Case discussion: How would you treat this patient? [19 September]

In this week’s case discussion from Dr Terry Harvey, we look at a 75-year-old man who has a previous history of one melanoma and 10+ non-melanoma skin cancers, presenting for a routine skin check.

What do you think, and what would you do ?

case discussion

Update:

The pathology showed lentiginous melanoma in situ. What next?

case discussion

 

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19 comments on “Case discussion: How would you treat this patient? [19 September]

  1. Enough clinical suspicion for shave biopsy.
    I would scoop off full thickness and place a split skin graft on the defect, which I would harvest from adjacent to be covered by the same dressing. Kaltostat and a cotton ball to the wounds and a Tegaderm. Shave hairs for dressing security.
    Further management would be based on histological diagnosis. I would include the smaller lesion too though it looks less concerning, because its only a small extension of the shave.
    Review for change of dressing in 3 days.
    Firm bandaging for haemostasis especially if he’s taking blood thinners.

  2. I would peform an excision biopsy on the lesion shown at the 10 o clock position in the dermoscopic image, with 4 mm margins for histology .

  3. 8 x 10 mm PSL on ? forearm. The only benign diagnosis I can think of is a confluent lentigo. Superficial spreading MM until proven otherwise. Shave biopsy to upper dermis seems best approach here – capture as much of the lesion as possible.

  4. Naked eye PSL with more than two colours.
    Dermatoscopically I can’t see a specific pattern apart from dark brown various shades in blotch. If it’s new and has a smooth surface rather than rough then warrant attention to biopsy it to rule out any sinister growth at this age like MM.

  5. Clinically= A variegated brown pigmented macule, on top of severe sun damaged skin.
    Dematoscopic image= Lentiginous network + variegated black blotches, one or 2 angulated lines with some grey peppering. The lesion is > or = 8mm. Has a lot of solar lentigo’s
    IMPRESSION= lentigo maligna/superficial spreading melanoma needs to be excluded vs atypical lentiginous junction naevus vs solar lentigo with some regression.
    PLAN= I would perform an excision biopsy with a 2mm margin, you could get by with a shave as this is a superficial lesion. (esp. if he has a lot of similar lesions) I would favor an elliptical full excision biopsy (in case a breslow measurement is needed).

  6. biopsy, but what about the one in the upper left corner on the dermascope picture? possible satelitte/extension of big lesion?

      1. Maybe next April 1st Terry you could send in a dermatoscope image of just a pen mark and see what management suggestions you get? 🙂
        I reckon you’d get at least one “excise with 5mm margins” 😉
        I think this confirms what I’ve always suspected which is that the biggest suspicious feaure a skin lesion can posess is appearing in this Case Studies section!
        An interesting case as always – thanks

        1. A have a few ‘interesting’ cases that might be worth throwing in the mix!

          If it appears on a skin cancer blog it is a very poor prognostic sign… if it already has markings to be surgically removed then that is usually even worse!

  7. As suggested, there are enough red flags, or should that be black aggregations, variation in blackness, associated sun damage and asymmetry, to consider MIS or melanoma. Would do an excision biopsy, and given favourable Langer’s lines skin graft possibly not needed, just a Z plasty .

  8. the small pigmented area at the top left of the dermoscopy image is concerning with thickened black lines and a bit of a blue white veil. It look s like this is separate to the other larger pigemnted lesion so I would probably just excise the smaller lesion with a 2-3 mm margin to confirm or exclude melanoma.

  9. For Melanoma insitu , he needs a further excision with 5mm margins. Graft vs an elliptical excision or a flap, depends on the area needed to be removed.

  10. Deep shave to include whole lesion and base. Will manage according to histo result Won’t cut it before that Should not need graft in this area if MM for definitive management