Case discussion: How would you treat this patient? [10 September]

This week we have an interesting case from Dr David Stewart. An 41-year-old woman presented for routine skin check. Lesion on face had been treated the year before with cryo but had recurred.

What do you make of the clinical and dermoscopic images and what would you do next?

Case discussion     Case discussion

Update:

These are the results from the pathology report. What is your conclusion and what are the next steps you would take to treat this patient?

Case discussion

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

  1. It is always a concern when something persist/recurs after cryo; on macro it has a thickened, pinky/purple scar like edge with central ulceration; on dermatoscopy there are white circles at 3 o’clock, and polymorphous vessels, a large white structureless area and central orange structureless (keratin/serum) with bleeding and polymorphous vessels; there may be some grey at 12 o’clock; I would feel for regional lymph glands and do a 4mm punch biopsy through the centre of the lesion PDx SCC

  2. Rosettes, Structureless white and ulceration and failed to respond to cryotherapy. Likely SCC. Certainly needs biopsy.

  3. Dermoscopy is very suggestive of low grade invasive SCC, either keratoacanthoma – but the duration of 1 yr is more suggestive of SCC. I would confirm this with a 4mm punch either a deep shave. Diagnosis seem pretty straightforward here – it would be interesting to see the preoperative markings for the final surgical treatment.

  4. With that history, the ulceration, rolled edge, structurelss , white, polymorphous vessels
    I agree with Rosettes( had to look it up)
    Check Ln’s PDx SCC low grade
    I would 4mmpunch biopsy also and let her know she is likely to need a definitive surgical procedure
    Question ?
    Lets say the Punch biopsy removes the lesion ( Macro, no margin) and the scar 1 month later looks clear .
    (I know not ideal ) I know some dermatologist go then to an ALDARA course .
    Do we have experience in this? Is it permissable

  5. 41year old female
    Lesion below left lower lip +- 10 mm x 5mm
    Lesion without pigment
    ulceration and white clues present
    white circle 3 o’clock
    rosettes 9 o’clock
    hairpin vessel 4-5 o’clock
    Large vessel 12 o’clock
    Diagnosis;
    SCC ? KA
    Management;
    Standard systemic assessment
    Biopsy
    If confirmed – refer for Moh’s surgery

  6. I would discuss with the pathologist since there is a mismatch between clinical/dermatoscopic image en pathology report. It is suspect for SCC (duration, no response cryotherapy, rosettes , ulceration white circles . Treatment would be surgical excision, margin depending on diagnosis

  7. I would refer for Mohs surgery; I would see in 6 months for follow-up to check site and check for new lesions; full skin check if not already done; needs regular/annual skin check

    A question for David:

    What item number do you use for a shave excision of a pigmented lesion that 1) turns out to be benign or 2) is a melanoma? Thanks, Bronwyn.