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1800 867 1390Case discussion: How would you treat this patient? [18 November]
This week we discuss a compelling case from Dr Mokesh Raj of a man aged 60+ with sun damaged skin – a common presentation in both skin cancer clinics and general practice settings in Australia.
There is no history or clinical picture. What is your opinion on the dermoscopy image? Are there any features or criteria of note?
Would you biopsy this lesion from what you see here? Why? How?
Update:
These are the results from the pathology report. What would you do next?
Specimen.
SKIN LESION LEFT CHEEKGross Description.
The specimen consists of a skin ellipse 7 x 4 x 2 mm with a central brown macule 5 x 3 mm. 3 NR 3LMicroscopy.
The epidermis shows scattered foci of atrophy and the dermis shows elastosis. Extending diffusely along basal epidermis and down follicular infundibula are melanocytes with enlarged, hyperchromatic nuclei. No dermal invasion is identified. The lesion focally involves a radial margin.MALIGNANT MELANOMA IN SITU ON SUN DAMAGED SKIN (LENTIGO MALIGNA), FOCALLY INVOLVING A RADIAL MARGIN
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chaostic lesion, asymetrical, atypical network- for excisional biopsy 2mm margin
lesion asymmetrical, blue-white coloration and network.
excisional biopsy with 2mm wide margin
lesion asymmetrical, blue-white coloration and network.
excisional biopsy with 2mm wide margin
atypical lesion with irregular edges and chaos, it is melanoma, Need EXCISION with 2mm margin.
Asymmetrical, atypical network, biopsy with 2mm margin looks like melanoma
i think it need skin biosy
there is atypical bloch
regression white area
shiny white streaks
Will arrange excisional biopsy
has dermoscopic grey and regression with peripheral dermoscopic island pigmentation, shave biopsy will be enough. most likely a highly dysplastic nevus
Chaos of colours and structures. Thick reticular lines asymmetrically distributed with some grey area.
Which warrant a biopsy.
However, some of Clark nevi’s can present with similar grey and [pigmented network. Few hairs come through the lesion, which suggests this lesion could be benign as well.
Hard one to decide, to excise or not.
Atypical
it is a typical
Asymmetry. No network. B W spot +
Excisonal bx with 2 mm margin
on careful view, the dermoscopy is clear here – score at least. 2 on 3 point (asymmetry and atypical network) – requires 2mm excision biopsy. now needs excision with 5mm margins
Chaos in structure and colour, Atypical network at most areas of upper part of lesion.
Excision biopsy with 2 mm margin.
Needs excisions biopsy (2mm margin) after discussion with patient regards to facial scarring. Most patients are just happy to get rid of the lesion but some are unrealistic about cosmetic outcomes and they will need referral to ensure they feel they have had the best chance removal plus good scar (whether they actually get it or not!)
LM without clearance of radial margin – re-excise with 5-10mm margins
Chaos of structure, colour and border. Dermatoscopically gray on the face. Initial 2mm margin excision biopsy. Pathology on this mandates 5 mm clearance margin on re-excision. Possibly a bit more than this given that the original excision biopsy had melanoma at the margin
Excise with 5mm margin. As LM may extend beyond the clinical margins in this sun damaged skin with adnexal involvement and “bread-loafing ” has a 9%
incomplete margin assessment, mapped serial excision or
Moh’s by a qualified practitioner may be required.