Case discussion: How would you treat this patient? [27 January]

This week, we discuss an interesting case from Dr Mokesh Raj. A 60+ year-old patient reported that his lesion has been getting darker over the last 6 months. Please examine the dermoscopic image below.

How would you evaluate this? If you were to do anything next, what would you do?

Case discussion

Update:

These are the results from the pathology report. What would you do next?

Anatomical Pathology:         

Specimen.
SKIN LESION RIGHT CHEEK

 

Gross Description.
The specimen consists of a skin ellipse 40 x 15 x 5 mm with an eccentric irregular variegated lesion 20 x 11 mm. X R 3L 


Microscopy.
Sections show severely sun damaged skin to subcutis in which there are features of an in situ melanoma. This is characterised by a proliferation of atypical melanocytes both singly and in nests along the basal layer of the epidermis. There is focal pagetoid spread and extension around adnexal structures but no evidence of dermal invasion is seen. The dermis contains a heavy chronic inflammatory cell infiltrate with scattered melanophages. The lesion appears to extend to within 0.4 mm of the nearest circumferential excision margin.

 

SKIN, RIGHT CHEEK: IN SITU MELANOMA, NARROWLY EXCISED.

 

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20 comments on “Case discussion: How would you treat this patient? [27 January]

  1. Pink and brown make me frown, history of reported change in older male, chaos of structures, and multiple colours and border irregularity, angulated lines.
    excise with minimum 2mm margins to sub cutis

  2. I go with pink an brown here. Also recent changes, periferal dots, ? polygons. Melanoma till otherwise proven. Excision biopsy 2-3mm margins to sub-cutis.

  3. Any changes in an existing mole requires excision.Excise with 2 mm margin for histology and arrange wider excision after the histology report

  4. Sorry didn’t know I had to magnify the image:
    chaotic lesion
    eccentric structureless area, grey dots.
    excision with 2 mm margin for staging

  5. white lines on polarisation, polygons, dermoscopic grey with regression within a nevus, possibly level 2 melanoma which needs 3mm margins excision for histopath

  6. When in doubt excision biopsy, the only way to be sure,
    most likely Melanoma with irregular melanocytes and white ridges

  7. 1) changing lesion in an adult male: exception to chaos and clues : should lead to excision biopsy
    2) chaotic lesion with chaos of structure and colour, with white lines: excision biopsy with 2 mm margin.

  8. Is is asymmetric.Choas.
    Thick lines, blue grey area
    Melanoma
    Excision biopsy with 2 mm margin or refer to
    Specialist

  9. Clearly, Chaos in terms of color and structure with Clues- Angulated lines with partial rhomboid or polygons with some clods (^ melanin proliferation). Thus 2mm margin excion and go from there.
    Imp: LM or LMM

  10. A recent change in a skin lesion in a 60 yrs old favour a more sinister process ie malignancy
    The lesion can be described as c with asymetry in pattern, colour and border.
    it exhibits pigmented lines angulated and perhaps branched, with few brown clods and dots.
    There is ar of blue and grey colour suggesting deep dermal melanin and a sml structurless area
    there is no reticular eork I could see which would make a possibility of other malignancies
    although i would think Melanoma is highest in the list it is possible for a pigmented BCC and SCC to present this way.

  11. Given the impression i have posted earlier I would excise this lesion with a 2 mm margin and await the histology report and further act accordingly.

  12. Complete excision and further referral to Melanoma clinic in hospital setting.
    will need pan scan and lymph node biopsy so referral is must
    Plastic surgeons input, plus further investigations

  13. Thanks for all the comments. We all seem to agree that this is a suspicious lesion – and needs a biopsy. I agree! The most appropriate way forward, as most agree, is a 2mm excision biopsy. The aim here is to get a diagnosis. You should not do a 3 or 5 or other mm excision biopsy. You need a diagnosis before you treat. If the diagnosis is confirmed as in situ melanoma (as it is here) then you can do the excision for treatment (5mm margins) in general practice (if you are competent to close the hole) and the patient needs no referral and no further treatment. My firm advice is if the excision biopsy shows invasive melanoma, you should discuss the case with the local melanoma unit and see whether they want to see the patient. Why? Because guidelines are changing frequently, in response to new research findings and some trials may be underway that the patient is eligible for.