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1800 867 1390Case 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?
Update
Here is the pathology report. What next?
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1300 856 695
+44 203 514 0688
1800 867 1390
Nodular melanoma . Excise with margins
needs excision with 2 mm margin
? nodular melanoma
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.
blue nevus. leave alone. reasses in 6 months
Nodular melanoma
Excise 2mm margins
Melnoma until proven otherwise
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.
suspicious for a nodular melanoma. I would excuse with 2mm margins.
with no history available,looks more suspicious
Nodular lesion with color chaos,grey blue clods,eccentric structureless area
For 2 mm excision biopsy
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
suspicious lesion – ? nodular melanoma
Blue grey veil, peripheral clods, asymmetry in colour
Excision biopsy with 2mm margin
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
Single elevated skin lesion showing white blue veil snd peripheral dots/ clods. Excise to rule out malignancy.
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.
Raised > 6mm Blue grey veil, Peripheral dots chaos and irregular pigment ( dark at 70clock)
Excised 3mm margin : Nodular melanoma
Nodular melanoma until proven otherwise. Excise with 2mm margins. Further management as indicated by Breslow thickness.
Suspicious lesion: 3 point score on dermoscopy at least 2.
Excise with 3mm margin
multiple colores and structures
network globules
comedo like opening
blue whitish veil
melanoma
pigmented lesion with blue grey areas, melanoma, excision advised
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).
Mm
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
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.