Case discussion: How would you treat this patient? [9 November]

In this week’s case discussion, we feature a case from Dr Terry Harvey, whose patient came in for a skin check.

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

Case discussion    Case discussion

Update:

Here is the pathology report. What next?

Case discussion

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22 comments on “Case discussion: How would you treat this patient? [9 November]

  1. According to 3 point checklist
    Asymmetrical
    Atypical network
    No blue white structure
    Will do a biopsy aiming complete removal

  2. Well defined margin, reticular pattern – periphery
    One color with dark in centre.
    There are some white lines
    Colour pattern asymetry
    I think it is melanoma in situ and needs excision biopsy

  3. Not sure about his lesion who would probably do an excisional biopsy. SOme asymmetry of colour and border abruptness. Grey areas peripherally.

  4. Fairly straight forward with asymmetry and reticulation and small rhomboids,the darkness means i would aim for 5mm with excision biopsy—good pick up though especially given the size ,and what about the two other pigmented lesions slightly bigger ?

  5. This lesion seems noted in a person with multiple nevi.

    Dermoscopy of the lesion does not seem to conform to nevi, seborrheic keratosis, sebaceous hyperplasia, dermatofibroma or hemangioma.

    Its a pigmented chaotic, asymmetrical lesion. assymmetric colour, abrupt and gradual margins.

    Clues for melanoma noted are gray areas, peripheral black dots and clods, eccentric structure less areas, thick angular lines, white streaks/ lines.

    Many features of superficial spreading melanoma.

    I would consider deep shave biopsy or excision with 3 mm margin.

  6. This is a tiny pigmented lesion (no scale markings shown) maybe 3mm in diameter.
    Difficult to diagnose melanoma confidently at this stage of development if it is a melanoma.
    That said irregular in shape and colour
    Can’t see a reticular network, nor areas of regression.

    So if in doubt I would remove probably with at least a 6mm punch.

  7. Asymmetric lesion with irregular pigment net work ,irregular border;will do excision with 2 mm margin

  8. leave it alone, do annual skin check. its too small maybe 3mm and the image is not in focus. too hard to comment on

  9. I agree with most colleagues there are thick reticular lines and rhomboids as well as possible grey zones in the periphery. There are also dots and clods but not only peripherally but throughout the lesion.
    Melanoma certainly needs ruling out with an excisional biopsy of 2mm. This could still however be a dysplastic pigmented naevus or a pigmented SK

  10. asymmetrical with atypical network, with ? regression structure. Possibly melanoma. excisional biopsy with 5mm margin

  11. I will be honest and say that I doubt very much that I would have picked this up! I hope the patient might have reported it as new, but I honestly don’t think I would have looked twice. The dermoscopy does nothing for me, so I reckon I would have missed this one!!! Nice pick up Terry!

    1. David
      I recall in the course that anything less than 6mm can be difficult to diagnose as a melanoma (is that correct?).
      This is a mere 1mm x1mm is it possible to say anything about a pigmented lesion so small (except if in doubt cut it out)?

    2. I actually tried to wipe it off with an alcohol wipe a few times because I was convinced it was a bit of ink/oil or something.

      All his other flat naevi were perfect reticular line patterns and this just didn’t fit!

      1. so this an ‘ugly duckling’ hence reason to excise it?

        As my learning point, he needed a WLE after for 5 mm clearance? Thanks for the case

        1. Yes. He went on to have a wide local excision to achieve a total of a 5mm clinical margin from the edge of the tumour.