Case discussion: How would you treat this patient? [9 August]

In this week’s case discussion, submitted by Dr Cheh Goh, we look at the case of a 69-year-old male who presents for a skin cancer check and gives no history at all.

  • 69-year-old male patient
  • No history

What do you make of this? What would you do?

case discussion case discussion

Update

Here is the pathology report. What next?

case discussion

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23 comments on “Case discussion: How would you treat this patient? [9 August]

  1. Chaos of colour and pattern, eccentric structureless are top right, blue grey areas and peripheral dots. Most likely nodular melarnoma. Excisional biopsy with 3mm margin.

  2. Agree with other comments– likely to be melanoma ,the differential Nodular pigmented BCC although unlikely due to structures and whorls commonly associated with Melanoma.Excise 5mm margin.

  3. with no history available,looks more suspicious
    Nodular lesion with color chaos,grey blue clods,eccentric structureless area

    For 2 mm excision biopsy

  4. I would be concerned due to being a lesion with significant asymmetry in colour and shape .It also shows dots and pseudopods in the periphery. Being being raised gives differential of nodular melanoma

  5. suspicious lesion – ? nodular melanoma
    Blue grey veil, peripheral clods, asymmetry in colour
    Excision biopsy with 2mm margin

  6. It is a pigmented chaotic lesion with some clues: peripheral clods, blue grey colours and eccentric structureless area. It is highly suggestive of melanoma. To excise with at least 2mm margin

  7. Single elevated skin lesion showing white blue veil snd peripheral dots/ clods. Excise to rule out malignancy.

  8. This chaotic pattern most likely represents a nodular melanoma. DDx a BCC. If unsure then a 3mm excision but ultimately this will require a 5 to 10mm re-excision once pathology is back and extend of infiltration is known.

  9. Raised > 6mm Blue grey veil, Peripheral dots chaos and irregular pigment ( dark at 70clock)
    Excised 3mm margin : Nodular melanoma

  10. Nodular melanoma until proven otherwise. Excise with 2mm margins. Further management as indicated by Breslow thickness.

  11. No Hx given.
    Clinically a suspicious pigmented nodular lesion.
    Dermoscopically, (1) white-grey and blue-grey veil centrally, centric structureless, (2) peripheral dots, (3) dark clods, (4) extension (from main) polygonal at 1-2’o clock.
    Initially 2mm margin excisional biopsy and go from there (depending upon Breslow Thickness and type of MM).
    Impression is SSM or combined SSM+Nodular.
    Generally, peripheral dots and polygonal will reflect SSM, and central white-grey and blue-grey veil will reflect nodular (thickness).

  12. Lesion – Multiple high risk features including irregular dots and globules, eccentric hyperpigmentation in the top right of the image and central white body. Most of the lesion has a clearly demarcated border. Features would favour nodular MM (NB I have already seen the histo report!!).

    My initial management would be to excise with a 2mm margin.
    Next I would risk assess the lesion with the histology report to see if a sentinel node biopsy is indicated. If so, I would offer this to the patient and refer the patient for specialist care. If not, I would excise my scar with 1cm margins

  13. Hello all – a great case. Most of you went straight for the “obvious” nodular melanoma diagnosis. Great to see that thinking. No way this can be a blue nevus and observed – sure, it “could be” but without a history that is a very high risk strategy. This is a great example of BEST – Benign or Suspicious Test – could be Benign, could be Suspicious. So, MUST BE BIOPSIED.