Case discussion: How would you treat this patient? [6 February]

This week’s case discussion, submitted by Dr Renuka Ranasinghe, features a hospital worker in her late 60s who was sent in for a skin cancer check by her hairdresser who had noticed a benign pigmented seborrhoeic keratosis on the back of the patient’s neck.

Upon a full-body skin examination, a freckle was noted on the patient’s left anterior thigh. The patient reported it was unchanged for years.

What is your differential diagnosis here? What would you do next?

  case discussion


Here is the final histopathology report. The lesion is invasive lentigo maligna melanoma, Breslow thickness 0.7mm, Clark level 4. Suspicious for lymphatic invasion.

case discussion

Here are the follow-up photos of treatment:


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case discussion


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11 comments on “Case discussion: How would you treat this patient? [6 February]

  1. It is asymmetrical shape, and colour, abnormal networking, areas of regression with normal skin colour.
    I believe it is an In situ Malignant Melanoma and that needs to be treated with excision biopsy with 5 mm
    clear Margin and further follow ups every three months.

  2. It is a pigmented melanocytic lesion, has atypical network, asymmetry and different shades of brown, some has thick reticular lines. Hence, Melanoma needs to be ruled out by excision with 2-3 mm margins.

  3. looks like definite angulated lines around 12 oclock of the lesion with suggestion of grey hue. There is also a more hyperpigmented area marginal at 5 oclock and I feel the lesion does look somewhat chaotic in colour and structure
    MM until proven otherwise. If patient is agreeable I suggest excision biopsy on an easy anatomical area or get him back in 1 months to compare dermsocpic image for any interim change ( less preferred option)
    dd atypical naevus.

  4. Assymetry and areas of irregular network. Warrants biopsy but may well just be lentigo.

    Large lesion – around 15 x 20 mm from the scale which is seen on one of the dermoscopy views.

    Shave or excision?

    Not a difficult excision from the body position, so I would favour excision biopsy with 2 mm margins

  5. Asymmetrical with extra reticular network on one end of the lesion. I think to exclude MIS or lentigo maligna , excision with 2mm margin.

  6. Looks suspicious, but surely if the patient states it hasn’t changed in years she might be resistant to what will be a large excision. It looks superficial, would there be any risk in just taking a photo and bringing her back for a review in 3 months time?