Case discussion: How would you treat this patient? [28 October]

This week we have an interesting case. What do you make of the clinical and dermoscopic images below?

Is there a differential diagnosis? If so, how would you biopsy?

Case discussion

Update:

These are the results from the pathology report. What are the pros and cons of the treatment options here?

PATHOLOGY RESULT:
Within background features of solar lentigo, there is a subtle increase in melanocytes with mild irregularity in junctional arrangement (assessment includes SOX-10 immunostain). The features appear to amount to unstable solar lentigo (transitional lesion). They do not amount to lentigo maligna. Peripheral margin focally involved.

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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12 comments on “Case discussion: How would you treat this patient? [28 October]

  1. Modified pattern analysis- one pattern (Reticular lines ), one colour brown only.
    Has scalloped border to suggest solar lentigo
    Has clues – thick reticular lines which are segmental. which prompts for excision with 2mm margin.
    Other Differential would be – Solar lentigo, LPLK

  2. Chaos – in pigment and pattern
    Pigment- Asymmetric with non central light and dark pigment
    pattern- not consistent and darker lines in one area and fading in some area.
    Need more detailed dermoscopic views. likely need excision

  3. Chaos in colour (brown, tan & grey) & structure ( assymetric network with grey Structures on right side of image). Cut -off border between 7-10 o’clock. Asymmetric thickened network and asymmetrict grey structures. White lines. Suspicious of ssm. DDx SSM, SL.
    Depending on the site of the lesion: 2mm excision or shave bx

  4. Background of a lentigo with an area of chaos and clues including thickened reticular pattern, angular lines, peripheral dots and clods suggesting pagetoid spread at 8oclok Mark.
    Needs excision biopsy with at least 2mm margin to exclude MIS clashing with a solar lentigo

  5. Overall reticular pattern with moth-eaten borders. In the left medial segment annular-granular pattern, thick lines, dots, structureless areas in the upper part of this segment. In the right segment grey dots.

    Diagnosis: Lentigo maligna collision with Solar Lentigo.
    Excisional biopsy with 2 mm margins.

  6. Irregular border and asymmetrical in colour (dark to light brown) chaotic lesion with atypical network at 6 , 7 , 11 and 1200 .
    surgical ex with 2mm margin
    Lintigom Maligna?

  7. Irregular border and asymmetrical in colour (dark to light brown) chaotic lesion with atypical network at 6 , 7 , 11 and 1200 .
    surgical ex with 2mm margin
    Lintigo Maligna?

  8. Moth eaten borders on elephant approach with no obvious reason to biopsy this. Elephant approach from Guiseppe Argenziano is of great help in looking at the lesion as a whole and then going into finer details for a reason to biopsy or NOT

  9. I thought this was a good case to share, because to the experienced skin cancer GP with good dermoscopy skills, this is an “obvious” solar lentigo. It has all the relevant features. However, the darker area with an apparent network is a little confounding, and is a good enough reason to biopsy. As Geppi (and others) says – if in doubt cut it out. If I am thinking to myself “mmmm – I am not 100% sure” I will cut it out!

  10. Looks like Solar Lentigo
    I do understand some describing different shades and the network.
    I would probably monitor and photograph.
    Some people are always in doubt and cut everything out.