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1800 867 1390Case discussion: How would you treat this patient? [25 October]
This week’s case discussion, submitted by Dr Terry Harvey, features a 65-year-old woman who presented for a routine full skin check. This lesion was identified on her right leg.
The patient had no concerns about it, as she stated that it had been sampled in 2015 and the result was ‘benign’. She saw another doctor about it in 2019 who retrieved the old histology results and also advised that it was benign.
- 65-year-old female
- Lesion on right leg
What do you make of the clinical and dermoscopy pictures?
Update
Here is the original pathology report. Thoughts? Reactions? What next?
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1300 856 695
+44 203 514 0688
1800 867 1390
Lesion looks benign
Superficial spreading malignant melanoma
Gray peppering, irregular pigment pattern. Suspicious for malignant melanoma . Previous biopsy may have been taken from a segment that was benign?
The peripheral pigmentation looks more suspicious on the macro view, on dermoscopy there a individual blue clods in the centre. It would be interesting to know the technique of the previous “sample” and whether it was a partial shave. Looks suspicious of MM.
it is chaotic with clues such as eccentric structureless area, blue structure at left lower area and peripheral dots and clods. I would do excisional biopsy with 2mm margin
Looking asymmetrical. Areas of likely regression noted.
It has features of dermatofibroma, LPLK, no clear looping vessels, appear to have 2-3 different types of vessels, unsure of white streaks.
Worth biopsying the most atypical sites to rule out melanoma, other cancers or benign lesions.
This looks like melanoma to me with chaos, grey areas, pink areas, thick lines and peripheral dots.
I would like to call this a PITA lesion.
Most likely benign with plenty of opinion to this effect on record, but messy enough in parts that malignancy is hard for me to fully exclude.
There is no history as to change over the 6 years since the biopsy.
Given the likely benign diagnosis it is not justified excising the whole lesion… significant size and lower leg location.
Propose biopsy, and I would favour the upper right quadrant for this.
No specific pattern but chaotic pigment. There are peppering which in keeping with LPLK. Some faint vessels. Taking the age to would excise to double check and exclude MM.
Suspicious 3/3 for melanoma.
Excision biopsy 2mm margins
The irregular pigmentation and asymmetry while not classical (with rhomboids and reticulation or white whorls) is suspicious of M Melanoma with peripheral and eccentric structuring of pigment plus peripheral dots — question on type of biopsy relevant as to whether representative of the lesion; but needs excision biopsy
Asymmetry
Areas of faint psedopods
Area of structureless zone in the middle
? Melanoma
1. Irregular borders
2. ?black dots/lines
3. ?structureless areas
?Superficial Melanoma
?Melanocytic lesion
?Solar lentiginous
asymmetrical lesion
curved lines
atypical dotes clodes
linea angulated blood vessels
melanoma for exision
Suspicious lesion – asymmetry colour, shape, structureless area, peripheral clods, blue grey veil
? Shave biopsy
? Melanoma
Clinically this looks like an ugly duckling. Dermatoscopically, several clues to melanoma – overall chaotic, numerous polygonal structures, asymmetric black dots/clots, gray area mixed with some bony white and hint of milky pink. Size and location of the lesion makes it difficult to biopsy – I would do a large, deep shave of the entire lesion. I would be very surprised if this came back as anything other than a melanoma.
The lesion is not symmetric in content and it presents blood vessels like comas. There is a kind of small blue-white structure on the low side of the dermoscopy. Lady has 65 years and doe not mention having the nevi from her birth, According to the lesion I propose to do a deep and large biopsy because the lesion is suspected to be nevi in degenerescence.
Lentigo maligna
Lichen planus like Keratosis, given dermoscopic findings- shave of the lesion appears to be prudent to exclude SSM
Risk Factors
Age
ABC score of 3
Blue grey Veil
Pseudopods etc
Highly suspicious for Melanoma
Excision Biopsy should have been done before as partial bx missed the lesion part
it would be interesting to know what the previous path report said; also good to know whether this lesion was changing; the lesion was previously partially sampled, which can result in false negative reports; unusual lesion, not sure what benign lesion it is; doesn’t have the polygons I would expect with LM; looks like background lentigo; some grey at 6 o’clock, otherwise multiple shades of grey and black and brown; central structureless area, ??old scar from previous biopsy; not really sure what it is, ??exogenous pigment; I would consider whether the previous histo report matched what I could see dermoscopically, and if it did, I would do short term monitoring of this lesion; if it didn’t, I would shave biopsy the most abnormal areas, being most of what is in this dermoscopy image (this looks like only part of the lesion)
This lesion o the leg right now has chaos with 3 clues ( eccentric structurelss area, thick lines , Grey matters .
Must exclude MSC.
A few key points to make here. The clinical image is highly suspicious – the lesion is the only one with this appearance. Second the dermoscopy is 2/3 or 3/3 on 3 point. And the history is worrying – was the original biopsy partial or complete? Reported to be partial – demonstrating the risks of partial biopsy for PSL. And, broad shaves convey the accurate diagnosis. So, the message is 1) always sample PSL with a complete removal, and 2) be deeply suspicious of lesions that grow after 1 or more biopsies!
A bit of insight into my thought process here…
The second I saw this I knew it was melanoma. There really wasn’t anything else it could be.
I didn’t track down the old results as this was all done in a single consult – and I foresaw no result that a previous biopsy could show that would change my management in any way. It would purely be academic.
Ideally, excision biopsy is gold standard. But ‘don’t let perfect be the enemy of good’.
This lady was frustrated that I was ‘wasting my time’ looking at this lesion as ‘we already know its fine’ from her previous biopsy. Two doctors have told her that.
If I had have suggested excision biopsy (and the subsequent split thickness skin graft to fix this with weeks off her feet) – it is likely I would have never seen her again.
If I suggested a management plan like that and she fails to follow through I have a 0% chance of diagnosing her melanoma. Or if I allow her to convince me that excision is just ‘over the top’ and ‘too invasive’ and I just decide to ‘watch it’ instead I also have a 0% chance of diagnosing her melanoma on that day.
If I do broad shaves to remove the whole lesion I have a 95% chance of diagnosing her melanoma.
This lesion was flat and always going to be in situ. By shaving the whole lesion off I have given the pathologist the same amount of dermoepidermal junction (where the action is) that they would have had with an excision biopsy.