Case discussion: How would you treat this patient? [6 January]

In our first case study for this year, we discuss an engaging case from Dr Tomy Varghese. A 65-year-old male presented for his routine check-up and scripts, when a pigmented lesion (10 x 12 mm) was noticed on his forehead. The lesion has become darker since his last visit about a year ago. How should this be managed?

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11 comments on “Case discussion: How would you treat this patient? [6 January]

  1. Superficial spreading melanoma, needs excision biopsy with 3mm margins. Radial streaming, grey dots, thick reticular network, peripheral atypical dermoscopic island, regression

  2. could be LM with grey asymmetric follicular opening 5 oclock, chaos of borders on dermatoscopy.

    mx: deep shave excision 1mm depth

  3. Chaos in colour however I can only see a bit A bit Of streaming on the left side with some areas of dark blotching which would mandate an excision. Plus the patient stated it recently darken.

  4. Excisional bx with 2mm margin most likely lentigo maligna, growing pigmented lesion on face at his age, multi color, streaming lines 9:00 o’clock, thick dark brown lines

  5. pseudonetwork with irregular color and rhomboids, grey dots on the left, structureless pink in the upper center and on the right, white lines in the center, radial streaming on the upper border.
    LMM / MIS
    Excision with 2 mm borders.

  6. Pigmented lesion on forehead ;It has changed ;clinical suspicious dermoscospy Grey circles,non lentigo like border This is melanoma in situ.It requires shave biopsy initially

  7. An Irregular Pigmented Lesion noted macroscopically. On Dermatoscopy a Solar Lentigo with background uniform brown pigmented is noted. However in areas 1 to 3 O clock there is loss of Pigment pattern with pink structureless suggesting regression and Pseudopods in this area Peripherally. I could not see detailed enough to note any blue grey dots . At 9 O clock peripherally is a region of darker thick pigmented lines and Pseudopods. Similar loss of structure at 6 0 clock. Impression Changing Solar lentigo : Lentigo Maligna Melanoma : Melanoma in Situ. As per guidelines 2mm margin Excision Biopsybut practically after discussion with patient I may do a 5mm margin Excision to avoid re-excision. However the final treatment will depend on Diagnosis and Breslow Score. Even a severe Dysplastic Lentigo would have to be treated as a Melanoma in situ with a final 5mm margin all round.

  8. Enough chaos and regression for a 2 mm excision, though I appreciate Renuka’s suggestion of 5 mm to start, I wish I was more confident.
    Can I ask would, would people favour a H flap or A on T or an some other alternative ?
    I seem to keep finding the superficial temporal artery around here .
    Hence I try to tie off any bleeders rather than diathermy, to be sure. Any tips on avoiding this vessel?

  9. Thanks for everyone’s input here. This is a “live” case and there is no pathology (yet). For me, this is a seborrhoeic keratosis on dermoscopy. All features are quite typical, but I agree that there is some doubt. What I would do here is a shave biopsy, because that would be quick and easy to do, would remove the very ugly lesion, and provide a definitive, histological diagnosis. I think that is a much better option than is doing a 2mm excision biopsy. This case shows the value of having some “intermediate level” dermoscopy skills. I hope Dr Varghese lets us know the histology when he gets it.

    1. Shave biopsy done when the patinet returned after his holiday.
      HISTOPATHOLOGY REPORT
      MACROSCOPIC EXAMINATION
      R forehead: Specimen consists of a shave biopsy measuring 11 x 9 x 1
      mm. Skin surface is covered with a mottled pigmented patch. Trisected
      1A.
      MICROSCOPIC EXAMINATION
      R forehead: Sections show a LEVEL 1 MELANOMA (melanoma in situ),
      lentigo maligna subtype. There is no evidence of dermal invasion.
      There is extensive areas of established regression.
      PERIPHERAL MARGIN CLEARANCE: Involved.
      CANCER COUNCIL AUSTRALIA RECOMMENDATION: Definitive excision with a
      cumulative clinical clearance of 5-10mm.
      SUMMARY:
      SHAVE BIOPSY LESION R FOREHEAD: LEVEL 1 MELANOMA (MELANOMA IN SITU).