Case discussion: How would you treat this patient? [14 June]

This week we have an interesting case discussion from Dr Saad Raheem Abed in Iraq at the Alhussain Teaching Hospital. A 30-year-old man has been watching this pigmented lesion over the last two years. His wife has prompted him to consult his GP. His GP photographs the lesion using a dermatoscopic attachment for his phone, and sends these images via the local tele-dermatology service.

  • 30-year old patient
  • Pigmented lesion noticed over 2 years

What do you think?

case discussion

Update

The pathology report returns showing malignant melanoma, Breslow thickness 1.4mm, Clark level III, with ulceration and mitoses count greater than 5 per mm².

What is the management for this patient?

 

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27 comments on “Case discussion: How would you treat this patient? [14 June]

  1. Size /colour/ growth/pigmentation with reticulation visible even at this magnification/ Dark smooth hue –Melanoma, which needs removal with wide margin

  2. Irregular shape lesion with multiple colours and patterns. Reticular pattern and peppering . R/O Melanoma by Excision biopsy’s with wide margins.

  3. MM
    Variable colours
    Peripheral network
    White lines centrally
    Peripheral dotted and linear vessels
    Excuse with 2 mm margin to allow for sentence node biopsy and wider margin depending on histopathology

  4. Suspect Melanoma – presence of irregular pattern, colours ,blue grey veil
    Recc immediate excision biopsy with 2mm margins in first instance to obtain confirmation and grading with follow up treatment accordingly

  5. Irregular outline, veil present, dark round areas near the periphery, streaming edges, all strongly suggest melanoma

  6. Dark naevus
    Atpical pigment network
    Blue white structures
    High Susp for melanoma
    Refter for treatment and diagonosis

  7. ASYYMETRICAL LESION WITH MULTIPLE STRUCTURES COLORES
    BRWON NETWORK AT 11 CLOCK
    BLUSHISH BLOCH AT 12 AND 1 CLOCK
    MANY SWS
    AREAS OF BLUE WITICH VEIL
    IT IS MALIGNANT ?? MELANOMA ?? BCC

  8. Both macroscopic and dermoscopic pictures shows chaos of colour and structure.
    There is eccentric structureless area with greyish blue veil appearance. White lines with peripheral dots and polymorphous vessels.
    Diagnosis- Malignant Melanoma
    Management- 2WW for urgent Excision.

  9. This can be diagnosed macroscopically via elephant approach and diagnosis is confirmed on dermoscopy of a superficial Spreading melanoma so needs the 3mm margin excision shave is what i prefer

  10. This is a MM .Irreg outline ,multiple pimentation ,ugly duckling .Wide excision +/- sentinal node biopsy.

  11. Blue -white hue is suggestive of melanoma, but the clods on the periphery would suggest pigmented BCC. Excision with 2 mm margin will confirm the diagnosis.

  12. Three point check list score 3/3
    Highly suspicious of melanoma
    Need excision biopsy with 2mm margin
    Excision following the biopsy report.+/- referral for centinal node biopsy+ dermatologist care- depending on the report.

  13. Further info of duration, evolvement and FHx would be much helpful. Although age and ethnicity was not in the prevalent MM side,
    this relatively large (13mm) Chaotic lesions harbours several clues- dark clod, dark-gray and white-gray structures, white lines, eccentric structureless (L side), dotted and polymoprhic v/s.
    Shaved biopsy may miss actual thickness?? Thus 2mm margin excision and go from there.

  14. Sorry, attempting to upload annotated dermoscopic pic, see! (may or may not allow)
    dotted v/s (8′ clock), eccentric structure less (L side) embedded with polymoprhic v/s, …..

  15. Macroscopically single dark lesion macroscopically chaotic and asymmetrical in structure and colour.
    Dermoscopically see raised central blue black with white lines consistent with nodular melanoma. Extending from this are brown reticular areas and more than one type blood vessels more consistent with spread than existing naevus.
    Needs immediate excision biopsy with at least 2mm clear margins. Await histology which I would expect to require sentinel node and pet with specialty unit and wide excision and immunotherapy

  16. A great case from Dr Saad – thank you. This is an “obvious” melanoma, and need is “very definitely” a suspicious lesion. As such it needs an excision biopsy with 2mm margins. There is no excuse to do wider margins or a shave in a lesion like this. 2mm margin, excision biopsy is the national consensus guideline for best practice, and hence is the medico-legal standard. Pathology shows Breslow 1.4mm, with ulceration and mitoses, so this is an aggressive tumour. The most appropriate next step is SLNB at the time of wide excision (1-2cm margins). Why? Because this patient will need SLNB for consideration for entry into melanoma treatment trials, and / or adjuvant treatment following resection.