The Evolution of a Melanoma: A Dermoscopic Case Study
Introduction: Presenting a real-world case to illustrate the dynamic nature of melanoma
In my dermatology practice, I often encounter patients who wonder why we monitor certain moles over time. Today, I want to share an anonymized case that beautifully illustrates why sequential monitoring is so crucial in skin cancer detection. This particular case involves a patient in their mid-40s who came for a routine skin check. Like many people, they had numerous moles but were particularly concerned about one on their upper back that had been present for years. During our initial consultation, I explained how we would use advanced diagnostic tools including a handheld dermatoscopio and handheld woods lamp to establish a baseline of their skin lesions. The patient's story highlights a fundamental truth about melanoma: it's not always obvious from the start, and its evolution can be subtle yet significant. Through this case, we'll explore how modern dermatology tools allow us to detect changes that might otherwise go unnoticed until it's too late. This approach represents a significant advancement in early skin cancer detection, potentially saving lives through timely intervention.
Initial Presentation: Showing the dermoscopic image of a mildly atypical mole at the first visit
During the patient's initial visit, I documented all their moles with clinical photographs and dermoscopic images. The mole in question measured approximately 5mm in diameter and was located on the upper back. When examined with the naked eye, it appeared as a symmetrical, light brown macule with relatively regular borders. However, when I placed the handheld dermatoscopio against the skin, a more detailed picture emerged. The dermoscopic examination revealed a subtle pigment network with minimal architectural disorder. There were no clear melanoma-specific features at this stage – no atypical streaks, no blue-white structures, no regression patterns. The pigment distribution was relatively even, and the network lines showed only focal slight thickening. I also used a handheld woods lamp to assess the lesion's fluorescence characteristics, which showed uniform pigmentation without significant variation. Based on the Total Dermoscopy Score system, this mole fell into the category of a mildly atypical nevus. We discussed the findings with the patient and decided on a follow-up approach rather than immediate biopsy, given the absence of high-risk features. I emphasized the importance of regular self-examinations and scheduled a follow-up appointment in six months to monitor for any changes.
Follow-up at 6 Months: Displaying a new dermoscopic image with subtle changes emerging
When the patient returned six months later, they reported no noticeable changes to the mole from their perspective. However, when I compared the current dermoscopic images with the baseline documentation, subtle alterations had indeed occurred. Using the same handheld dermatoscopio with identical lighting and magnification settings, I detected a slight expansion of the pigment network at the lesion's periphery. The network lines showed minimal thickening in certain areas, and there was the emergence of what appeared to be very faint tan structureless areas. These changes were subtle enough that they wouldn't have been noticeable without side-by-side comparison with the baseline images. The handheld woods lamp examination now revealed minimal heterogeneity in fluorescence that wasn't present during the initial visit. I documented these findings meticulously and had a detailed discussion with the patient about the nature of these changes. We agreed that while the alterations were minor, they warranted closer monitoring rather than immediate intervention. I explained that the biological behavior of melanocytic lesions exists on a spectrum, and we were observing what might represent early evolution. This intermediate stage highlights the value of sequential monitoring – the changes were too subtle to warrant biopsy at the first visit, yet significant enough to raise our index of suspicion six months later.
The Critical 12-Month Visit: Revealing clear-cut dermoscopic features of melanoma under dermoscopy
At the twelve-month follow-up, the transformation was unmistakable. The lesion had developed classic features of melanoma under dermoscopy that were absent in previous examinations. The pigment network had become markedly asymmetric with abrupt termination at the periphery. Prominent dark brown to black dots and globules had appeared irregularly throughout the lesion, and I observed multiple blue-gray structures indicative of regression. Most concerning was the development of radial streaming and pseudopods at the lesion's border – features highly specific for melanoma. The handheld dermatoscopio now revealed a multicomponent pattern with at least three distinct structural areas: an atypical network peripherally, irregular globules centrally, and regression structures scattered throughout. The evolution from a relatively banal-appearing mole to a lesion exhibiting multiple high-risk features was both striking and concerning. This dramatic transformation over twelve months perfectly illustrates why we emphasize the importance of monitoring changing lesions. The features we observed represented textbook examples of melanoma under dermoscopy, making the diagnostic decision straightforward at this point. The case demonstrates how melanoma can evolve through different stages, and how dermoscopic monitoring allows us to capture this evolution at a potentially curable stage.
Diagnosis and Management: Discussing the biopsy result and subsequent treatment
Given the clear dermoscopic evidence of melanoma, I performed an excisional biopsy of the lesion during the same visit. The pathological examination confirmed our clinical suspicion: invasive melanoma, Breslow thickness 0.4mm, Clark level II, with no ulceration present. The mitotic rate was 1 per square millimeter, and there was no evidence of regression on histopathology. The patient subsequently underwent a wider local excision with 1cm margins to ensure complete removal and reduce the risk of local recurrence. Sentinel lymph node biopsy was discussed but not recommended given the favorable prognostic features. Throughout this process, we used both the handheld dermatoscopio and clinical photographs to explain the pathological process to the patient, helping them understand the rationale for each step of their management. The handheld woods lamp continued to play a role in surveying the rest of the patient's skin for other potentially atypical lesions. The patient is now enrolled in our regular surveillance program, with skin examinations every six months and instruction on thorough self-skin examinations. This comprehensive approach ensures early detection of any future skin cancers while providing peace of mind through structured follow-up.
Key Takeaway: This case underscores the power of sequential dermoscopic imaging
This compelling case demonstrates why dermoscopic monitoring has revolutionized melanoma detection. Without sequential imaging using tools like the handheld dermatoscopio, the subtle evolution of this melanoma might have been missed until it reached a more advanced, potentially dangerous stage. The ability to compare lesions side-by-side over time allows us to detect changes that would be imperceptible through clinical examination alone or even single dermoscopic evaluations. The handheld woods lamp provides additional valuable information about pigment distribution and fluorescence patterns that complement dermoscopic findings. Most importantly, this case highlights the dynamic nature of melanoma under dermoscopy – how it evolves through recognizable stages that we can now document and intercept. This approach represents the gold standard in modern pigmented lesion management, balancing the need to detect melanoma early while avoiding unnecessary procedures for stable, benign lesions. For patients and clinicians alike, understanding that melanoma often announces itself through gradual change rather than dramatic transformation is crucial. Through appropriate use of dermoscopic monitoring, we can detect melanoma at its earliest, most treatable stages, ultimately saving lives through timely intervention.
