Case discussion: How would you treat this patient? [7 May]

This week we have another interesting case. What is your assessment of the clinical and dermoscopic pictures, and what would you do next? This lesion was on the upper back and the patient was unaware of it.

Case discussion    Case Discussion

Update:

These are the results from the pathology report. What is your conclusion and what are the next steps you would take to treat this patient?

Microscopic:
Sections show a pigmented seborrhoeic keratosis with an adjacent atypical junctional melanocytic proliferation amounting to at least malignant melanoma in situ of superficial spreading subtype. There is prominent inflammatory and established regression. Ulceration is not seen. Focally small numbers of atypical melanocytes are present within the papillary dermis in an area of regression. Dermal mitoses are not seen. While these may represent cross-cut junctional nests, the features are suspicious for early invasive melanoma, Clark level 2, Breslow thickness 0.2mm.  In situ tuxmour lies 2.5mm from the closest peripheral margin and invasive tumour lies 5mm from the closest periphreal margin and 0.7mm from the deep margin.

Summary:
R OF T2:
– MALIGNANT MELANOMA (CLARK LEVEL 2, BRESLOW THICKNESS 0.2MM)

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? [7 May]

  1. Looks very chaotic with gray, black dots, aborising blood vessels. I would do excisional biopsy 2mm margin

  2. This lesion exhibits chaos and more than one clue, highly suspicious of a melanoma. Definitely needs an excisional biopsy with min 2 mm margin to be sure

  3. on the whole it looks like an irritated Seborrheic keratosis but has some regressive features with dermoscopic grey which is suspicious seb K, on that pretext he would need this monitored for 4 months and then excise if enlarging.

  4. This ugly duckling among several pigmented Seb K, bears blue-white, blue grey and thick reticular. There is a usual challenge for MM vs. Seb K.

    But this article (n=134) indicated with presence of the blue-black sign, pigment network, pseudopods or streaks, and/or blue-white veil> likely MM. Let’s see 2mm excisional biopsy and go from there.

    [https://jamanetwork.com/journals/jamadermatology/article-abstract/2612723?redirect=true]
    [https://www.ncbi.nlm.nih.gov/pubmed/?term=PMID%3A+28355453]

  5. I think this is a great case. very difficult to see clinically, among all the lesions on this person’s skin. it is a case that shows so well how a Seb k can mimic or collide with a melanoma – great pick up!

  6. Great work in spotting and excising it. I would follow with a WLE with 5mm marginto be sure that it’s all gone.