Case discussion: How would you treat this patient? [7 April]

Jerry, a 53-year-old recreational fisherman with history of multiple sunburns presents for skin check. Left upper chest lesion has been present for several months and has bled occasionally when towelling off after showering. Lesion is slightly tender and is getting larger.

Is this lesion BENIGN or SUSPICIOUS? Why?

If SUSPICIOUS, how would you BIOPSY?

What is your differential diagnosis?

Clinical image
Clinical image
Macro view
Macro view

 

 

 

 

 

 

 

Dermoscopic view
Dermoscopic view

UPDATE:

Pathology report:

Clinical Notes: ROL Left Chest – ?BCC

Macroscopic:
1. Left chest: The specimen consists of a skin ellipse and subjacent tissues measuring 46x15x8mm. Examination of the skin surface reveals a pink raised roughened and ulcerated lesion measuring 15x8mm. There is a suture at the longitudinal tip which is placed at 12 o’clock and the 3 o’clock margin differentially inked green.
Blocking Details: 1ls 2ts A, 4ts B, 1ls 2ts C. DIAGRAM.

Microscopic:
1. Left chest: Sections are of skin, including subcutis. There is multifocal superficial and nodular basal cell carcinoma extending into deep dermis. There is a 3mm clearance from both transverse margins, greater than 5mm longitudinal margin clearance and 2.5mm deep margin clearance.

Summary:
1. SKIN, LEFT CHEST:
– BASAL CELL CARCINOMA (EXCISION APPEARS COMPLETE)

Questions:

Orientation of the excision with marking suture location- but no perioperative images available.

Is this an “aggressive” or a “non-aggressive” BCC. Why?

What re the treatment options for this BCC?

Excision by ellipse is one treatment option. How would you orientate the excision?

Please share your thoughts in the comment section below. Professor David Wilkinson will provide his opinion and advice.


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26 comments on “Case discussion: How would you treat this patient? [7 April]

  1. It looks suspicious of BCC, both clinically and dermoscopically. I would do excision biopsy both for diagnosis and treatment.

  2. L chest lesion suspicious due to a number of reasons:
    – history of bleeding with towelling off
    – history of getting larger
    – history of multiple sunburns and outdoor workplace
    – dermoscopic appearance of lesion = BCC most likely but I would not discount combined lesion such as MM that has regressed with BCC overlying as I note that there is grey so, there has been regression. It can also be any other pink growing lesion (though much less likely from dermoscopy) such as atypical fibroxanthoma (i have seen one on a younger person and it looked like bcc), merkel cell carcinoma, SCC. There are no benign differentials as this does not look like pyogenic granuloma.

    Management:
    – I would likely recommend excision biopsy with 2mm measured from the dermoscopic edge so that if it is a non-aggressive type BCC then it has been treated. If it is one of the other more sinister differentials including aggressive type BCC then would need a re-excision for margins. If I was concerned that the patient may not book an excision appointment or see the urgency for treatment or not believe that he has a skin cancer, then, I would shave biopsy the lesion so that I have the pathology (proof) and then he will not be lost to followup within our clinic system. Our nurses would call him and book excision based on the results.

    1. Just to clarify. The shave biopsy would be an immediate event during the first appointment versus doing an excision biopsy which would require the pt to book an appointment in an ‘excision session’.

  3. Definitely suspicious with dermoscopic appearances of a pigmented BCC.
    i would do a 4 mm PB thence excise according to the result.
    i don’t really believe there is a differential here

  4. It is most likely a BCC both clinically and dermatoscopically.
    I will do an excision biopsy both for dx and treatment with 2mm margin.

  5. Lesion is suspicious
    Typical Bluish pink hue and irregularly arborizing blood vessels,ulceration
    Excisional Biopsy with 2 mm margin
    DD: SCC, melanoma in situ,

  6. History and appearance are both concerning and suspicious.
    Macro and dermoscopically strongly suggestive of pigmented nodular BCC perhaps combined with some superficial BCC elements mixed in.
    Shave or punch would be fine to attempt to exclude micronodur or infiltrative components but in reality may not know for sure until excisional biopsy performed.
    Margin could be 2-4mm.
    I would be surprised if this were not a BCC but a hypomelanotic melanoma should probably be in the mix.

  7. history of bleeding on contact meaning superficial ulceration. macro and dermoscopic images show pigmented BCC.
    I agree excision with 2 mm margins. May require more treatment if it turns out to be one of the more aggressive subtypes.

