Case discussion: How would you treat this patient? [22 August]

In this week’s case discussion from my own practice, a 60-year-old female came in for her first presentation for a skin cancer check. Her mother had a melanoma and her father had BCCs.

On examination, the patient was found to have skin type II and fairly tanned forearms. There were multiple seborrhoeic keratoses on her face, shoulders and upper back. There were less than 25 naevi on her back and a few scattered, small lesions on her shoulders. The seborrhoeic keratoses on her nose were treated with cryotherapy.

Four months later, the patient returned for a spot check on her nose. See the two images. What would you do next? What do you think?

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A shave biopsy showed melanoma in situ. What next?

– Prof David Wilkinson

case discussion


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21 comments on “Case discussion: How would you treat this patient? [22 August]

  1. Circular pattern with gray circles. Lentigo maligna. Usually excision/shave biopsy to confirm the diagnosis. Then 5 mm excision margins

  2. The clinical and dermatoscope features, could fit post cryosurgery atrophic changes with remnants of a seb K, but a Lentigo Maligna needs to be excluded , hence a shave biopsy is the way to go.
    Dermoscopy features = 1 The follicles are yellowish and variable in size + ? some atrophic post cryosurgery changes ? a residual seb K, BUT = 2 Atypical pigmented follicular openings with some annular granular areas+ no obvious Pigmented Actinic Keratosis /lentigo features apart from above 1 features.
    IMPRESSION= Lentigo Maligna needs to be excluded
    PLAN =A shave biopsy

  3. Couple of follicles are surrounded by dark pigmentation raising possibilities of early lentigo meligna changes. An excision biopsy of suspicious area can clarifies the doubt.

  4. The pigment is focussed around sebaceous glands presumably on the site where the SK was removed.
    With her anxiety over melanoma I would suggest a shave biopsy and obtain histology to guide our further management.

  5. Circles in circles : concerning . Likley Lentigo maligna I would not immediately go to biopsy.
    First visit, I might need to get her confidence because I am about to give her a decent scar on her nose.
    f I could be 100% confident she would return I would give her 2- 3 months , document a change and we know lentigo maligna are not aggressive melanomas.
    I would then likely punch and referr : I am not confident in adequate depths or cosmetic results of shaves on nasal tips. I appreciate those with the skill and confidence to take it on in young women.

  6. She has a direct family member with melanoma so her risk of melanoma is at least an order of magnitude than the average person.
    So one would be suspicious for melanoma from the outset.

    The are 7 areas which collectively could be called a lesion. These comprise some esp at 10 o’clock which show asymmetrical melanin deposits, an early (pseudo) network.

    Needs ‘excision biopsy with a 2mm margin’ but difficult area so shave excision should do to establish histology.

  7. I would do a 4 mm punch biopsy due to family history of melanoma and due to recurrence and irregular pigment

    1. Beware of punch ( partial biopsies) of pigmented skin lesions. They have a strong association with misdiagnosis leading to adverse outcome,

  8. It could be remnants of seb k, early Lentigo Maligna, solar lentigo or pigmented actinic keratosis. I would be happy to watch it with serial images, but give the patient the choice of a small shave of the most pigmented area, if she preferred. I don’t see grey in the image.

  9. Pigmented brown circles on the right and grey circles on the left suggest melanocytic activity in facial hair follicles and this was a Solar Lentigo becoming Lentigo Maligna Melanoma. Due to cosmetic reasons an excisional biopsy is difficult. Consider a shave biopsy .

  10. Without definitive proof, it is most likely that the original lesion was a lentigo maligna melanoma, and that the cryotherapy was an error. The patient as seen by an inexperienced doctor at the first consultation. The lesson / the message here is – be very cautious about treating anything before diagnosing something. You really do need to be really sure what the clinical diagnosis is before treating, especially with destructive methods. Diagnosis of facial pigmented lesions is very tricky (I find), even for experienced practitioners. Be cautious, and biopsy.

  11. will consider refer plastic specialist or excision with 5mm margin with preauricular full thickness graft or bilobed skin flap.

  12. Excision with recommended 5mm rather than 10mm margins followed by a Flap or a Graft for Melanoma In situ. Consider 2mm margin safe excision and treatment with Imiquimod ( off licence ) but I would not do this personally. It would be a discussion with what the patient wishes to have done in view of Cosmesis.

  13. Gray circles in cicles patterns speak of LMM but something more, she has direct familiars with Melanoma .
    What to do? Biopsia Punch 4 mm and wait the results.