Case discussion: How would you treat this patient? [28 February]

This week’s case discussion, submitted by Dr Bronwyn Edmunds, features a 53-year-old female who presents for skin check. A large dark nodule is noted on her left upper arm. She had first noticed this in September 2021, and describes it starting as a small, brown macule which bled a few times and grew and kept growing.

What is your impression and what would you do next?

case discussion

Update

The lesion was excised and the report is as follows. What are the next steps?

case discussion

– Prof David Wilkinson

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33 comments on “Case discussion: How would you treat this patient? [28 February]

  1. dermoscopy clarity is poor but i can see polarised white lines at 90 degrees to each other and to exclude a invasive melanoma needs excision by 2mm margins

  2. The history clearly is troubling – growing dark lesion in an adult which bleeds. Examination however (at my ability to enlarge it) looks significantly less worrying with at least in some areas, very clearly defined, smooth edge to the lesion. However, even if feeling it is a seb. ker., with that history, I would at least curette it and get a histological confirmation, and if not curette material, an excisional biopsy with 2mm margins ….

  3. Looks like one that might trick us! Looks innocent but I don’t like the inflamed edges and there appears to be inconsistencies in colour and architecture throughout – I would excise to play it safe..

  4. I agree that dermoscopically it looks like a benign Seb K but the history is definitely worrying. I got caught once with a lesion like this one snd it ended up being a thick nodular melanoma. Once bitten!!!! I would definitely excise based in the information provided.

  5. The dermoscopy image is a bit dark and not so clear.

    However, the history suggests a suspicious lesion as “change trumps everything” (quote from the Healthcert course 2019). So on this basis alone I would excise with 2mm margins.

    The image is suspicious 2/3 with asymmetrical colour and structure, shiny white structures (crystalline) and perhaps heavy melanin deposits obscuring an underlying network.

  6. The history is quite concerning, the Dermoscopy is quite concerning (irregular pigment with polarised white lines at 90 degree angles) . The lesion needs to removed on the spot with a 10-12mm punch as it is a nodular melanoma until proven otherwise.

    1. If you shave and it’s a melanoma, you may cut through the base and affect the thickness and depth visible for the report.

  7. I would excise this lesion, suspected melanoma. Asymmetrical pigment globular and chrysalis are On dermoscopy

  8. Had one like this recently which the patient wanted removed for cosmetic reasons but that strange gut feeling , despite no real distinguishing features for melanoma or SCC —was still surprised when it came back as SSC in situ, maybe the same in this case especially with white lines

  9. It looks like compaund nevus, who’s changing, or maybe Seb. K

    Biopsy / ph analysis will resolve the dilemama.

  10. Physically looks benign despite of the poor quality photo. She said bled sometimes. Was that non traumatic at all. U said it’s growing and changing. In that case I would send a biopsy for histology to double check.

  11. Full excision biopsy needed with at least 2mm margins – as on upper arm can do 5mm margins
    Several different structural areas give chaos
    Distinct polarized lines at 8 oclock hence malignant and most likely melanoma with the diverse structure.

  12. Irritated Seb.K oDif.Dg. Nodular Melanoma.
    Excision like suspicion lesion by 2 mm margin with histology

  13. This lesion has the abrupt borders of a seb K but the history is not fitting. It also has white lines so my suspicion would be a melanoma. I would do an excision biopsy with 1mm normal skin around for histology

  14. not good picture ,some parts look like seb/k,some part suspiscious for melanoma,new lesion 50 year old ,better do excision biopsy

  15. Irritated seborrhoeic keratosis
    I will wait for 2 weeks & check again after giving mild topical steroids

  16. A dark lesion with Cobblestone-like structures pleads for nevi. However, the apparition on a 53 years old person with bleeding information and rapid growth plead for a melanoma. We have to do a large and deep excision of 3mm margin and bring it to anatomy pathology for examination and direction for the excision treatment.

  17. A range of interesting responses to Bronwyn’s case – thank you all. It is easy to think this is “benign” and it could be benign, when looking at it. HOWEVER, 1) the history is “screaming” that the lesion is “suspicious” (growing, changing, bleeding) and 2) when looking at it, there are quite plausible malignant diagnoses. And, as we see here, it is indeed a nodular melanoma. The ONLY way to manage a lesion that looks like this is – excision biopsy, not observation, not photos.