Case discussion: How would you treat this patient? [17 January]

This week’s case discussion features a female patient who came in for a skin check, and this lesion was identified. There is no history available.

What do you make of the clinical and dermoscopic images below? What do you think of each and what would you do?

Case discussion      Case discussion

Update

Here is the pathology report. What next?

case discussion

– Prof David Wilkinson

We encourage you to participate in the case discussions and submit your own clinical images and questions, so we can all learn together.

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19 comments on “Case discussion: How would you treat this patient? [17 January]

  1. A pigmented lesion, featuring chaos and clues.
    The chaos of colour ( some grey as well), clues- grey structures.
    Suspected for SSM

    Excise with 2mm margin for confirmation of diagnosis

  2. No history is noted. Chronically sun-damaged skin clinically. Looks to be non-palpable.
    Dermoscopy shows asymmetry in two axes. Regression. Eccentric clods/dots.
    Long standing slow progression would favor Lentigo Maligna versus Lentigo Maligna Melanoma.
    Otherwise Superficial Spreading Melanoma.
    Excise en-toto with 2 mm margins.

  3. A lesion is seen that is probably greater than 6 mm. It is observed: Atypical pigmented reticulum, asymmetry in the pigment network and irregular structures. Globules. Few punctate vessels. Pseudopods.
    Excise with 5mm margin for confirmation of diagnosis

  4. 3×4 mm PSL on the left retroauricular area showing multiple shades of colour, dark blotch and brownish structureless area. I can’t see any specific feature or pattern. Excision biopsy with 3mm margin to exclude malignancy DD: MM

  5. Severe solar elastosis present. There seems to be some grey pigmentaion at ~0630 position. Some peripheral brown dots in linear arrangement ?pigmented IEC? Need to consider lentigo maligna. Shave excisional biopsy.

  6. I would biopsy this lesion to rule out lentigo maligna/MM. I do not see clear signs that it is a melanocytic lesion vs irregular lentigo, but due to eccentric unstructured dark blotches, greyish color, and pink background I would biopsy to rule out melanoma.

  7. This patient has a pigmented lesion and chronically sun-damaged skin lesion is pink and brown, asymmetrical in colour and structures with atypical pigmentation. Differential includes lentigo maligna or severe dysplasia.
    excision with 2 mm margin

  8. Clinically, a standout pigmented lesion over sun exposed area (upper neck). Dermoscopically, it fits into category of to be biopsies, whatever your preferred dermatoscopic algorithms (3 points, 7 points or Chaos and Clues, ….. ).
    The clues are structureless areas and irregular dark clods.
    Ideally, 2mm peripheral excisional biopsy and go from there, or may go with shaved (deep saucer) due to possible appearance lentigo /superficial type plus location (care with accessory nerve).
    Imp: LMM
    For WLE (either 5 or 10mm), referral to an appropriate trained specialist if you are uncomfortable due to potential damage to XI cranial nerve.

  9. Macro: large irregular pigmented lesion on generally sun damaged skin; Dermatoscop: asymmetry of reticular network with particular signs of malignancy – pseudopods /eccentric globules); Likely Dx MM – requires excision with 2mm margin for complete histopathology

  10. PSL on sun damaged skin of the anterior neck. Dermoscopy= chaotic lesion with clods arranged in lines, strutureless brown and various shades of brown. ?pBowen’s. pAK. Shave biopsy for conformation.