Case discussion: How would you treat this patient? [8 August]

In this week’s case discussion, submitted by Dr Terry Harvey, we look at the case of a 70-year-old male who presented for his first ever skin check. This lesion was identified on his back, but it was not symptomatic.

What do you think and what would you do next?

case discussion

Update

Excision biopsy showed melanoma with Breslow 0.88mm. What would you do next?

– Prof David Wilkinson

case discussion

 

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20 comments on “Case discussion: How would you treat this patient? [8 August]

  1. A erythematous raised with a slight brown diffuse pigmentation, asymptomatic 1.5cm
    Dermoscopy image . It would have been good to also have the non polarized image. Because the differential would be a pigmented bowens vs and irritated seb k vs a mainly amelanotic melanoma.
    The striking feature is dotted and glomerular BVs , you could argue that at the margin is some linear dotted BVs typical of Bowens. Clusters of BVs with some white structureless and brown pigmented areas. But there is no scale.
    The concerning feature is the brown/grey angulated lines with a mainly non pigmented lesion, with clusters of of dotted BVs so a melanoma needs to be excluded
    If we had the non polarized image we might have found white crypts, the BVs seem to be centered, not quite the mother of pearl pattern of a Clear Cell Acanthoma, but ? an irritated seb K or funny CCA .
    Plan = shave re likely Bowens, but excision is better if a possibility of a melanoma. Further management based on histology.

  2. Ugly duckling
    Not melanocytic no network visible
    Irregularly shaped pink-white lesion in an older person
    White areas could be regression
    No abnormal vessels
    ?BCC ?Amelanocytic melanoma
    At minimum dual punch biopsies
    Consider immediate excision with 2mm margins

  3. Ugly duckling with assymetry of structure and colour.
    Suspicious of malignancy- Melanotic melanoma, Bowens.

    Needs excision biopsy which in this area could be done with 2mm margins rather than shave.
    I would have liked both polarized and non polarized dermoscopy and better definition in the image and indication if rough as in irritated seb . raised or flat .

  4. Many ugly looking waxy papule with regular border and smooth surface– these might be seborrheic keratosis. One of the lesions is suspicious because of irregular border and surface and having different colour in it but no melanin pigment– could be amelanocytic melanoma. Need biopsy with 2mm margin.

  5. Brown pinkish PSL showing multiple colour and structure with red dots. Some angulated lines at the bottom. Differentials BD vs MM
    Excise to rule out with 2 mm

  6. Grey 6 o’clock and polymorphic vessels means it should be excised.
    I’m thinking malignant melanoma

  7. 10mm + PSL mid back, assymetric, mainly pink with central irregular tan veil with irregular brown clod(s).
    Irregular and assymetric distribution of regression and polymorphous blood vessels (? resolution of image not great).

    DDx – MM, IEC, Superficial BCC, lentigo

    Plan – If this was more obviously superficial BCC, I would consider just shaving this but suspicion for MM is high, so would excise with 2mm margins.

  8. Macroscopically type 1 skin with a hypochromatic anomalously large lesion in form of triangle with multi notched edge, gloss sign, peripheral clearing zone focal polygons and dermoscopy chaos with irregular dot vessels, variegated pink tan with focal structures and chequer board chrysallis. Absence of radial pigment lines and rosettes no scale or milia. Highly suspicious of melanoma . Long margin to margin incisional biopsy. Careful scrutiny of other lesions especially pink with pleomorphic vessels or chrysallis for biopsy/ excision.

  9. Ugly duckling
    Asymmetry of colour and structure.
    Eccentric structureless area
    Blue / grey structure
    Glomerular like vessels / ? dotted vessels
    ? raised and red

    ? pigmented Bowen’s / ? MM

    Excisional biopsy with 2mm margins

  10. Just as well I said an excision biopsy rather than a shave in case it was a Melanoma. Because a shave might not have given us a Breslow thickness.
    The Breslow is 0.88, hence an invasive melanoma, so if microscopic or mitosis a referral for a wide local excision and consideration for a SLNB. If no ulceration or mitosis and if the algorithm for SLNB is saying it is not needed, then a 10mm wide local excision. Appropriate follow up will need to be arranged.

  11. Thanks to Terry for another really good case, and to all our contributors for comments. I think we all agree that it needs biopsy, as it is a fairly obvious “ugly ducking” or “lonely lesion”. Excision biopsy is preferred and a deep shave is fine if you are confident in your technique. Next steps depend, as noted by others, on the detail in the pathology report, but if no ulceration or mitoses, then wide local excision would be sufficient

  12. needs re excision with 10mm margin. no ulceration and <1mm so no need for sentinel node biopsy if no mitoses. so read the histopathology report carefully and either arrange re excision or refer for specialist melanoma/plastics review.