Case discussion: How would you treat this patient? [26 October]

This week we feature a case discussion from Dr Terry Harvey, whose patient came in for a skin check:

  • Adult male
  • No history

Please review the clinical and dermoscopic images below. What is your assessment and what would you do next?

Case discussion    Case discussion

Update:

Here is the pathology result. What next?

CLINICAL NOTES
7×5 right back flat pigmented lesion with brown reticular lines inferiorly, superiorly amelanotic with linear  vessels eccentrically excision.

MACROSCOPIC EXAMINATION
1. Right back: The specimen consists of a skin ellipse measuring 19 x 10 x 4 mm. On the skin surface is a pigmented macule measuring 5 x 4 mm. A marking nick is present which is placed at 12 o’clock. The 12 o’clock margin is scored and sections are taken as per the diagram. 3 TS submitted in 1A.

MICROSCOPIC EXAMINATION
1. SYNOPTIC REPORT FOR IN-SITU MELANOMA
Site: Right back.
Type: Superficial spreading.
Ulceration: Absent.
Regression: Present.
Associated benign melanocytic lesion: None identified.
Nearest peripheral margin: 2.5mm.

TNM stage (8th Edition): pTis.
Cancer Council Australia recommendation: 5mm clearance.

SUMMARY
1. RIGHT BACK, EXCISION: IN SITU (LEVEL 1) MELANOMA, CLOSEST MARGIN 2.5MM.

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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27 comments on “Case discussion: How would you treat this patient? [26 October]

  1. Agree with previous opinion –rhomboid pigmented shapes /irregular pigmented reticulation –excise 5mm margin

  2. It is not symmetrical and there is some changes to the network. I would have a low suspicion of melanoma. I would consider excision with a 2mm margin

  3. 3 point check:
    Asymmetry colour/structure
    Atypical reticular network
    Assessment: suspicious
    Management: 2mm clinical clearance excision biopsy

  4. No clear seborrheic keratosis features, no BCC or AK, SCC features.
    Network with thick peripheries hence doubtful features of lentigo maligna. Can wait and watch or based on history and other relevant data may consider biopsy

  5. Atypical pigment network, grey area on L inferior region, pink central area with ?regression – there’s enough here to warrant 2mm excisional biopsy to rule out melanoma.

  6. Chaotic with grey changes and eccentric structureless area with grey veil appearance. options: 1) repeat examination in 1-2 months or excise with 2mm margins. Would probably excise this.

  7. Chaos of structure ; disrupted reticular network with thickened grey angulated lines.
    Central hypopigmentation/ regression with chaotic vessels
    Melanoma needs to be excluded
    1. 2mm clear margin excisional biopsy for histopathology diagnosis
    2. Further definitive margin excision pending histopathology

  8. Chaos: irregularity of structure
    Clues: peripheral brown dots 5 o’clock, grey area 7o’clock, eccentric structureless area in middle of lesion
    Excision biopsy with 2mm margin (if melanoma will need wider excision)

  9. Two areas showing line reticular. I don’t think they are thick. However is a bit subtle grayish area that made a bit wary also few peppering. I would shave it to rule out any malignant changes. However I would go with reticular Nevus from this dermatoscope image. Pls update us the result. Thanks.

  10. This could be a solar lentigo or seb k under an immune attack => ?LPLK
    – the “top half” especially
    So, I think probably keratinocytic

    Lines branched; possibly some polygons
    I would say 1 color with some darker lines but thick lines per se
    Is there true chaos or an eccentric structureless component?

    Grey veil on the bottom left is a little atypical and there are possibly some grey clods amongst the vessels
    Vessels are dots/coiled/monomorphous

    Any similar lesions?
    Overall, atypical enough to warrant biopsy
    ?lentigo maligna
    Probably excisional with 2mm margins rather than a shave or with wider margins
    Alternative could be sequential imaging with review at 2 months
    But would excise, as above

  11. Between Th he 2 reticular areas in The centre is a suspicious area? Regression?
    Need to do a shave biopsy to assess. Melanoma?

  12. 1. Irregular pigmented lesion
    2. Light and dark spots
    3. Rhomboid pigmented shape
    & if pt reports that recently came up than plan would be excised considering lentigo melanoma? Melanoma? Until proven otherwise.
    Excise by 5mm excision.

  13. irregular shape and size brown pigmented lesion , with reticulum /rhomboids and some brown clads interspersed between rhomboids, suspicious- need to rule out melanoma excisional biopsy with 2 mm margins.

  14. Tricky case, I think, Difficult to see on the clinical – good pick up! Demoscopy for me is 3/3 on 3-point checklist. That leads to 2mm excision biopsy. The lesion is so small, and flat that I would do a deep shave in real life. With MIS confirmed I would then do a full excision. I would never go to 5mm excision directly – I would do 2mm first, to get the pathology and then a final excision knowing what I am dealing with

  15. Thanks for the HP report
    Margin 2.5 level 1 Melanoma. Superficially spreading melanoma. Head and neck.
    Needs wider excision.
    No need for Sentinel LN study as it is classified as Level 1.