Case discussion: How would you treat this patient? [15 November]

This week’s case discussion was submitted by Dr Terry Harvey. These two dermoscopic images were taken three months apart on a 32-year-old female patient. What is your initial evaluation and how does it change after reviewing the second image?

  • 32-year-old female
  • Same lesion 3 months apart

What would you do?

case discussion  

– Prof David Wilkinson


Here is the pathology report.

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24 comments on “Case discussion: How would you treat this patient? [15 November]

  1. as the change in 3 months is significant, it warrants shave to exclude SSM as 10% of melanomas can only be found out by monitoring the progression in dermoscopy

  2. Change in a lesion that was already suspicious warrants excision biopsy with 2mm margins.
    I would have excised it initially and not observed, and copped it if histology was benign

    1. There are generally always a few comments like this on any case of melanoma found through sequential imaging.

      My food for thought is that whilst it is hard to give you the full picture with only seeing one mole – if you sign up to excise this on the first image you have also signed up to excise the 40 other moles with the same morphology that didn’t change at all over my monitoring period.

      That’s a lot of scars, a lot of time off work, a good dose of surgical risk, and multiple thousands in surgical costs to patient and taxpayer – and all for no change in patient outcome.

      Monitoring of flat, pigmented naevi can be very safe in selected circumstances and give superior whole-patient outcomes as was the case here.

  3. Changing so for excision biopsy 2mm margin.
    However is there history of recent generalised tanning / increased sun exposure to explain increased pigmentation as otherwise looks much the same as previous lesion? If it were not changing I would otherwise suggest this were a benign nevus so if change explained otherwise potentially could give advice on sun protection ++ and recheck after short interval.

  4. Asymmetrical lesion – colour and pigment distribution
    Progressing – grey circles, structureless area
    ? Melanoma
    Shave or punch biopsy indicated

  5. I would excise based on change in interval. Initial image shows asymmetry, inverse network, suggestive of melanoma. Poss ddx dermatofibroma but shouldn’t change over 3 months

  6. The lesion is atypical in color and structure.
    Has progressed and shows Tan like structureless areas and atypical network.
    Excise with 2 mm margin

  7. Note the comments as to whether this should have been excised at first visit. I think it would depend on some other factors. A close up suggests thickened and irregular network in parts and definitely assymetric. But consider – where on the body – sun-exposed or not? Family history, personal history, history of the lesion. Has it been there since she can remember. Hindsight is easy. What if the person did not show up for the 3 month appt and was lost to follow up? I think I would have excised at first presentation.

  8. We are in the presence of a globular lesion whose structures are distributed asymmetrically and atypically. It is a congenital nevus whose 3 point checklist is 2. The modification of the distribution of the elements composing it also pleads against a benign lesion. The nevus is degenerating. A large and deep biopsy will be done in order to confirm the melanoma which is the most likely lesion and then excision of the tumor will follow with anatomy pathology follow-up.

  9. Maybe excise the lesion now due to the change to it over the span of 3 months. It just reminded me of a skin check I did yesterday with a woman with a similar lesion. I might get her back to have it followed up over 3 months too as I am not keen to excise the lesion at this stage.

  10. I would have observed as was done.
    This is a young person and unnecessary excisions should be avoided.
    The site is not mentioned and it looks small. If not on the face i would excise with 2 mm margin. On face I would consider a shave biopsy to completely remove.
    I would then be guided by the histopathology.

  11. the initial image shows an asymmetrical pigmented lesion with apparent areas of regression and also some grey areas.
    the 3 month review shows significant progression with some rhomboid structures and circle-within-circle.
    excision with 2 mm margins to exclude MM

  12. A great case, and thanks to Terry (again) for sending so many really good cases through. This one raises some interesting issues and commentary. A key point is made by Terry in his response below – how does the morphology (appearance) of this nevus compare to the others on the patient. If morphology is similar, it is safe to leave / monitor (especially in a young patient). If this one looked very different from the others, one would excise (and Terry would have). So, the patient acts as his / her own control. Second point – many nevi change on monitoring, but marked change (like this one) is more likely to be melanoma. Finally, if we committed to very careful examination, and very careful consideration of nevi – which includes for Terry (and me, and many others) high quality Total Body Photography on many patients (with digital dermoscopy) this scenario plays out many times a day. This is the new standard of care (in my view) and will (soon) become what most patients expect and ask for (this is happening right now in my practice)