Case discussion: How would you treat this patient? [13 March]
This week’s case discussion, submitted by Dr David Stewart, features a 53-year-old female patient who visited Dr Stewart after attending a dermatologist appointment with her son the preceding week.
During that consult, the dermatologist had noted a lesion on her arm and insisted she attend her usual GP to get it removed. Because the appointment was for her son, the dermatologist did not remove it himself.
What do you make of this lesion? What would you do next?
Here is the pathology result.
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20 comments on “Case discussion: How would you treat this patient? [13 March]”
Would do ecxisional biopsy with 2 mm clear perimeter.
This is a junctional neavus,I would monitor this lesion.
Review the lesion in 6 and 12 months initially then annually.If any changes noted(especially if the clinic has a mole max scanner) then perform excisional biopsy with 2 -3 mm margin.
Ugly duckling. Excision biopsy, histopathology and if appropriate referral to plastic surgeon.
Melanoma in situ
Lentigo with pigmentary incontinence. Manage with reassurance and 3/12 R/V.
Lesion is an ugly duckling.
– asymmetrical structure and colour
– atypical network
– white regression area
Excision biopsy 2mm margins.
I would only surgically refer if the Beslow depth was >1 mm ie. a ‘thick’ melanoma. Not because wide excision would be difficult, it wouldn’t be, but sentinel node biopsy may be required and this should be done prior to wide excision.
Also if ‘thick’ >1mm then referral to a melanoma clinic
would be also be indicated.
it is benign
ugly duckling ->needs excisional biopsy with 2mm margins and send for histopathology , depends on the report will refer to Skin cancer clinic vs wait and watch
Asymmetry of shape & structure with maybe a faint blue-grey haze, despite tiny size. Stand out lesion in the area sown at least – but check rest of her in case she has 20 of these, or, something worse. Suspicious for melanoma in situ. Excise with 2 mm margin.
2.5 x 3.5 mm irregular pigmented lesion, R upper arm deltoid region.
1 x 1 mm darker area approximately central. Looks to have irregular thickened network.
Enough to suspect MM. Excision biopsy 2 mm margins
A flat reticulated brown macule, with mild asymmetry. Dermatoscope= an atypical network. No other clues of note that I can see. IMPRESSION, it could be a reticulated flat seb. K vs a junctional naevus vs a superficial melanoma.
PLAN= D/W the patient, either monitor with a repeat DDI in 3 months, if a change or further clues for an excision. Or an excision with 2mm margins.
I’d usually like more background history about patient; ?Personal/family history of skin cancer; how long lesion present, suspicious symptoms, noticed changes. But, looking at this lesion it is asymmetrical and contains several colours of pigment. I’d say at least an atypical lesion and excise.
asymetric: shape and structures, area of regression, atypical network and appears to be ugly duckling on the limb.
Without history assume new/changing
DDx: melanoma, nevus,
Excision biopsy 2mm margins t rule out melanoma definitively
Ugly duckling lesion. Thickened central polygonal reticular lines with a cloudy hue. Biopsy with a 2mm clear margin.
appears to be lentigo or a moderately dysplastic nevus
I would feel I have no choice here: the dermatologist has spoken! . It’s a no win. Remove the lesion.
But on its merits: it has the clear edge of a seb K and some Milial cysts. It has as featureless area and asymmetry . Unless the patient had other similar Seb k’s , I would feel it needs removal: excision biopsy 2-3 mm , but a low index of suspicion
Pretty much my thoughts exactly when I saw this lady 🙂
Needs to do excisional biopsy.
Wait patient results after treatment.