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1800 867 1390Case discussion: How would you treat this patient? [17 August]
In this week’s case discussion from Dr Raghu Vasanthan, we present a:
- 56 year-old female patient
- Slow growing lesion on her arm
Please review clinical and dermoscopic images. What is your evaluation, and what next?
Update:
Here is the pathology result. What next?
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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1300 856 695
+44 203 514 0688
1800 867 1390
Nice dermatoscope pictures. Some white lines, grey dots, loop/dilated vessels, consider lentigo maligna, should biopsy, esp on the 3 o’clock area
Excision biopsy 2 mm margin to exclude Melanoma .
Structureles lesion, on upper right gray dots and wide lines.
Suspicious for LM.
Excisional biopsy 5 mm borders.
Clinically it is difficult to assess without feeling the lesion. Dermoscopically I am not convinced of any specific features pointing to any specific skin cancer. However with history of change it is worth considering biopsy for this lesion with possibilities of dermatology problems like morphea listed in the DDx together with other skin cancer possibilities such as desmoplastic melanoma or morpheic BCC
chaotic lesion, some grey circles, dotted vessels, leaflike pigmentation, structure-less areas
? BCC or melanoma
excision biopsy 2mm border
Given all the other flat tan-coloured lesions on the arm, this lesion might night attract much interest except that
– it is an ugly duckling compared with the others
– clear history of change
– asymmetrical in shape
– it is pigmented with some small areas of network which are dissimilar notably at 3o’clock
– possible white areas of regression (although it seems like normal skin just ‘poking through’)
Therefore it is suspicious and must be excised with 2mm margins.
Possible lentigo maligna
Comma vessels seen in dermoscopy
may be dermal naevus or compound naevus
Slow growing,tan ,largish lesion,flat lesion with no ulceration macroscopically on Type 1 skin.Paler adjacent skin at one pole.Lesion looks not otherwise unduly suspicious
Dermatoscopically I cannot see any network or other evidence of a melanocytic lesion
Polymorphic vessels stand out feature I reckon.
Certainly some strange different types of structures through lesion.
I’d punt for a Morphoeic BCC because of the vessels and strange structures within each field.
I’d excise all the tan area with 2 mm margin and be prepared to re-excise the paler area if not clear at margins.
Lentigo Maligna is the most probable diagnosis. Excisions biopsy to confirm diagnosis and plan definitive treatment.
features
pigmented lesion
asymetrical structure
polymorphic vessels,some white lines
not sure ? pigmented BCC or lentigo melanoma
need biopsy to confirm diagnose
Regressed seborrheic keratosis , recheck in 4 months as its a flat lesion
with the short history and examination symptoms is it flat or raised ? however with the pink homogenous, regualr, symetrical pattern and comma shape blood vessels around I would think of Dermatofibroma.
while I will reassure the patient will ask to return if noticed any change in color or texture within the next 3 months.
Two areas of interests
1. Nodular changes proximal tip of the freckle—excision with a large punch
2 . Lower adjacent whitish area —4-5mm punch biopsy to exclude amelanotic melanoma
Thanks for this one, interesting. I see a patch whiter than the rest of their skin ? regression and some polymorphous vessels which cause concern.My understanding is the few serpentine vessels make pigmented Bowen’s less likely so ? melanoma.
A colleague once told me this nice aphorism – “pink and brown makes me frown”
A great case. So easy to overlook a case like this right? Lots of people with lesions like this. The key issue here is the “pink and brown” – when you see these 2 together, get a biopsy. If it is not an obvious solar lentigo, or an obvious Seb k then do a biopsy. Any doubt – do a biopsy! The doubt is – it is a lonely lesion, it could be benign or malignant and you can’t be sure, and there is pink and brown. This is the perfect lesion for a nice big shave biopsy. Quick and easy