Quiz Challenge – 70yo with Lower Lid Lesion

Case Study: 30yo Lady with Reduced Vision and Night Vision Issues
Dr Charles Su

A 70 year old otherwise well man presents with a lower lid lesion which has been obvious in the last 3 months. It is palpable as a lump of about 1.5cm in diameter.

1. As a first step, would you:

  1. Take an incisional punch biopsy then refer to a specialist
  2. Do a comprehensive work up for metastases and then refer on to an specialist
  3. Refer straight away to a specialist

2. What kind of specialist would this patient need?

  1. Dermatologist
  2. Plastic Surgeon
  3. Ophthalmologist
  4. Head and Neck Unit
  5. Any of the above

Click for Discussion

This is a pigmented mass largely involving the epithelial surfaces as well as deeper tissues. A malignant melanoma is the likeliest diagnosis. Management is likely to involve extensive tissue loss, and possibly loss of the eye and orbital tissues. Evaluation of its extent could include high resolution imaging as well as sentinel lymph node biopsy.

Management is thus best conducted from a multispecialty facility, such as the Melanoma Clinic at the Alfred Hospital or the Peter MacCallum Centre’s Head and Neck Unit. The most useful first step is to expedite the referral, and to confirm that the patient is given a correct appointment. Taking a biopsy or investigating systemically is more likely to cause unnecessary delay, and these are best decided upon and done by the team which will continue the management, and their own pathology and imaging services. A referral to any of the specialists listed above would result in a successful transfer to such a unit as well. However it is arranged, any referral must be confirmed to be within about 10 days or less. It would not be safe to allow the patient to make their own booking.