Case discussion: How would you treat this patient? [31 January]

In this week’s case discussion, we look at a case from Dr Terry Harvey. This patient is a 30-year-old male with no previous skin cancer history who had been seen by another doctor in 2018 who imaged a lesion on his right thigh, but decided on no further action at the time. Dr Harvey saw him in 2021 and examined the same lesion and tracked down the previous imaging from 2018.

case discussion

  • 30-year-old male
  • No previous skin cancers
  • Same lesion in 2018 vs 2021

What do you think, and what would you do (if anything)?

Update

Here is the pathology result. What are your thoughts and reactions?

pathology

– Prof David Wilkinson

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24 comments on “Case discussion: How would you treat this patient? [31 January]

  1. PSL, asymmetric with white non polarising lines and structureless eccentric as clues to melanoma, grown since 2018, excise, high probability of melanoma.

  2. considering some technical differences in photographing there are only minimal changes that have happened over three years. This can support the benign nature of this mole. Taking a shave biopsy or cylinder one can confirm the diagnosis. If a cylinder biopsy were to be taken, I suggest it be taken from the site of 5 o’clock

  3. Unusual lesion. There is a subtle change in border and size, would usually expect more from an invasive melanoma in that time frame. The area which could be a structureless area suggesting regression has now developed white lines and while its difficult to ascertain from the photo whether there is a true network, there are features on the latter image to suggest a negative network pattern and melanoctyes grouped together in clods. Excise with a 2mm margin asap. Be very interested in the histopath result !

  4. Firstly there is definite change and atypia in structure and symmetry so requires excision biopsy for probable malignancy.

    The negative network more obvious and developed in 2021 and now asymetric pigmented dots.
    At least a melanoma in situ and requires excision biopsy with at least 2mm margins for definitive diagnosis.

  5. No criticism of the first doctor, and with the great benefit of hindsight:

    The lesion was 2/3 suspicious in 2018 and needed excision biopsy 2mm margins then.

    I never use imaging to ‘follow’ progress in my general practice (not a fulltime skin cancer clinic). The fact that an image was taken indicates a concern in 2018, and applying the ‘if in doubt cut it out rule’, excision was indicated at that time. It also demonstrates the ‘lost to followup’ principle.

    The lesion has clearly progressed in the subsequentl 3 years and is now 3/3 suspicious, and excision biopsy is mandatory.

    A very instructive case, thanks.

  6. I am for excisional biopsy.
    There are certainly chainges from tbe previous photo of the lesion in 2018.
    The structure is fairly irregular with darkening of the lower part structure, blue veil / structureless area at 6 p.m.

  7. Are both in polarised light.
    If yes then 2021 lesion shows eccentric structure less area at 6 o clock position
    Would go for an excision box with 2 mm margin.

  8. an ill defined lesion with significant progression of the negative network and new vessels at 5 o’clock and new brown dots at 8-9 o’clock; I would excise with a 2mm margin, ?MM

  9. it is a nevus which grows in surface and in thickness and the hairs are reduced there. we also discover an increase in the network. This lesion does not reassure on a 30-year-old person. I propose to do a shave biopsy and a deep biopsy by puncture

  10. A pigmented lesion that has changed on the dermatoscope image. The eccentric hypopigmented area has extended, with some increased negative pigmented network ( rather than crystalline white lines) Some grey peppering and new irregular globules. The size has also increased .
    Impression , a Melanoma needs to be excluded so a full excision with at least 2mm margins.

  11. I’d be concerned about the clumping of pigment in the 2021 picture and would refer for dermatology review

  12. Update comment
    Histology = a melanoma insitu= concordant with the dermoscopy image
    He needs a further excision to get at least 5mm margins of clearance

  13. The key comment i would make here is how subtle early melanoma can be (2018) and how powerful serial imaging can be when done selectively and effectively. In our practice (I work alongside Terry) we are doing more and more total body photography and selective digital dermoscopy, and working how to best us the technology. It is not easy, nor is it automatic, but it is powerful…….more cases and expriences to come

  14. There’s regression in that lesion as well as other irregularities and I’m assuming it is an “Ugly Duckling” on this man. Even without the 2018 imaging that’s enough suspicion for an excision biopsy. I personally find photography gimmicky and skin can look different on any given day depending on weight loss/gain, fluid loss/gain, light, positioning, camera, operator, time taken to source and review etc. Imaging can provide good information and can give patients confidence (sometimes false) in the practitioner. However, at approx 6-7mm diameter this lesion is easily excised with an 8mm punch in a 15 minute appointment. Diagnosis made, booked for re-excision at earliest opportunity, next patient please. Biopsy with histological analysis is the gold standard of skin cancer diagnosis.