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1800 867 1390Case discussion: How would you treat this patient? [10 February]
This week, we present a case from Dr Mokesh Raj. There is no history or clinical picture.
What is your evaluation? What would you do next? How would you biopsy, if you choose to biopsy?
Update:
Here is the result. What would you do next?
Specimen.
SKIN LESION MID BACK EXCISION
Gross Description.
Skin ellipse 15 x 7 x 2 mm with a central tan to dark brown skin 10 x 3mm. Margins inked blue. Transversely sectioned. 4 NR
Microscopy.
Sections show melanoma in situ. The melanoma cells are at the basal epidermis with focal intraepidermal spread to involve the upper epidermis. There is no invasion. The dermis shows focal lymphocytic infiltration. There is no regression. The lesion involves one radial margin.
SKIN LESION MID BACK EXCISION MELANOMA IN SITU AT ONE MARGIN
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Biopsy
Appearance suspect, irregular assymetric pigmentation, appears to be ?single lesion as appears to be joined by strip of non-pimented, but different, skin to the surroundings.
Long shave biopsy probably kindest to the face, but excision biopsy of entire lesion with 2mm margin would give more accurate diagnosis.
In appearance there are suspicious features, but may be atypical pigmented seb.keratosis, difficult to see surface architecture clearly.
as this is non contact dermoscopy of a lesion, it is not possible to comment properly but phenotypically resembles a melanoma with atypical dermoscopic islands and multiple colours, can do multiple punch biopsies at the darkest regions in this lesion of 3mm size at different spots as the lesion is not showing clear cut margins.
excision biopsy with 2 mm margin
More history needed, how long and where, generally an excision biopsy is need with 3 mm margin depending on the site as the Melanocytes distribution favor melanoma
chaos in pigment, excise with 2mm margin for histo
Asymmetry of color and structure
irregular pigmented network
look suspicious
excision biopsy with 2 mm margin
Asymmetrical lesion with variability of pigment, Irregular border looks suspicious , would go for Excisional biopsy with 2mm border.
Not the best dermoscopic image, but I can’t confidently call it a sebK or solar lentigo, which is the main differential. Suspicious enough to excise with 2mm margins if possible, otherwise a deep shave of the entire lesion with same margins.
Hard to comment without a dermatoscope image, however, there is two colours and would appreciate the history and the dermatoscope in order to comment.
one doesn’t punch or shave a pigmented lesion suspicious of benign Melanoma, RIGHT ?
ONLY excision for history and biopsy,
chaos present (structure and colour), eccentric hypopigmented area, poss. psuedopods
Imp: melanoma
Plan: excision with 2 mm borders
thanks all. Fairly straightforward case this week. For me the key issue here was the asymmetry. Highly suspicious lesion – needs biopsy. Options are 2mm margin excision biopsy or deep complete shave (suitable for a flat, small lesion)
Asymmetrical structure and colour
irregular pigmented network
suspicious, when in doubt cut it out
excision biopsy with 2 mm margin