Case discussion: How would you treat this patient? [31 May]

In this week’s case discussion, submitted by Dr Terry Harvey, we look at two dermoscopy images from a 60-year-old male patient.

  • Left image: Dermoscopy of cheek
  • Right image: Dermoscopy of deltoid

What do you make of these two images?

Update

Here is the pathology report. Thoughts? 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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20 comments on “Case discussion: How would you treat this patient? [31 May]

  1. Cheek: asymmetry colour and structure; atypical perifollicular pigmentation; annular granular structure: suspicious – excision excisional biopsy
    Deltoid: asymmetry colour and structure; atypical reticular network : suspicious: needs and excisional diagnostic biopsy

  2. Cheek – I can see some grey circles -> excisional biopsy

    Deltoid – chaos and ~polygons -> excisional biopsy

  3. First show some polygons and second some linear reticular snd dots and clods. I would excise both to exclude malignancy.

  4. Lesion on the cheek shows follicular opening, asymmetric pigment networks with a few globules, the border is also irregular, so I am still not confident to diagnose it as lentigo simplex. To r/o lentigo malignant my management is a total shave biopsy of the lesion if not very large or map biopsy if large.
    Lesion on the deltoid does not look malignant and just needs follow up and review in three month in my opinion.

  5. DELTOID SOLAR LENTIGO
    CHEECK ?? EARLY ANNULAR GRANULAR PATTERN FOLLOW after 6 monthes

  6. Cheek: lantigo maligna as you can see grey circles
    Deltoid one could be a melanoma. Very different from every angle. One side of the lesion you can see polygons! Melanoma??

    1. 1. cheek: brown asymmetrical pigmentation of follicular openings; some ‘annular granular’ changes and polygons; background lentigo; I would be suspicious of LM; depending on size of the lesion I would wither punch it out if small or shave it if larger
      2. deltoid: background lentigo, sun damaged skin; asymmetrical lesion with peripheral brown structureless area, several shades of brown; suspicious for LM, excision 2mm margin

  7. Lesion on the cheek shows atypical network with spokewheeling?
    suspicious and needs excision.
    lesion on deltoid is atypical in structure but not color.
    This can be monitored for change in 3 months with mole mapping.

  8. cheek lesion shave biopsy given grey circles- could be just pigmented AK too.
    leave the shoulder lesion alone-benign lentigo

  9. both asymmetry of colour and shape
    grey circles
    deltoid lesion more grey veil
    both suspicious – excision biopsy with 2mm margin – ? Melanoma

  10. Thanks for presenting this case
    Reviewing the cheek: so we have level 1 Lentigo maligna
    But the biopsy does extend to the depth and width of the lesion.
    Can we make that histological diagnosis if the specimen is not complete?
    I have some reluctance to shave pigmented lesions, for this reason.
    Is that correct ?
    I am assuming this will need a further wide 10mm margin if possible , as will the deltoid ( 5-10mm)

  11. Very tricky cases – I wonder whether I would have noticed these, in real life and whether I would have biopsied them? Maybe the cheek, but…..clinical context and clinical appearance matters, of course. Both now need excision of course 5-10mm depending on site and context. Thanks Terry

  12. Good photography and cases;
    cheek melanoma in situ:black dot in circle non lentigo like border MIS
    deltoid non lentigo like lesion with brown dots clods MIS
    excision of both with 2–3 mm margin