Case discussion: How would you treat this patient? [14 May]

This lesion was on a patient’s arm, and the patient reported change over the preceding few months. No other lesion like this was seen. What is your assessment of the clinical and dermoscopic pictures, and what would you do next? 

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?

Location: posterior arm
Patient: Fitzpatrick skin type 1. The patient had noted this lesion to be changing over a few months. There were no other lesions like it. 

Microscopic:
Sections are of skin to mid-deep dermis.  There is superficial spreading malignant melanoma:
TYPE – Superficial spreading
CELL TYPE – Epithelioid, severe cytological atypia.
PIGMENT – Sparse
ULCERATION – Not identified
CLARK LEVEL – Focal early dermal involvement with a few cells within papillary dermis, Clark level 2.
BRESLOW THICKNESS – 0.15mm
MITOTIC RATE – No dermal mitotic figures identified.
TUMOUR INFILTRATING LYMPHOCYTES – Mild.
REGRESSION – No significant regression fibrosis.
PERINEURAL OR LYMPHOVASCULAR INVASION – Not identified
SATELLITE DEPOSITS – Not identified
PRE-EXISTING NAEVUS – Not identified 

Summary:
SKIN SHAVE, R ARM:
–  SUPERFICIAL SPREADING, MALIGNANT MELANOMA
–  CLARK LEVEL 2, BRESLOW THICKNESS 0.15MM
–  SUPERFICIAL SPREADING, MALIGNANT MELANOMA
–  CLARK LEVEL 2, BRESLOW THICKNESS 0.15MM
–  MARGIN CLEARANCE 0.5MM, WIDE EXCISION RECOMMENDED

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14 comments on “Case discussion: How would you treat this patient? [14 May]

  1. there are asymmetry in colour, bit blurry picture for me. Because of history of change I will do 2mm excisional biopsy.

  2. This is a moderately dysplastic nevus, can be observed for 4 months and reassesed for changes. No concerning features for excision at this stage. What is the age of the patient ?

  3. The lesion is definitely choatic with no clue. The red dotted blood vessles with no clear pigemted network could be a hint to pigmented BCC or SCC. Recent change will need excision with 2 mm margin or a shave biopsy .

  4. No pigment network nor clues. I would excise with 2 mm margin based on the recent history of change.

  5. I’ve seen those dot blood vessels in most IECs.
    Biopsy ,probably excisional anyway because of atypia.

  6. The history is concerning, as is the fact the this is the only lesion of its’ type on the patient. Macroscopically it is multicoloured and irregular in shape. Dermatoscopy shows it is structureless, with multiple colours, dot vessels and perhaps some grey clods at 10-11 o’clock and 6 o’clock. With the history of change and these dermatoscopic findings, the lesion should be excised with a 2mm margin.

  7. asymmetry, variegated colors and dot vessels- looks suspicious; will excise with 3 mm clinical margins

  8. I like Bronwyn’s analysis. For me, even though we have little history, change of this nature in an adult with what seems to be normal skin mandates excision, even before using the dermoscope. I ask – what is the differential? Dermoscopy for me makes this a melanoma – the vessels.

  9. Hello fellow Skin Cancer Doctors,
    I have started to do more shave biopsies for my lesions and would like someone to advise me as how to obtain some aluminium tri chloride for haemoatasis. Collin during one of the courses mentioned the content of commercially available antiperspirant is the same thing. I have tried using one of the brands from Coles but it did not achieve haemastasis that I want. Anyone who is an expert on this, please advise. Much appreciated

    1. Hi Dr. Lim, On behalf of Doctor Colin Armstrong (Presenter of the Advanced Certificate of Skin Cancer Medicine and Skin Cancer Doctor at the Redcliffe Skin Cancer Centre): “All we do at Redcliffe is buy the Driclor brand from the chemist. You get AlCl3 60ml in a roll-on bottle. We just decant the contents into a sterile container (eg: urine spec jar). You can mangle the roll-on top to get at the contents or just push an 18g needle into the bottom of the bottle and draw up with syringe. Or you can put another needle into the top of the bottle so it drains faster.”

      1. Hi Abinaya,
        Thank you for your advice. I could not see your reply till now. I am thrilled. Will head off to get one right away.
        Much appreciated.
        Annie

      2. My nurse one day just picked up the Driclor roll-on, held it upside down and squeezed it firmly – few drops nicely dripped down, aimed on a cotton bud – no touch, very clean. I keep the Driclor in it`s original pack now and `just squeeze it`.