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

We present an interesting case from Dr David Stewart this week, which features a:

  • Pregnant 25 year-old female patient
  • Change noted in a long standing scalp lesion
  • Usually brown flat, now dark and raised

What is your assessment, and what would you do next?

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

Case discussion      Case discussion

Here is the pathology report. What now?

Case discussion

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

  1. it is a changing lesion in an adult.
    clinically blue structure less lesion on scalp , most consistent with blue naevus. but in view of changing lesion melanoma needs exclusion .
    perform excision biopsy with 2 mm margins.

    1. I won’t excise – Classic Blue nevus clinically in a 25 year old that have changing pigmented naevi anyway – long standing lesion. Outside distal chance of MM but there are no chaos or clues or any algorithm to this being the case. My experience of 24 years and seen multiple of these things gives me the confidence of this lesion been benign .
      I wont excise initially. Being 99+% certain I would review in 3 months instead – I wont hold my breathe waiting for a change . New / recent changing lesion in a much older patient I would consider a MS metastatic deposit but not a primary.

  2. Lesion is clinically a blue nevus, there is a history of change and growth, so biopsy, biopsy shows blue nevus, fully but closely excised. Clinical and histopathology in agreement, no further action needed

    1. Sorry Pete, With regards to PSL and suspect melanoma, I would consider excision with possible 2mm margin as best practice, IF you were considering a malignant melanoma. Too dangerous to partial bx , no margins nor Breslow to consider. I have seen this sort of thing been done with all sorts of complications that have arisen, to consider this as not acceptable management.

      Long standing pigmented lesion is certainly NOT the behaviour of a nodular melanoma in this age group. They are very rapid fast growing tumours.

  3. Clinically and dermoscopically it is highly suggestive of Blue nevus. However with histiry of change, excision is still recommended for peace of mind.

  4. Suspicious Pigmented lesions need excision biopsy with 2mm margins, punch biopsies can miss things. So excision biopsy required would have done that initially.

  5. Looks like a Blue Nevus, but as patient noted change and excision biopsy is indicated to exclude melanoma

  6. I would agree given age of the patient the clinical presentation and macroscopic view are all consistent with blue naevus however diferrencial diagnosis is malignant melanoma and hence an excisional Bx of with two mm margin is the appropriate course of action.
    Histology confirmed diagnosis of Blue naeves with no atypical cells, and a close but clear margin no further action is required.

  7. the history of a blue nevus presenting as a brown spot is rather odd. wonder if it was indeed blue in the beginning

  8. Punch biopsy in a pigmented lesion cannot be trusted and given the history of recent change, excision seems the best choice.

  9. Just to clarify, for those people commenting about the inappropriateness of a punch biopsy being done on a pigmented lesion, I measured this lesion as 3mm (see dermoscopy view) and so felt comfortable that I could remove the lesion entirely with a 5mm punch biopsy (which the path report showed that I did ). I totally agree that partial biopsies of pigmented lesions are inadequate but that’s not what happened here.

  10. Hi All – great comments. Thanks. The key here is that she is pregnant – change is often seen in pigmented skin lesions (including blue nevi) in pregnancy. For the experienced GP this is without doubt a blue nevus and can be left alone. Any doubt – a less experienced doctor, an anxious patient or partner etc, warrants excision biopsy. As Dave Stewart notes, this is easily done with a Punch Biopsy tool – simple to do, complete removal. Much easier than a 2mm excision biopsy on the scalp etc