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1800 867 1390Case 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?
Update
The lesion was excised and the report is as follows. What are the next steps?
– Prof David Wilkinson
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1300 856 695
+44 203 514 0688
1800 867 1390
Looks like irritated seb k
Observe
History is too risky just to watch.
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
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 ….
Seb K
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..
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.
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.
Treat it as melanoma: making sure that LN are not palpable ( if they are then tertiary ref urgently)
History of new, growing and bleeding mandates excision. Chrisalids visible. ?pigmented BCC, eliminate MM.
Troublesome history
Looks like a sebk, but would do an excision biopsy to exclude melanoma
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.
Will do excisional biopsy or pinch biopsy to rule out melanoma or SCC.
likely sebk but given the history of change would biopsy – shave biopsy
If you shave and it’s a melanoma, you may cut through the base and affect the thickness and depth visible for the report.
I believe the lesion is a pigmented nodular BCC. I will perform excision biopsy.
I would excise this lesion, suspected melanoma. Asymmetrical pigment globular and chrysalis are On dermoscopy
Possibly previous seb k with new changes.. excise/ biopsy to confirm histological.
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
It looks like compaund nevus, who’s changing, or maybe Seb. K
Biopsy / ph analysis will resolve the dilemama.
2mm margin excision biopsy rule out MM as s/s worrying.
ASYMMTERY
SWS
SW AREAS
ATYPICAL CLODS
BRAIN LIK APPEARANCE
MELANOMA VERSUS SEB K
PUNCH BIOPSY
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.
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.
This looks like pigmented seborrheic keratosis
Must rule out nodular melanoma by elliptical excision
Observation is NOT an option with a nodule
Irritated Seb.K oDif.Dg. Nodular Melanoma.
Excision like suspicion lesion by 2 mm margin with histology
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
not good picture ,some parts look like seb/k,some part suspiscious for melanoma,new lesion 50 year old ,better do excision biopsy
Black, bleeding and new.
Melanoma until proved otherwise.
Excision biopsy ASAP.
Irritated seborrhoeic keratosis
I will wait for 2 weeks & check again after giving mild topical steroids
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.
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.