Case discussion: How would you treat this patient? [08 January]

This week we have another interesting case from Dr Slavko Doslo. A 61-year-old female with concerns about pigmented lesion on nipple.

 Please review and describe the clinical and dermoscopic images. What is your assessment, and what would you do?

Case discussion_080118 Case discussion_080118

Case discussion_080118

Case submitted by Dr Slavko Doslo

Here are two pictures submitted by Dr Tim Aung to complement his comment below.

Update:

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

case discussion

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11 comments on “Case discussion: How would you treat this patient? [08 January]

  1. Melanosis of the nipple is rare but considering the features of blue/black colour, short white linear lines plus a pigmented base with thickened polygon lines a biopsy must be carried out for melanoma/pagets.

  2. Looks suspicious particularly the dermoscope image- variegated colors (blue, white, brown), aysmmetrical, blue white structureless areas, peppering. I would excise to rule out MM.

  3. Multiple colours, blue black and white with surrounding brown. Any new pigmented lesion in this age group is suspicious if not definitely diagnosed as a Seb K. Excision biopsy to exclude MM.

  4. Hx of duration, ± pre-existing naevus and any recent evolving s/sx would be much helpful. Anyway
    Clinically: a slightly raised variegated dark-gray pigmented lesion with distorted nipple.
    Dermoscopically: CHAOS present in term of structure (asymmetric) and colour (>1). CLUES- Initially thought, it lacks network but there is, which r/o Seb K. Blue-white veil, blue-black signs and dark clods (follicular obliteration), combined with clinical appearance are very concerning and pointing to MM otherwise proven benign.
    Shaved with little deep dermal or wide bore punched (4-5mm) biopsy is reasonable in view of location and size (small), and go from there!
    If MM with depending upon Clark Level and Breslow Thickness, she would be a candidate for referral to specialist for further management. Lymphatic spread is common in this location, thus axillary L/n check is not to forget.
    See pictures.

  5. dermoscopic blue and black with a lot of polarising white lines, this could be a level 4 melanoma. needs a complete nipple removal done by plastics and sent for histopath analysis

  6. There are all dermatoscopic features on a nipple melanoma with assymmetrical nipple displacement -this is suspicious of spred of the melanoma deep in the breast tissues
    An mammogram , US of the breast and sentinel LN biopsy with shave biopsy of the lesion
    to confirm melanoma of the nipple with possible spread is required

  7. Just to be aware, mild distorted / atrophic nipple is not uncommon in postmenopausal women, thus mayn’t necessarily mean malignancy. Correct me if I am wrong. One of D/Dx could also be early stage of pigmented paget d/s.

  8. get this rechecked by another pathologist before accepting this diagnosis as benign. dermoscopy is clearly not matching histopath

  9. happy new year folks – hope everyone is well, had a nice break, and is ready for 2018. the key lesson in this case is that some parts of the body have very different skin type and structure, and as such, very different dermoscopic appearances. So, for this case, the clinical view is important – and clearly this lesion is unusual, cannot be named, and needs biopsy. The dermoscopy (in my view) does not help, and we cannot interpret it in the way that we would on skin on most of the rest of the body. The biopsy result makes sense.