Case discussion: How would you treat this patient? [4 November]

This week we have an interesting case from Dr Colin Armstrong. An 85-year-old male presented for a skin check and suspected for melanoma. Please review the clinical and dermoscopic images below.

How would you biopsy this suspicious pigmented lesion on the chest? What is your differential diagnosis?

Case discussion      Case discussion

Update:

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

DIAGNOSTIC SUMMARY:
SHAVE BIOPSY RIGHT MID CHEST:
– PIGMENTED INTRAEPIDERMAL CARCINOMA.
– COEXISTING, SMALL JUNCTIONAL LENTIGINOUS NAEVUS AND SEBORRHOEIC KERATOSIS.

Clinical notes:

Histopathology – shave biopsy, right mid chest ?atypical naevus excl melanoma (polygons).

Macroscopic:
Labelled ‘R mid chest’. A 15 x 10 x 1mm shaved skin specimen with a dark brown macule 8 x 6mm. 1A-1B 3TS each.

Microscopic:
These sections of skin show several pathologies. There is pigmented intra epidermal carcinoma. Deep to the in-situ disease is a lichenoid inflammatory cell infiltrate and there is associated patchy pigment incontinence within the papillary dermis. There is no invasive malignancy. The in-situ disease appears clear of the shave edges in the sections examined. Adjacent to this is a small junctional lentiginous naevus which also appears clear of the shave edges. There is also a small seborrhoeic keratosis towards one peripheral edge of the shave.

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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15 comments on “Case discussion: How would you treat this patient? [4 November]

  1. Highly suspicious for melanoma ( SSM type).
    Elliptical excision biopsy with 2mm margin recommended.
    Differential diagnosis – LPLK

  2. Pink and brown =frown on severe sun damaged anterior trunk
    Chaos and clues of grey structures, angulated lines.
    High suspicion melanoma
    Excise 2mm margins

  3. In this stand out ugly duckling lesion in an 85 year old with severely sun damaged skin, dermoscopy shows chaos, brown pink grey and black, multiple areas with dots, polygonal structures, and a branched vessel at 6 o’clock.
    highly suspicious for SMM.
    Excision with 2 mm margin.
    Further management dependent on results.

  4. definitely demonstrates asymmetry of structure and colour with definite blue grey areas and polygonal areas
    Differential could also include pigmented BCC as there are branching vessels aswell as melanoma.
    I would do an excision biopsy – ellipse with 2mm margins

  5. A standout macula on the right chest of a 85 year old male with severe sun damaged skin.
    Dermatoscopy: Chaos in structure and colour (brown, grey, pink & tan) with cut-off borders on right side of the image. Remnants of brown network, asymmetric brown and grey dots and brown clods and a few polygons. Structureless white and brown areas. Areas of erythema in background.
    Highly suspicious of melanoma
    Excision biopsy with 2mm margin.

  6. The pathology report (SCCis?) doesn`t match up with the dermoscopic image. There is a `naevus` detected so it is melanocytic. Ther report suggests no sign of invasive malignancy.
    I guess I would treat it as a suspected melanoma in situ and excise the shave biopsy scar with 5mm margins.

  7. Hi All – I agree with the comments here. Suspicious pigmented skin lesion. 2mm excision biopsy. Pathology is consistent with dermoscopy. No further treatment needed.

  8. I am confused by the pathology report
    ” Pigmented intra dermal carcinoma ”
    So we would manage as a SCC in situ or a pigmented BCC not a lentigo maligna
    So the shave excision performed is adequate ?
    Is that correct?

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