Hunting malignant melanoma behind a tattoo

A 56-year-old woman with a past history of melanoma presents for a routine six-monthly skin examination.

A 3mm papule with a slightly elevated contour is noted within a tattoo on her thigh (figure 1a, the cross hairs of a sniper rifle are Photoshopped onto a 3mm-diameter papule).

There is nothing remarkable clinically about this minute pigmented lesion between the eyes of the tattooed wolf’s head (figure 1b), but dermatoscopically, it has hallmarks of malignancy, being asymmetrical (chaotic) and with the clue of white lines (figure 1c, asymmetrical pigmented lesion — the peripheral clods and white lines are clues to malignancy).

Elliptical excision biopsy confirms invasive melanoma, Breslow thickness 0.4mm, arising from a dermal naevus.

Trophy hunting

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