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1800 867 1390Case discussion: How would you treat this patient? [21 August]
This week we have another case discussion from Dr Slavko Doslo. It is about an elderly man presenting for reasons unrelated to his skin. A full skin check is done and these clinical and dermoscopic images are taken. How do you evaluate them?
Update:
This is the pathology result. What is your conclusion and what are the next steps you would take to treat this patient?
Case submitted by Dr Slavko Doslo
Please share your thoughts in the comment section below. Professor David Wilkinson will provide his opinion and advice.
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Chaos showing red area with blue clods. Could be bcc. Excise it.
biopsy with 2 mm margin
Pigmented BCC
8x6mm pigmented erythematous lesion on the upper arm. On Dermoscopy it shows dark clods/globules with some blue gray ovoid nests eg at 10 o clock position. Erythema. No definite vessels seen. No pigment pattern. It is a probable pigmented BCC. Advise an excision biopsy with 3mm margin
Sorry for being late joining after listening Johnny’s webinar.
Chaos + present in term of structure and colour (red, pink, dark,…)
Clues: thick reticular lines, subtle polygons, dense black clods with follicular obliteration.
2-3mm margin excision and go from there.
Report already available- MM (CLevel IV with Breslow thickness 3mm with perineural invasion).
As a primary care GP, will refer to next level for further workup: wider excision (15-20mm), +/- sentinal node, +/- metastasis,.., although we can do a wider excision.
must be referred to specialist because of perineural invasion.
Considering the Breslow 4.0, high mitotic activity and perineural invasion, I will refer to specialist for further /wider excision and SNLB and possibly radiotherapy/chemotherapy and close follow up and monitoring.
correction: Breslow 3 not 4 mm and is Level 4
very hard to see any dermoscopic melanoma features honestly other than regression
Will refer to melanoma clinic for SLNB and wider excision at same time after discussion with patient. If patient declines referral: excision with 2cm margins
I agree with Mignonette , however there should be both deeper and wider excision margins.
To further stage tumour and decide on modality of further management the specialist would need to do sentinel nodes. furthermore I would also request the lab to do markers which will assist with oncology treatment or management and prognosis.
Nasty looking lesion with asymetry of colour and structure. Erythema also suggests malignancy. Dermascopically eccentric increased structureless pigmentation to periphery with patches blue grey and some radial streaming a dark globules and with thickened rete network more centrally. Very fine vasularity in erythematosus areas and some dot vessels. This is a melanoma and with histology findings of perineural spread needs referral to specialist for consideration of wider excision, sentinal node biopsy and radiotherapy.
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