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1800 867 1390Case discussion: How would you treat this patient? [24 October]
In this week’s case discussion, submitted by Dr Terry Harvey, we look at a 60-year-old male patient who presented for a routine skin check with no specific concerns. He has a history of multiple keratinocyte skin cancers and one previous melanoma in situ on his shoulder.
This lesion was identified on his arm. What do you think, and what would you do?
Update
The lesion on his left forearm was excised and the histology showed a melanoma in situ of superficial spreading subtype. How would you treat it?
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1300 856 695
+44 203 514 0688
1800 867 1390
Ugly duckling.
P/h melanoma
Suspicious lesion 3/3
Excision biopsy 2mm margins.
Has some pigments and structures areas
Significant history
? Bowel’s
? Lentigo
Excision
Irregular border , asymmetric , areas of regression , ? peripheral pseudopods .
Suspicious for melanoma .
I would shave to confirm diagnosis .
I would biopsy
Brownish dots snd clods with subtle angulated lines at top part. Different shades with no specific structure but chaos. Excise to rule out any sinister growth.
If the patient did not have a history of melanoma, I would not pay attention to this formation … In this case, it is doubtful and alarming – removal.
Appears to be a dysplastic nevus, reasses in 4 months
Clinically a variegated pigmented macule on severe sun damaged skin. This person has had a PHx of a Melanoma and several NMSCs.
Dermatoscopically= This is a subtle pigmented macule, you have to look hard for clues = an irregular black blotches and globules, an eccentric structureless hypopigmented area with? some grey pigmentation, it is just 20%. Some white lines. Some atypical brown pigmented follicular openings like Lentigo Maligna on the face.
IMPRESSION= Again an early superficial spreading melanoma until proved otherwise. The differential diagnosis would be an early flat seborrhoeic keratosis/lentigo.
MANAGEMENT = Shave (looks superficial and a good size) or an excision with 2mm margins.
The lesion is an asymmetrically pigmented macule with features suggesting it is melanocytic.
I think it is higher risk and deserves an excisional biopsy, especially in view of the history.
My DDx includes solar lentigo / early sebK, and dysplastic naevus.
Chaos
Grey circles
Excision 2mm mArgin
The lesion is asymmetrical shape and colour with deranged network. He has history of Melanoma in situ which I believe in this case is highly suspicious and needs biopsy and then complete excision after the confirmation.
For Melanoma in-situ, re excision with 5mm margins and down to the fascia.
Further excision 5-10mm margins