Case discussion: How would you treat this patient? [21 January]

This week we have an interesting case from Dr Dave Stewart. An 92-year-old male with this suspicious lesion on the chest.

Please review the clinical and dermoscopy images. What is your differential diagnosis and how would you biopsy?

Case discussion      Case discussion

Case submitted by Dr Dave Stewart

Update 1:

The patient declined biopsy, repeatedly, and here is the lesion 12 months later, when he finally agreed to biopsy. How do you deal with patients who refuse biopsy when it is obviously indicated?

Case discussion      Case discussion

Update 2:

Here is the final result. The patient refuses to proceed with the surgery! What is the next step you would take?

Case discussion

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9 comments on “Case discussion: How would you treat this patient? [21 January]

  1. asymmetry of colour and structures
    black dots / greyish pigmentation at 8 o’clock
    streaks brown and white
    structureless areas
    Dx MM

  2. I do a lot of medico-legal work. The key message from this case is to make sure that you clinical notes are clear and of high quality. It is the patient’s choice and decision about treatment. Our job is to provide clear advice and recommendation, and to diligently record our interactions. The biggest single issue with medico-legal cases is poor quality, and inadequate medical records.

  3. In this case, although aged 92 the patient is mentally sharp as a tack, and despite my best efforts at persuading him to have it removed just feels “at my age Doc, you’ve got to go of something” which is a bit hard to argue with. Interestingly, if you look at the pathology report you will see he had a crusty spot on his shoulder which he was much more concerned about. I finally did a bit of horse trading with him and said I would remove this (clearly benign) crusty spot if he would let me do a shave biopsy of his melanoma “otherwise the extra local anaesthetic would go to waste”. I think it was the thought of wasting the local that finally worked! As David has suggested, I have made sure to record every conversation where we have discussed this lesion, including his fully informed decision to refuse definitive surgical treatment. Thanks everyone for your input.

    1. Ask pathologists to further cuts . Dermoscopic view suggests some parts may be LMM. Lentigo maligna melanoma is invasive and changes the course of action. If all of it is just LM and then observation in a 92 year old may not be a bad decision.

  4. If he won’t go for WLE, maybe he’ll accept imiquimod. I think this may actually appear as a potential option in certain circumstances in the new guidelines.