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

UPDATE:

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.


Learn more about skin cancer medicine in primary care at the next Skin Cancer Certificate Courses:

Skin Cancer Certificate Courses in Australia

Leave a Reply

Your email address will not be published. Required fields are marked *

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 ,