Case discussion: How would you treat this patient? [23 November]

This week we feature an interesting case from Dr Uchenna Nweze whose patient presented with a lesion during a skin check:

  • 45-year-old male patient
  • Past history of melanoma

What is your assessment? What would you do (if anything)?

Case discussion

Update:

Here is the result. What next?

MACROSCOPY:
Left upper chest: The specimen consists of a skin shave measuring 13x10x1mm. A poorly defined patch covers much of the surface. Quadrisected, all in, block 1.

MICROSCOPY:
The sections show a shave of severely sun damaged skin with a MODERATELY DYSPLASTIC JUNCTIONAL MELANOCYTIC NAEVUS and adjacent changes of PIGMENTED SOLAR LENTIGO. There is focal pagetoid melanocytosis in an area of more significant melanocytic atypia in keeping with a supervening melanoma in-situ.

MELANOMA (IN-SITU) STRUCTURED REPORT
SITE:LEFT UPPER CHEST
TYPE OF SPECIMEN:SHAVE BIOPSY
BRESLOW THICKNESS: NOT APPLICABLE
EXCISION MARGINS:
– PERIPHERAL : 6mm
– DEEP: 1mm
ULCERATION: NOT IDENTIFIED
MITOTIC COUNT: NOT APPLICABLE
CLARK LEVEL: I
LYMPHOVASCULAR INVASION: NOT APPLICABLE
EARLY REGRESSION: NOT IDENTIFIED
INTERMEDIATE/LATE REGRESSION: NOT IDENTIFIED
DESMOPLASTIC MELANOMA COMPONENT: NOT APPLICABLE
NEUROTROPISM: NOT APPLICABLE
ASSOCIATED MELANOCYTIC LESION: DYSPLASTIC JUNCTIONAL MELANOCYTIC NAEVUS SATELLITES: CANNOT BE ASSESSED IN A SHAVE SPECIMEN
INTRAEPIDERMAL GROWTH PATTERN: PAGETOID

MELANOMA SUBTYPE: Superficial spreading melanoma PATHOLOGICAL STAGING (AJCC 8TH EDITION): pTis
2. The sections show a punch biopsy of severely sun damaged skin with a moderately dysplastic SOLAR KERATOSIS, completely excised. No invasive carcinoma is seen.
3. The sections show a shave of skin with confluent junctional proliferation of lightly atypical epitheloid melanocytes with foci of pagetoid melanocytosis. These are seen overlying an area of sclerotic fibrosis and lymphocytic infiltration. This appears to be active and late regression rather than a pre-existing scar or previous biopsy site but a history of previous biopsy in this location would be important.
MELANOMA (IN-SITU) STRUCTURED REPORT

CONCLUSION:
LEFT UPPER CHEST, SHAVE BIOPSY:
– MELANOMA IN-SITU (NO ULCERATION, SUPERFICIAL SPREADING TYPE) – MODERATELY DYSPLASTIC JUNCTIONAL MELANOCYTIC NAEVUS
– EXCISION APPEARS COMPLETE

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18 comments on “Case discussion: How would you treat this patient? [23 November]

  1. Bg of melanoma, significant sun damage as a background. I make it 2/3. Some grey peripheral globules at 4 o’clock? I’d do a 2mm margin excision to start

  2. Has reticulolyte pattern but this patient has a past history of melanoma, Has irregular border and is surrounded by superfical blood vessels so would be inclined given the history to perform an excisional biopsy.

    1. Hi Gayle you mention reticulolyte pattern.. Do you mean reticulocyte skin pattern? – perhaps a typo ie Reticular pattern – defined by a pigment network. I see thick lines reticular and branched on back ground of sun damaged skin with increased dermal telangiectasia

  3. ?Solar lentigo or LPLK on severe solar elastosis. However it is lacking structure and there are some grey dots/clods and ?? Some polygons. Excisional (2mm margins) or shave biopsy depending on size/location.

  4. At first glance I thought possibly solar lentigo on solar damaged skin or possibly a pigmented SCC in-situ but black/grey globules/dots make it suspicious and it lacks structure, 2mm margins-excision biopsy.

  5. lesion 10mm asymmetry in colour and shape, dark clods, red and brown colour, structureless areas, previous hxt of melanoma – ? Melanoma
    excision biopsy with 2mm margin or referral to dermatologist

  6. Hexagons and irregular dots are suspect clues to lentiginous melanoma in situ . Chaos of structure and colour , clues present here also to malignancy . Standard excision with the recommended 2 mm margins .

    Can I ask Paul Anderson why he suggests 5mm margins for initial excision for Bx purposes?.. Not quite what the current melanoma guidelines recommend.

    1. whoops , typo –should read “polygons” not hexagons.. blame it on spell checker!!. = Thick line reticular and branched . This is a lentiginous melanoma suspect with irregular shape, structure and colour Grey or brown lines forming polygons (larger than perifollicular rhomboid structures of lentigo maligna) Grey dots (more than black) Multiple hypopigmented areas structureless areas .. scary features better seen when the image is enlarged

      I would have liked to know WHERE this lesion was sighted – face or torso. Of course the skin on the face does not have well defined rete ridges as seen eg on the torso, therefore I won’t see a nice pigmented reticular network. I suspect the site is not facial as there is a lack of adnexal openings, and is on quite marked solar damaged skin that is atrophic with increased dermal telangiectasia …much more than I would like to see on a 45 year old.

  7. He has chroncally sun damaged skin with a past history of melanoma.
    Has tan colored structureless areas on dermoscopy however the lesion does not look very chaotic
    Monitor for 3 months with dermoscopy and biopsy if changes.

  8. I would not choose shave biopsy for this lesion at the first place, because it can mislead the results especially in terms of depth. I don’t think the result is reliable, so I will organize for a deeper excision.

  9. Confusing report. Initial report is 1 shave biopsy. Point 2 states a punch biopsy..????

    Moderately dysplastic solar keratosis..?? When does this become SCC in situ.. Bowen’s disease?

  10. MIS on path
    excise with a minimum 5mm margin
    If past history of prior melanoma, needs a skin check every 6 months for life