Case discussion: How would you treat this patient? [08 October]

This week we have an interesting case from Dr Peter Ryan. A 70-year old male with a history of multiple NMSC.

How would you describe this lesion, what is the differential and how would you biopsy this?

Case discussion      Case discussion

Update:

Pathology result states BCC, actinic keratosis and in situ SCC! What is your definitive treatment?

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14 comments on “Case discussion: How would you treat this patient? [08 October]

  1. Interesting lesion, I see, some blue-grey, some blotches, ulceration, pigmentation. I would be excising this for a formal dx with margins. Likely to be a melanoma, ddx BCC.

  2. a background of sundamaged skin; macro appears to have white circles; dermatoscopically pink and white lesion not white circles though, blood/ulceration, some brown, some blue/grey, no defined blood vessels; probably SCC, DDx melanoma; excisional biopsy

  3. Area of ulceration scarring, blue black, pigmented globules pigmented Bcc , bcc , melanoma. Shoulder lesion looks bigger than 1 cm, more likely requiring flap ? Shave bx for diagnosis and plan for flap

  4. This is Pigmented Actinic keratosis with Rosette pattern, use cryotherapy 2 weekly until dissapeared. No biopsy needed

    D/D- Superficial BCC, Bowens

  5. I`m not really sure from the macro pic, but this appears to be a raised lesion. My initial impression was that this could be an SCC with rosettes and white circles, but on closer inspection I think I see several blue clods and even a few spoke wheels at 5 o`clock, together with multiple ulcerations – making it very likely to be a BCC. I would do a 4 or 5mm punch to confirm this before deciding on final management.
    I think I`d manage this comfortably with a larger ellipse.

  6. There is no obvious melanocytic network. Pink red white suggesting scc but blue clods and some radial lines/ leaf like structures of Bcc features. This needs excision. Possibly basilosquamous carcinoma but need to consider melanoma.

  7. Raised skin lesion showing chaos with area of ulceration and blue clods, with white circles would make it BSC. Excise it any way with a margin of 3-4mm and send for the histology reading.

  8. This is a large ? Flat lesion on the shoulder tip~~~possibly 20 mm in longest diameter,making surgical choices challenging,
    Needs excision in any event,
    I can,t see any melanocytic reticular network,and lots of white,surface flakes[? Keratin] suggest SCC. Ulceration ,dark clods suggest BCC, but no surface vessels seen.
    I may do a deep shave excision to avoid ugly scar from a wide ellipse, but probably refer to a plastic surgeon re some kind of local flap repair of defect,

  9. To me a large flat lesion about 18mm x 15mm with a central ulceration (h’age) plus scattered brown pigment with no network. White clods/blocks in the background of erythema is suggestive of BCC but no specific v/s. D/Dx would be in order:
    1/ Pigmented AK
    2/ Seb K (pigmented and ulcerated)
    3/ Ulcerated solar Lentigene
    4/ IEC/Bowen disease.
    5/ mixed carcinoma
    Method of biopsy depend on how much possibility of sinisters such as Hypomelanotic MM, and SCC. A wide bore 4-5mm punched (priority 9″clock) or shaved biopsy is reasonable in this particular case. Interesting to learn the HP report.

  10. Features of SCC
    White structures but no classical white circles
    Ulceration + fiber
    Pink
    Leaflike brown structures (grey dots) 9 0’clock

    Features of MELANOMA
    Chaos
    Blue grey colour
    Milky pink areas
    Brown clods spread throughout the lesion
    Dotted vessels (on 11 0’clock meridian near centre)
    Lines radial segmental ( 9 0’clock 3 0’clock)

    This is an invasive lesion
    Assessment
    Look for nodes etc
    Excision biopsy
    Requires wider margins and deeper for SCC
    Requires biopsy to plan definitive treatment
    (A case to be made for biopsy for melanoma first and then going back to do surgery for either)

  11. Very interesting to learn the HP- mixed BCC, AK and IEC/in situ SCC.
    Definitive treatment would be excision with 2-3mm margin. Simple elliptical is achievable in elderly with loose tissue in the shoulder area.

  12. For a lesion this size and with this histology with SCC in the mix I would opt for excision with 5mm margins. Closure might become challenging but possibly still doable with a large ellipse – would have to feel the skin to decide – alternatively a flap – maybe a rhomboid with skin harvested from the dorsum of the shoulder-upper back.