Case discussion: How would you treat this patient? [09 October]

This week we have another fabulous case from Dr Colin Armstrong. An 80-year-old female presented for a skin check and a lonely lesion was noticed on the calf as indicated.

What is your assessment of the clinical and dermoscopic images? What would you do – if anything?

Case discussion_Slavko      Case discussion_Slavko

Case discussion_Slavko      Case discussion_Slavko

Update:

This is the pathology result. What is your conclusion and what are the next steps you would take to treat this patient?

Clinical Notes: Left postero-lateral calf ?Atypical naevus excl – MM – polygons / dermoscopic grey.

Macroscopic:

The specimen container is labelled ‘L postero-lateral calf‘. The specimen consists of a shaved portion of skin measuring 18 x 12 x 1mm. Examination of the skin surface reveals a variegated brown patch measuring 15 x 11mm.
Blocking Details: 1A-1B 3TS each in toto.

Microscopic:

The sections show a junctional melanocytic proliferation arising on a background of more broad changes of solar lentigo / pigmented seborrhoeic keratosis. Focally, there is pigmented parakeratosis together with dermal pigment incontinence in keeping with changes of irritation. Immunostainsarerequiredforfurtherassessmentofthelesionandareportwillfollow.

Summary:

LEFT POSTERO-LATERAL CALF:
– JUNCTIONAL MELANOCYTIC PROLIFERATION ARISING ON A BACKGROUND OF SOLAR LENTIGO / FLAT PIGMENTED SEBORRHOEIC KERATOSIS.
– IMMUNO STAINS ARE REQUIRED FOR ASSESSMENT AND A REPORT WILL FOLLOW.

Supplementary report added

Sox10 immunostains have been examined and confirm a broad lentiginous junctional melanocytic proliferation with focal nesting and scattered Pagetoid spread into the overlying epidermis. The features are of a melanoma in situ (Clark level 1) of Lentigo maligna subtype. Invasive malignancy is not identified. The lesion is poorly defined peripherally but appears to lie 0.5mm from the biopsy edge.

Summary:

LEFT POSTERO-LATERAL CALF:
– LENTIGO MALIGNA (MELANOMA IN SITU), 0.5MM FROM THE CLOSEST EDGE MARGIN.

We encourage you to participate in the case discussions and submit your own clinical images and questions so we can all learn together.

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8 comments on “Case discussion: How would you treat this patient? [09 October]

  1. Chaos with different shades showing angulated lines, thick line reticular with eccentric brown grey structureless area with small regression. Excise to rule out LM.

  2. asymmetric lesion with atypical pigment distribution, and structureless areas,.
    Excision biopsy with 2 mm margin as suspicious of melanoma.

  3. Hi everyone:
    Clinically solitary pigmented lesion in an 80 year old lady’s leg is highly suspicious of melanoma.
    Dermatoscopically chaotic PSL, mainly reticular pattern but a large grey structureless area is covering most of the upper left half containing different size grey clods. The dermoscopic features increase the suspicion of lentigo maligna melanoma. The main DD in this lesion is LPLK but an excisional biopsy with 2 mm margin should give us the right pathological diagnosis.

  4. Dermoscopic grey and polygons on an isolated lesion in a person of this age needs excision biopsy, most likely superficial spreading melanoma

  5. Clinically fairly large macule 10mm x 20mm
    Chaos- asymmetric + >2 colours.
    Clues:
    1/ eccentric and centric structureless (hypopigmentation/regression) areas.
    2/ thick reticular lines especially R hand side (3’ o clock)
    3/ 1-2 dark clods/globues (6’ o clock)
    4/ lots of grey-whites

    Thus, enough to suspect for MM with 2-3mm margin excision and go from there!

  6. Fascinating case – thanks for sharing this one. Very lonely clinical lesion that needs excision biopsy on the clinical alone. Dermoscopy, with grey and polygons confirms suspicion and would be melanoma for me. Interesting that the first pathology look didn’t show melanoma and that special stains were needed.