Case discussion: How would you treat this patient? [9 May]

This week we revisit an engaging case from Dr Alvin Prakash. A 63-year-old woman presented for excision of a cyst on her back. A full skin check was done and a pigmented skin lesion was noted on her lower back.

Please describe what you see. What would you do?

case discussion

Update

Here is the pathology report. What now?

pathology

– Prof David Wilkinson

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28 comments on “Case discussion: How would you treat this patient? [9 May]

  1. This is completely structureless lesion , Asymmeteric borders , Asymmetris surface pigmentation , Chaos appearance , deeply pogmented central area extending bto peripheral part , first suspected diagmosis is Melanoma

  2. irregular outilne ,irreg pigmentation ,ugly duckling .Wide excision and if MM referral to surgeon for wider excision

  3. Suspicious pigmented lesion 3/3
    Excision biopsy with 2mm margin
    If melanoma confirm then wide excision according to histology

  4. It is highly chaotic and pigmented so I’m sure the answer is excise with 2mm margin, but for lesions like this (high clinical suspicion of melanoma) in a low morbidity area, I would just excise it with a 5-10mm margin and down deep to a good plane.

    I’d postpone the cyst excision to another day.

  5. It would surprise me if this was anything other than Melanoma. 2 mm margin excision, and then refer for lymphatic mapping prior to wider excision.

  6. Chaotic lesion, Asymmetrical.
    Excision biopsy with 2mm margin
    If melanoma confirmed then wide excision according to the result.

  7. PSL showing different shades of colour with very dark blotch. Complete chaos. Excise with 2 mm margin to exclude MM.

  8. An asymmetrical and outstanding pigmented lesion with unknown history in an elderly woman rise suspicion clinically. Dermatoscopy reveals chaos of both structures and colors, pinkish regressive area, eccentric pigmented blotches, atypical network. Excision with a diagnosis of melanoma.

  9. Multiple levels of pigmentation, irregularity, Non symmetry all point to Melanoma.
    My initial biopsy would be a full excision to > 10mm depth possibly all depth to muscle & if reasonable at least a 5mm margin of clearance. If it is fortunately only Melanoma in situ this would preclude a re excision. Patient should be warned re excision is on the cards.

  10. Eccentric globules on right side.
    4 different colours
    Atypical pigment network inferiority
    Regression

  11. Asymmetric pigmented lesion with irregular outline and multiple colours. Highly suspicious of malignant melanoma. Needs excision biopsy with 2mm margin

  12. Clinically this is a Superficial Spreading Malignant Melanoma, I suspect that it is invasive, possibly T2 or deeper, with Greyish (denoting Tindal effect – in deeper lying melanin) and Pink areas (denoting regression more centrally).
    This is on a background of asymmetry of ~ 5 colours, structures and outline,
    Loss of the pigment network
    small area suggests a blue-grey veil.

    Plan: This patient requires clin exam of all skin, and consent for treatment:
    1. This lesion requires 2mm margin excn Bx & direct closure, ASAP.
    2. Lymph node exam of Axillary & Groin nodes.
    3. 1 & 2 to determine definitive Rx plan.

    Thanks

    Richard Thompson

  13. Variegated pigmented lesion lower back approx ? 2 cm diameter 5 cm Left of midline L1 region.

    Central pink nodule with dark black region adjacent/inferior
    surrounding brown irregular and assymetric patches with irregular network.
    Chaos and clues in abundance.

    MM until proven otherwise, excise with 2 mm margins

  14. Large pigmented lesion, irregular pattern, about three colours, some areas of regression. Chaos consistent with melanoma.
    I will do an excision biopsy with at least 2mm margin.

  15. Almost certainly a melanoma,maybe small SCC associated, with all the features described by others below. Excision required and then ? wider excision possibility of a Z-plasty.

  16. There are many different lesions in the same place. It seems to be a Keratoacanthoma and pigmented skin lesions around. Do a large and deep excision biopsy of the whole lesion and bring it to the pathologist.

  17. This is a melanoma until proven otherwise
    Atypical pigmentation with spikes at the 1 o’clock position
    Atypical colors and structures .
    3 point check list score is 3
    Full excision with 2 mm margin

  18. Now path staging pT1a, but with some pre-op picture suggested some regression, so:
    – inform patient, and re-examine back, skin and all 6 Lymph Node stations for locoregional recurrence, and other lesions.

    If clinically free from further anomalies / residual / recurrent disease, I would recommend:
    – review of the Pathology at MDT to confirm Pathologists’ support to “… treat as for pT1a”, then
    – offer completion of 1cm (i.e. a further 9mm) WLE to deep fascia & direct closure, as an ellipse in the line of the ribs.