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Case discussion: How would you treat this patient? [1 June]
This week, we have another interesting case from Dr Tim Aung, featuring:
- 70 year-old male patient
- Lesion near right wrist noted for 6-12m
How do you evaluate the below images? What would you do next?
Update:
Here is the result. What next?
We encourage you to participate in the case discussions and submit your own clinical images and questions, so we can all learn together.
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Excision with 2mm margin
Asymmetrical pigmented lesion on background on sundamaged skin. pigmented globules. no obvious reticular pattern seen. Irregular margins.
DIfferential diagnosis – 1st Pigmented BCC . 2nd – Melanoma.
Management biopsy- excision biopsy with 2mm margins.
Melanoma
For excision biopsy 5mm margins
Looks like a BCC to me
Excision biopsy with 2mm margin.
Need histo before taking anything more than that.
Lentigo maligna type melanoma likely given age and remains flat despite size.
Whole depigmented area adjacent should be taken in the same specimen.
Excisonal Bx with 2 mm margins
Irregular border, structureless center, pigmented clods and lines on periphery, pink structureless area on the left.
Pigmented BCC
Excision 2 mm borders.
Possibility of a compound naevus, and/ or melanoma in-situ— magnification shows irregular border and variable pigmentation, although limited reticulation, exercise with 5 mm border.
pigmented lesion, irregular borders, nest of melanocytes, best excised with 3mm clear border, fits in melanoma in-situ, I won’t put my money on BCC
grey with polygons and regressed. will need WLE 3mm margins to r/o SSM
The pigmented area is part of a larger lesion with scarring and a second pigmented area on the other side of the scarred area. Has he had previous treatment to the area? Consider pigmented BCC or MM. Excise with 2mm margins.
Looks like a big chaotic lesion – I suspect the pink area is part of it so it looks like a triangularly shaped lesion of nearly 2 cm diameter. I suspect a BCC but cannot be sure. I would do a a punch biopsy (?or 2 -> 1 in the pink and 1 in the pigment) before deciding on further management of such a large excision and likely complex closure.
For those who are challenged by pink/red area: that can be AK (Sol K) skin, partial resolution of bruise/ecchymosis in think skin of elderly which are not uncommon. Thus, it may not be important in this case.
Thanks for the clarification Tim. Nice case!
Some suggestion in the new guidelines that 10mm margins would be required for Lentigo M. and lentiginous melanoma`s ? Not sure if everybody does this … ?
Thanks everyone. A fairly straightforward case this week – suspicious PSL, needs 2mm excision biopsy. LMM confirmed, so 5mm excision for definitive treatment