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1800 867 1390Case discussion: How would you treat this patient? [20 May]
This week we have an interesting case from Dr Renuka Ranasinghe. An elderly male presented for a skin check for benign seb k’s noticed by his wife.
The below shown pigmented lesion was noted – what do you make of the clinical and dermoscopic pictures? How would you biopsy this lesion?
Update:
Here is the pathology result. Are you surprised? What would you do next?
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1300 856 695
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1800 867 1390
This lesion does not fit the recognized clues if seb k. Border is not well circumscribed, considering non polarised dermoscopy – lack of white dots/clods. Appears to have dermoscopic grey colours and ?white lines. I would excise this lesion to rule out melanoma.
Clinically: Ugly duckling. A pigmented macula with keratin surrounded by erythema
Dermatoscopy: Pigmented lesion with fine reticular network superior peripheral part of image but mainly erythematous with keratin. Few white circles.
DDx: Invasive pSCC. Unlikely MM, BCC
Will do a 4mm punch biopsy
Lesion has irregular structureless brown pigmentation pattern in the center with light brown pigmented radiated streaks on periphery. Whitish depigmented clods in the center. Thin scales overall a lesion, mainly in the center. Dotted vessels on the upper part.
Lesion is suspicious for SSM (Superficially Spreading Melanoma).
Excisional biopsy would be preferable in this case with min 5 mm margins of surrounded skin.
starburst appearance with peripheral radial streaks and white lines on polarisation which is not very evident due to non contact dermoscopy, needs contact done for evaluation. needs excisional biopsy anyway, most likely malignant melanoma as does not fit seb K criteria
I could have been fooled by this one, I thought the white dots were milia cysts. I think the macroscopic appearance was most concerning .
Just to put my hand up and say anything other that Superficial or under 0.5mm I send off. I need to sleep at night.
I appreciate the depth of clinical detail entered by the doctor referring detail, I am still not sure my pathologist is that interested, or it could be me, so I will write more
Thanks for the case
Macro and micro is kind of hard to tell really but the HP is surprising. Needs to be excised with safety margin.
Initially my answer was SSM but it turns out MM. I’ve recommended above to excise it with 5 mm margins for biopsy.
According a PH report only 4 mm margins are clear of MM, thus 5 mm margins were not achieved in this case.
Thus, a local wide reexcision with the 10 – 20 mm margins and including superficial fascia are recommended in this case to achieve 5 mm HP clearance. Also, ulceration, mitosis and Breslow > 1 mm are indicators for sentinel LN check.
Thanks for all the input here. The clinical appearance is very worrying – a lonely lesion – it is pigmented and not a typical Seb k, therefore it needs excision biopsy. The margins should be 2mm, as this is a diagnostic procedure, not a therapeutic one. This is what national guidelines require. This approach would then provide the diagnosis of invasive melanoma, and all such lesions should now be discussed with the local melanoma unit to determine best next steps. Melanoma therapeutics are moving so rapidly now.