Case discussion: How would you treat this patient? [15 March]

This week’s case discussion, submitted by Dr Dave Stewart, features a 70-year-old female patient presenting for a skin check. She has no concerns, but this pigmented lesion is noted on her upper chest.

  • 70-year-old female
  • Pigmented lesion on chest

How do you evaluate this? What would you do next?

case discussion

Update 1

The lesion was photographed and reviewed one year later, with no change reported by the patient. How do you evaluate this? What would you do next?

Update 2

Here is the pathology report. How do you evaluate this? What would you do next?

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26 comments on “Case discussion: How would you treat this patient? [15 March]

  1. History would be very important here. This is an ugly duckling. I wonder whether it’s a congenital nevus with a “colliding” BCC. I would do an incisional biopsy including the central portion. It’s perhaps too large to consider an excisional biopsy as a first step.

  2. If I will score it base on 3 point score is 0/3 but is a solitary lesion and nothing ti compare it with. At the center there’s an arborization of vessel ? BCC within a benign naevus ?
    I will refer for expert advice or do a punch biopsy where possible the BCC is.

  3. Asymmetric in shape and colour
    Atypical network
    Possible central area of regression

    Is an ugly duckling she is elderly
    DDx atypical naevus

    Excise with 2mm margins and apologise in advance for the large scare!

  4. asymmetry pigment and colour
    blue gray structures
    atypical network – negative
    I would do an excision biopsy to exclude melanoma – 2mm border

  5. Blue/grey structures top left + far right.
    Assymetry of pigment.
    Vascular lines in centre + top left.
    Moth eaten edges.
    8mm there abouts.
    Biopsy – considering its size, would you biopsy a couple of areas? Eg, centre and areas with grey dots?

  6. Though this is not a concern from patient, I will excise it or at least offer short term monitoring for such an ugly ducking mole with some grey colour seen at 12 and 3 o’clock position.

  7. large pigmented lesion , elderly patient with her skin type as shown in macro , with dermatoscopic feature of assymetry, blue veil , blue globules, some grey dots . I would do excision biopsy of this suspicious lesion to check for melanoma .
    thanks !

  8. A pigmented lesion, irregular borders, irregular multiple network pattern, , Possible area of regression.
    DD: Pigmented BCC
    Atypical Nevus

  9. Irregular borders.
    Unusual network.
    Blue grey structures within.
    I would excise the lesion.
    Query melanoma

  10. Irregular borders! but pretty symmetric!
    But honeycomb appearance of dysplastic nevus
    ?Polymorphic vessels middle of lesion
    DDx: ? BCC; ? ?Dysplastic nevus – ?melanocytic; ?Sebarhoiec keratosis
    Most Likely: BCC

  11. Chaotic PSL with some network at periphery with line radial and thick line reticular ? The central blood vessel is confusing. Either the way as it’s a stand alone PSL in 70 years I would excise to rule out MM.

  12. First lesion is seborrhoea keratosis
    The dermis copy year later shows seborrhoea keratosis with some amorphous , pink areas ? Areas of intraepidermal carcinoma in seborrheic keratosis.
    With this dermatoscopic appearance, I would prefer to perform biopsy , shave biopsy.

  13. I would say 2/3 on initial one also looks like ugly duckling. I can see why someone might monitor it though. Some thickened pigment areas and asymmetry in pigment networks. The follow up photo is different. There’s a larger area from 9-12 o’clock and a new grey but at 3 o’clock. I would definitely excise with a 2mm margin at this point.

  14. central part of the lesion has structurless areas, telengiectasia,grey discolouration etc. I will proceed to do an excisional biopsy with 2mm margins.

  15. Starting with a history is crucial to me .

    However, Derm score is likely to be 2/3 ( asymmetric , chaotic appearance with peripheral meshwork.

    Pigmented lesion is likely more than 1 cm in diameter , total full excision is hard to be excised. I will explain to my patient for incisional biopsy to centre and peripheral 2 biopsies .

  16. A great case! History is key – is the patient reliable though? Has it been there “for ever”? Even if there for 20 years and growing so slowly that she doesn’t notice it, it could be a melanoma (some grow very slowly). I think the clinical and dermoscopy is borderline suspicious and I would never monitor a suspicious lesion. In the follow up image we see real change which rightly prompts excision biopsy – but it is reported as a low grade dysplastic nevus (whatever that really means!). Key points to make: 1) if in doubt excise – don’t do a punch or an incisional biopsy, do a deep shave or an excision, 2) if you do see change like this, excise, 3) low grade dysplasia requires no further treatment if a complete excision biopsy was done. Great case!!

  17. Thanks everyone for the comments.
    The history here was that the lesion had been present for over 10 years with no apparent change.
    As the eagle eyed among you will have noted, she has a couple of tattoo marks from previous radiotherapy to that breast so I managed to talk myself out of removing the lesion when I first saw it, a decision I immediately regretted when I reviewed it and saw the alarming changes on dermoscopy!
    A deep shave removed the entire lesion, but 4 weeks later it still hasn’t healed, possible because of the previous radiotherapy.

  18. I gave it a score of 0 initially, however after reviewing the pathology report give it a score of 1.
    No treatment needed other than monitoring and use of sun protection.
    I would only excise it if the patient is anxious and wants it removed

  19. I would ask for a review of the histology.

    The lesion I thought was suspicious sufficient for excision originally.

    The second photo shows significant progression with extension at 9o’clock and enlargement of the central blue grey area of regression.

    In any event I would have no regrets regarding slow to heal, as if in doubt…..