Case discussion: How would you treat this patient? [5 April]

In this week’s case discussion from Dr Dave Stewart, we look at a 47-year-old lady who was initially seen with a long-term pigmented skin lesion on her upper arm in 2018 and returned again in 2021.

  • 47-year-old female
  • Long-term pigmented lesion

case discussion

The patient was reassured in 2018. She returned in 2021, reporting “recent change in the lesion”. Please review and compare the images. What is your assessment? Has this changed? What would you do next?

 

 

Update

Here is the pathology result. What would you do next?

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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21 comments on “Case discussion: How would you treat this patient? [5 April]

  1. First image shows suspicious pigmented lesion, possible melanoma: chaos, clods and veil.
    Updated image has the same with added areas of blue.
    Cannot comment on any change in size as no scale in second image.
    Still looks like melanoma.
    Plan:
    Excise 2mm margin, review histology and if (still) superficial complete treatment with excision to 10mm margin; or, if not superficial, refer specialist melanoma service.

  2. the 2018 dermoscopy image had enough features to warrant a 2mm margin complete excision for histology with the comment – ?Spitzoid patterned Melanoma

    the 2021 features together with the reported concern of change confirms to me that the lesion was a Melanoma back in 2018

    i would excise the lesion after advising the patient that there is an arguable option of a 2mm vs 5mm margin excision in the first instance in her case and point out the reasoning

  3. “Change trumps everything”

    The lesion is now assymetrical in shape and colour, has an atypical network, and has developed a blue-grey veil.

    Now scores 3/3 and highly suspicious for melanoma.
    Excision biopsy 2mm margins.

    It does beg the question, waht was the lesion 3 years ago when it looked quite different?

  4. I think I would have removed it in 2018, already but definitely now as an excision biopsy 2 mm margin .
    Ugly duckling , white lines

  5. Change + highly suspicious (in both of the images ) lesion, in conjunction with a “nice” location that would allow easy initial wide “curative” excision suggests a wide excision should be done initially.
    A diagnostic punch or shave biopsy could be done first, though the appearance and the changes shown strongly suggest this to be a melanoma and warrents treatment as such ASAP.
    The closeness to the axillary nodes and the duration of the melanoma (probably more than 3 years) is of concern, and once histology confirms melanoma, considering lymph node spread may be present and refer appropriately to oncology.

  6. PSL showing different shades of colour and structure of dark blotch and white lines and bluish veil in the second one. Excise with 1 mm margin and then if was in keeping with melanoma excise with 10 mm margin.

  7. I this was at least2/3 on 3 point checklist in 2018, now 3/3 and needs excision biopsy with 2mm margin to plan appropriate further management depending on Breslow thickness

  8. Area of asymmetry in the 5 o clock position with some regression in the centre of the lesson.
    Need complete excision .

  9. With the initial features I would have expected a much more convincing melanoma with the follow up. But there’s a blue/grey veil and you need to be careful with any change in a melanocytic lesion in an adult. So I would do an excisional biopsy with 2mm margins.

  10. looks more like seborrheic keratosis variant but given the variation in size would be prudent to shave it

  11. The first picture shows some irregular pigment pattern and possibly white segments, 1-2 out of 3 on checklist
    I tend to err on the side of caution and likely would have excised then, however history that it was unchanged for years at that point may have been misleading

    certainly on the review there is now the added atypical networks plus irregular pigment and perhaps white segments 3/3, in addition to reported change this is highly suspicious, excision with 5mm margins

  12. On 2018. Image chaotic lesion with thick and segmental lines and peripheral black clods as clues to malignancy. DDx Melanoma Vs Spitz/ Reed naevus. I would like to think I would have removed it then. Nevertheless there has been substantial interval change. It needs excision with 2mm margins for a histological diagnosis.

  13. Historically patient has reported a change : in colour. Shape. Size? Time frame
    Clinically 3/3 highly suspicious : asymmetry; atypical reticular network; blue grey veil
    Warrants an excision biopsy 2mm margins

  14. I find these cases quite tricky. It`s a changing pigmented lesion in an adult, and confirmed melanocytic on the histology. I suspect that this lesion was excised with 2 mm margins as per guidelines, and the histo report confirms a clear margin of 1 mm. The question remains if we are going to accept this — either not, and re-excise further with 5 mm margins (and basically treat this as a melanoma in situ) .
    I recently read this article about dysplastic neavi excised with involved margins and in the `Discussion` at the end of the article an interesting reference to another study of longterm follow-up on 115 patients over 17.4yrs, dysplasti naevi excised with involved margins and not re-excised : nil evolved to melanoma !
    I`d be keen to hear what Professor David Wilkinson opinion is on this case.

    hinks of this

  15. Great case again from Dave! Thanks!! Easy to say I would have removed it on first visit – maybe, probably, maybe not? Definitely, due to change on second visit. Now it is “moderate dysplastic”. We all rightly reject the “dysplastic” diagnosis, and I would follow the rule that if it is REPORTED as “moderate dysplastic” then a 2mm margin (from the original excision biopsy) is enough. The literature provides strong support for this approach.

    1. Thanks 🙂 When I saw the change at the review visit I definitely wished I’d removed it the first time! I was very relieved when the pathology came back as non malignant. Thanks for using the case in the blog.

  16. I would ask for a review of the histopathology, but also do a wider excision of the scar – 3mm margin