Case discussion: How would you treat this patient? [18 September]

This week we have an excellent case from Dr Ross Baverstock. A 48 year old male presented for a routine skin check with skin type 3. Dr Baverstock noticed lots of benign looking naevi but one of them stood out in the right scapular area.

We have the dermoscopy picture below. What do you think about the lesion? What are the next steps you would take to treat this patient?

Case discussion_Ross Baverstock

Update:

Dr Baverstock found it suspicious, so did an excision biopsy. Histopathology reported as:

Clinical Details: Excision biopsy suspicious pigmented lesion right scapular area. Suture medial. Macroscopic Description: Right scapula: An orientated skin ellipse 9 x 4 x 6mm with a central well circumscribed brown macule 2mm in diameter. A suture marks the medial aspect arbitrarily designated 12 o’clock, the 3 o’clock margin is inked green, the 9 o’clock margin is inked black. 3-2P JXT

Microscopic Description: Sections show a predominantly lentiginous junctional melanocytic proliferation. A few small nests are seen and the papillary dermis demonstrates lamellar fibroplasia. A dermal melanocytic population is not present though there is melanin deposition within the papillary dermis. There is also fibrosis and chronic inflammation with the changes in areas being in keeping with regression of the lesion. There is architectural and cytological atypia within the lesion, the margins of which are poorly defined, though the changes fall short of a diagnosis of malignant melanoma in-situ.

Conclusion: Skin lesion right scapula: Severely dysplastic junctional melanocytic naevus. There are changes in keeping with regression. The lesion extends within 1.5mm of the 3 o’clock margin and further local excision is recommended.

What would you do next?

 

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12 comments on “Case discussion: How would you treat this patient? [18 September]

  1. I agree the picture is a bit blurry, network difficult to distinguish and asymmetrical in shape.

    Would need comparing against others if multiple atypical naevi. 40s, male with trunkal – best to perform excisional biopsy if in doubt.

  2. Small lesion (looks about 2mm) so dermoscopy may not be as helpful as with a larger lesion. If it stands out on general examination, and given that it is asymmetrical looking, simplest thing might be a 3mm punch biopsy to remove the whole thing

  3. Dermoscopic grey, regression with minor polygons, needs comparative approach to evaluate this lesion with the other nevi, could be a Sclerosing nevus. Given that, it needs excision if different from the other nevi noted on the chest and back.

  4. Hi everyone

    2-3 mm PSL; chaotic with gray colour on left and structureless eccentric area on right and different sizes clods. it is suspicious for Melanoma and a 6 mm punch biopsy will give us histopathologic clues. The patient is 48 years old and this lesion can not be considered a growing naevus.

    1. Another 5 mm margin should be excised. It should be considered Mis because of multiple clinical, pathological and dermatoscopic factors;
      1. Age 48
      2. Peripheral clods
      3. Severe dysplasia in a junctional naevus

  5. In this case I would excise to 5 mm margin and treat like melanoma in situ as in few cases might be melanoma in specimen ( overlooked) , and I would excise any other suspicious looking nevus for this patient.

  6. given histology result and suspicious clues (asymmetrical thickened network), regression, white lines, I would do a wider excision (need also find out ?FHx of melanoma, ?severe sunburns in the past)

  7. This is a great case from Ross. Thank you.
    1. First lesson here is the power of clinical observation and action on anything suspicious, as Ross did. Most of us would agree that the dermoscopy is unremarkable. If in doubt – cut it out.
    2. Second lesson: “severely dysplastic nevus” should be treated as melanoma in situ, and so re-excision is required here with 5mm margins.
    In reality there are only 3 pathology results I would accept: 1) nevus, 2) melanoma and 3) I don’t know. If “I don’t know” then treat as melanoma in situ. Mild and moderate dysplasia can be treated as benign but severe dysplasia should be treated as melanoma in situ.
     
    Thanks Ross

  8. Thank you everyone; sorry I have been away so not seen the posts until today.
    I need to improve my dermoscopy photo technique!
    This naevus clearly stood out from the others that he had; it was the ugly duckling.
    I’ll get him back in and do the necessary.
    Cheers,
    Ross