Case discussion: How would you treat this patient? [26 February]

This week we have an engaging case from Dr Tim Aung. An 80-year-old male with past history of melanoma and NMSC. The below shown lesion was noted on regular skin check. 

Please review and describe the clinical and dermoscopic image. What is your evaluation, and proposed next step/s?

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Case discussion    Case discussion

Update 1:

Below are the results of Dr Tim Aung’s excision. 

Case discussion   

Update 2:

And below are the outcome of Dr Tim Aung’s re-excision.

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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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9 comments on “Case discussion: How would you treat this patient? [26 February]

  1. No offence but the non contact polarised images looks pretty bad quality for judgement. I would always use contact polarised mode with immersion oil. This looks macroscopically atypical and dermoscopically non characterisable as a seb K or nevus. Hence excision was the right choice. Features are hard to describe dermoscopically

  2. Avagard 1st choice, Aquium gel second choice on cotton ball can do trick for moisturizing skin as does not leave skin messy with oil
    to me even with dry scaly skin to compromise view did not look right, on 3 o ‘clock there is small area of pepper dots, ( I found in most of melanomas)
    I do not know why we got so early release of histology for this case?

  3. Dear Colleague,
    Agreed, I should have applied immersion or alcohol wipe. To me, dark dots and clods lead me suspicious for MM although unable to visualise true network. In retrospect, there is also curved/angulated lines potentially forming polygons (learned from Jeff Keir).

  4. An assymmetrical in shape and colour lesion with cloodds assotiated with past history of melanoma ana NMSC
    highly suspicious for melanomal lesion
    The histopatholopgy has proven dysplasia at the dermoepidermal junction
    I agree with the repeted complete excision of the lesion

  5. Hi Tim,
    Thanks for the case.
    Do you have an explanation for why the original report said “excision incomplete at all resection margins”? It looks like you have clearly given it a 2mm margin from the path photo. And then the re-excision shows no residual melanoma at all – despite it being present on all margins for the initial excision biopsy.

    1. Thanks Barry. Sorry for delay as I’ve just come cross your query. I don’t know exact answer. Clearly 2mm margin for initial excision.