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

This week’s case discussion, submitted by Dr David Stewart, features 70-year-old man with a past history of lentigo maligna removal eight years ago by a dermatologist. He presented for a skin check with a crusty lesion overlying the lentigo maligna scar.

  • 70-year-old male patient
  • History of lentigo maligna
  • Crusty lesion over scar

What do you think? What would you do next?

case discussion

Update

Here is the pathology result.

case discussion

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21 comments on “Case discussion: How would you treat this patient? [12 July]

  1. Very suspicious of recurrence of melanoma- if take erosion as centrepoint then 4 o’clock have grey homogenous and lines with pink polymorphic vessels.at 9’oclock pink polymorphic vessels and 7 o’clock possible melanoytic reticular pattern with grey polygons.
    So this is deeper amelanotic/hypomelanotic melanoma until proven otherwise!
    A wide excision biopsy of whole lesion for staging is required

  2. I see an ulceration area with line radial converge on the right side and also some orthogonal white lines and some blood vessels which all would fit with bcc. Having the history of a removal of LMM would also imply the element of recurrence. Either the way excise for histology. Interesting case.

  3. What were the margins in the earlier excision? Was it shaved?

    Need to consider melanoma but could be an SCC. Consider BCC also but there is a pigment network in parts of the area in question.

    Would do excisional biopsy with >2mm margins.

    The surgical scar is affecting interpretation.

  4. Suspicious lesion recurrent melanoma
    Excision biopsy 2mm margins
    Would be very interested to see the original histology / case notes to see if the recurrence relates to a demonstrably inadequate excision first time around (as a learning exercise)

  5. Concerning ! polymoprhpisc vessels, white streaks, hyperkeratosis and ? blue veil at 4 o’clcock
    Simple excision with 3 mm margins
    Suspicious for reoccurrance.
    Unless recently removed ( does not look like a new scar, though) and this is a stitch abcess,

  6. chaos in colour and structure
    polymorphous vessels
    white lines
    eccentric structureless area
    grey structures
    – likely recurrence and progression of melanoma
    wide excision 1-2 cm margins

  7. whit structureless areas of scare
    polymorphus blood vesseld
    ersion
    bly grey ovoid nest
    blu grey ovoid globules
    basal cell carcinoma

  8. Structures areas, irregular lesion, peripheral pigmentation and polymorphic vasculature suspected for melanoma. Excision biopsy with 2 mm margins

  9. His is a suspicious looking lesion in chronically sun damaged skin with a history of LM.
    The lesion is new,has surface crust,central scar like area and an erosion.
    Need to R/O SCC or BCC.
    I would Biopsy with a 2 mm margin

  10. Pink flat lesion with central superficial ulceration on background of heavily sundamaged skin and a scar. The lesion appears chaotic, there is a lot of structureless white and glomerular BV`s but also other clues that may or may not be part of the lesion either part of the background noise – ?solar lentigo reticular network /?hyperpigmentation on the scar, loop BV on the scar … Conclusion: I can`t say what it is + located on scar from a LM – so it needs a biopsy. Few corkscrew blood vessel at 9 o`clock making it highly suspicious for invasive melanoma. I think I`d prefer to do an incisional biopsy across this part of the lesion, either a full excision with 2mm margin if the patient agrees to this relatively large excisional biopsy. It may turn out to be `just` SCCis …

    1. Hello Doctor, every Wednesday the blog post is updated to include the pathology report. If you look back on previous case discussions, you will see this has been the case every week. Thank you, Abbie | HealthCert Education

  11. The best way to approach this, I suggest, is to recognise (as most did) that this is a suspicious / risky situation, and further action is needed. That further action is, surely, a biopsy, as Dave did – and I think a nice shave biopsy is the right approach here. As we see there is no recurrence and so a larger excision / procedure is avoided.