Case discussion: How would you treat this patient? [13 July]

In this week’s discussion, we present a recent case from Dr Mokesh Raj, which features:

  • 30 year-old patient
  • No history

What do you make of the image? Would you do anything here? Why / why not?

Once you have made your assessment, scroll further for the pathology report!

Case discussion

 

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Here is the pathology report. What now?

Specimen.
SKIN LESION FROM LEFT CHEST


Gross Description.
Skin ellipse 14 x 9 x 2 mm with a central brown macule, 4 mm in diameter. Margins inked blue.  Transversely sectioned. 2 R

 

Microscopy.
The lesion is a relatively broad poorly circumscribed junctional melanocytic naevus consisting of a lentiginous proliferation of melanocytes as well as occasional fused nests of melanocytes.  There is an underlying stromal response with eosinophilic fibrosis and lamellar fibroplasia. There is no pagetoid infiltration into the overlying epidermis and excision is complete. The closest radial margin measures 0.7 mm.


SKIN, LEFT CHEST WALL:
DYSPLASTIC JUNCTIONAL NAEVUS – COMPLETELY EXCISED.

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12 comments on “Case discussion: How would you treat this patient? [13 July]

  1. Agree excision essential. Asymmetry and chaotic structures but I m surprised by the pathology . I would rather go back and excise more here I m uncomfortable with that margin.

    How many blocks ? Have deeper levels been taken ? What did IH ie Mart 1 or other preferred stain show ?

    I would want to know that around 1:00 branched streaks and 3:00 focal peripheral dots included in sections taken .

    Do you put an orientating mark on clinical image and macro view to allow correlation of ELM features to histology report ?

  2. I am not happy with the report because it is not reported under the most recent classification for Dysplastic nevus (though some may argue this term should not exist anymore). So one option will be requesting a review with more sections or just proceed to excise with further margin 5-10mm depending on clinical and dermoscopic suspicion of the lesion

  3. Asymmetrial lesion. Radial lines 1 OC
    I would ask for a pathologist review/second opinion after discussing my concerns.

  4. chaotic lesion with asymmetry of colour and structure; a little difficult to tell from the photo, but maybe some radial streaming at 12 o’clock; also a pink blush centrally; once again difficult to tell from the photo but there seem to be quite a few vessels centrally and at 12-2 o’clock, but I can’t discern their morphology; grey area at 12 o’clock; no comment in report re moderate or severe dysplasia; I would discuss with the pathologist and ask for deeper levels; I would also be interested in whether this was a stand out lesion or whether there are many others like it on the patient’s skin

  5. I put some bright yellow nail polish onto the area of clinical concern before I excise it, to let the pathologist know what part of the lesion i specifically want them to look at

  6. I am less concerned about the dermatoscopic appearance which doesn’t seem to have any real definite clues to malignancy. The history is important: is it new or growing or changing? Also is it a lone lesion or distinctive from other naevi they have? In this case excision with a 2mm margin would be indicated. If it is unchanged, been there a long time and looks like others on the patient then observation and check in 6 months would be reasonable.
    As to the report, the calling of it as a dysplastic naevus does raise some concerns given the controversy of this as a clinical diagnosis. But, given my lower level of initial alarm I would probably accept the pathology particularly if the pathologist is familiar and trusted by me. If unfamiliar with the pathologist then a phone call for a query and perhaps discussion of another look and further stains.

  7. This lesion does not need any further action. Dysplastic junctional nevi are not concerning at this age. If this was on a body of a 60 year old, then I would discuss it with the pathologist to review the slides.

  8. Thanks all. An interesting case. Lesion scores 1/3 on 3 point checklist = benign. If the patient had other, similar lesions I would leave alone. If this was a lonely lesion I would do excision biopsy 2mm margin. The report, as provided is sufficient to be confident that the lesion is removed, and needs no further excision. There is very good research to show that (so-called) dysplastic nevi, when completely excised with 2mm clinical margins) pose no additional risk of recurrence / malignancy

    1. Thanks David
      However with the last sentence saying 2mm clinical margins have good outcome , this pathology shows 0.7mm margin.
      Is this not a good enough reason to re excise ?