1300 856 695
+44 203 514 0688
1800 867 1390Case 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!
Updated
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.
Learn more about skin cancer medicine in primary care at the next Skin Cancer Certificate Courses:
1300 856 695
+44 203 514 0688
1800 867 1390
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
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 point check
Asymmetry colour and structure
Atypical reticular network
?grey veil
Suspicious for melanoma
Management: 2 mm clinical clearance excision biopsy
Growing, irregular, some ? white areas?? I would err on the side of excision biopsy 8mm margin or refer to dermatologist asap.
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?
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!
Chaos – asymmetry of colour and structures, clues -eccentric colourless area, clods at 5 o’clock.
Excision.
Chaotic appearing lesion and growing.
Excise with 2mm clinical margins as suspicious for a melanoma.
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.
Asymmetrical, structureless area, blue grey veil
? melanoma
excision biopsy 2mm margin
Asymmetrical. Chaos Growing. Excise. ? Melanoma .
Excision with 2mm margin to rule out melanoma as chaos and clues are present.
agree with Suveer
Scoop shave biopsy and removal would be the option I think. Negative margins to be ascertained in histopathology.
I am unsure about 2 mm 8 mm margin for shave.
Compound melanocytic nevi with mild dysplasia. Reasses in 4 months
Pt concerns and clinically not able to give a diagnosis.? Can we observe? Or do a shave biopsy.
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.
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.
T1NxMx; Clarke level 2; Breslow 0.5 – assuming there is no lymphadenopathy
Needs wider excision 5-10mm clinical clearance
Regular skin checks
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
Thanks everyone – pretty straightforward case for initial assessment and action. Suspicious PSL, needs 2mm excision biopsy. That is that! Next step requires wide excision
Reticular network
Chaos in colour and structure
Eccentric and structureless area
?solar lentigo but need biopsy to exclude lentigo maligna