Case discussion: How would you treat this patient? [4 December]

This week, we have another interesting case from Dr Slavko Doslo. A 18-year-old male presented with concerns about a pigmented lesion on the chest.

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

Case discussion_Slavko Doslo     Case discussion_Slavko Doslo

Update 1
Here is a better version of the dermatoscopic picture. 

Here is a picture submitted by Dr Tim Aung to complement his comment below.

Update 2

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

Case submission_Slavko Doslo

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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13 comments on “Case discussion: How would you treat this patient? [4 December]

  1. Solitary brown macular lesion on the chest wall. Dermoscopy assymetry. Unable to detect irregular network nor presence of blue white. Can be F/up 3/12 short term once or excision biopsy re solitary brown lesion.

  2. Age is young . Unlikely malignant.
    No chaos.
    Neavus.
    However as he is concerned I would do a shave biopsy

  3. Its blurred and not in focus. I cant see any network..all are brown with follicular opening. Maybe short monitoring follow up if in doubt or the patient state its a new PSL.

  4. Reassure her, this is seborrhiec keratosis, has milia like cysts with sharply demarcated borders. No excision necessary

  5. The photo seems a bit out of focus which could interfere with correct interpretation. To my impression there appears to be an area of atypical network at 9 to 10 o’clock, and some dermatoscopic grey in the central part of the lesion + possibly an area of regression, and an unsharp border at 11 o`clock. I don’t see clear clues to suggest a SebK, and it would be uncommon to see a SebK in an 18yr old.
    The young age of the patient makes malignancy rather unlikely and the lesion appears small and flat: I would advise a shave biopsy with 2mm margins.

  6. I would say it’s a benign lesion. Best to get the patient to monitor it for the next 3 months and explain to him what to look out for (ie, change in colour and size). I would keep a photo of it in his file and get him back for a review in 3 months and compare the pictures .

  7. unfortunately blurred image
    looks like radial streaming between 7 & 11 o’clock ( i.e. active growth)
    black/brown clots esp. at 10 o’clock
    on magnification thickened network at 3 o’clock
    greyish structureless area in the centre
    I would suggest excision to exclude superficially spreading melanoma

  8. The age was unlikely for MM, BUT this shiny pigmenetd macule (clinically) and reddish-brown (dermoscopically) concerned me.
    Dermoscopically:
    CHAOS present in term of structure (asymmetry) and color (3-4 colors: pink, brown, black, pale/white).
    CLUES: pale/white structureless (centric and eccentric-6’o clock), 3-4 areas of dense black patch (clods) especially L hand side), 3-4 small black dots L hand side, subtle polymoprh/dotted v/s (of course, not very clear).
    As per current guidelines, better not say nor document, “wait and see, will follow-up”. Decide benign or possible sinister (malignancy). This case with some C & C warranted 2mm margin excisional biopsy and go from there.
    Could be MM arising from naevus!

    Would be nice exploring FHx of MM, How long it has been there, any recent changes in size, color,… as well.

  9. A great case and some terrific comments. Here is my thinking. 1) patient is concerned, 2) this is a very lonely lesion – we can’t see anything else like it, although we can’t see the whole body. Dermoscopy is unremarkable to my eye. I would offer / recommend excision biopsy, even though age makes melanoma less likely, but not at all impossible. (I never forget a 20y old male with a similar story who had melanoma). Pathology result is unhelpful. Dysplastic nevus not not exist and what is “moderate” to one pathologist is not to another – there is wide variation in reporting results between pathologists and over time. So, for me, the lesion is now out (with good margins) – end of story, and (in my view), the right thing done! Thanks to all who comment

  10. there are patients with lesions of multiple dysplastic nevi, there is no end if we start excising dysplastic nevi of mild to moderate degree with 5mm margins, then the patients will multiple moles will have half their body cut out honestly ! only severely dysplastic nevi needs a 5mm margins clearance to be treated as a melanoma in situ. others can be left alone, including this which has very benign features of a globular nevus, reassure the patient