Case discussion: How would you treat this patient? [16 March]

Our case study this week comes from Dr Dave Stewart and features a 9 year-old child with a long standing mole that has been changing and growing, according to their parents.

What is your assessment of the dermoscopy image, and what would you do next? Why?

Case discussion

Here is the pathology result. What should be done next? Why?

CLINICAL NOTES

Shave excision of an irregularly pigmented lesion on the right forearm of an 8 year old? Spitz naevus? Atypical naevus? Melanoma

MACROSCOPIC EXAMINATION
“Right forearm”: A shaved piece of skin, 8 x 8 x 1 mm, bearing a well-defined, brown plaque, 5 x 5 mm. 2P1BBAE. (VA)

MICROSCOPIC EXAMINATION
Skin sections show elongated epidermal rete edges associated with a proliferation of pigmented melanocytes exhibiting a relatively uniform spindle nuclei and slightly pigmented cytoplasm. There are dermal melanocytes also, but the picture is obscured by prominent inflammation and pigmented incontinence. Immunohistochemistry has been requested for further assessment. The histology will be discussed with Professor Kossard. The lesion extends to the peripheral edge and to the base.

SUMMARY

RIGHT FOREARM: COMPOUND MELANOCYTIC PROLIFERATION WITH SPITZOID FEATURES, DERMAL INFLAMMATION AND PROMINENT PIGMENT INCONTINENCE. PENDING IMMUNOHISTOCHEMISTRY AND SECOND OPINION.

SUPPLEMENTARY REPORT

  1. This case has been discussed with Professor Kossard. Although the lesion resembles a Spitz naevus, there is a prominent host response. An opinion from Professor Scolyer will be sought.
  2. Sox10 and Melan A decorate the junctional melanocytes and the dermal component highlighting disorganised architecture of the lesion. HMB-45 is positive predominantly with the junctional component. A Second opinion is pending.

MICROSCOPIC REPORT
Sections show skin including superficial dermis with a compound melanocytic lesion with some evidence of superficial irritation. The junctional component consists of nests of pigmented spitzoid cells being round and oval with prominent nucleoli and mild to moderate atypia. Focal upward spread is noted but there is no confluence or marked atypia. The dermis is obscured by a prominent chronic inflammatory infiltrate but shows similar appearing Spitzoid cells with some mild atypia and possibly incomplete maturation. Occasional dermal mitoses are seen upto 2 Per mm2.

There are some definite atypical features present including some dermal mitoses, atypia and incomplete maturation. However in the context of the prominent inflammation, raising the possibility of regression, and evidence of irritation. Overall I favour an atypical compound Spitz naevus. The lesion is probably best managed as a lesion of uncertain malignant potential.

The lesion extends to the peripheral margin and to ensure the lesion is entirely examined and to minimise the problems in interpreting a regenerating lesion should it recur, a further excision should be considered, id clinically appropriate.

Clinical Correlation is recommended.

SUMMARY

Shave biopsy, skin of right forearm:

  • Difficult borderline compound spitzoid lesion, marked involved.
  • Favour atypical Spitzoid naevus with irritation and regression

 

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14 comments on “Case discussion: How would you treat this patient? [16 March]

  1. On magnification an area of increased irregular darkened pigmentation.My preference err on the side of caution –excision biopsy under local

  2. may be an irritated seb k with regression but there are signs of asymmetric growth- pseudopod upper L, and I have never seen seb k in children. Excise for pathology.

  3. Reed nevus with peripheral pseudopods which can be left alone, doesnt need a biopsy . seb k doesnt usually happen in this age, i have never seen one before

  4. chaos in colour
    worrisome that parents report it has been changing (increasing in size)
    possible pseudopods, white lines
    Imp: poss. melanoma, differential dx Spitz, SK (but no milia seen)
    Plan: excise

  5. issues: 9 year old boy with long standing naevus: probable diagnosis: congenital naevus: probability of melanoma in this age group is very very small.

    Dermoscopy: fairly well defined lesion with globular pattern with hyperpigmentation and white lines.
    DD: regressing naevus, melanoma

    based on chaos and clues algorithm: it has chaos and white lines:—> excise

    but in the context of the whole case:

    1) If the child has more lesions of siimilar type then follow comparative approach and decide
    2) if it is isolated lesion : then options are either to follow up with drmoscopic imaging at 3 month mark or excise.
    The blue white area borders on around 50%. technically is it is more than 50% then it should be excised.

    given all he above mentioned reasons: I will follow it dermoscopically at 3 months.

  6. Looks like seb K considering the yellow/orange and white clods. However, seb K is very uncommon among children. Dermoscopically, it’s not worrisome but historically it’s changing and parents are concerned, hence I will do shave excision for peace of mind of everybody.

  7. Brown clods and chrysalis structures. In this age group I would be concerned about melanoma. Chrysalis structures can also be seen in Spitz nevi, but I do not see features of that here.

  8. Looks like sebK but agree with colleagues,uncommon in this age group.Due for parents anxiety ,I will excise

  9. This is a great case that stands up to my BEST protocol well. Is this “Benign or Suspicious”? There are plausible benign diagnoses. Seb K is NOT (in my view) a plausible benign diagnosis in a 9y old child – vanishingly rare. There are plausible suspicious diagnoses – we are all aware of risk of melanoma (very low, but real). So – we need to know is this lesion 1 of many that look similar / the same. If yes, reassure and review. If not 1 of many that look the same – you must do excision biopsy. This simple approach – Benign or Suspicious works every time. In this case the lesion turned out to be benign, but even the pathologists couldn’t be sure what it was. Don’t fall into the trap of “wishful thinking” by coming up with a plausible benign diagnosis and settling on that – when a plausible suspicious diagnosis exists.