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

This week’s case discussion, submitted by Dr Saad Raheem Abed, features a 54-year-old man who presents to clinic with a nodule on his skin. It has been present for over 12 months and has been asymptomatic. It has grown a little over that time but his GP has reassured him on a number of occasions. Concerned, the patient has checked out ‘a mole checking service’ which analysed the picture and recommended that he be seen by a dermatologist.

  • 54-year-old male patient
  • 12-month growing lesion

What is your differential diagnosis, and what would you do next?

case discussion


Here is the update from Dr Saad Raheem Abed:

 The outcome of dermatoscopy:

After dermoscopy, dotted and comma vessels on the upper left corner are visible, hairpin vessels on the right side of the lesion and linear vessels all through pointing towards polymorphic vessel morphology in an irregular distribution and mostly central. Lesion is a partially pigmented melanoma due to the presence of some pigment in the periphery of the lesion. There is also blue-white veil at the top right part of the lesion. The vessels most likely disappeared in the top right image due to compression via dermatoscope and the fluid medium. There are also milky-red areas with multiple shades of pink.

 So briefly, the dermatoscopic features are:

  •  Irregular pigmentation
  • Irregular dots/globules
  • Polymorphous vascular
  • Reticular depigmentation
  • Dotted irregular vessels, linear irregular vessels, or combination of dotted and linear irregular vessels
  • White lines

Thus, combining the clinical features with the dermatoscopic features, the diagnosis is nodular melanoma (amelanotic nodular melanoma).


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

  1. Appearances suggest nodular BCC DD amelanocytic melanoma

    Could waste time with a punch biopsy first, but suggest excision with 3mm border if patient happy to proceed with that.

  2. I would excise the nodule with a 2mm margin.I would not just biopsy this lesion .
    Possible amelanotic melanoma ? BCC ? other skin cancer ? benign lesion .

  3. Looks malignant. EFG lesion. Agree that excision biopsy is the way to go. Hopefully relatively slow growth means its not too nasty

  4. clinically elevated, firm, growing:
    dermoscopic: chaos of colour with white lines

    clinical diagnosis: melanoma
    needs excision biopsy

  5. New lesion on someone over age 40
    Dermatoscope- structureless area, polymorphic vessels, pigment around edge of nodule.
    Suspicious for melanoma and would do excisional biopsy

    1. Pink nodule, elevated, firm and growing. Pigment at base.
      ? Melanoma or Merkel Cell
      Excision biopsy

  6. A growing nodule in 54 yo,
    Red nodule, White steaks with dilated ? Polymorphic blood vessels, all fit into high possibility of amelanotic modular melanoma. I would do an excision an biopsy , then referral to melanoma team

  7. Nodular melanoma – immediately surrounding the nodule I can see some form of pigment pattern. There are white structures and polymorphous vessels. I would also consider Merkel Cell Carcinoma as a differential diagnosis.

    Perform an excisional biopsy and plan further management based on histopathology.

  8. Better apply EFG’s rule (Elevated, Firm, Growing), requiring biopsy without hesitation or follow-up. Either shave or punch or 2mm margin excisional (given male thigh), and go from there.
    Dermoscopically difficult to suggest a precise diagnosis. Given white stuff with linear and tortuous v/s in the milky-erythema background, D/Dx could be:
    (1) nBCC,
    (2) nMM,
    (3) MCC (shiny dome surface additionally; Ref: PMID: 23574613).

    1. Skin adnexal origin such as Pilomatrixoma, Cylindroma, can also be considered in the D/Dx, in addition to nBCC, nMM, and MCC.

  9. Differential: Merkel cell carcinoma vs BCC .
    Excision with 2mm margins as if does turn out to be a Merkel Cell carcinoma he may require a sentinel node biopsy for staging.

  10. Single nodular lesion. I would excuse and send for HP. I can see shirt white lines and polymorphic vessels. My DD: MCC, nodular melanoma.

    Why you said the GP reassured him. Is the GP thinking of DF. I don’t think it’s the case. In such an age and with such history and changes it’s sinister until proved otherwise.

  11. Amelanotic melanoma,Nodular BCC would have to be considered, on history and apperance but also Merkel Cell tumour.Wide 3mm excision

  12. Strongly suggestive amelanotic melanoma. Check nodes and excise 2mm margin. Straight to melanoma centre if positive nodes without waiting for histopath

  13. Differential diagnoses include Merkel Cell Carcinoma,
    Amelanotic melanoma as well as Atypical Fibroxanthoma
    . Excision biopsy recommended.

  14. elevated firm growth lesion
    peripheral brown pigmentation
    polymorphic blood vessels and white lines
    DD: nodular melanoma, nodular BCC, Merkel cell carcinoma
    Management: excision biopsy with 2 mm margin

  15. New lesion in a 55 year old. Need tissue biopsy. If sufficient skin ellipse or a halo. Clinically ? Pyogenic granuloma ? Merkel cell carcinoma

  16. A great case this week – great to see everyone thinking the right way: “this looks ugly and needs to come off”. I would recommend thinking EFG and excise with 2mm margins to get a diagnosis. Then, plan for definitive treatment.