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1800 867 1390Case discussion: How would you treat this patient? [16 August]
In this week’s case discussion, submitted by Dr Mazharul Islam, we look at the case of a 51-year-old patient who presents for a full-body skin cancer check. There is no past history, but this lesion is noted on the lower back.
- 51-year-old patient
- Lesion on lower back
How do you evaluate this? What would you do next, if anything?
Update
Here is the pathology. What is your reaction? What would you do next?
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1300 856 695
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1800 867 1390
Different shades but no specific network. Watch it.
EXCSIEW WITH 2 MM MARGIN
? LENTIGO MALIGNA
Excisional biopsy of 3mm margin
There is asymmetry of pattern and colour with possible polygons in the upper right corner. I would be concerned abouot melanoma in situ and excise with a 2mm margin
Does it look different under polarised light? I’d be tempted to excise
asymmetry shape and colour, blue grey veil
? melanoma
excision biopsy with 2mm margin
Asymmetrical lesion,greyish brown color upper right corner ?? chaos ?? melanoma
Plan : 2 mm excision biopsy
I think this is a lentigo maligna.
Dermoscopy – there is patchy pigmentation with ill defined borders. The left part of the biggest patch has assymetrical follicular openings and i think the eccentric hyperpigmentation to the right indicates follicular destruction.
Management- excise with a 2mm margin and then if history confirms lentigo maligna (in situ) then excise to achieve a 5-10mm margin. If there is invasive melanoma then whether SLNB is indicated needs to be considered before WLE or referral.
Asymmetrical.irregular network, grey circles but other features not that clear. Most likely dysplastic naevus. Excise with 2-3 mm margin or recheck in 3 months
If I’m being honest, if I was doing this skin check then I would probably have called this a Clark naevus and moved on, but given that it’s in the blog section I am immediately suspicious of it 😉 Its flat and small so I’d shave lesions like this if I’m concerned – if it turns out to be a melanoma then you can do a wider excision later, if its a “dysplastic naevus” and you’ve got the whole thing then you’re fine
Dysplastic nevus or early melanoma
Excise 2mm margins
Dermoscopy is suspicious enough – irregular / assymetric. Not convinced about polygons and if there is a blue veil there it could be artefact from the marker pen – would like to see polarised and another view after the pen marker cleaned off. No History, so I have to assume worst case scenario and therefore excision biopsy.
compound melanocytic nevus, reasses in 4 months as its a flat lesion
It seem to be a benign lesion . Can we observe and give her an appointment each month .
What a great case. I think the key learning for me here is that we need to have a high level of attention and suspicion. Like many of you I think I would have missed this, UNLESS it was obviously an ‘ugly duckling’ – and it looks like it might be. I think the best biopsy technique is a shave, on what is a small and flat lesion. MIS is confirmed, so wide excision follows with 5-10mm and no need to consider SLNB in MIS.