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1800 867 1390Case discussion: How would you treat this patient? [3 September]
This week we have an interesting case from Dr Robert Mundell. An 62-year-old man with this lesion on his shoulder, past history of BCC. This is the only image, and there is no history.
So, what is the differential diagnosis here, and what would you do?
Case submitted by Dr Robert Mundell
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1300 856 695
+44 203 514 0688
1800 867 1390
shave excision to exclude melanoma
ddx – solar lentigo
Pigmented BCC
Melanoma
Dysplastic Naevus
Excisional biopsy 3mm margin
This is the ugly duckling on the skin; on dermatoscopy it has multiple clues to malignancy – peripheral black clods and dots, grey areas, eccentric structureless areas, thickened network and possibly some radial lines. I would excise with a 2mm margin, PDx melanoma, possibly invasive.
dermoscopy shows thickened pigmented network , multiple colours & areas of regression
Ddx is Superficial spreading melanoma, solar lentigo & dysplastic naevus
Excise with 2mm margin
Chaos with different shades, thick line reticular peripheral, dark black blotch, some invisible vessels, area of regression, and eccentric structureless area. Excise with 2 mm to exclude MM.
a 10×8 mm lesion shows
Assymetry
Ill- defined borders
Color variation is obvious between brown, red and dark
Dermoscopically:
Choas in color and pattern
Clues:
Peripheral Structureless are at the left lower part
Convergent radial lines suggesting Superficial BCC
DDX
Superficial BCC
Superficial Melanoma
Intraepithelial SCC
Excisional biopsy with 2 mm margin
a 10×8 mm lesion shows
Assymetry
Ill- defined borders
Color variation is obvious between brown, red and dark
Dermoscopically:
Choas in color and pattern
Clues:
Peripheral Structureless are at the left lower part
Convergent radial lines suggesting Superficial BCC
DDX
Superficial BCC
Superficial Melanoma
Intraepithelial SCC
Excisional biopsy with 2 mm margin
Polygons, central regression, dermoscopic grey with chaos. Phenotypically appearing like a Seb K, Dermoscopically appearing like a Collision lesion b/w solar lentigo and a superficial spreading melanoma. I would just do a shave for histopath first
DDx lentigo maligna/invasive melanoma,
Pigmented BCC
An ‘ugly duckling’ casual naked eye appearance of seb K but dermoscopically…
This is a chaotic lesion with asymetry of structure and colour. Dark blotches
Clues to malignancy of eccentric structureless areas, blue gray veil at 3 o’clock, pigmented dots at 9 o’clock- some grey, thickened lines reticular, some peripheral radial lines.
On back, definitely malignant and small. Excise with 2mm margin.
With previous recomendations for MIS of 5mm I would have gone ahead with initial 5mm margins but now this extended to 1cm a biopsy 2-3mm margin more appropriate.
So, we all agree that a biopsy is needed, and for all the right reasons. I agree, and I would do a shave excision biopsy here, because the lesion is small and flat. And this procedure is quick. Dr Mundell recommended excision and the patient declined, so an option was obtained from a dermatologist at a high quality centre. The opinion was benign (LPLK) review in 6m. My view is that this is wrong. First you cannot make a definitive benign diagnosis here – we all have malignant differentials. The makes it suspicious. If it is suspicious you biopsy. Fingers crossed for the patient!
Thanks for everyones valued comments and your vaulable input David. I agree with all you opinions regarding this chaotic lesion with what i see as regression, blue grey, asymmetrical structureless areas and thickened lines reticular. I can understand Seb K and LPLK differentials too , but cannot leave a superficial spreading MM out either.
I will have further discussions with this patient and keep you updated. If i can persuade it to be put in a bottle i will update you with the pathology report
Thanks for everyones valued comments and your vaulable input David. I agree with all you opinions regarding this chaotic lesion with what i see as regression, blue grey, asymmetrical structureless areas and thickened lines reticular. I can understand Seb K and LPLK differentials too , but cannot leave a superficial spreading MM out either.
I will have further discussions with this patient and keep you updated. If i can persuade it to be put in a bottle i will update you with the pathology report ..
This lesion has multiple suspicious features including colour variation , areas of regression, which also appear to have vessels, thickened networking and some peripheral dots. This lesion needs excision biopsy with minimum 2mm margin.
dd – severe dysplastic naevus /superficial spreading melanoma