Case discussion: How would you treat this patient? [12 September]

In this week’s case discussion, submitted by Dr Terry Harvey, a 76-year-old man presented for his first ever skin check as his wife was concerned about a lesion on his left posterior flank.

What do you think, and what would you do next?

case discussion


The pathology result showed invasive melanoma, Breslow 2.4mm with ulceration. What next?

case discussion


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18 comments on “Case discussion: How would you treat this patient? [12 September]

  1. This is a raised regularly pigmented symmetrical lesion that looks very inflamed and there looks to be surface skin features consistent with abrasion.
    So at best this could be a stable pigmented benign lesion that got abraded by a work shirt rubbing on sweaty skin such as if he had been doing manual labour with his arms like hedge clipping or digging.
    There should be at least some clue about history that would help in the decision about likely diagnosis and appropriate management.
    If history suggests a novel and recently appearing lesion then it would be appropriate to do a simple excision beyond the red perimeter and get a histological excisional biopsy. If benign you are clear and everyone can relax. If melanoma then this would be a significant Breslow thickness and would demand sentinal node sampling.

  2. This lesion appears to be asymmetrical with arras’s of brown pigmentation seen at the periphery and what appears to be a haemangioma more centrally however given the appearance of a blue grey veil centrally with ? Arborising white lines , plus the gentleman’s age /location I would recommend an excision biopsy to be done ideally with 4mm borders

  3. I’m concerned it’s a melanoma. Initially it looked like an irritated naevus but there are some grey structures in the central area of pigment so I wonder if the surrounding area is amelanotic melanoma?
    History would be important but given my concern I’d excise it.

  4. I do not like the lesion at all, it is a lesion that seems to be rising, very black, with chrysalises and erythema around it which means activity and growth, it is more than 10mm, it is asymmetric, more than three colors and irregular edges. MM.
    Biopsy removal margins not less than 0.5 mm. Wait for results from Breslow to make another decision.

  5. pigmented lesion with red nodular lesion in the middle. could be a melanoma so excision biopsy is recommended

  6. Ugly duckling
    Pink white irregular structure with crystalline streaks. Central dark nodular structur with some ulceration and areas of possible regression. No network however.

    Suspicious lesion possible melanoma excision biopsy 2mm margins.

  7. Raised red PSL would need attention. Dermatoscope shows uniform reddish purple background with some short white lines and pigmented mole at periphery. Taking the age snd history I would biopsy to rule out sinister lesion. Differentials can be melanoma vs vascular lesions like angioma … etc

  8. central dark blue to black structure less area, peripheral blush without blood vessels seen, peripheral light brown structureless area, widespread shiny white streaks, and areas peripheral blue grey ovoid globules ?? basal cell

  9. CLINICALLY =A new concern (from his wife) for an ugly duckling lesion, that is solitary. A central black, blue structureless area with pink and red surrounding colour.
    Dermatoscopic features=The central blue and black structureless raised area with a possible blue-white veil, overrides any symmetry. This lesion has a lot of melanoma clues. Crystalline white lines, amongst a pink/ red areas, was well as polymorphic blood vessels (dotted and linear irregular) The blood vessels are not centered (like with benign lesions). Some peripheral clustered black dots at 10 O’clock. Peripheral brown structureless areas with some atypical brown follicular openings.
    IMPRESSION = A melanoma with a central nodular invasive area (Black blue rule), the Beslow thickness is likely > 0.8mm.
    PLAN = Elliptical excision with 2mm margins, so not to compromise, further management like a wide re excision +/- SLNB

  10. ‘when in doubt take it out’–this supports the old adage –certainly enough concern here for possible melanoma to warrant excision biopsy.

  11. Approx 9 mm PSL with 4 mm roughly circular central region which is irregular, black and possibly nodular. Central black region has surrounding reddened area (approx 1 mm circumferential halo).

    Possible traumatised naevus, but MM until proven otherwise.

    Location flank/back is readily accessible and easily excised – excise with 1 – 2 mm margins of lesion border.

  12. Pigmented, Asymmetrical Colour and shape, nodular malignant Melanoma is most likely and needs excision biopsy
    first then further excision after histopathology results.

  13. need wide local excision with sentinel node biopsy . Need multidisciplinary discussion for involvement of other organs with secondaries. Might need immunomodulators .Need a thorough skin check to see any other lesions. Need ongoing skin checks for life

  14. Amelanotic nodular melanoma arising from a brown naevus at the base. Excision box , then referral to melanoma team