Case discussion: How would you treat this patient? [26 September]

This week we have another real life case from Dr Slavko Doslo. We have here an elderly man with past history of melanoma, SCC and BCC. During the skin check a lesion on his back was noted as shown.

What is your evaluation and next steps based on the photos?

Past History of Melanoma_160919     Zoomed image_160919

Case submitted by Dr Slavko Doslo


Interesting result/s – any comments?

12022014_slavko 20022014_slavko

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

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

  1. Cant enlarge the dermatoscope image……what i see is sun skin damaged and a surface scales with some hemorrhage….could be BCC, SCC cant be sure though.

  2. I agree with Ebtisam and would remove the entire area and repair with a rotation flap. The diagnosis, with out the benefit of dermoscopy is SCC or BCC

  3. This is a large lesion on the background of severely sun damaged skin
    It would be good if some sort of history was available as to how long the lesion has been there , if it bleeds intermittently & if it is tender
    Ddx would be BCC, SCC, and Amelanotic Melanoma
    I would do an incisional biopsy taking the thickest part out
    Report would dictate how much margin is required & the its complete removal

  4. Huge lesion which I would like a definitive diagnosis on before I inflicted a big flap on the patient.
    Thinking SCC on dermoscopy but may be superficial BCC ( and therefore amenable to Aldara treatment instead of more scars on his back). ( or if superficial could do a curettage and cautery on it)
    Punch biopsy of part first.

  5. For me the starting point is “I need a diagnosis, and dermoscopy doesn’t help me”. For me, 2 or even 3 nice large punch biopsies (4-5mm punch). Diagnosis first, then decisions about therapy

  6. Bleeding points / ulcerated at the margin of a previous scar : punch biopsies 5mm labelled 1-3 to help gauge the edge.
    Expecting wide excision with a flap.
    The pigmented lesion on the left shoulder also has my attention also. ( closer look please)

  7. I would favour BCC/SCC as most probable diagnosis and also amenable to taking a few punch biopsies and then weigh up my options. Not sure of exact size of this lesion but would think that a defect up to 3.5cm on this patient could be closed with an ellipse, provided she is positioned correctly – on her stomach and shoulders slightly tilted backwards.

  8. My comment after sighting histopahtology would be very challenging and we will never get right. If an expert dermatologist/skin cancer specialist missed one melanoma once a year, I might miss 10 times. Let’s learn again from this. many thanks.

  9. like most of you, i wasn’t thinking “melanoma” here. i think what this great case shows us is the importance of biopsy before treatment, and indeed biopsy of all suspicious lesions

  10. I have a couple of questions.

    – Why was the initial punch biopsy only 2mm?
    – The lesion has a scar close to it, is there a history of previous excision? could this be just a recurrent nevus?

    1. * I do only 2 mm biopsy, targeted well after good view under dermoscope, so I target suspicious change in lesion, 2 mm heals well, not much scaring, I have seen 4/5/6 mm and they look horrible to me ( sorry but I maybe saw only bad examples and prolonged healing in particular shave biopsy which I never performed)
      * if the lesion is large and need big excision, biopsy is must for me as patient would like to know as well I that we are doing for good reason
      ** last time I performed FLAP was 2010, since I did not see any point doing as I can do well normal elliptic excision regardless of size

      1. If a melanoma is suspected a punch biopsy esp 2mm can miss melanoma component of the lesion. In these intances a small targeted incisional biopsy will provide adequate sample to the pathologist for diagnosis

      2. If you listen to dermatopathologists, they would tell you never use a 2mm punch!!
        I agree that it is too small and doesn’t show dermatopathologist the whole picture, especially with such a difficult case.

        Is there a history of previous excision on the same area?

  11. I think Geith has raised a very valid point
    Is there a history of previous excision?
    Sometimes recurrent nevus cells would look different under the microscope & can confuse the pathologist
    However recurrent nevus is usually confined to the scar whereas a recurrent melanoma would extend beyond the scar margins

  12. *** comment for Dr Neil Donovan , good eye spotting lesion on left shoulder, I took close look and was removed January 2015 , histology came back as solar lentigo , so after my reviews of all lesions ( performed yearly) of 425 files and going I requested second opinion which was again the same, I have photo and it would be interesting for everyone to see, I was convinced and still I am that is Melanoma ,