Case discussion: How would you treat this patient? [20 April]

In this week’s case from Dr Alexander Speight, we have a patient who presented for a routine skin check:

  • 67 year-old male who has had previous BCCs only.
  • Multiple previous excisions elsewhere.
  • Multiple naevi and seborrhoeic keratoses over his whole body.
  • Noted that a lesion on the right flank was different to all the others, paler.

How do you assess the clinical picture and dermoscopy? What would you do next?

Case discussion    Case discussion

Update:

Here is the pathology. What would you do next?

Case discussion

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

  1. pink white colour, eccentric pirgmentation surrounding the follicle
    needs a biopsy as this may turn out to be a melanoma

    1. Chaos of color and structure. Reticular pigment pattern with thick lines on periphery rim, most prominent at 7 o’clock, central whitening and pink structureless area with white lines.
      Melanoma in situ.
      Excision with 5 mm borders, biopsy.

  2. 10 mm flat pigmented lesion , brown and pink . Dermoscopy shows thickened network at 6-7 o clock and central regression ,white structures .
    Exc biopsy with 2 mm margin, D/D melanoma, LPLK ,

  3. Reticular pigment –most prominent at 7 o’clock and size the concern , .
    Biopsy excision with 5 mm borders

  4. Standard excisional biopsy. Likely in-situ melanoma. Marked regression, white lines & stand out lesion in a 75 yo make it an easy decision

  5. “Ugly duckling” lesion with suspicious dermoscopic features such as asymmetry, atypical network, white lines, variable colors of brown, pink and white, suggestive of MM. I would do excision biopsy with 2-3 mm margins to rule out MM.

  6. ugly duckling with asymmetry of colours and pattern, atypical network, white lines, polymorphous vessels:
    enough to tell me it needs excision with 2 mm margins.

  7. Melanocytic lesion with different colours, different reticular pattern, polymorphic vessels, white lines.
    Possible Melanoma.
    Management- excision biopsy with 2mm margins

  8. Elephant approach this is benign and i will observe this flat lesion for upto 4 months with a review. wont excise at this point as its lacking in essential criteria for biopsy with just central regression alone

  9. Irritated ?naevus either a sebK. There are polymorphic blood vessels and possibly some chrysalis lines present so cannot ignore it – but likely attributable to irritation. Gut feeling/blink tells me it is a benign lesion. It is a flat lesion so there`s the option to review after 3 months. Alternatively do a shave excisional biopsy.

  10. peripheral pigmented lesion, central chaos, white lines, suspicious of mm
    would do excisional biopsy with 2mm border

  11. remnants of a network in the periphery and regression covering more than half of the lesion needs excision to exclude melanoma

  12. Elderly male with past history of skin cancer, and a lesion that looks different from the others. That is all you need to know. That makes the lesion suspicious. No way this lesion can be confidently made benign. Needs a biopsy – excision biopsy with 2mm margins. In Situ melanoma then requires further excision with 5mm margin.

  13. Eccentric pigmentation, structureless pink area, blotch reticular pattern, bx. Polarized DS would be of interest next to this photo. Path indicates MMis, thus 5mm margin excision required.

  14. This lady has had sun exposure resulting in skin cnacers later in life. Therefore high risk of more skin ca. Lesion is irreg in outline with areas of dipigmentation seen. For excision .