Case discussion: How would you treat this patient? [14 October]

This week we have another engaging case. A 75-year-old Caucasian Australian male with a past history of solar keratosis and no previous melanoma or significant personal or family history of melanoma. Previously, he worked only indoors. The patient presented for opinion on a darker area of change in an existing “freckle” on his neck that was present for several years.

How would you respond to this presentation?

case discussion

case discussion

case discussion

Update:

How would you manage a patient with these findings? Please share your feedback.

SYNOPTIC REPORT FOR MALIGNANT MELANOMA
Diagnosis: Invasive malignant melanoma Site: Right mid neck Subtype: Superficial spreading Margin status: Involved Tumour Thickness (Breslow): 0.7mm Clark level: 3 Ulceration: Absent Mitotic count: 1/mm² Microsatellites: Not identified Perineural invasion: Not identified Lymphovascular invasion: Not identified Regression: – Early (TILS): Minimal (non-brisk) – Late (Fibrosis): Absent Associated benign naevus: Not identified Excision Margins: – Peripheral invasive: 1.5mm – Peripheral in-situ: Involved – Deep: Tumour focally abuts the deep margin.

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9 comments on “Case discussion: How would you treat this patient? [14 October]

  1. Macroscopically: sun-damaged skin, black lesion = ugly duckling
    Dermatoscopically: black clots, possibly thickened network, lesion seems to extend superiorly
    Looks suspicious for melanoma
    I would recommend urgent diagnostic excision with 2mm margin

    1. Agree macro suspicious ugly duckling
      Pigmented lesion, with enough asymmetry to need a 2mm margin.
      Could this be part of a wider lesion and need punch biopsies to exclude Lentigo maligna
      He may be lost to follow up, he clearly has his head in the sand ( photo 1)

  2. Pigmented lesion with chaos. Inside circumscribed segment the pattern is structureless, pigmentation is mainly presented with brown and gray clods, some brown and gray dots, residual reticular pattern with thickening lines.
    Diagnosis: Lentigo maligna.
    Excisional biopsy with 5 mm borders.

  3. A chaotic lesion with no clear clue! pigmented structureless area if I want to be very picky, maybe grey color?
    I would do an excisional biopsy with a 2 mm margin just based on his age and changing lesion.

  4. definitely not a solar lentigo, defintely not a compound nevi, has dermoscopic grey and structureless lesion, I would shave biopsy the most suspicious area for histopath

      1. Shave biopsy in the right hands makes all the difference, i do it a lot as i’m comfortable with it if its a flat lesion. if you’re a novice dont do it

  5. The lesion looks like a lentiginous melanoma, lentigo like but without a lentigo border.
    The whole pigmented area will be melanoma, all of to needs excising for cure. Tramlines (strips of skin) are cut around the lesion with a double bladed scalpel and sutured, margins are examined and declared involved or free of melanoma. A way of defining the orientation of the skin strips is needed.
    I involved a further 2mm is removed and further histology awaited. Eventually clear margins will be achieved and everything within the tramline plus the relevant margin is excised and the defect closed.
    Sometimes the margin fizzles away slowly with atypical melanocytic hyperplasia, the to call it quits is a discussion with the pathologist. In that case Imiquimod can be used as per a melanoma protocol to mop up.