Case discussion: How would you treat this patient? [25 March]

This week we have an interesting case. No clinical image or history.

What do you make of the dermoscopic image below? How would you biopsy?

Case discussion

Update:

These are the results from the pathology report. What do you think now? How would you treat further?

Case discussion

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11 comments on “Case discussion: How would you treat this patient? [25 March]

  1. Chaos and clue of black dots peripheral on dermatoscopy, also possible grey colour at 12 o’clock . I would opt for excision biopsy with 2mm margins.

  2. its hard to say without seeing a non magnified image of the area on scalp. looks like a pigmented BCC with globules of black amongst a structureless brown lesion

  3. It is asymmetrical skin lesion with abrupt borderline and islands of pigmentation with blue-grey discoloration on right lateral border making it suspicious for melanoma. I would go for an excision biopsy under local anaesthesia with 2 mm margin.

  4. Too much blue for a shave – will muck up the Breslow. Excise w 2 mm margin for suspected invasive melanoma.

  5. Looks like a BCC on Dermoscopy ( blue clods. Peripheral brown lines, serpentine vessel, structureless area).
    Biospy?/ excision confirms
    I’d excise further aiming for clear margins ( 4mm). I find Dermoscopy can assist to check placing of edges. Spec to histology. This way can confirm all out.

  6. Thanks David and Ashwin . This highlights a perennial question for me.
    I worry about shaving a pigmented lesion, but there are times it would be handy for say ? lentigo maligna .
    I notice it is often recommened in this forum for pigmented lesions.
    I did once take a shave too shallowly for a pigmented lesion and want never to repeat that.
    Is it the technique,? how do you know how deep to shave and margins?
    I shave allot of Seb K ‘s ( for free) so I have little practice in full depth shaves.
    The technique does not really come up at in the procedures meetings, they seem always to be shallow.
    Thanks

    1. Don`t take my word for it as I`m not in a position to teach ( I sometimes get mistaken for Prof. David who started this blog – that`s not me) . Anyway – to my understanding a shave for diagnosing a melanoma is appropriate when you suspect melanoma in situ or a flat thin melanoma – and in that case you expect to see mostly irregular brown network – you shouldn’t see blue, lots of grey or regression … in those cases an excision is usually more appropriate if you don`t want to `mess up` the Breslow. I recently saw a webinar by Dr Robyn Shaw oncologist-surgeon, and her opinion is that a deep shave should basically be down to the subcut fat tissue. Personally I`ve never done shaves this deep- must heal slowly and be quite unpleasant for the patient!?

  7. Thanks everyone. This is a tricky case. Clearly an asymmetric pigmented lesion, and needs a biopsy as it is suspicious. Following the rules, we would do a 2mm excision biopsy to be safe as melanoma is clearly in the differential. A shave is definitely an option for a small, flat pigmented lesion – this is quite a safe approach, because usually you will get the full thickness, and if you don’t (but it is a melanoma) you can move to full excision anyway. how deep to go? just 1-2mm will do the trick and they heal nicely.