  8. Agree with BCC diagnosis.
    I like the idea of a punch biopsy and a 2 step procedure here
    1. The patients are often surprised by the size of the proposed scar required when a (2 mm) excision biopsy is taken. I prefer to know I have their confidence, hard to gauge first up.
    2. I think , given the scarring after PB , the overall scar will be less ? Is that fair.?
    3. Absolutely confirms the diagnosis and required margin
    However , It is more time consuming and not as cost effective .

  9. A reasonably big nodular BCC, punch biopsy then return for excision with the appropriate margins when histology back.

  10. Suspicious, This is almost certainly a BCC. It is unlikely, but differentials include melanoma. I think this argues against a punch – which is unnecessary and potentially misleading, as it might be mixed sub-type. Better to get the whole thing at once.

    I would agree with those that go straight to a 2 mm excisional biopsy, alternatively, a saucerisation shave aiming to get the whole lesion and diathermy to margins, then wait to get results before further treatment. If just nodular / superficial 2 – 4 mm margins on re-excision would be OK, if morphoeic / infiltrative components – 5 mm + margins.

    Caveats on that would be whether the patient is a regular, or one off – in which case compliance with follow up is uncertain. What is his skin cancer history – has he had similar lesions or treatment before and what have been the outcomes. Also location – if in the tropics, leaving an open wound could be at increased risk of infection depending on his wound care skills.

  11. Likely BCC on clinical, gross, and dermatoscope grounds.
    DD has however to be borne in mind
    1. SCC
    2. (rarely but importantly) amelanotic or other melanoma
    3. (quite unlikely) pyogenic granuloma, verruca, seb k, KA

    There is certainly enough to make it a suspicious lesion.
    Excisional biopsy is the major and best option. I do not like shaves.
    Incisional biopsy is both unnecessary and undesirable.
    Initially 2mm clearance.
    The pathologist will give the exact diagnosis.

    Option then is to re-excise with larger margin if needed without compromise.

  12. BCC, spot diagnosis, with pigmented elements
    Elleptical crease excision in toto ,with 2 MM. margin should be possible leaving a linear crease scar

  13. Nodular BCC – Pearl, telangectasia, spots of brown pigs.
    2 options:
    1. 2 step approach – complete shave bx+diathermy, confirm histo then curative excision with 2-5mm margin (depending on how big the lesion) +/- flap
    2. 1 step approach – curative excision with 2-5mm margin (depending on how big the lesion)
    Depending on what pt prefers, but I’d do bx first if it is big as it will require a flap (if big).

    Ddx – ?nodular/amelanotic melanoma

  14. suspicious for BCC
    would excise w/o prior PBx (unless pt concerned about cosmesis) w/ 2mm margin
    would be worried about possibility of nodular melanoma

  15. It is a pigmented BCC. Excision with or without prior biopsy is the treatment of choice incorporating 3-4 mm of surrounding normal skin.

  16. It is definitely suspicious because clinically changing, chaotic on macro and dermatoscopic views and dermatoscopic clues to malignancy including blue/grey structures, structureless eccentric area and polymorphic vessels. I will do an excisional biopsy with 2mm margin. My dx is BCC and DD MM. I will not punch this lesion.

  17. Thanks to everyone for comments so far on this case. Here is my perspective:

      – clearly suspicious, as described by many colleagues; middle aged male with new lesion, bleeding on touch. Clinically, very much an ‘ugly duckling’ – that is, it stands out as being different from the rest of the skin

      – for the beginner or without a dermoscope, next step would be a 4mm punch biopsy. This is a non-pigmented lesion and so a large punch is the recommended biopsy technique here

      – for the doctor with intermediate dermoscopy skills the appearance is classical of nodular BCC

      – my practice is always to get a diagnosis before i consider treatment, so although nBCC is most likely here, I would recommend biopsy (punch) first to confirm my suspicion. I would do this at the same time as the consultation.

  18. This is a “run of the mill” BCC with excellent prognosis with morphead , micro nodular BCC been the most aggressive subtypes.
    For me , excision is the only way of treating a nodular BCC .Of course a shave excision or C&D could be considered but the risk of scarring here would deter me from C&D
    Excision along RSTL which is near horizontal here but there is a great risk of a bad scar here on the chest- hence meticulous excision , deep dermal sutures , so no wound tension , def taping post ros for a few months.

  19. This is a Malignant Melanoma until it is on the slide!
    No, the diagnosis is not secure enough to do a wide & deep clearance but it is too disorganised and has enough pigment for the red flag to fly!
    There is no excuse to biopsy it unless you want an argument with the Coroner.
    Excise and be prepared to passed onto a Specialist!
    After 40 years of experience this thing gives me the creeps!