Case 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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26 comments on “Case discussion: How would you treat this patient? [22 February]

  1. 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

  2. Chaotic PSL showing brown white structureless area with a dark blotch and thick line reticular at one side. Excise to rule out MM.

  3. 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

  4. Chaotic lesion with clues (thick reticular lines likely at 6 o’clockish, structureless area to the right) – though difficulty to augment the image)

  5. 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.

  6. 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