Case 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?

Case discussion Case discussion

Case discussion  Case discussion

Case discussion

Update:

Here is the pathology result. What next?

Case discussion

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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16 comments on “Case discussion: How would you treat this patient? [17 August]

  1. Nice dermatoscope pictures. Some white lines, grey dots, loop/dilated vessels, consider lentigo maligna, should biopsy, esp on the 3 o’clock area

  2. Structureles lesion, on upper right gray dots and wide lines.
    Suspicious for LM.
    Excisional biopsy 5 mm borders.

  3. 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

  4. chaotic lesion, some grey circles, dotted vessels, leaflike pigmentation, structure-less areas
    ? BCC or melanoma
    excision biopsy 2mm border

  5. 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

  6. 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.

  7. Lentigo Maligna is the most probable diagnosis. Excisions biopsy to confirm diagnosis and plan definitive treatment.

  8. features
    pigmented lesion
    asymetrical structure
    polymorphic vessels,some white lines
    not sure ? pigmented BCC or lentigo melanoma
    need biopsy to confirm diagnose

  9. 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.

  10. 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

  11. 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.

  12. 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