Case discussion: How would you treat this patient? [05 November]

This week we have an engaging case from Dr Dave Stewart.

How would you describe the clinical and dermoscopy images below? How would you biopsy? What is the differential?

Case discussion      Case discussion

Case submitted by Dr Dave Stewart

Update 1:

Dave’s registrar was considering cryotherapy (without biopsy) as treatment. What is your view on this approach?

Update 2:

Initial history confirmed that this lesion had been previously treated, and the patient told “it was nothing serious”. Review of pathology results indicated an infiltrating BCC, excised but with incomplete margins. What is the best way to respond to such a situation?

Case discussion      Case discussion

Case discussion

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14 comments on “Case discussion: How would you treat this patient? [05 November]

  1. pink, ?raised, NPSL #5mm on the site of a ?previous surg scar, on b/g of aborising blood vessels. DDx ?recurrent BCC/SCC. 3 mm punch and go from there.

  2. Sun damaged skin,about 5 mm non pigmented lesion,multiple arborising blood vessels.
    Highly likely to be a basal cell carcinoma.
    The lesion needs a nice big punch biopsy and possibly wide local excision later, depending on biopsy.
    The patient also needs a full skin check and sun smart advice.

  3. Just to clarify, the trichoepithelioma/BCC report was from an excision a few years prior at another surgery (no further excision was done despite that report) and that is the scar you can see in the original images.
    The punch biopsy and other excision report was by me.

  4. I disagree w just cryotherapy. I would do 3mm punch, and once confirmed as BCC- to further excise to get appropriate margin. considering the situation I would do 4mm margin (using dermos) and go further as per histo report.

  5. I would want to achieve better than 0.8mm clearance considering the type and history of this bcc. I would reexcise the 12oclock margin to 5 -10mm.

  6. 1. should not cryo pink lesion with suspicious features (has arborising vessels on white base, I would be worrying about possible morphaeic subtype of BCC; alternatively, area could have been frozen in the past & hence white base); in this case also close to previous (incomplete) excision (i.e. recurrence is always a possibility)

    2. will need to explain to patient that the lesion needs complete excision (and that it could be a re-currence or new skin CA)

  7. The histopathology of an infiltrating BCC points to a more aggressive subtype of BCC. Cryotherapy will not do for this diagnosis. A WLE with 5mm margin or Mohs surgery will be the more definitive method of management. Needs to check draining lymph nodes to be sure.

  8. Thanks to everyone for comments. Key factor here, in my view is “never treat, without a diagnosis”. I advocate always doing a biopsy before treatment, even when you are confident about the likely diagnosis on clinical and dermoscopic grounds. That is why biopsy is available and funded. Of course there are exceptions, and that is what we call clinical judgement (eg solar keratosis, patient lives a long way away etc). But I see plenty of medico-legal cases where failure to biopsy leads to all sorts of trouble.

  9. Just for everyone’s information, due to the narrow margins on my original excision (despite aiming for 5mm because of the infiltrative nature of the BCC) I did a subsequent excision of the site at the 12 o’clock margin which showed no residual malignancy. The lesion was on his upper back (see image) so there was no need to refer for Mohs surgery. And my Registrar was horrified when he saw the large scar which was the end result of this little crusty spot he was going to freeze! Thanks everyone for the input

  10. Lesion ; Recurrence after previous incomplete removal.

    Dermoscopy ;
    Stuctureless
    Pink
    Pale
    Polymorphic vessels
    Branching
    Serpentine
    Fine linear 3 – 4 o’clock
    D
    Recurrent BCC
    ? Squamous changes
    Rx
    Wide excision if site allows
    Moh’s.