Case discussion: How would you treat this patient? [23 May]

This week’s case discussion, submitted by Dr Terry Harvey, features a 70-year-old male patient who noticed this area on his cheek enlarging over two years.

What is your differential and what would you do next?

case discussion

Update

Shave biopsy showed MELANOMA IN-SITU, superficial spreading subtype, Clark level 1, at least 6mm in diameter. No dermal invasive melanoma is seen. There is associated superficial regression change. What would you do next?

– Prof David Wilkinson

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26 comments on “Case discussion: How would you treat this patient? [23 May]

  1. Pigmented reticular lesion is suspicious 2/3 on dermoscopy.
    Also suspicious on history.
    Excision biopsy 2mm margins.

  2. I find this one difficult due to the orientation and size of the lesion. An 2mm margin excisional biopsy orientated with the long axis of the lesion would be fine, but then what happens when it comes back as a melanoma and we need a big margin? Orientation in this way for the definitive excision would be very difficult.

    I know there are some issues with shaves, but this would be one I would be considering as complete a shave as I can manage as a biopsy.

  3. my differential diagnosis :
    1-lentigo maligna melanoma as I see polygonal lines around hair follicles
    2-solar lentigo
    I would do excision biopsy or at least punch biopsy from the most suspicious area

  4. looks more like a seb k or compound melanocytic nevus with normal growth pattern. cannot see features warranting an excision even though enlarging in nature

  5. Looks like Lentigo Maligna melanoma
    Excision biopsy with a 2mm margin excised in a way that will leave me a definitive treatment plan option depending on the Histology report for the wider and deeper excision.
    Where lesions feel very flat I have in past done a saucerization shave of the whole lesion. You just do not want to transect the deep margin and then not get a Breslow thickness if present

  6. Blurry photos but can see rhomboidal with different shades and some follicular obliterations which fits with LMM. Excise.

  7. large irregular with ugly duckling lesion, required excision biopsy of this lesion , I will refer to plastic surgeon

  8. very dark PSL “ugly duckling” that has thick reticular lines, atypical network, different shades of brown, asymmetrical, “circle within a circle” highly suggestive of Lentigo maligna melanoma. Excision biopsy with 2-3 mm margin is recommended.

  9. Assymetry; Blue/gray patches; Irregular thickened network
    LM / Superficial Spreading MM until proven otherwise (possibly Seb K or naevus but seems unlikely).
    Could do excision biopsy along the long axis of the lesion but this orientation is perpendicular to RSTLs.
    Not clear but looks like a pre-existing scar just superior to the lesion running about 5 cm toward nose which could affect surgical plan. Definitive treatment likely a transposition flap to follow the RSTLs, so a deep shave covering as much of lesion as possible could be considered.

  10. A pigmented lesion growing is a suspicious feature for a lesion. Please do an excision biopsy of a 3mm margin

  11. It needs full excision. I would offer private referral but not public due to long wait times. I would be happy to fully excise this lesion if patient agreed. I think the site is relatively safe and easy to excise with primary closure.