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

This week we look at a young (mid 20s) female patient who I saw in my practice recently. She has skin type 1-2, no relevant personal or family history and presents with a history of growth in a lesion on her neck.

See the clinical and dermoscopy images. What would you do next?

case discussion

Update

I did a shave excision biopsy. Here is the pathology result. What do you think? What next?

case discussion

– Prof David Wilkinson

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

  1. This is a melanocytic pigmented lesion in an at-risk skin type.

    The overall shape is symmetrical, but there is assymetry in colour – a peripheral tan-coloured ‘ring’ an inner lighter colour that looks like involution, and a central heterogenous pigmented area.

    There is a ‘fragment’ of network at 9 o’clock with thick lines and irregular holes, and a different kind of network at 3 o’clock which is ill-defined and structureless.

    The inner ‘ring’ looks to be a grey-blue area of depigmentation/regression.

    So I think a case can be made for 3/3 suspicious and the lesion should have excision biopsy with 2mm margins.

  2. On the dermoscopy I would consider this lesion symmetrical but the network looks abnormal – thicker at one peripheral edge than the other. I’d say there is a little blue/grey discolouration centrally. Scoring her 2/3. Combining this with her high risk skin type and it being new I’d recommend an excision biopsy. I personally wouldn’t be confident excising in that location on her neck so i would refer her

  3. It is a very symmetrical lesion, and also appears to have hairs growing in it. Groth in a young person is common. I would image and r/v in 3/12. If it becomes bigger, but is still symmetrical, I would continue to monitor it.

  4. If she has reported growth or change in this lesion and looking like a pigmented skin lesion with asymmetrical pigmentation, I would recommend an excision biopsy with 2mm margin – ? Melanoma

  5. PSL showing faint line reticular at 9 o’clock and the central part is abit of different shades. The periphery is faint brown all around. If she is worried and declared changes then excise and check histology to exclude any sinister growth. It could merely a nevi.

  6. new rapid growth pigmented patch

    not reassurable
    – I reckon there is a clue of thick line radial on 10 o’clock
    – should excise 2 mm margin to exclude pigmented BCC

  7. Macroscopically there is a macula, pigmented lesion of more than 6 mm at the neck. There are others smaller for instance in the hollow of the clavicle. If the others have been present since his childhood they can be taken for NEVUS. according to the rapid growth of the Great Lesions and the Results of the Pathology Anatomy, this Pigmented Lesion is a melanoma. However, its score of the 3 Check List points is 1. The Lesion is Symmetric and Irregular in Color. we will do an excision extraction of the wide lesion . We will have to do an excision biopsy of the small which is in the hollow of the clavicle and do an in-depth study of all presented spots on her skin.

  8. I asked the patient if she had any recent photos, and she had (on her phone). These showed recent, rapid growth. I did a shave excision and the report is shown here. What you do next?

    1. I would treat it as a melanoma in situ and proceed with an excision aiming for 5mm margins + advise the patient lifelong annual skin checks.