Case discussion: How would you treat this patient? [7 March]

This week’s case discussion, submitted by Dr Terry Harvey, features a 70-year-old female patient with a past history of BCC only.

What do you make of the dermoscopic image (if anything)? Does the clinical image change your evaluation at all?

case discussion 

Update

Here is the score from the FotoFinder AI module – borderline benign (score <0.5 is benign) and the pathology.

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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28 comments on “Case discussion: How would you treat this patient? [7 March]

  1. Dermoscopy shows irregular border and pattern
    Although could not appreciate much reticularity
    I would biopsy the lesion

  2. asymmetric color , white lines, probably more than 6 mm in size
    I would do an excision biopsy with 2mm margin initially. strongly suspicious for melanoma

  3. The lesion is highly suspicious for a melanoma.
    Excise with 2 mm clinical margins and wait for the pathology report to guide any further action.

  4. The lesion has asymmetrical shape but the pigmentation and colour is almost symmetrical. There are Keratotic peals, no regressions. This is very likely a pigmented Seborrheic Keratosis.

  5. Lesion is an ugly duckling on heavy sun damaged skin.

    It is suspicious at least 2/3 can’t see a network but excision biopsy 2mm margin is indicated.

    The DDx could include a pigmented SebK as it has some milia-like cysts, possibly some scalloping of the edges and even comedo-like openings. But it has to come out.

  6. The image is not in focus and hardly to look for details. I can see a PSL in sun damaged skin with dark and light brownish pigmentation and some milia like but no specific patterns. Some red dots on the right side and probably streaming but can’t be certain due to the image quality. I would excise with in mind SK vs MM.

  7. Looks benign at first glance.
    Suspicious blotch at 3 o clock and pseudopods at 3 oclock. ? MM
    Excision for histology.

  8. i do not see clear cut indication to biopsy this unless if this is a new lesion. Reasses in a year

  9. Not a lot of clues in clinical picture and dermoscopy picture to worry.

    It may be reasonable to re check the lesion in 3 months time for any changes

  10. Another one of those when in doubt take it out –excise ,—irregular coloring, asymmetry, difficult to see whorls or reticulations at that magnification, but possibly Melanoma given age and sun exposure.

  11. I can see come spikes at the 5 o’clock position as well as atypical pigmentation on one side of the lesion.
    I would do a punch biopsy

  12. Nice ugly duckling !
    Irregular margin , colour . Finer details difficult to make out .
    Needs complete excision for melanoma

  13. Excision Biopsy with 2mm margin; it looks suspicious – asymmetry, white lines and peripheral dots

  14. We are in the presence of a lesion very different from the surrounding tissue and whose three-point checklist is zero. The result of the paraclinical examinations speaks about a superficial Melanoma whose surface is greater than 6 mm. I’m going to do a biopsy of nearby lymph nodes(SLNB) and a mapping looking for metastases. In the meantime, a large extraction of the lesion is indicated

    1. 1/ Three-point checklist is to determine for +/- biopsy. You may use other dermatoscopic algorithms, given none of decision making dermatoscopic algorithms are perfect. If you go with Chaos & Clues or simple ABCD, it does point out non-benign features, requiring 2mm margin excisional biopsy to r/o MM.

      2/ SLNB requirement is dictated by Breslow thickness (BT), not the surface size. Spread to lymph nodes or systemic body lies on tumour thickness (via lymphatic and blood v/s which are located in the subcutaneous structure (after deep/reticular dermis). Small thickness like this may be confined to epidermis or dermis. Latest Australia melanoma guidelines suggest only 1mm or 0.8mm BT with ulceration would require SLNB.

      Cheers 🙂