Case 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?

Case discussion

Case discussion

Update:

Here is the pathology report. What next?

Case discussion

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? [4 May]

  1. 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.

  2. suspect ‘silhouette’ with irregularly irregular dermoscopy features and reported change

    2mm margin excision – ?melanoma

  3. excision biopsy, 2mm margin.
    1. GOLDEN RULE – patient concern with specific lesion.
    2. family history of melanoma.
    3. brown pigmented lesion – full excision biopsy

  4. “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.

  5. likely junctional nevus, leave it alone and redo check in 4 months to observe for changes

  6. 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

    1. 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.

  7. 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.

  8. melanotic nevus with central hyperpigmentation . Lesion is almost symmetrical , no chaos or clues

  9. Reticular pattern bug uniform colours and no asymmetry, still I would do excision biopsy as it is changing
    Is this a Clark nevus?

  10. 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.

  11. 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.

    1. 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.