Case discussion: How would you treat this patient? [17 February]

For this week’s analysis, we have a case from Dr Mokesh Raj. Some key points to consider:

  • No history or clinical picture
  • Lesion is located on the face
  • Patient is a 70+ male
  • Review the image below

What is your evaluation and how would you proceed? How would you biopsy, if you choose to biopsy? It is prudent to remember that not all lesions are skin cancer.

Case discussion

Update:

Here is the result. What would you do next?

Specimen.
SKIN LESION RIGHT FACE


Gross Description.
Skin ellipse  8 x 4 x 1 mm with a central slightly raised brown lesion 6 x 3 mm.  Margins inked blue.  Transversely sectioned. A2 radial margins B2 transverse section NR


Microscopy.
SYNOPTIC REPORT FOR MALIGNANT MELANOMA
Sub-type of Melanoma: Lentigo maligna


Microscopic findings:
Growth phase: Vertical
Breslow thickness (to nearest 0.1 mm): 0.3 mm
Clark level: II
Ulceration: Absent
Mitotic rate of the dermal invasive melanoma: per square millimetre- zero
Lymphovascular Invasion: Absent
Neurotropism: Not identified
Regression: Absent
Tumour Infiltrating Lymphocytes (TILs): Present
Microsatellites (note this does not include adnexal involvement): Absent
Associated Benign Melanocytic Lesion: Absent
Associated Benign Squamous Lesion: Absent
Surgical Excision Margins Involved: Positive
Nearest Peripheral Margin to Invasive Component: 0.5 mm
Nearest Peripheral Margin to in situ Component: Positive
Distance from tumour to Deep Margin: Positive (in situ down adnexae)


AJCC pTNM staging (8th edition)
Primary Tumour (pT):
pT1a: Melanoma less than 0.8 mm in thickness, no ulceration


Regional Lymph Nodes (N):
NX  Regional lymph nodes not assessed

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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20 comments on “Case discussion: How would you treat this patient? [17 February]

  1. I suspect that this is an actinic keratosis.
    I would not do a biopsy. Instead I may trial either a direct or field treatment with Efudix BD for 4 weeks and see if this lesion will resolve or remain. If it does not clear I will do a shave biopsy.

  2. looks like solar keratosis : treatment option : Aldara 5% if he can afford, efudix if he is happy to tolerate the redness or liq nitro if he is happy to except skin diacolouration.
    2mm Punch biopsy if nothing works

  3. This is a chaotic pigmented lesion on the face that shows per-follicular pigmentations or pigmented circles as well as some inflammation or structurless area in the middle which is suspicious for Melanoma.

    This will ideally need excisional biopsy, however, if it’s a big lesion then we can do shave excision instead to check it

  4. AK in collision with solar lentigo. Possibly some LPLK on the lower end. Only worisome aspect I detect it the poorly defined borders to the lesion. Comparative approach with other pigmented lesion on the face could help support the conclusion that this is likely a benign lesion. I don`t think I would biopsy unless this were a solitary lesion `sticking out` clinically.

  5. It could be IEC or SCC on background of solar lentigo. I would do shave biopsy with 1-2 mm margin around the erythematous area .

  6. This looks benign, pigmented solar keratosis with scaling in the middle, can be left alone or treated with cryotherapy. No need for biopsy at this stage as there is no obvious dermatoscopic features of malignancy

  7. lesion on face of a 70 year old man.
    structure less pigmented lesion with circles around follicular openings.
    working diagnosis LM.
    management.
    1) confocal microsocopy if available.
    2) excision biopsy is ideal
    3) shave biopsy of whole lesion can be done as well.

  8. Suspect this is AK/early SCC in a solar lentigo. Would trial topical treatments first and followup in this case. Excision biopsy if there is no response /if any redflags.

  9. Good case.History ,subtle chaos( asymmetry of colour) suggest LM,especially with pigmented circles superiorly.But could be simply solar lentigo.
    Possibly a case for short term SDDI here(digital monitoring).
    Shave biopsy( ? whole lesion )would be my choice in this cosmetically sensitive area.

  10. Not especially concerning lesion. “Depigmented” area looks superficial and keratotic ?collision or recent minor trauma. Probably solar lentigo, worst case is LM, in which case there is no urgency to excise (very slow growing whilst in the superficial phase) so digital monitoring is my preferred option. If patient remote, otherwise high risk (previous melanoma/LM) punch biopsy or if lesion small/easy area (e.g. pre-auricular) excision biopsy with narrow (1mm) margin.
    [In response to comment above, under no circumstances should a 2cm margin ever be applied to a lesion which might be benign, especially the face. Always biopsy with minimal margins first, definitive margins derive from pathology – dermoscopy is a great tool but will never accurately predict Breslow thickness, which determines your definitive margins. Primum non nocere!]

  11. the reason we posted this case, this way, is to point out how indistinct, and non specific, facial melanoma can be. I don’t see any specific dermoscopic criteria here that lead me to be more confident one way or the other. This lesion is perfect for a shave excision biopsy – it is small and flat

  12. Next step now that you know it is malignant…re-excuse with a 1 cm margin am driving the lesion is 0.3 mm thick

  13. Holy Moly! I think my `facial shave biopsy rate` will be going up in the next few months
    Great case indeed.

    Next excision with 10mm margins ideally indeed – according to current guidelines.