Case discussion: How would you treat this patient? [13 November]

This week we have an interesting case from Dr Sanazsadat Hejazi. A 77-year-old female presented for a skin check and a lesion was noticed as indicated on left forearm. Here is a clinical picture of a rapidly growing (3 weeks) lesion in an elderly lady.

What is the important differential diagnosis list here? How would you biopsy this?

case submission_Sanazsadat



This is the pathology result. What is your conclusion and what are the next steps you would take to treat this patient?

Case Discussion

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11 comments on “Case discussion: How would you treat this patient? [13 November]

  1. 3 week history of a rapidly growing red nodule with what looks like keratin. differential includes keratoacanthoma, SCC, pyogenic granuloma, melanoma nodular. A full lesion excision biopsy to be carried out.

  2. D/D- Poorly differentiated SCC, Dermatofibrosarcoma, Atypical Fibroxanthoma, Furuncle, Nodular Melanoma. Needs Shave biopsy done as its a raised and nodular lesion.

  3. All I can see is a red nodule with surface scales/ pus. If was a pus then boil would be the diagnosis as it can grow fast in size with pain and oozing pus. If was a surface scale then it could be MCC as u said it was a fast growth. SCC would be a possibility but I assume not that fast. I would punch biopsy it all.

  4. Based on doom shaped, nodular smooth pinkish lesion with few keratin over, D/Dx:
    1/ KA (keratoacanthoma)
    2/ PG (Pyogenic granuloma)
    3/ nBCC
    4/ MCC (Merkel CC)
    5/ lastly amelanotic /nodular MM.

    If strongly suspicious for MM, excisional biopsy should be carried out, but how much possibility here?? Dermoscopic pic can guide for how much possibility of the above listed, and method of biopsy (either punched or shaved or excisional,..).
    Having said that, given the lesion needed to be out, it is not wrong to go with 3mm margin excision and go from there> DONE (if KA or PG or BCC), or further cut if MM.

  5. Thanks everyone – the right list of possible diagnoses is here. I always think “what is trying to kill the patient” that I need to deal with. In this case EFG – elevated, firm, growing = nodular MM until proven otherwise. So, excision biopsy would be my preference here. A quick, simple, complete excision and closure. I like Tim’s approach – 3mm.

    1. Isn’t it normally 4mm for SCC ?(Based on Cancer Council Guidelines,the lesion is 1cm which is less than 2cm)

  6. 5mm margins are safer than 3-4 usually if you do get caught up in litigation later which is very common these days for people to come after GPs assets