Case discussion: How would you treat this patient? [19 November]

This week we have an engaging case from Dr Thuy Au. A middle aged male presented for travel immunisations, and as part of a preventive health check was asked about a skin check. He noted a spot on his chest that had been present for years. His wife noted it had grown and become darker in the last year, but his GP had advised it was nothing to worry about and to see if it changed more.

Please review the dermoscopy image. What is your differential diagnosis and how would you do next?

Case discussion

Case submitted by Dr Thuy Au

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? [19 November]

  1. DD
    Pigmented BCC most likely
    Melanoma to be excluded

    Lesion appears relatively small , on the chest , I will excise with 3 mm margins . If BCC all done , if otherwise deal with it accordingly

  2. Chaotic lesion.
    Clues of peripheral dots. Grey.

    Maybe some leaf like pigment at 7 o’clock.

    Excision biopsy of whole lesion including the extension between 12 and 2 o’clock.

  3. clinical History:
    growing,chaotic
    dermoscopy:
    hypo pigmented areas
    BWV
    dots grey peripheral asymmetric distribution
    sticky fibre clue at 3 o,clock
    DDx: pigmented BCC, melanoma,
    Rx: surgical excision minimal 3mm border

  4. Pigmented lesion
    History of change

    Chaos-Colour and structure
    Multi – coloured
    Blue – grey
    Brown and dark brown
    central area of white ? regression
    Lines reticular
    Clods peripheral and central

    DD
    Melanoma
    ? Other

    Assess nodes etc
    2 mm excision biopsy
    Dx and type plus Breslow
    Plan accordingly

  5. The key, as we all know, is in the history here. ‘Growing and getting darker’ mandates biopsy. The GP was incorrect to reassure the patient. Assuming the lesion is flat a deep shave is a good, quick option here, but excision biopsy with 2mm margins is the alternative. This will confirm the diagnosis of melanoma and then a final, definitive excision can be done. However, It is important to do the excision biopsy or shave first, because all patients with invasive melanoma should be referred to the local melanoma unit for consideration of SLNB, adjuvant therapy, and also inclusion in the latest clinical trials. That is current optimal care.

  6. In WA patients with thin melanomas (Breslow thickness <0.8 ) without any complications are not accepted by WAKMAS. They also take into account if there are any untoward features in HP report.
    This is a very thin melanoma (Breslow 0.2 ) and HP report shows no ulceration, no mitosis and no perineural or lymphovascular invasion.
    No investigations are recommended for this level melanoma (including SLNB)
    As this is a Lentigo Maligna Melanoma which grows mainly laterally , it can be removed safely with 0.5-1 cm margin down to subcutaneous tissue.
    The key is to check remaining skin for other lesions and followups 3-4 monthly for next 2 years

  7. Where are the blue clods at 930 to 10 coming from if it is so thin ?
    I guess melanophages but clods rather than dots ?

    I am a bit of a novice and not sure whether we should accept these or not ?