Case discussion: How would you treat this patient? [27 June]

This week we revisit an engaging case from Dr Tim Aung. A 55-year-old female presented with 1-2 years’ history of slow growth of an asymptomatic, non-tender lesion on the upper chest. Please review the images.

What is your impression, what is the differential diagnosis, and (if you would biopsy) what technique would you use?

Case discussion      Case discussion

Case discussion      Case discussion

Update:

These are the results from the pathology report. What do you think now? How would you treat further?

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– 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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38 comments on “Case discussion: How would you treat this patient? [27 June]

  1. Growing lesion on an adult, and nodular appearance – need excision biopsy.

    Dermoscopoically – not much chaotic appearance. maybe polarised white lines.
    features are suggestive of Dermatofibroma. However, Df’s are mostly seen in extremities.

    Age 55, growing, nodular appearance – suspected for melanoma, need excision.

  2. Loss of pigmentation centrally and irreg outline. Increase size. Theregore exsicion biopsy with adequate margin and sent for histopathology.

  3. This looks like a classical dermatofibroma image to me both microscopically and dermoscopically. I will reassure and advice for whole body skin check

  4. Central white structureless Peipheral regular brown reticular pigment. Macroscipically and Dermatoscopically suggests a Dermatofibroma

  5. My clinical and dermoscopic impression is dermatofibroma.

    DD
    XANTHOGRANULOMA
    DERMATOFIBROSARCOMA
    However non of dermoscopic ccc are displayed

    My approach If it is cosmetically bothering this lady I would remove it, others than this I will reassure her.

  6. Older person, slowly growing, striated colouration on dermosocpy.
    Dermatofibroma is possible.
    It would be helpful to know the result of the ‘pinch test.

    Punch biopsy would be an easy and quick way of settling the matter.

    Even if it is benign, she may appreciate its removal given the position and the fact that it is growing.

  7. looks like dermatofibroma, if on palpation it feels like dermatofibroma I would assure and leave along but if not could consider punch biopsy

  8. Rounded smooth raised/ nodular skin lesion.
    Dermatoscope: clear Centre with faint radial white lines.

    Impression DF
    Do dimple test. Ask about any history of local trauma or insect bite.

    DD; DF, Keloid, burn, as she is old just to consider nodular melanoma which is not the case at all.
    Excise and send for HP if it’s bothering the lady. Otherwise leave it.

  9. It looks like a dermtofibroma to me. DD could be amelanotic melanoma but seems unlikely given the slow growth and lack of symptoms.
    But if it keeps growing, or patient is concerned, or patient high risk for melanoma, I would suggest to excise it. Probably just with a 2 mm margin.

  10. Probably a benign lesion like a DF and history probably not quick enough for a NM but this lesion needs further evaluation apart from clinical examination.So,cosmetically sensitive excision biopsy with 2-4 mm margin.?NM

  11. Appearance clinically & dermoscopically of dermatofibroma. However concerned by history of ongoing growth which wouldn’t expect with dermatofibroma. Pink growing nodule. Hence would excise with 2mm margin

  12. looks and sounds like a dermatofibroma
    If the patient was concerned or unhappy with appearance or catching /bleeding etc then consider elliptical excision

  13. Looks like Dematofibroma rule out Scar on clinical and dermoscopic image. However the history of lesion growth, location of the lesion, patient’s older age and that patient is concerned , it’s worth checking to rule out Nodular/Amelanotic MM. Hence, I would probably excise it with 2mm margin for safe practice and peace of mind for both patient and doctor.

  14. Dermoscopoically – Dermatofibroma
    Klinicaly – slow growth nodular lesions. A 55-year-old female.
    Dif.Dg. Melanoma?
    Suspected for melanoma, need excision.

  15. It looks like dermatofibroma on both macro- and micro- scopic images. If it feels like the one too on physical exam, I will reassure patients and discuss management if she would like to get read of it for cosmetic reason

  16. Depends on history – any previous trauma or biopsies
    Dx. Dermatofibroma keloid neurofibroma
    If concern or no previous trauma history punch biopsy 3mm punch and review warning pt that if keloid may get worse

  17. I suggest that the key issue in a case like this is: it looks very much like it is a DF or a keloid scar clinically, BUT what am I missing? Is there anything it could be that is more serious, and that I must not miss? What about rare but horrible things like desmoplastic melanoma? This is how I try to think. If it is a DF or a keloid, I risk making it worse if I excise it! So, what to do? Discuss openly with patient, explore history carefully and then make a shared decision about whether to leave alone or excise, noting pros and cons