Case discussion: How would you treat this patient? [4 June]

This week we have an engaging case from Dr Dave Stewart. An 80-year-old male presented with prior melanoma (see scar!)

What is your evaluation of the clinical and dermoscopic images? 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?

Case discussion

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16 comments on “Case discussion: How would you treat this patient? [4 June]

  1. Certainly chaotic. Are those rhomboid structures? Can not confidentiality say it is benign. Shave bx to be on the safe side.

  2. Old solar damaged skin in someone with P /h of melanoma.
    This chaotic melanocytic lesion with areas suggesting regression is a melanoma until proven not to be.
    Excision biopsy with 2 mm margin would be my preference

  3. This is a melanoma arising within a prexisting excised scar, needs wide excision with grafting

    Dermoscopic features: greyish dots, polygons, polymorphic vessels

    1. Hi
      Grafting backs may not be a good idea due to the thickness discrepancy between the graft and defect. This will leave an indentation and the skin graft may be prone to breaking down due to friction. Primary closure or Keystone or Mercedes flaps are usually sufficient on the back.

    2. The lesion is actually the one at the bottom of the image (it looks like a map of Australia which is partly why it caught my eye!) It some distance from the previous excision scar. Probably should have marked the image to make this clear before sending it through – sorry.

  4. chaos with grey dots, white lines and polymorphic vessels – needs excision biopsy and then management based on lab results.

  5. I’m a bit late with a response today; dermatoscopy: eccentric structureless areas, white lines 12 oclock, angulated lines, grey dots; needs biopsy, particularly in view of past history; path: the lesion needs WLE; I would calculate my margin using 2mm from the visible lesion edge plus 5mm for WLE for MIS; if the lesion edge is unclear, I would take a larger margin around the biopsy site, as the biopsy margins were involved, ideally up to 10mm; however, he is 80 years old, and co-morbidity should be taken into account

  6. also, white lines equate to scaffolding for the melanoma to grow vertically; is this really a MIS; should the pathologist take deeper sections to look for invasion? at 80, it may not change the management anyway, but may affect the WLE margin

  7. thanks everyone, great case I think. lovely dermoscopic picture of the “lentiginous melanoma”. I think a good way to biopsy these flat, small lesions is a shave. of course 2mm excision biopsy is ideal, but a deep-enough shave is quite safe.

  8. Good mahogany staining LM. Generally graft has no place over back which is usually provide a good forgiving whatever method. A 5mm margin with local flap (O-Z) or even simple elliptical would be okay. Prior deep suture can be considered to get a nice apposition if affordable.

    1. I just removed it with a simple ellipse and it came together with no problems. Hopefully it will look prettier than the other excision scar (which was not my handiwork) but time will tell!

      1. Agreed (nothing wrong with elliptical). Scar stretching is depending upon individual how they manually work with shoulder and back day to day. Placing deep suture would minimise the stretching but cost ^ for practice.

  9. So this basically is a Atypical junctional lentiginous nevus of elderly ! needs to be treated as a melanoma in situ