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1800 867 1390Case 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 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?
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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1300 856 695
+44 203 514 0688
1800 867 1390
Irregular asymmetric lesion with blue hyperpigmentation
Possible malignancy Melanoma or BCC
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
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.
Meant to add looks like MM. Can’t rule out sBCC.
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
Exclude MM as it’s chaotic with dark clods. Excise it.
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
dermoscopic blue, grey and faint polygons, needs shave excision to rule out SSM
Excise 1cm margin deep to fascia.
Hi Peter
Why 1cm margin & deep to the fascia?
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.
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
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 ?