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1800 867 1390Case discussion: How would you treat this patient? [4 May]
We present another case this week from Dr David Stewart with the following:
- 38 year-old male
- Mole on the lower leg, reported to be getting darker
- Uncle has a history of melanoma
Please review the below images, and advise what, if anything, you would do next?
Update:
Here is the pathology report. What next?
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1300 856 695
+44 203 514 0688
1800 867 1390
Dermoscope , thick lines reticular , would do a punch biopsy with 2 mm margin
a new pigmented lesion with island of melanin, reticular lines , warrants for excision biopsy
No Chaos in pattern or colour, clue is thick lines reticular. Looks like reticulated seb. K. But recent change and family history prompting me to go for biopsy.
This is most likely benign, but easy enough to punch excise given the history of change.
suspect ‘silhouette’ with irregularly irregular dermoscopy features and reported change
2mm margin excision – ?melanoma
excision biopsy, 2mm margin.
1. GOLDEN RULE – patient concern with specific lesion.
2. family history of melanoma.
3. brown pigmented lesion – full excision biopsy
i would do excision biopsy? melanoma
thick reticular,lines, leaned more weight on hx of acute onset
i woudl do a excision bx
“change trumps everything'” – course quotation
family history not strong ie. uncle, but relevant
if in doubt cut it out
So excision biopsy is required on these counts alone.
Then irregular in colour and shape with possible regression areas, but I can’t see a network. So 2/3 suspicious.
And then the patient will want it removed!
So excision biopsy.
But DDx could be boring pigmented SebK. Doesn’t matter.
review dermoscopicaly every 3 month with photo documentation
most likely benign
likely junctional nevus, leave it alone and redo check in 4 months to observe for changes
Change and thick reticular lines warrant excision biopsy. ? Seb K ? melanoma.
reported changing , cannot confidently assure benign , , excise with 2mm margin , ( I would shave )
derm shows symmetry, two colour brown, pigment central ( benign ) and extends peripherally.
no chaos , but small and a clue ( thick lines ? reticular) I am not sure if I see network due to image quality
Clark Nevus , D/D seb K , MIS
Hx of Uncle with melanoma just increases pt anxiety , not pt risk of melanoma
Patient is concerned and I cannot say with certainty this is benign. Excisional biopsy with 2 mm margin.
Another option could be photography and 3 month follow up.
To me the dermoscopic features dont support a suspicious lesion.
The issues are recent change in lesion and patient concerns.
I will perform excision with 2mm margins.
melanotic nevus with central hyperpigmentation . Lesion is almost symmetrical , no chaos or clues
Reticular pattern bug uniform colours and no asymmetry, still I would do excision biopsy as it is changing
Is this a Clark nevus?
Thanks everyone. I found it difficult to get excited by the patient history and demographics (38y old – allowed to have changing nevi) and the dermoscopy was benign for me. But, in small lesions, the dermoscopy is often unconvincing. I agree with the approach that says – patient anxiety / concern, easy to do a punch excision (clear of margins) and then it is out.
Clinicopathological judgment overrules regardless of DS findings. Would excise w/clear margins. It is too risky to leave behind; excision of this small lesion has low risk compared to if left behind and benefit outweighs risk. Pathology report leans toward atypia of uncertainty.
Due to the uncertainty of the pathology report, I did a further excision with 5mm margins which came back as clear. Patient was happy with the end result.