Case discussion: How would you treat this patient? [4 July]

This week we revisit a case from Dr Slavko Doslo. A 72-year-old male presented for a skin check and this lesion was noted. Please review and describe the clinical and dermoscopic images.

What is your assessment, and what would you do?

case discussion


Here is the pathology. What now?

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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30 comments on “Case discussion: How would you treat this patient? [4 July]

  1. Melanoma. Excise. Chaos and clues.
    Several colors, atypical network, streaks, black clods.

  2. clinically it is dark almost black and well demarcated.
    Dermoscopicaly,it is symmetrically unsymmetrical.
    regular network and almost seems like 2 lesions colliding with each other.
    I would do a punch biopsy

  3. Probable inv melanoma chaos grey lines regression etc
    2mm excision all biopsy await histopath for def excision margin

  4. Asymmetry with some atypical network developing and maybe some grey areas. I’d excuse this

  5. Likely melanoma regression noted and Chaos
    2 mm excisional biopsy await histopath for definitive clearance margin

  6. Asymmetrical lesion with eccentric structure less area,blacks clods
    2 mm excision biopsy to rule out melanoma

  7. Melanoma.Chaos and clues esp regression
    Excise with 2mm margins and tell him to expect another wider excision.
    What is that thing pointing to the lesion?

  8. PSL showing multiple colour and structure. Thick line reticular, angulated lines, dark blackish gray structureless area, line streaming. Excise with 2 mm to exclude MM.

  9. A darker asymmetrical pigmented macule. Dermoscopically asymmetrical , colour and structure , the boarder is ok= a dermoscopically chaotic lesion. Clues= a darker eccentric structureless area, the network is slightly atypical.
    IMPRESSION an atypical melanocytic lesion, as above, not enough clues for immediate excision
    PLAN repeat the DDI in 3 months if a change or new clues for a melanoma , for an excision, otherwise 1 yearly follow ups


  11. Macro
    7mm irregular shaped unusual looking naevus
    3 point checklist
    Asymmetry of colour and structure
    Atypical network
    Scores 2/3 – biopsy
    Chaos present + 3 clues
    Eccentric structureless area, thickened lines, black clods – biopsy
    Elliptical excision biopsy with 2mm clinical margin

  12. ‘Textbook’ melanoma, excise with 2mm margins initially (cannot watch and wait.) Features include chaos, assymetry, muliple colours, black clods, grey areas, pseudopods, abnormal reticular network, structureless areas.

  13. Dear Colleagues,

    Better not go or say with wider or 5 mm excision initially. No doubt, we human are easily excited dealing with colours and tool. Dermatoscopic evaluation (with or without algorithms) does not suggest wider excision but rather suspicious enough to be biopsied or not. Please also note, Dermatoscopy is not 100% perfect tool, with limitations (specificity and sensitivity < 85%), and at times it can be naevus with or without dysplasia. Prof Wilkinson used to say, not every pigmented lesion looking like melanoma are not melanoma.
    In this case, it certainly looks suspicious for a melanoma based on ABCD, 3-point check lists or Chaos&Clues’ decision-making algorithms. Thus, as per Australasian guidelines, 2mm peripheral margin excision over cosmetically non sensitive area initially, and go from there for further steps. If it is a melanoma, your next step will be determined by Breslow thickness. For example,
    • WLE (ranging from 5mm – 20mm)
    • Referral for SLNB/tertiary centre (≥ 1mm or 0.8mm with ulceration)

  14. For me, impossible to leave this on the patient, unless I have total body photography! If this is my first visit with the patient I would recommend shave excision (small, flat lesion, and I am confident with the technique). I would want to check his other nevi very carefully to see if they look similar – if this is a stand out lesion I would not accept the report of mild dysplasia, and would want 5mm margins as a safety. And, I would want total body photography going forward