Case discussion: How would you treat this patient? [12 October]

In this week’s case discussion from Dr Richard Try we present the following patient:

  • 50 year-old female
  • Concern over growing lesion on shoulder

Please review the clinical and dermoscopy images. How do you interpret these? What would you do next?

Please leave your comment today and check back on Wednesday when we upload the pathology report!

Case discussion       Case discussion

Updated

Here is the pathology result. What next?

Case discussion

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

  1. Interesting on gross magnification possible BCC at 10’oclock in a dysplastic naevus — excision biopsy, and dermatoscopic examination of two other neavi 1-2cm suerior to this specimen

  2. Sun damaged skin. Lots of solar lentigenes noted. The one in question is irregular in shape, may be more than 6 mm. Pigmentation around the follicle on some areas slightly noted thicker lines, slight obliteration of follicle openings

    Rule out lentigo maligna

    Other differential could be pigmented AK

  3. 3 point check
    Asymmetry colour and structure
    Atypical reticular network
    ?grey veil
    Suspicious for melanoma
    Management: 2 mm clinical clearance excision biopsy

  4. Growing, irregular, some ? white areas?? I would err on the side of excision biopsy 8mm margin or refer to dermatologist asap.

  5. Chaos +
    Clues: Grey color at 10 – 11 O’ clock. This area could well be classified as Eccentric structureless area.
    Asymmetry in color

    In the view of presence of above, I will diagnose this as Melanoma in situ
    Plan for shave biopsy?

  6. Agree with Suveer.
    Add in history of slowly growing, heavily sun-affected skin, and age over 50, completes the picture.
    Highly suspicious and action required!

  7. Chaos – asymmetry of colour and structures, clues -eccentric colourless area, clods at 5 o’clock.
    Excision.

  8. Changing pigmented lesion in a 50 year old patient
    Chaos of structure and colour
    Clues: eccentric structureless area (? or perhaps grey veil)
    Likely melanoma but regardless of what exact diagnosis is, will require excisional biopsy with 2mm margin.

  9. looks like a solar lentigo (reticular pattern) colliding with a dermal nevus (structureless raised skin colored/ pink area. To exclude malignancy I would punch biopsy the raised part of the lesion.

  10. Interesting, thanks. growing lesion arising from a pigmented lentigo on 50 year old patient who clearly has been exposed to a fair bit of sun is suspicious enough for me to worry. Lentigo with an off centre amorphous papule. Possibly some grey, white and red (on the macroscopic view). I can’t be confident it is benign so I’d prob excise with 2mm margin.

  11. T1NxMx; Clarke level 2; Breslow 0.5 – assuming there is no lymphadenopathy
    Needs wider excision 5-10mm clinical clearance
    Regular skin checks

  12. Type 1 sun damaged skin, growing lesion in a 50 year old – concerning
    Macro shows this lesion is quite different to surrounding lentigos and it has a nodule
    Dermoscopy shows a structureless light tan area corresponding to the nodule; there are no obvious blood vessels that I can see; the network isn’ t regular, with some darker, slightly thicker network centrally
    High suspicion for melanoma; I would excise this lesion with a 2mm margin

    Histo shows 0.5mm Clark level 2 MM with no adverse features; management is WLE with 10mm margin; given the initial biopsy was a punch biopsy, I would measure the 10mm from the dermoscopic edge of the whole pigmented lesion

  13. Thanks everyone – pretty straightforward case for initial assessment and action. Suspicious PSL, needs 2mm excision biopsy. That is that! Next step requires wide excision

  14. Reticular network
    Chaos in colour and structure
    Eccentric and structureless area
    ?solar lentigo but need biopsy to exclude lentigo maligna