Case discussion: How would you treat this patient? [5 February]

Case discussion. A 77-year-old male presents with a request to drain a lump on his elbow. Another GP drained the lump previously.

Please describe what you see. How would you manage this situation?

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Case submitted by Dr Slavko Doslo

Update:

What is your interpretation and what would you do next, if anything?

CLINICAL NOTES
Lump on right elbow drained in past by lancenting removed today due to increased size.

MACROSCOPIC DESCRIPTION.
Specimen labelled: ‘R elbow’. A skin ellipse 28x21x13mm with a tan rough nodule covering the entire surface. Slicing reveals an underlying cyst like structure with tan firm contents. 4CTS-2P. DL/ss

MICROSCOPIC EXAMINATION.
Sections show skin including dermis and subcutis in which there is nodular expansile tumour centred in the dermis composed of sheets and irregular trabeculae of small to intermediate sized cells with fine granular chromatin, nuclear molding and frequent mitoses and apoptotic figures. There is extensive haemorrhagic degeneration in the centre of the lesion. Perineural or lymphovascular space invasion is not identified. The tumour cells show cytoplasmic dot-like CK20 and AE1/AE3 positivity. Synaptophysin is strongly positive. TTF-1, chromogranin and LCA are negative. The features are consistent with Merkel cell carcinoma. The lesion appears narrowly clear of the margins (0.2mm from closest deep dermal margin).

CONCLUSION.
RIGHT ELBOW – MERKEL CELL CARCINOMA, CLEAR OF MARGINS (0.2MM FROM CLOSEST DEEP MARGIN).

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


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10 comments on “Case discussion: How would you treat this patient? [5 February]

  1. round area with large blue veil depigmentation and pigment around lateral and superior edges. A nodular malignant melanoma ope a amelanotic melanoma to be considered. Advise an excision biopsy with 2mm clear margins.

  2. Irreg shaped ?nodule
    Irreg area of regression with a pink background: polymorphic blood vessels- dot, sepiginious, linear.
    Irreg reticulate depigmented network.
    Highly suspicious of an amelanotic melanoma. Therefore needs as an excision biopsy until proven otherwise

  3. I agree this looks suspicious. But it is over bony prominence, near a joint and has been drained. Could this lesion relate to the jiont ? Could it be a scarred ganglion? I am tempted to get an USS to check before I biopsy something that may relate to joint.

  4. unfortunately patient died 8 months later as at time of diagnosis he had wide spread metastasis through body

  5. Histological diagnosis given as MCC. Immediate referral to oncology as metastatic potential very high and over a short period. Prognosis: Nearly all would die in 5 years (I hope I remember it right. Please correct if I am wrong) See Dr Slavko said the patient already died.