Case discussion: How would you treat this patient? [24 July]

This week’s case discussion is about an elderly man presenting with a cough. On examination, both a basal cell carcinoma and the pigmented lesion shown here were noted.

What is your assessment? Is there anything to be concerned about?

Case discussion - Slavko Doslo     Case Discussion _ Slavko Doslo

Case submitted by Dr Slavko Doslo

Update 1:

Here is the pathology result. What next steps would you take?

case discussion-Pathology

Update 2:

Here is the final pathology result. What do you think?

Case discussion - Slavko

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? [24 July]

  1. Dermoscopic chaos noted within a structureless loner lesion. Brown dots in upper half withing a pink background, no features of a nevus or lentigo,elevated nodular spot on gross appearance, will need 3mm margin excision given no classical features of a benign lesion. ? desmoplastic melanoma

  2. Chaotic PSL with peripheral clods and a pink area, and white eccentric structureless area with polymorphic vessels. Excise to rule out MM.

  3. I wonder as the margin is clear by 3 mm and as it is a superficial spreading melanoma routine follow up would be sufficient.
    Also some experts recommend 5 mm histological clearance . Would like to know the exact histological clearance for superficial melanoma.

    1. In my humble opinion, to follow local guidelines (such as NHMRC, Dermatological Society and RACGP) which is designed to be safe for professionals as well as patients. Generally 1st excision is to establish Dx and 2nd step to ensure for cure. Thus it is wise to do wider excision as per guidelines despite clear of margin in 1st Histopatho report. Pathologists also usually mention their recommendation in the report for next step.

  4. I always thought 5mm would be the standard for MIS. Superficial spreading would probably be more reason to have a 5mm wide margin. See Cancer council guidelines NOV 2016

  5. Margins are important and often confuse people. Margins are clinical, not pathological. So, the guidelines that we should do 5mm margins for MIS are clinically measured margins, not pathology-reported margins. Let me be clear – the survival outcomes for melanoma are related to the clinical margins that we measure on the skin. Pathology margins will be different. As Tim says, start with a 2mm margins for the biopsy (all 2mm means is – take the whole lesion; there is no magic about 2mm). Then, for MIS do a 5mm clinical margin, drawn on the skin. Finished. What is etc role of the pathology result? To confirm that margins are clear. The mm margin measurement is not relevant.

    1. Thank you very much professor with the explanatory answer for the melanoma in situ excision margins.