Case discussion: How would you treat this patient? [22 June]

In this week’s discussion, we present a case from Dr Christopher Jensen, featuring:

  • 69 year-old male patient
  • New pigmented lesion on his right cheek
  • History of invasive melanoma and melanoma in situ, 20 years and 1 year ago respectively

What do you make of these images? What would you do, if anything?

Case discussion    Case discussion

Update:

Pathology report is:

Clinical Details:
Pbx R cheek

Macroscopic Description:
Right cheek: A 4mm punch of skin, 5mm deep. Bisected. 2-1A.

Microscopic Description:
Sun damaged skin with subcutis. There are large epithelioid melanocytes along the junction in a lentiginous pattern extending into follicular epithelium and showing focal pagetoid infiltration. Dermal invasion at a depth of 0.87 mm is present.

PRAME is negative.

Conclusion:
Right cheek, biopsy:
Diagnosis: Malignant melanoma
Subtype: Superficial spreading
Breslow Tumour thickness: 0.9 mm
Mitotic rate (/mm2): Nil
Ulceration: Absent
Level of invasion (Clark): Level IV
Vascular invasion: Absent
Microsatellites: Absent
Regression: Absent
Neurotropism: Absent
Desmoplasia: Absent
Tumour infiltrating lymphocytes: Moderate infiltration at the peripheries
Associated benign melanocytic lesion: Absent

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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14 comments on “Case discussion: How would you treat this patient? [22 June]

  1. New onset, past history of melanoma, lesion with chaos and black and grey dots/colour on face (though photos not in focus), I will definitively excise it for histology

  2. Magnification shows pigmentation irregularity at 12 o’clock –?melanoma in situ especially with history –excision 5mm margin

  3. 3*2mm hyperpigmented irregular border nonulcerated fast-growing lesion with the past history of melanoma is highly suggestive of melanoma so the best thing is to arrange an urgent excision biopsy with 2 mm margin

  4. its quite blurred to comment exactly as its a non contact image. any new grey lesion on face of a patient >60 needs shave done to confirm diagnosis. its only a 2mm size lesion with features not evident enough but seem to have dermoscopic grey +

  5. New pigmented lesion with PHx x2 melanoma warrants biopsy; lesion is not well defined, multiple colours including grey; I tend to shave biopsy flat pigmented lesions on the face

  6. New lesion, hx of melanoma, irregular lesion, pale area, peripheral clods, looks like invasive melanoma-in-situ, would do excisional bx with 2mm margin

  7. I think this is a good case because it reminds us that small melanomas – almost be definition – have no / few features to support diagnosis. The combination of age, new lesion (and history) mandates 2mm excision biopsy. Invasive melanoma confirmed, requiring 1cm+ margins