? [9 July]

This week we have another interesting case discussion from Dr Colin Armstrong. Please describe what you see here and what you would do next.

Case discussion

Update 1:

Here is the dermoscopy image – please describe the appearance and indicate your preferred diagnosis.

case discussion

Update 2:

What biopsy options do we have?

Update 3:

Now, with these results, what would you do next?

Clinical Notes: Flap/WLE right scapula spine lateral – melanoma on bx

Macroscopic:

The specimen container is labelled ‘right scapula spine’. The specimen consists of a tear drop shaped portion of skin and subjacent tissues measuring 56 x 43 x 10mm. Examination of the skin surface reveals a cream and tan, irregular, centrally scabbed lesion measuring 30 x 30mm. A marking suture is present on an apex, indicating 12 o’clock. The 3o’clock margin is inked green and 9 o’clock margin is inked black. Blocking Details: 1A 1TS 1LS 12 o’clock; 1B 1TS bisected; 1C 1TS bisected; 1D 1TS bisected; 1E 1TS bisected; 1F 1TS bisected; 1G 1LS 6 o’clock.

Microscopic:

The sections show a healing biopsy site which is completely excised. There is adjacent residual Level 1 malignant melanoma of lentigo maligna type. No residual Level 2 / invasive component is identified. The excision appears complete and residual Level 1 (in-situ) lentigo maligna melanoma has the following clearances:  3 o’clock – 5mm. 9 o’clock – 5mm. 12 o’clock – 7mm. 6 o’clock – 8mm.

Summary:

WIDE LOCAL EXCISION, RIGHT SCAPULAR SPINE LATERAL: – RESIDUAL LENTIGO MALIGNA MELANOMA, COMPLETE EXCISION.

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


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9 comments on “Case discussion: How would you treat this patient? [9 July]

  1. all what i see is bad sun damaged skin with 2 PSL? i need a dermatoscopic view to comment.

  2. could be a lentigo maligna in evolution, also maybe solar lentigo. however need dermoscopy to diagnose

  3. irregular shaped skin lesion , abnormal borders
    Dermascope view : middle zone : abnormal pigmentation , grey white scar : needs biopsy ? Melanoma
    Superior edge : dark pigmentation , and grey white scar

    complete excision biopsy ???

  4. Irregular symmetry and pigment.Radial lines at the lateral aspect of middle zone.. Also blue white hues .Most probably superficial spreading melanoma . Needs biopsy at 2 sites before a wide excision

  5. Clinically- very irregular shaped pigmented lesion Solar lentigo.
    Dermoscopically:
    Chaos present in colour and structure (asymmetric)
    Clues:
    1/ Polygons (pale/yellow circle/hexagon) in superior zone (12- 2’ o clock)
    2/ radial streaming in blue circle area
    3/ sun damaged regressing eccentric and centric structureless in yellow circle, superior zone and middle zone.
    4/ Polymorphous v/s in middle zone
    5/ dark-grey dots in 10-11’ o clock position (between superior edge and blue circle).
    6/ large black clods (follicular obliteration) 8’ & 5’ o clock.

    Thus sufficient enough to suspect MM (?LMM) and dermoscopic guided shaved or whole 2mm margin excisional biopsy with marking with knot + alerting pathologist with both macro and dermoscopic pics. Then go from there. As there are wide spread location of clues, even wide-bore punch could miss for thorough analysis from pathologist.

  6. very irregular borders, asymmetrical, atypical network, grey/black blotches and peppering, white structureless areas,various colors of brown, grey and black , excision with 2-3mm clinical margins to rule out Melanoma

  7. There are polygons, dermoscopic grey, irregularly distributed black dots,subtle radial streaming this is a collision lesion between a solar lentigo and superficial spreading melanoma. Needs referral to a plastics for wide excision and flap/graft.

  8. – Eccentric structureless areas throughout the region.
    -superior edge also has black grey zone at 12o clock but no blue
    – large keratotic like regions which also could represent regression
    -middle zone lower half periphery has radial lines , and some dots and clods black, ? polygons
    – blue circle has brown thick railway like lines
    – yellow circle has possible keratotic plaque or amelanotic area

    All of above suggest a few differentials: a. lentigo maligna melanoma or superficial spreading melanoma
    b. ?pigmented bcc

    would agree with TIM – either do shave biopsy or 2-3mm excisional biopsy with orientation marking.

  9. The clinical picture here is highly suggestive of melanoma as most comments indicate. It is larger and darker than the rest of the surrounding skin. Dermoscopy confirms suspicions – the polygons are key. So the challenge is how to biopsy, to confirm the diagnosis. Realistically, I think 2-3 shave biopsies, in areas that are most suspicious (e.g. the polygons) is almost certain to confirm the diagnosis. Of course we don’t like partial biopsies of lesions suspected to be melanoma, but we have no choice here, and we would not accept any biopsy result other than melanoma! We can then plan treatment.