Case discussion: How would you treat this patient? [28 May]

This week we have an interesting case from Dr Tim Aung. An 50-year-old male presented for other reasons, but a lesion on his face was noted.

What is your evaluation of the clinical and dermoscopic images? What would you do next?

Case discussion     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?

Case discussion

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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17 comments on “Case discussion: How would you treat this patient? [28 May]

  1. sharply demarcated borders, some apperance of milia. on the whole looks ugly but does have polygons which can also happen for seb K on face mimicking melanoma. no need to excise, leave it and reasses in 4 months for growth. Overral diagnosis – Seborrheic keratosis

  2. Pigmented skin lesion on the face with probably subtle blue/white veil in the centre but most importantly, grey circles were present on one side of the lesion. Needs excision biopsy.

  3. Chaos of colour and structure. Dark brown black dots. Angulated lines. Some follicular obliteration. Excise to exclude LM.

  4. Clinically an ugly duckling, but well demarcated border. Dermatoscopic: Chaos in structure and colour. Sharp borders only at left side of border (dermatoscopic image). Central erythematous background. Peri-follicular thick lines with some grey and some follicles obliterated. Polygons present.
    DD: seb K LM
    Preferred Dx: LM
    Plan: Excision with 2mm margin

  5. “the ugly duckling” featuring chaos and clues- grey and black dots, thick reticular lines, polygons; needs excision biopsy to rule out MM/LM.

  6. can’t name this as a benign lesion; no features of seb k; asymmetry of colour and pattern; grey centrally; circle within a circle, thick lines, pigmented circles; suspicious of melanoma, requires biopsy, shave biopsy

  7. Chaotic structure with darker clods centrally and pigmented circles to right and left of the dermoscopic lesion. Most likely lentigo maligna. Needs shave/excision biopsy

  8. thick melanoma, level IV; refer to Melanoma unit for MDT discussion, consideration SLNB (although not straight forward in head and neck melanoma), and consideration of Rx/drug trial

  9. great case from Tim – many thanks! I am with Bronwyn here – can’t name it, no Seb k features at all, needs biopsy (great circles are a huge clue to melanoma). Tim – what happened next? I predict the melanoma unit did a wide excision and no SLNB.

  10. Thanks everybody. Bronwyn, your’s hammer did not miss the nail.
    As per Aust & NZ guidelines, such thickness required SLNB which I have to refer to skin cancer clinic of local hospital although I am comfortable for WLE. Unfortunately SLNB was not done, instead WLE in 2/12 time. SLNB in head and neck is usually without risks. Attached pic is my plan of WLE. I did send all my sketch to them. Also literature/experts indicate LM/LMM has low risk of metastasis in comparison with nodular/invasive type.

    Dermoscopically: thick reticular, angulated lines, rhomboid leading for LM or LMM.
    If shaved biopsy: false negative of BT might be reported. If female and less likely MM, I might go with shaved biopsy.