Case discussion: How would you treat this patient? [10 August]

This week, we present a new case from Dr Alexander Speight, featuring a patient who came in for a routine skin check:

  • 72 year-old female  with PH melanoma
  • No history of lesions of concern
  • This lesion looked a little different from the multiple, presumed, lentigos on her face

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

Case discussion

Case discussion    Case discussion

Update:

Here is the pathology result. What next?

CLINICAL NOTES:
Histology
left face near eye, ? regressing solar lentigo, r/o lentigo maligna/LPLK. prev hx of MIS.

MACROSCOPY:
Left face near eye: The specimen consists of a skin shave measuring 23x19x4mm bearing a brown patch measuring 20x13mm. 7TS, all in, 1 block. See Macroscopic Photo 1. (RT/acm)

MICROSCOPY:
This case was reviewed as requested.

Two lesions are present in this specimen.

The first lesion is an INTRADERMAL MELANOCYTIC NAEVUS.  The symmetrical lesion shows maturation of depth. There are no dermal mitoses.
Clearance from lesion:
– Peripheral: 1mm
– Deep: MARGIN INVOLVED

The second lesion is a SOLAR LENTIGO. There is no evidence of in-situ or invasive malignant melanoma.
Clearance from lesion:
– Peripheral: 0.5mm
– Deep: 1mm

CONCLUSION:
LEFT FACE NEAR EYE, SHAVE BIOPSY:
– FIRST LESION: INTRADERMAL MELANOCYTIC NAEVUS
– SECOND LESION: SOLAR LENTIGO, EXCISION APPEARS COMPLETE

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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19 comments on “Case discussion: How would you treat this patient? [10 August]

  1. grey circles, white lines, linear dots, color variation – grey, pink, structure-less areas
    biopsy – I would do a punch biopsy

    1. There are grey dots scattered around many of hair follicles, so DDx will include MIS, Pigmented AK, LPLK. With PH melanoma, I will do a deep shave biopsy for this lesion to exclude melanoma in situ.

  2. This is a nodular lesion in an elderly patient with a history of melanoma and I cannot clearly diagnose it as a benign lesion and therefore I would biopsy.

  3. The lesion shows a pseudo-network with irregular / asymmetrical deposition of melanocytes around facial hair follicles. The lesion itself is asymmetrical and there may even be areas of grey-white regression.
    Add the age and past history of melanoma and it is definitely suspicious and probably lentigo maligna.

    Punch biopsy is insufficient as malignancy may be missed so shave excision biopsy; the lesion is 10mm in shortest diameter so ellipse with 2mm margins could also be considered.
    DD is boring solar lentigo.

  4. perihilar pigmentation and some brownish pigmentation, and along the history of previous MM and his age to be taken in consideration I would be wary. Will biopsy to double check and rule out MM.

  5. asymmetrical deposition pigment melanocytes around hair follicles of some concern. I am not seeing grey ( but that may be my old Mac’s screen! ) I think dd lentigo malignant LPLK, solar lentigo. I’m less convinced that pigmented AK or bowens. Options of wide shave as no features of invasion, excision with 2mm margin.,serial dermoscopic image 3 and 6 months.

  6. This lesion looks nodular to me.
    in a 72 year old with a past history of MM , but when and what anatomical site ?

    i think the overlying skin looks like solar lentigo,but if the lesion is nodular ,as appears to me,
    i would want to know what is underlying . ? skin metastasis of past MM
    Needs biopsy

  7. Irregular size and colours like white , yellow , Multiple grey dots , white lines in a nodular lesion with a past H/O MM, I would excise with margins of 2 mm. DD is SK, LPLK.

  8. Dermoscopy of pigmented facial lesions is very tricky, even for highly trained and experienced skin cancer doctors. On balance I think it is a regressing solar lentigo (the fine granular appearance), but for me, the clinical report that “it looks a little different” to the multiple lentigos means I would do a shave biopsy to exclude melanoma

  9. Thanks Alex
    I saw the nodular “elephant in the room” and missed the lesion in question.
    I have adjusted the lighting and colour on my screen .
    it looks like a regressing solar lentigo ,but if it is different from surrounding lentigenes, woud warrant a shave biopsy

  10. This has annular granular pattern with greyish peppering and grey circles consistent with LMM, needs shave excision to rule out a lentigo maligna

  11. Clinically a flat pigmented macular lesion.
    Dermoscopy – well defined margins with some scalloped edges. Pattern of dots and circles.
    There is some grey peppering as a clue
    Most likely a Solar Lentigo undergoing some Lichenoid change.
    DDx Lentigo Maligna
    Shave Removal for histology still indicates given the grey peppering.