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

This week we have another engaging case. A 65-year-old Caucasian female with no history of melanoma presented for excision of a cyst on her back. A full skin check was done and a pigmented skin lesion was noted on her lower back.

How would you respond to this presentation?

Case discussion      Case discussion


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

Microscopic: 1. Sections are of skin, including subcutis, and show malignant melanoma: TYPE – Superficial spreading CELL TYPE – Naevoid to epithelioid, moderate tending to moderate-severe cytological atypia, moderate increase in pale cytoplasm. PIGMENT – Mild ULCERATION – Not evident CLARK LEVEL – 3; expanding and tending to fill papillary dermis. BRESLOW THICKNESS – 0.68mm MITOTIC RATE – No dermal mitotic figures identified. TUMOUR INFILTRATING LYMPHOCYTES – Focal REGRESSION – No significant regression fibrosis. PERINEURAL OR LYMPHOVASCULAR INVASION – Not identified SATELLITE DEPOSITS – Not identified COMPLETENESS OF EXCISION – 1mm from both transverse margins, >5mm from longitudinal ends.


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

  1. Her skin does NOT show a lot of sun damage, lesion looks like ugly duckling macroscopically.
    Chaos, multiple colours, black clots brown dots, pink & red areas, white lines with polarisation…
    I would excise this lesion with two mm margin , most likely malignant, ??MIS

  2. Chaos of structure and color. Brown clods, brown and grey dots peripherally in upper part, white regression zones indicate on melanoma. Central black clod and pink structureless around may indicate on invasive process.

    Diagnosis: Invasive melanoma.
    Excision with 5 mm margins.

  3. It’s a melanocytic lesion
    As per 7 point checklist :
    Irregular pigmentation / blotch – near centre
    Atypical pigment network at 2 o clock
    Regression more than 20%
    Provisional diagnosis – melanoma in situ
    Needs excision biopsy (elliptical ) with 5 mm safety margins at least as per guidelines – however final margins based on the Histopath report

    1. Suspicious looking Melanocytic lesion
      Initial punch biopsy to diagnose
      Follow up with excision with 5 mm margin all round,.
      If histology shows complete excision, follow up
      If excision is incomplete, refer dermatologistfor review.
      May need further surgery and radio

  4. Chaotic lesion with central erythema (v/s component), 1 dark-bluish clod, and few brown dots, my preferential would be: (1) pBCC; (2) MM.

    Ideally punched biopsy is for NMSC but it is important to r/o MM in this case, thus 2-3mm margin excisional biopsy and go from there. WLE margin 5mm, 10mm should not applied at fist instance w/out establishment of Dx with breslow thickness.

  5. Pigmented lesion.
    best to apply Chaos and clues algorithm.
    Chaos of structures( clods , dots, and structureless areas) , Chaos of colors ( brown, pink and black)
    Clues- Eccentric structureless and peripheral dots/clods

    Mx- Excise with a 2mm margin
    Dx- melanoma ( pink, brown, polymorphic vascular pattern)

  6. This is a pigmented lesion
    Chaos of structures and colours, Clues- thick reticular, structureless and dots
    Melanoma suspected here. Excise with a 2mm margin.

  7. Stand out isolated “ugly ducking” in older person, likely melanoma mandates 2mm margin excision biopsy. Diagnosis is confirmed and thickness is <1mm, so final excision margins are 10mm. Cheers to all

  8. oriented elliptical excision with 2mm clinical margin followed by wide local excision +/- sentinal node biopsy depending on the initial report