Case discussion: How would you treat this patient? [1 March]

In this week’s case discussion, submitted by Dr Alex Speight, we review a 70-year-old male patient with a slow growing lesion on his right arm.

  • 70-year-old male
  • Slow growing lesion on arm

Please assess the images and provide your assessment. If you decide to biopsy, how would you do this?

case discussion

Update

Here is the pathology result. What next?

pathology

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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18 comments on “Case discussion: How would you treat this patient? [1 March]

  1. Lesion appears to have “stuck on”appearance to naked eye. On dermoscopy the underlying blue pigment from tattoo is a bit confusing. There is some assymetry however I would score this lesion a 1- non- suspicious. Possibly a SK?

  2. excision biopsy with 2mm margins as the history is suspicious and she is an elderly lady putting her in a high risk category. Dermatoscopy features –peripheral atypical network,assymetry,clods etc

  3. It’s highly probable it’s a melanoma in the radial growth phase. The chaotically variable network, early radial streaming at 4 oclock and central regression are very suggestive as is the patient age and history of slow growth, although the blue pigment is obviously unreliable. Biopsy is mandatory. I’d have a chat with the patient recommending formal excision with a 2mm margin and stuff the tattoo, but if they really insisted it’s feasible to perform a deep shave/saucerisation or incisional biopsy and if it turns out to be benign the tattoo might be repaired by a skilled tattoo artist. My least preferred is the incisional biopsy due to the risk on a non-representative sample and this would be against medical advice. Most sensible patients would go for formal excision.

  4. asymmetry pigmentation, black clods, blue gray colour
    excision biopsy with 3mm margin
    ? Melanoma

  5. 2/3 check points+suspicious

    irregular pigment pattern
    white/blue structures

    pigmented lesion so requires excision biopsy with 2mm margins
    ? melanoma

  6. Obviously a PSL with a very chaotic structure, colour and blotching. Needs to be taken off to exclude MM.

  7. A chaotic lesion, asymmetrical for both color (light brown, dark brown, blue-gray), and structure (peripheral remnants of pigment network, central hypopigmented structureless areas, asymmetrically distributed central and peripheral brown clods). I think this is melanoma and should be excised.

  8. The lesion looks chaotic with 3 point check list of 3.
    atypical in color and structure.
    blue(? tattoo but definitely white)
    atypical network at 6 o’clock.
    although some milia cyst visible, definitely suspicious for melanoma.
    excise with 2 mm margin

  9. Chaotic with variations in colour and shape.
    Need to exclude melanoma.
    Excision biopsy with 2 mm margin will give diagnosis.
    A deep shave would also be possible, but I would do an excision.
    A broader view of the body would give some hints as those with seb k usually have others.
    I suspect this is an ”ugly duckling” and hence suspicious.

  10. Hello all, sorry for the late comment. I have been on leave this past fortnight, with no internet. This is a “barn door” melanoma. At the very least it is a “suspicious pigmented skin lesion” (70y old, growing) that MUST be biopsied. There certainly are 1-2 plausible benign diagnoses here (eg Seb k) but for 2 reasons biopsy is MANDATORY: 1) the age and history, and 2) the fact that melanoma is a plausible (possible) diagnosis. Biopsy MUST be by complete removal – you cannot consider a tattoo more valuable than an accurate diagnosis. The diagnosis is confirmed and as it is MIS, cure can be effected with a 5-10mm further excision. Easy work.