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1800 867 1390Case discussion: How would you treat this patient? [27 March]
In this week’s case discussion, submitted by Dr Robert Teunisse, we look at the second of two suspicious lesions found on an 80-year-old male patient with a past history of melanoma in situ.
This lesion was identified on the patient’s mid-back. What do you make of it? What would you do next?
(Click here to see last week’s case featuring the same patient.)
Update
Here is the pathology report.
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the irregularity of colour/pigmentation and asymmetry, plus the history suggestive of a mother melanoma in situ. Excision required..
polygons, regression, dermoscopic grey, Likely Melanoma in situ or highly dysplastic nevus, can be shaved
Suspected Melanoma ; irriguler shape different colours asymmetrical pigmented patch pluse the history of melanoma make it highly suspect ion need exc safety margin for ref to the regular oncologist for treatment
Suspicious pigmented lesion 3/3
Excision biopsy 2mm margins
Consider Melanoma
Malignant lesion. Hallmarks of melanoma with polygons.in and regression – Grey black and red .
Looks raised in the non o
Polaroid view.
Infiltrating melanoma , ellipse with 10 mm margins
Excision biopsy first with 4 mm margin
The patient first do a Dermatoscopy. 3 point check . If suspicious would do a biopsy.
Asymmetry of pattern and colour ( chaos ) with eccentric structureless, blue grey clods, pseudopods 5 and 6 Oclock and thicker lines. Regression from 12 to 3 0 clock. Excisional biopsy with clear 2 to 3mm margins for Diagnosis and Breslow score . The result will the guide to the further management plan.
A chaotic brown macule. Dermatoscope image = Atypical network, eccentric white structureless area/scar like regression. Blue dots/globules, with some peripheral globules. There is also angulated lines.
IMPRESSION = a superficial spreading melanoma on sun damaged skin
PLAN= excision with 2mm margins, further management dependent on histology
5 x 3 mm irregular PSL Upper back. Marked assymetry. Structureless area, thickened network in parts (5 O’clock), blue/grey veil. ?clods 11 O’clock. MM until proven otherwise.
Already know this MM from the path report from last week’s case, but initial treatment is excision 2mm margins
Hi Everyone
Some of you all might have seen the histology from the previous post – which makes this case a bit easier to predict.
This lesion has good features that are seen in non naevus-associated, high-chronic sun damage melanoma subtypes.
In a patient with a back like this, we can think about what specific features of melanoma we are likely to find based on the type of skin we are seeing in general.
Which features of melanoma are more common in different melanoma subtypes?
Hi Terry,
In addition to asking questions, could you please provide us with some of your pearls?
I, for one, have time to glean a pearl from you in the discussion, but I don’t have time to go looking up the answers to the questions you throw in from time to time! Maybe others are in the same position?
Just a thought
Chris
Hi Chris
Thanks for the feedback – I’ll certainly try to include a bit more of this kind of comment.
With this case I am hinting that melanoma clues such as angulated lines, poor border circumscription, grey structures that are usually seen in lentigo maligna or lentiginous melanoma in chronically sun damaged sites.
In this patient due to his high degree of background sun damage you are likely to find lentigo maligna or lentiginous melanoma.
I wish we had higher resolution images. There’s a bit of guesswork needed to decide which structures are present in these cases.
Chaos> yes
Grey structures> yes
That’s all that’s needed to decide on excision with a 2mm margin, especially with the prior history of melanoma.
In addition, other clues may be present:
Asymmetrical featureless areas
Grey dots
Brown dots (but I don’t think this is IEC)
Possibly thickened network in the 5 o’clock segment
I think this is MIS.