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1800 867 1390Case discussion: How would you treat this patient? [19 October]
In this week’s case discussion from Dr Pearly Cooray we present the following patient:
- 62 year-old male
- Lesion noted on forehead during skin check
Please review the clinical and dermoscopy images. What is your differential diagnosis and what would you do 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
suspected melanoma – excisional biopsy with wide margin
As an RN these are my thoughts…
Assymetrical
Border uneven
Colours – multiple
Appears evolving – but unsure without a history.
Given the evidence of AKs on the patients forehead, robust actinic damage.
Melanoma – superficial spreading query
Solar Lentigo, Malignant Melanoma
Punch biopsy
Asymmetry in colour and shape
excision biopsy with 2mm margin
? Melanoma
A bit young for lentigo maligna but certainly has asymmetry and thickened network
Difficult location – excision Bx would be ideal but could easily just be a flat seborrheic keratosis
One of the few times I would consider a shave biopsy – will get the dermo-epidermal junction and should allow a definitive diagnosis with minimal cosmetic defect if benign
Pigmented AK
Lentigo Maligna
Lentigo Maligna Melanoma
Consider shave biopsy of the most pigmented area or if pt. doesn’t prefer, follow up and field treatment with imiquimod.
DDx: HMF ,SSM, pigmented AK
next step: shave, incisional or small punch bx
Suspicious lesions.
i would go for excision with 2 mm margins
Chaos in structure and colour.
Clues – thick lines reticular at 1-2 o’clock
Excisional biopsy with 2 mm margin
Simple elliptical excision should be okay
DDx – ?melanoma ?melanoma-in-situ
Some features of AK, looks a bit dry and scaly. ?? Beginnings of polygonal structures. Asymmetrical. Unclear if changing. If in doubt I would probably do a shave biopsy to r/o Lentigo maligna with pigmented AK being my main differential.
Suspicious for a melanoma because of asymmetry and atypical network. Excise with 2mm clinical margins.
Suspicious lesions.
i would go for excision with 2 mm margins
Lentigo maligna ? especially superior portion of lesion Excise in-toto with “H”flap using forehead creases.
it has thick lines reticular on the head, not too much chaos. Unable to rule out melonoma. I would do an excisional biopsy, narrow margin.
Probably benign but has messy features. Main worry are the polygon forms. Lesion has regions and very poorly differentiated (chaotic?) bridge between them. Margins are not well defined. Lesion is just on the margin for my GP skills to excise with 2mm margin but he also has another lesion nearby (at 4o’clock). So I will be sending him to a dermatologist.
Asymmetrical
Atypical network
Possible regression areas centrally
Excise with 2m margins
Chaotic colour and structure. White circle. Would biopsy to rule out any malignancy.
PAL and SL
Chaotic Lesion with Clues (Thick reticular lines) – needs excision biopsy
History is important. I will go for shave biopsy first.
DD: Lentigo maligna, Actinik keratosis, Junctional melanocytic naevus
collission lesion: actinic keratosis (with follicles, rosettes + keratin) with solar lentigo (structureless)
Diff diagnosis:
Actinic keratoses, pigmented Bowens disease, solar lentigo, lentigo maligna, melanoma
Treatment: complete excision with 3mm margins and after that depending on histology
Asymmetry of color and shape, Atypical pigment network, 2/3 – warrants excision with a 2 mm margin.
At a glance, pAK or p-Bowen with scales and oval/round circles in the background of pigmented Erythema. But careful look at top-part, disruption of follicles with angulated lines/polygons + thick retics which indicate abnormal proliferation of melanocytes . Thus shaved (saucer) or 2mm margin excisional biopsy and go from there.
Imp: ?LM or MiS.
Let’s see HP report.
–
Solar lentigo with moth eaten borders, leave it alone
Asymmetrical hyperpigmentation in polygonal pattern on the face.needs to rule out lentigo maligna.Circle in circle pattern not seen most areas of the lesion
WARRANT EX/B WITH 2MM MARGIN
I think need excision biopsy
Lentigo maligna
fits the ABCDE: likely Hutchinson’s melanotic freckle/ LENTIGO MALIGNA , I would excise it with 2mm margin
Solar lentigo, I cannot see any clues for LM ( grey color, grey circles). NO action needed
Thanks for all the comments. A small number of colleagues are adamant this is benign, and will leave it alone. Many others propose excision biopsy. Both groups are wrong! In my humble opinion. Let’s do “first principles”: there are benign options here – Seb keratosis can look like this, and so can solar lentigo. Malignant options exist for sure – lentigo maligna melanoma is the obvious one. That is on the clinical view alone. Thus you MUST biopsy – and the best and easiest way is a shave that is deep and wide enough to remove the whole lesion. Easy to do – use the local anaesthetic to elegant the lesion from the surrounding skin and simply shave it off 1-2mm. Dermoscopy is very helpful – but you need to be good at facial lesions dermoscopy: suspicious for melanoma (note the variability in colour across the lesion, with red and brown and the variation in network thickness). Not diagnostic but certainly confirms needs for biopsy
Thank you for the feedback. Do you have the histopathology results?
As many of you thought I biopsied that suspecting Lentigo Maligna
Results came as solar lentigo and solar keratosis. No malignancy.
Rechecked with pathologist.
Looks like a variegated ugly duckling
Lots of actnic lesions on lateral left forehead and temple
Brown structureless punctuated by follicular openings
Seems to a small amount of grey but no grey circles appreciated
I would say it was keratinocytic
DDx incl pigmented AK/IEC and lentigo maligna
Seems more worrying clinically vs dermatoscopic findings
I would shave biopsy this
Color asymmetry +
Grey color
Lentigo Maligna needs to be considered
Plan: Shave biopsy