Case discussion: How would you treat this patient? [12 April]

In this week’s case discussion from Dr Terry Harvey, we look at a man in his 50s with no history of skin cancer who presented for a full skin check with no lesions of concern.

  • Male aged 50+
  • No lesions of concern

Please review the images. What do you think? What would you do, if anything?

case discussion

Update

Here is the pathology result. What 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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18 comments on “Case discussion: How would you treat this patient? [12 April]

  1. I think the scary thing about this is just how easily on first glance it may pass as a naevus ,despite the asymmetry –magnification though shows the early pigmentation irregularity ,some early reticulation change and occasional whorl. Excision biopsy next step .

  2. dermoscopic grey with faint polygons, shave to exclude SSM which is most likely or a highly dysplastic nevus

  3. Sun exposed area, Subcentimeter brown reticular pattern macule, asymmetrical, irregular black dots peripherally, punch biopsy needed to R/O lentigo maligna

  4. An excisional biopsy with 2mm margins will be most appropriate.
    A punch biopsy will be erroneous as may not give an accurate diagnosis.
    Peripheral clods,structureless areas, melanoma until otherwise proven.

  5. I cannot see any feature in the dermoscopy (no atypical network or other concerning feature.
    I guess the histopathology report will say benign pigmented naevus.

  6. peripheral asymmectrical globules erythema ( blush or dotted blood vessels ) need biopsy to exclude melanoma

  7. It’s in a skin cancer blog so it gets special attention.
    Easily missed.

    Assymetric shape.
    Atypical (faint) network with melanocyte deposition in same
    Possible regression at 12 o’clock

    So 3/3= suspicious
    Melanoma likely

    Excision biopsy with 2mm margins

  8. Suspect superficial melanoma doing its best to look like a “dysplastic” junctional naevus.
    As pointed out by others there is a lack of symmetry and pattern in a pigmented lesion.
    Plan excision 2mm margin and I’d happy it’s gone even if the histology is non-malignant.

  9. Firstly why that lesion only is that different to rest I can see few in the region.How big this lesion?
    If that was different clinically ?dermatoscopically It has irregular border and structure less areas different colours , can observe or shave biopsy to confirm.

    1. Clinically this lesion was the same as all those surrounding it. I examined every visible lesion in the region with the dermatoscope (as I do with every skin check). This was the only lesion that showed concerning dermatoscopic features.

      An examination shouldn’t be trying to decide which lesions to examine with the dermatoscope based on clinical features – it should be examining every visible lesion with the dermatoscope. If I didn’t practice this way – this melanoma would have been missed.

  10. This lesion is assymetrical (chaotic) with an eccentric structureless area and peripheral black dots. I would remove as excision biopsy.

  11. Thanks Terry. Amazing case and a great pick up by you! I have to be honest and say that I doubt that I would have looked twice at this and even if I had laid the dermoscope on it, i am not sure that I would have done anything!! Just being honest here. So, some questions arise to me: 1) what is the natural history of lesions like this? How quickly do they grow? How many like this regress naturally? and 2) what is the role of total body photography in patients having a skin check? There is recently published evidence that has changed my view about TBP – I think we need to change our practice in response to new data. My (emerging) view is that TBP is becoming the standard of care for all high risk patients, and most intermediate risk patients……..more on this to come. Thanks Terry

  12. This case is quite scary though. It could be missed ….Well done Dr Terry.
    Where we can refer the patient for TBP in Adelaide?