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1800 867 1390Case discussion: How would you treat this patient? [8 November]
The topic of this week’s case is pigmented lesions on the face of elderly people. This 82-year-old woman presented to Dr David Stewart with a longstanding lesion on her cheek, possibly slowly growing.
- 82-year-old female
- Longstanding lesion on cheek
What is your differential diagnosis, and what would you do next?
– Prof David Wilkinson
Update
Here is the pathology. What next?
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1300 856 695
+44 203 514 0688
1800 867 1390
flat pigmented lesion on the face with geometrical lines , grey dots
most probably lentigo maligna , need excision biopsy
as the lesion is large I might do the most obvious part of the lesion
after the confirmation of the diagnosis need wide excision
Grey peppering, Grey circles
Lentigo maligna vs solar lentigo
Shave biopsy
Asymmetrical lesion with grey circles
For shave biopsy ?? Lentigo maligna
A spread out facial pigmented asymmetrical lesion (an elderly person)
Presence of grey dots and circles
Most likely lentigo maligna; a Shave biopsy
Macro – looks like lentigo maligna so probably is
– large & irregular
– flat
– pigmented but variable
Dermoscopy is consistent with this
– pigment dots around hair follicles (face/neck) = pseudonetwork
– colours
– maybe some regression areas
Partial shave excision including the most pigmented area. If histology is negative don’t necessarily believe and arrange a further biopsy.
When proven will need excision – presumably refer to plastics for skin grafting (but I would be interested if others thought it could be handled without plastics referral)
When diagnosis is proven, arrange
Asymmetrical lesion – colour and shape
Blue grey veil
Grey circles
? Lentigo maligna
for shave biopsy / punch biopsy 3-4 mm
white circles and scale suggestive of actinic keratosis
A longstanding pigmented lesion on the right cheek of a 82 year old woman.
Dermatoscopic: Assymmetric in colour and structure and colour. Colours white, tan, brown and grey. Peri-follicular grey and brown pigmentation, circle in a circle, brown and grey dots
DD: LM, May be Solar Lentigo: but not likely
Perifollicular grey dots with some follicular obliteration. Shave to exclude LMM vs SL.
peppering with early annular granular pattern
?? insitue melanoma for biopsy
The lesion is suggestive of a lentigo maligna with areas of grey pigmentation, APFO’s and polygons. I would probably do a complete shave removal initially to confirm the diagnosis. I think that a rhombic flap might be the best definitive surgical option after diagnosis.
Grey features on the face.
Need to exclude lentigo maligna.
Either shave or incisional biopsy, directed by dermatoscopy
Lentigo Maligna require excision and SSG
Get a plastic colleague to do it
grey dots around follicles are suggestive of LM
DDx: SL
shave biopsy of darker centre
consider referral as it is likely to need focal microscopy to determine extent of lesion
Flat lesion with irregular margins, milia like cysts in the periphery, grey peppering and circles. Solar keratosis versus lentigo maligna. Shave biopsy.
if rough and scaly its pigmented AK, if flat and non scaly needs a shave done to exclude LMM
history and pt age is suspicious of a malignant lesion , dermatosocpy showas asymmetry ,but no abnormal network /abnormal pigment .
DD= benign melanocytic naevus ,melanoma insitu transformation
plan-excision biopsy with 2mm margin
peppery pattern,
several colors.
tan like structureless areas and chrysalline structures?
excision biopsy to rule out Lentigo Maligna
I see peppering and blue grey features and I need a biopsy. I dont favour saucerisation / shaves though popular. ( I fear a partially sampled lesion with a shave? ) Macroscopically the pigmented lesion looks pretty well defined. So I would undertake incisional biopsy ( less than ideal) and then consider referral or consider doing with a flap ( aim for 10mm in Lentigo) and I have had some pleasing results but this one is a bit big for me
Could this a collision lesion with a Seb keratosis?
Melanoma. Polygon and circle
Macroscopically it is a healthy pigmented lesion that the patient has always worn and which apparently does not change dimension. Dermoscopically we notice the absence of a network, asymmetrical lesion with 3 checklist points of 1. it is a benign lesion that presents the same globule-like structures evoking cobblestones. Conclusion: a congenital nevus
action to be taken: No specific support.
The program of regular visits according to the country’s health policy remains to be followed in view of its age and the epidemiological picture of the region.
These lesions are so very common in much of Australia – certainly here in QLD – and the differential is Lentigo / Seb K, or Pigmented AK, or Lentigo. I find that, unless the diagnosis is “obvious” seb k or lentigo (all features classical) then I do a shave biopsy through most of the lesion / the most atypical looking part
Thanks everyone for the comments. In this case there was only one section which looked dermatoscopically suspicious so I only shaved that section. I was happy to leave the rest to avoid shaving a large section off this lady’s face.