Case discussion: How would you treat this patient? [26 July]

In this week’s case discussion, submitted by Dr Saad Raheem Abed, a mother has brought her 10-year-old son to the clinic and is concerned about a dark lesion on his right upper back.

He had this lesion for years but his mother noticed it has grown and is darker than the rest of his moles. There is no history of significant sun burn and no family history of melanoma.

  • 10-year-old male patient
  • Mother concerned about dark lesion

Please review the clinical and dermoscopy images. What would you do?

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26 comments on “Case discussion: How would you treat this patient? [26 July]

  1. Definite ugly duckling but dermoscopy shows starburst pattern suggesting likely Reed naevus. Given age < 12 years old melanoma possible but very unlikely. A brave person might leave it but given recent change, removal with skinny margins the safest option.

  2. Looks like a Reed naevus. Differentials would include melanoma and pigmented Spitz naevus. Malignancy is unlikely, but given the history of change I would be performing an excision biopsy to confirm.

  3. Pigmented skin lesion on the back of a 10 year old boy. Dermatoscopically appears as uniform pigmentation in a starburst pattern. Also the lesion is solitary. Clinically appears as a pigmented Spitzoid naevus.
    Pathology shows spindle epithelial cells and solitary pigmented cells in the base. Diagnosis of Spitz naevus.

  4. This looks like a Spitz nevus which is common in teenagers / younger people.
    Benign but observe for change

  5. Dermal naevus / compound melanocytes naevus.
    Deep Shave excision for Histological confirmation.

  6. The starburst pattern fairly characteristic for a Reed naevus. with the ellipsoid epidermal cells and the collection of melanin containing cells at the Dermis junction .The other suggestion is an atypical Spitz naevus ,due to scattered pigmentation and epidermal pattern. Atypical Spitz can become melanoma —would excise with 5mm margin .

  7. At first i see an Ink spot naevus, and considering naevus keep forming in youth til mid 20s, im not concerned until i see the globules at the outer edges of the naevus. I have no idea about Pathology being an RN, however, Im not a fan of the brown areas on the Path image. Considering it is solitary and no history of sunburns – consider congenital – but if I was in a position to excise, i would.

  8. look like spitzoid naevus,10 years old melanoma unlikely
    but need to check with Fhx if melanoma
    if mother concerned then i will consider excision biopy or observation in 3 months

  9. Spitz nevus. Symmetric radial lines. But differential includes melanoma. I would refer to dermatologist

  10. I guess the question is whether short term monitoring would be wise as a first step. Given the otherwise low risk and potential scar size for even small margins I would repeat imaging in 3 months.

  11. Pigment lesion characteristic features of spitz nevus, but in pathology the lesion shows invasive characteristic. So, now that the patient has a pathology result, consultation with a plastic surgeon would be a good plan to see if the lesion needs extensive further excision. Check the lymph nodes as well.

  12. Dark PSL showing irregular all around (steaming) Given the age it fits Reed or spitz Nevus. However keep an eye or take a biopsy to exclude any nasty changes. DD: MM

  13. Although a chance of malignancy (MM) is rare in 10 yo with lack of FHx, mother accounts of recently growing and darker in comparison other moles is concerning. Histology analysis is more important, as clinical and dermoscopic differentiation is difficult at times between Spitz and Reed naevi. Therefore, biopsy is needed {either from a GP who comfortable with cooperated child or referral to a specialist (surgeon or dermatologist)}.

    In this case, histology picture is blurred, and if presumed reticular dermis involvement with presence of vertical growth along papillary dermis as well as ovoid nests would favour a Spitz naevus; On the other hand, centre dark clods and radial streaming with pseudopods at the periphery and clinically darker lesion indicates a Reed naevus. Thus wait and see from verdict of expert’s histopathology report and go from there.

  14. starburst pattern, looks like spitz nevus. looking at the age changing in size should not be concerning too much
    if there is family history etc as a risk factor , biopsy can be offered.

  15. A changing Reed nevus even in a 10 yr old is a melanoma till proved otherwise. Assuming the Bx was excisional, I’d discuss the result with a dermatopathologist. Incisional or punch Bx not really appropriate for this lesion.

  16. Normally with starburst reed/ spitz naevus, I would observe and review in 3 months, but taking into consideration the changes described by the mother and the appearance of raised nodular lesion; I am more inclined to do excision biopsy even before I could see the Histology.

  17. Irreg outline, ugly duckling, change recent , areas of whiteness. For adequate excision biopsy.

  18. whilst children have alternative ABCD criteria, this fits ‘EFG’/elevated, firm, growing in the adult criteria; probably a pigmented Spitz naevus/Reed naevus but as it is not flat, it should be excised rather than monitored

  19. Dr Reed’s specialty
    Mother is concerned
    Therefore excision if you are confident to achieve a nice scar
    Then everyone will be happy

  20. According to the dermoscopic image this lesion is not a suspicious lesion . Score 0 . It is a Becker nevi .However literature consider it as a Mole and medically a Mole is a potentially malignant lesion . As it is moving , and it is nodular my humble advice to the doctor is to do a large excision for histopathological historic diagnostic and for treatment . He will have to be sure that all nevi cells are extracted . The wound will need a Graff in order to fulfill quickly the hole and for esthetic . .

  21. The lesion is homogeneously darkly pigmented with radial extensions around the whole periphery. As long as the lesion is flat and not elevated I would call it a Reed naevus and suggest that it should be monitored only, at this stage.
    It maybe be advisable to consider excision around puberty.

  22. Colleagues, there is a wide variety of responses here, suggesting a wide variety of knowledge / understanding. The answer – what to do based on evidence is in the attached.

    Ref: Management of Flat Pigmented Spitz and Reed Nevi in Children
    Aimilios Lallas, PhD1; Zoe Apalla, MD, PhD1; Chryssoula Papageorgiou, MD1; et alGeorge Evangelou, MD2; Dimitrios Ioannides, PhD1; Giuseppe Argenziano, PhD3
    Author Affiliations Article Information
    JAMA Dermatol. 2018;154(11):1353-1354. doi:10.1001/jamadermatol.2018.3013

    1. David, the reference you cite is an excellent one, but I wonder how applicable the opinions are to the Australian demographic.
      For the most the authors are specialist dermatologists, working in well funded European public hospitals, where the logistics of patient follow up and surveillance are different; if for no other reason the tyranny of distance. Furthermore , from my own experience studying in Europe, the decision to biopsy is made by a dermatologist, but the procedure is performed by a plastic surgeon.There seems to be a reluctance amongst some dermatologists to refer for biopsy,as it may be construed as a lack of dermascopic skill, or in fact, seen as over servicing.
      In the case in question, I would have thought that a competent GP with good communication skills could do a punch excision of this suspect lesion in the rooms…there and then. “ Problem solvered”, as we say here. On the back, scar not a problem. Parent’s anxiety alleviated, and they can all hop in the Ute and drive back out to the farm. Absorbable sutures: competant parent to ring for the result.
      A biopsy is a test: it hardly justifies the term “ surgical procedure”.
      I trust these comments might add a further dimension to discussion.
      Best wishes.
      Ken Leahey. FRCS (Edin.) . Dip. ACCO.