Case discussion: How would you treat this patient? [24 May]

This week’s case discussion, submitted by Dr Terry Harvey, features a 40-year-old female patient who attended for a routine skin check with no lesions of concern. A 1mm skin-coloured papule was examined with dermatoscopy on the chest (below the black mark in the wide clinical image). Initial pathology report was “benign skin only”.

  • 40-year-old female
  • 1mm skin-coloured papule
  • Initial pathology report: “benign skin only”

What is your assessment and what would you do next?

case discussion

Update

Here is the pathology report. What are your thoughts?

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23 comments on “Case discussion: How would you treat this patient? [24 May]

  1. Extensive sun damaged skin with ” ugly duckling “,irreg outline .Needs excision biopsy and histopathology.

  2. I would ask path to be reviewed. Chaotic lesion. Irregular pigmentation, ?melanoma. Would seriously consider excising the lesion, but downside is that pt is going to have to leave a scar on someone‘a anterior chest. How was the first box done? ?shave, ?punch

  3. A chaotic lesion with asymmetrical border, ? dotted vessels within pigment. Looking at the 360 o periphery of the border, this could be a nodular lesion. It would be good to know if this is a new lesion. Certainly requires an excisional biopsy to rule out melanoma.
    I would also be looking closely at the small dark pigmented lesion above which you cant see clinically.

  4. Suspicious for a pigmented BCC. How was the original biopsy obtained? Is there a chance a small biopsy missed the lesion of interest or suspicious area was missed in’s sectioning? In the central location an excision should heal well with a 3mm margin for definitive bcc treatment

  5. How can the pathologist give an opinion just from Dermoscopy ? I would have thought if the Dr who examined her had concerns or was unsure, an excision biopsy would be the best next step to get a more definitive diagnosis ?

  6. There appears to be a discrete lesion where the external skin vasculature ‘ceases’ at the border or changes.
    The lesion is not melanocytic but has pigment dots at dark reddish structureless areas.
    Suspicious lesion ?BCC
    For excision with 2mm borders at least.

  7. First i would ask how long the lesion has been present. If it is longstanding i woyld consider the lesion the remnants of an intradermal nevus. Given that the melanocytic component is not grey but brown and the lesion is nodular this could not be a pigmented BCC. No action is needed

  8. Not conforming with features of dermatofibroma, solar lentigines, or seb. K.
    No clear cut negative network, no polygonal lines, no aggregated globules, scattered peripheral globules noted, no streaks, no homogeneous blue pigmentation,
    Some of the BCC features noted are
    peripheral arborizing vessels, multiple blue gray non aggregated globules, some resemblance to leaf like areas, blue gray ovoid nests, multiple brown/blue gray dots

    No features of SCC

    likely BCC pigmented, nodular?
    Excise with margin or first punch the most atypical area after confirmation excise with margin

  9. change the pathology provider and treat the lesion as a BCC- arborisation with black dots central – try cryotherapy serial over 2 weekly cycles- excellent results

  10. This is a definite lesion, and it doesn’t fit seb k, sebacious hyperplasia, haemangioma, so I’m not sure what benign lesion it is; on dermoscopy it is suspicious for pigmented BCC; I would speak with the pathologist about this and ask for deeper levels to be assessed

  11. I would probably do an excision biopsy since it is a papule and pattern of pigmentation and depigmentation looks irregular.

  12. what is the detail of pathology report?
    The lesion is an ugly duckling and has pigment network with atypia. So, it might be an atypical nevus, which in definition is a benign nevus. I would prefer to have a second opinion of another pathologist and after confirming the benign nature of the lesion with the second opinion, If the excision is complete there is no need for further management rather than keeping an eye on the patient and educating her about the symptoms of skin malignancy.

  13. Blink diagnosis suggests BCC with brown clods and dots. Could also be a benign sebaceous or other `skin gland tumor`. It is tiny, 1mm, so very likely has been missed by the pathologist if only `normal skin` has been reported. It may be worth asking for extra slices if you wish to get the diagnosis confirmed. So next step: call the pathologist.

  14. For the doctor with basic dermoscopy skills this is “has to be a BCC” – the key clues are the milky white background and the typical dirty clods”. Big punch biopsy here – scar is minimal and not relevant: she has a cancer. I would not accept a benign diagnosis, and neither did Terry!

  15. Atypical lesion on chronically sun damaged skin with tan structureless areas ,ovoid nests and atypical in colour and structure.
    Excise.