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1800 867 1390Case discussion: How would you treat this patient? [1 August]
This week’s case discussion, submitted by Dr Randa Al-Hajali, features a 63-year-old man with past history of multiple skin cancer excisions. He presented for his routine skin cancer check and a large, pigmented lesion was noted on his right malar bridge. He noticed it is getting darker in colour.
What is your differential diagnosis, and what would you do next?
Update
Here is the result. What next?
– 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
Shave biopsy to rule out melanoma
Hi !!! The picture is not enought clear to see all the structures, but the tissue is completly actinic damage for time and now appear this a new dark macular lession , I sugest excision biopsia extirpation.
Thanks
? Lentigo maligna
Great example of a pigmented Actinic keratosis. Lovely rosettes, strawberry dipped in chocolate, with wide and white follicular openings.
So tx, LN2.
Pigmented Ak leave alone, Photograph and review once. If no change then leave alone . Rosettes non specific.
pink lesion- punch biopsy
D/D -BCC, SCC
PIgmented lesion
Assymetrical colour and shape
Atypical network or more than one kind
Possible regression area 9o’clock
Suspicious 3/3 Excision biopsy 2mm margins
Melanoma likely
DDx SebK
pigmented Actinic Keratosis – trial of cryotherapy and reasses in 4 weeks time
Flat lesion. Pigmented portion is irregular in shape, border and colour.
Differential includes lentigo maligna melanoma and pigmented superficial BCC.
It could also be benign such as dysplastic naevus.
My approach would be either excisional biopsy with about 2 to 3 mm clearance, if the skin has plenty of laxity, or a shave excision with the same border as an alternative.
Follow up management would then be based on the histology.
Do a wide excision biopsy and review
definitely elements of concern ,asymmetry 0f colour and shape, variable pigmentation, white whorls, some regression be good to see better picture,but enough to indicate, also with that history, excision biopsy 2mm clearance
Deep shave biopsy or multiple 3 mm punch biopsies as it is asymmetric and has pigmented network with past history of skin cancers.
PSL with various shades of colour and some follicular obliterations. Angulated lines. Rosettes. ?LMM vs PAK.
ANNULAR GRANULAR PATTERN
OBLITERATION OF HF
??LENTIGO MALIGNA
A solitary changing lesion is a concern. Darker with some asymmetry . It would be good to know if the lesion feels rough with some scale.
Dermoscopic image fits a Pigmented Actinic Keratosis = actinic sun damage, a strawberry pattern in 2/3 of the lesion. Rosette’s and variable follicular openings with an erythematous back ground. It looks like the also is some scale.
The other 1/3 to the right his dark brown pigmentation with some blue grey annular granular atypical follicular openings, as well as obliteration of a few of the follicular openings.
IMPRESSION I would still favor a pigmented actinic keratosis , but a lentigo maligna needs to be excluded with the changes on the right 1/3 of the lesion vs lentigo
PLAN =a simple shave excision biopsy, with management dependent on the histology.
Pigmented actinic keratosis
Scale, Erythema with the darker area having a well defined margin between 12 and 6 O’clock. Clods as Rosettes. I would say this is most likely a combination lesion of a Actinic Keratosis and Solar Lentigo. Consider monitoring in 3 months, shave or incisional biopsy to ensure one is not missing a melanoma.
Likely In situ melanoma 2mm excision wait on pathology for defin management
Network changes(atypical) regressive features superiorly
Should have included macro pic and included scale thanks
? Lentigo maligna. For excision biopsy
I can see polygons and grey structures to right of the photograph; which makes suspicious
asymmetrical pigmented lesion on face
chaos – YES
clues – thick lines, grey circles
likely lentigo maligna or melanoma
needs biopsy – preferably excision biopsy
I would take a photo and arrange urgent appointment with visiting plastic surgeon (or consider shave biopsy to confirm diagnosis if referral is difficult)
Severely sun damaged skin with active solar keratosis and pigmentation
could be pigmented Bowens disease or pigmented solar keratosis
multiple biopsies from from different part of the lesion is recommended
Asymmetric pigmented lesion; Thick irregular network; Blue gray patches
Superficial MM (Lentigo Maligna) until proven otherwise
Macro photo and size scale would be appreciated to see exact location
Shave Biopsy
Lentigo Maligna
This is a pigmented lesion with a pseudonetwork but i dont see any scales.
Differential includes AK although a lentigo maligna cannot be ruled out.
punch biopsy?
I find these lesions quite tricky! I recommend that colleagues become familiar with the “inverse approach” – get on Google and you will find it. Basically, you look for clear features of AK or solar lentigo, and if present make the relevant diagnosis. If they are not present, and clearly present, then it may be LMM and requires a shave biopsy