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1800 867 1390Case discussion: How would you treat this patient? [30 November]
This week we present another case from Dr Tim Aung, whose patient came in for a skin check:
- 70-year-old male
- Lesion noted behind right ear
Please review the clinical and dermoscopic images below. What are your differential diagnoses, and what would you do next?
Update:
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.
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1300 856 695
+44 203 514 0688
1800 867 1390
I will review lesion in 3month after picture is taken and stored in patient file
Clinical: Pigmented lesion, appears slightly raised, Irregular shape with well demarcated margin. Colour Asymmetry +
Dermoscopy: Pattern asymmetry. Clue +, Color asymmetry +, Grey colour at 11 and 4 O’Clock site. Curved vessels
Differentials: Malignant Melanoma, SCC
Management, Excision Biopsy
asymmetry in shape and colour
black clods, structureless area
excision biopsy with 2mm margin – ? melanoma
Ugly duckling in that area
chaos of structure and colour
black clods
grey structure
eccentric structureless area
2 tiny peripheral dots suggesting active growth
– excise with a 2mm margin for possible melanoma
Asymmetry of shape and colour with grey area at 5 o’clock adn structureless area at 6-7 o’clock. Borwn and black dots. Probable Melanoma. Excisional biosy with 2mm margin.
Fairly classic ,asymmetry, reticulation, irregular pigmentation .Melanoma or melanoma in situ .Fortunately lots of lacks skin in that area –excision biopsy 5mm margin
Probable Melanoma. Excision biopsy with 2mm margin.
Asymmetry in shape
Varied colour
Suspect new lesion? Peripheral blue grey clods. Melanoma vs BCC. Pigmented Seborheic keratosis.
Biopsy with 2mm margin.
Likely (nodular) melanoma
Certainly ‘suspicious’
Excision biopsy 2mm margins as usual
Not in focused however it shows different colours and taken the account of the patient age I would be very alarmed. Thus a biopsy is mandatory to rule out any suspicious growth.
Highly likely to be a melanoma,chaotic pattern, radial streaming, pale areas.
On assumption that an 8mm punch biopsy would include a >2mm margin, I would use 8mm punch biopsy. And if histology confirms , then a wide excision as per guidelines.
seborrheic keratosis with well demarcated margins on a raised lesion, leave alone !
Seborrheic keratosis, safe to leave, rev prn
Pretty compelling for seborrhoeic keratosis but given he’s almost certainly going to be repeatedly asked about it by every person moving behind him I’d do a shave removal to confirm
I would like to know how long he has had this lesion for/?change/?irritates
Looking at the pictures sveral networks ,area of dipgmentation and irregular outline -for excision
Possible melanoma. I would do a punch excision with an 8mm PB, closed with a Mirini absorbable suture, and see in 2 weeks for ROS and review.
Needs to be excised. Likely to be a melanoma
Appears to be a benign well demarcated “moth eaten border” macule / low papule lesion – pigmented Seb Ker.
I 1st see clues to benign SK.
Not enough chaos or clues to malignancy for me. I dont identify any radial steaming. I dont see lentiginous spread
Lesion has some “veiling” of orthokeratosis. No network seen. Darkish brown possibly pigmented keratin filled crypts if a pig SK . No vessels seen.
A pigmented BCC unlikely on a usually known glabrous area mastoid area
I dont see a larger area to call this an ugly duckling.
I would like a lot more history taken 1st before deciding ANY definitive management
Shave biopsy to rule out melanoma but I am thinking of Lentiginous lesion
Definitely excision biopsy
common area for nodular MM
Great comments re. MM vs Seb K.
To reiterate the principle again (as Prof Wilkinson usual say), to BIOPY if you are suspicious for MM and aren’t confident enough to leave as it is a benign. Either shaved or 2 mm marginal excisional will do. Given scar is not a issue in old man of location behind the ear, 2 mm margin is decent one. Retrospectively, this Australia map like is characterised by well demarcated border with brown dots and dark clods inside but no network. Cheers!
asymmetry , pigmented
probably shave biopsy and proceed