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1800 867 1390Case 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?
Update
Here is the pathology. What now?
– 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.
1300 856 695
+44 203 514 0688
1800 867 1390
Melanoma. Excise. Chaos and clues.
Several colors, atypical network, streaks, black clods.
Chaos in color and structure
dark brown thick line
suspicious of melanoma, for excision
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
Naevus , if no other lesions of same kind 3 months photo review
Probable inv melanoma chaos grey lines regression etc
2mm excision all biopsy await histopath for def excision margin
Asymmetry with some atypical network developing and maybe some grey areas. I’d excuse this
Likely melanoma regression noted and Chaos
2 mm excisional biopsy await histopath for definitive clearance margin
excisional biopsy with 2mm marge, sent for histopath to assess melanoma
Asymmetrical lesion with eccentric structure less area,blacks clods
2 mm excision biopsy to rule out melanoma
“Has to be” a melanoma
Excision biopsy 2mm margins
Excision with 4 mm margin
leave alone, reasses in 12 months, appears to be a Compound melanocytic nevus
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?
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.
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
ASYMMETRICAL HYPERPIGMENTED LESION
ECCENTRIC CLOD AND GLOBULES
ASYMMETRICAL PERIPHERAL STREAKS
?? MELANOMA EXCISION WITH SAFETY
Macro
7mm irregular shaped unusual looking naevus
Dermoscopy
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
Suspicious of melanoma, excision
Melanoma
Wide excite biopsy and histology
Chaos and clue seen. For 2mm margin excision biopsy
Lentigo maligna
ABC score 3/3
MIS possibly
Excision Bx with 2 mm margins
assymetry, atypical network, white structures, Likely melanoma. excise with 2mm margin
Needs excision and biopsy.examination ofLNd
Highly suspicious for Melanoma . Excisional biopsy with 2 mm margin.
‘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.
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)
All good. Reassure the patient.
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
Tape test could have helped here.