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1800 867 1390Case discussion: How would you treat this patient? [22 February]
This week’s case discussion from Dr Sally Parsons features a 47-year-old fair-skinned female patient who presented for a skin check. A small pigmented lesion was found on the patient’s shoulder, subtly getting darker over a 12-month period since it was first noticed.
- 47-year-old female
- Small pigmented lesion on shoulder
What do you make of the dermoscopy? Would you biopsy, and if so, how?
Update
Here is the pathology. What next?
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1300 856 695
+44 203 514 0688
1800 867 1390
Excise with 2mm margin?
Dermatoscopic appearance ?melanoma in situ on the background of dysplastic nevus! ?Solar lentigo.
Suspicious on at least two counts.
Excise 2mm margins
Differential diagnosis
Melanoma in situ
Seborrhoeic keratosis
Actinic keratosis
Asymmetry. Thickened network. Highly suspicious.
Excision biopsy with 2mm margins.
excision with 5 mm margin
For excision biopsy as irreg outline and mutiple network types .
Irregular lesion, pigmented , irregular network, clods , structureless area.
will biopsy to R/O melanoma.
Excision biopsy aiming for 2mm clearance in the first instance
The lesion is 3mm x4mm approximately
It is A asymmetrical B border is irregular c colour variation D NOT over 6mm E evolving
That is 4 out of 5 of the macroscopic clinical criteria for melanoma
I suspect it could already be an invasive melanoma : not in-situ
Asymmetry shape and pigmentation. Excision biopsy with 2mm margin. ? Melanoma
Dysplasia or melanoma lesion
Chaotic PSL showing brown white structureless area with a dark blotch and thick line reticular at one side. Excise to rule out MM.
It’s irregular. Multiple colours including black and grey. Black clods at 6pm. Therefore needs to go!
Melanoma is the concern. Shave or excisions biopsy
Highly suspicious
Excision biopsy with a 2mm margin
appears dysplastic, shave biopsy to exclude SSM
Suspicious. Excise 2mm margin
dysplastic changes in mole
dysplastic changes in mole .
excision biopsy .
DErmoscopy 3 point check list gives it a score of 3.
suspicious.
Excision biopsy with 2 mm margin
Chaotic lesion with clues (thick reticular lines likely at 6 o’clockish, structureless area to the right) – though difficulty to augment the image)
Follow up – DD. Lentigo Maligna
Suspicious lesion 2/3, excision biopsy 2 mm margins.
I agree there are significant features to suggest SSM. The thick reticular lines and if you look at the whole lesion there are multiple thick lines and rhomboids. Multiple dots and clods. Possibly structureless small areas on either side of the darker pigmented area. Excision with 2-5mm margins.
ExBx with 2mm margin and review
4mm excision biopsy
I think the key here is a changing lesion in somebody >40y. This leads to the dermoscopy, which is suspicious – I call it a 2/3 (asymmetrical and atypical network). This mandates excision biopsy. The best way to do this is a 2mm excision biopsy. As the lesion is small and flat it is ok to also do a deep shave. The report of an insitu melanoma of course then leads to a further excision, this time with at least 5mm margins