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1800 867 1390Case 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?
Update
Here is the pathology result. What next?
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1300 856 695
+44 203 514 0688
1800 867 1390
look like superficial spreading melanoma
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?
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
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.
Biopsy, suspicious for melanoma. Tatoo confounds
presence of blue white structures
Suspicious score 3/3
Melanoma in-situ very likely
Excise 2mm margins
3 point checklist
Possibly 2/3
Excision biopsy
irregular and , white structures in the centre. excision with 2 mm margin
asymmetry pigmentation, black clods, blue gray colour
excision biopsy with 3mm margin
? Melanoma
2/3 check points+suspicious
irregular pigment pattern
white/blue structures
pigmented lesion so requires excision biopsy with 2mm margins
? melanoma
Obviously a PSL with a very chaotic structure, colour and blotching. Needs to be taken off to exclude MM.
Pigmented BCC excision w 2 mm margin
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.
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
dermoscopic island , suspicious of melanoma insitue for biopsy 2 mm margin
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.
Superficial spreading melanoma- shave excision for histopath
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.