Case discussion: How would you treat this patient? [29 January]

This week we have an engaging case from Dr Dorothy Dowd. Older female with pigmented lesion on lower leg. Dorothy was questioning melanoma and in situ, and did a shave excision.

Here is the report. Dorothy is wondering what this means, and what to do next. What do you all think?

Case discussion Dorothy Dowd 180129     Case discussion Dorothy Dowd 180129

Pathology report stating diagnosis as “atypical nested and lentiginous melanocytic hyperplasia” fragment of pale tan skin 15mm across, suture marking 12 oclock. Specimen serially sectioned, all tissue submitted microscopy ‘superficial shave of skin demonstrating focal features of pigmented solar keratosis. Some sections however demonstrate a junctional proliferation of melanocytes, both singly and in small nests. There is a very little upward scatter of melanocytes. There is prominent hyperpigmentation of basal keratinocytes. There is no significant dyplasia with mild melanocytic atypia and features are interpreted to represent a pigmented solar keratosis with an area of atypial nested and lentiginous melanocytic hyperplasia. The melanocytic proliferation appears to involve the margins on the specimen and complete excision is recommended.

Case submitted by Dr Dorothy Dowd

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9 comments on “Case discussion: How would you treat this patient? [29 January]

  1. Pathology describes melanocytic proliferation along epidermal basal layer with severely sun damaged skin.
    This is also known as actinic melanosis.
    Quite common and has an insignificant risk of developing into melanoma.

    Reassure patient and do wider excision to comply with Pathologists recommendation

  2. assymmetrical in shape and colour lesion with few discrede nests of melanocitic proliferation
    The histopathology excludes melanocitis dysprasia ,but there are present junctional proliferation of melanocytes and area of atypical nested and lentiginous melanocitis hyperplasia .
    The differential disgnosis is Lentigo maligna , melanoma in situe , pigmented solar keratosis
    I would perform an excisional biopsy with 4 mm margin

  3. I would be happy with 5 mm margin but I would like to talk to pathologist to provide definite diagnosis, but I would treat as melanoma in situ

  4. Presumed that dermoscopic pics are before shaved biopsy. In retrospect,
    1/ nothing wrong opting shaved biopsy in this particular case (location and flat/macule lesion). However wonder it would be nicer to send pics of dermoscopy to provide the focus (areas of concern) to section and miscroscope thoroughly. I do at times for some cases (not routinely). Or asked pathologist again 2nd round check.
    2/ based on uneqivocal pathology report, it is wise and safe to do 5mm margin excision to ensure (balancing small scar vs unnecessary morbidity/mortality from MM).

    2x pigmented patches (NPL and PL) are areas of concern. Thick reticular, dark clods (follicular obliteration), and also blue-black and gray-white in NPL view. To Tx as suspected (LM or LMM).

  5. Suspicious looking lesion and the histology report leaves you in uncertainty, either way – although seems to suggest that it is likely a benign lesion.
    I would opt for an ellipse excision w 2mm margins (rather then 5mm), particularly since this is on the lower leg and closing the wound might become unnecessarily challenging with bigger margins.

  6. this is a great case – real life, everyday problem. what is happening here is that the pathologist is describing what he/she sees, not giving a diagnosis; because there isn’t one! this is a description of benign, sun-damaged skin. so, what to do? well, first of all – I agree that a shave excision biopsy is quite appropriate here, and the key is to remove the whole lesion; this wasn’t quite done here, and hence there is some uncertainty. my view is that this is benign, and no further treatment is needed, but the pathologist’s comment cannot be ignored for medico-legal reasons. I would do a 2mm excision

    1. This is from DermNet NZ
      https://www.dermnetnz.org/topics/lentiginous-melanoma/

      What is lentiginous melanoma?
      Lentiginous melanoma is a slowly progressive variant of melanoma found on sun-damaged skin of the trunk and limbs.

      Lentiginous melanoma is usually diagnosed when the malignant cells are in situ and it is thought to have a low risk of invasive melanoma. This type of melanoma has only recently been classified as distinct from superficial spreading melanoma and lentigo maligna (melanoma).
      ………..
      What is the treatment for lentiginous melanoma?
      Lentiginous melanoma should undergo surgical excision. This means cutting it out and repairing the defect. This may be by simply closing the wound and stitching it up but when this is difficult, it may be necessary to create a flap or skin graft. These latter procedures may be delayed for a few days while waiting for the histopathology report to confirm the melanoma has been fully removed.

      A second procedure is often arranged to remove a margin of healthy tissue based on whether it remains in situ (5-10mm) or whether it has become invasive (10-20mm or more).

      Shell we ignore this
      despite location I would chase 5 mm margin, if we are not happy with skills of locations referral to plastic surgeon is better option, ( it would be hard to defend in court against good lawyer)
      lawyers love doctors cases, as we look like pile of cash to them,