Case discussion: How would you treat this patient? [11 June]

This week we have an interesting case from Dr Thuy Au. An 78-year-old male presented for a skin check and a  lesion was noted. There is no clinical image, but how do you evaluate this dermoscopic image?

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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13 comments on “Case discussion: How would you treat this patient? [11 June]

  1. Chaotic lesion with eccentric structureless areas. Remove by excision with 2 mm lateral margin or by saucerisation.

  2. Looks like atypical junctional lentiginous nevus of elderly with multiple areas of chaotic black dots going along rete ridges with central regression, it will need to be treated as a melanoma in situ and needs excision. Contact dermoscopy could have yielded better quality pictures for a confident diagnosis, i don’t prefer non contact dermoscopy honestly

  3. Clod pattern , 78 y/o , grey structure , fair enough for excisional biopsy but I wont get surprise if it come back as a nevus.

  4. Chaos with different shades. Multiple dark brown to black dots. Area of grey/ white. Excise to rule of MM.

  5. the chaos is due to the asymmetry of the structureless area, which is also a clue as it is eccentric as well as central; the clods are fairly evenly distributed, but I would like to know whether there are any other pigmented lesion on him that have a similar pattern of clods; I would excise with a 2mm margin as I am not sure, but this may be an irritated naevus

  6. looks like a junctional naevus with area of regression and clods. Needs excision biopsy to determine whether these changes are dysplastic or malignant. Margin not important as long as entire lesion sampled as if MM wider excision required and if not minimal scarring desired. Not a NMSC from this appearance.

  7. Melanoma in situ of lentigo maligna type. Procede to excision with 5 – 10 mm lateral margins (as per the new melanoma guidelines which are soon to be released). Followed by regular skin checks as per the current guidelines i.e. every 6 months for 5 years and then yearly after that. Good idea for the patient to check their own skin every 3 to 4 months as well.

  8. LM requires WLE with margins 5-10mm

    from my reading of the AJCC Staging 8th edition and the current melanoma guidelines, this man is stage IA and the recommended follow up is annually for 10 years looking for recurrence/new primaries, and lifelong skin surveillance to detect new primaries;; the guideline also state that this is based on low level evidence, and that individual patient requirements should be considered; I find that patients want more frequent follow up than annually – what does everyone else think?

    also ongoing regular patient self examination

  9. Thinks needs excision. It has a chaotic pattern with brown dots/clods and eccentric featureless area centrally indicating possible regression. Excision for histology with a view to 5-10mm wider excision if MIS or wider dependent on synaptic report

  10. I suggest that this is a really tricky case. Of course there is no history and no clinical picture. When I saw this image I was not very excited! The clinical picture would be key for me – if this was an “ugly duckling” or “one of a kind” then maybe I would have looked more carefully. On its own, for me, the image is unremarkable. Obviously – I would have missed an MIS! Obviously re-excision now with at least 5mm margins. Thanks for the case!

    1. Thanks for your honest post David – I neither would have picked this lesion out as a malignant lesion based on the dermoscopy image only, as I don`t find it particularly chaotic to start off with. It is quite refreshing to hear a more experience skin ca doc say this.
      The fact that this lesion is posted on this blog creates a bit of bias into making our brains look harder for suspicious clues. I can only hope that the clinical image of history would have guided me to decide to do a biopsy here.