Case discussion: How would you treat this patient? [12 November]

This week we have an interesting case from Dr Peter Ryan. An 56-year-old male, rapidly growing lesion on his nose.

Please review the clinical and dermoscopy images. What is your differential diagnosis and how would you biopsy?

Case discussion      Case discussion

Case submitted by Dr Peter Ryan

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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24 comments on “Case discussion: How would you treat this patient? [12 November]

  1. Nodular lesion with Central keratin plug/ulceration.History of rapid growth.
    Site nose ,.Shave biopsy.Keratoacanthoma

  2. Small 4mm ulcerated nodule. Nodular Bcc scc keratocanthoma. Punch biopsy follow Hpe plan formal excision + graft pending hpe if required

  3. clinical: nodular rapid growing lesion on face, ulceration central
    dermoscopy: peripheral white streaks/lines, ulceration centre, ? linear blood vessels at 6 o’clock peripheral, pigmented grey halo
    DDx: cutaneous melanoma metastasis (?Hx) , keratacanthoma, dermatofibroma,
    Dx: keratocanthoma
    Rx: excisional biopsy

  4. Clinical: rapid growing elevated lesion face middle aged man
    dermoscopy: central ulceration, peripheral radial white lines, ?linear Blood vessels at 6 o’clock, grey/pigmented halo
    DDx: keratocanthoma, cutaneous melanoma metastasis, dermatofibroma
    excision biopsy
    EFG rule- elevated, firm, growing excise

  5. Single lesion with inverted edge and a central ulceration would fit bcc. It’s stated as a fast growing skin lesion. The differetionals r bcc and KA I can’t see any surface keratin. I would excise the whole lesion probably by a punch biopsy tool or by an excisional biopsy as it’s in a tiny place near the eye. Keep us updated pls.

  6. Nodular lesion with ulcerating centre is very suggestive of BCC though vascular structure is not very clear
    DDx, poorly differentiated SCC on KA or IEC lesion
    either case I would do excision biopsy, wat results and consider closing it with a Bilobed flap

  7. In view of
    (1) Statistically- location (BCC at nose),
    (2) Clinically- appearance of slightly elevated single non pigmented lesion over/near nose
    (3) Dermoscopically- white structure/clods with central ulceration (haemorrhage).

    Dx: nodular BCC. A 3mm punched biopsy is reasonable to confirm. Ideal place for V-Y flap.

  8. Non pigmented raised lesion with a central keratotic plug, possibly some white circles and hairpin vessels in the periphery -> likely a well differentiated SCC either a KA as suggested by the rapid growth.
    Either do a punch to confirm – but if one cannot do the final excision in the very near future I would do a shave biopsy of the entire lesion – that stops if from getting any bigger and buys some time.
    If well diff SCC confirmed – final excision with 4-5 mm margins – never done such a procedure myself in this location so not talking out of experience – but I like the suggestion of the VY advancement flap.

  9. Good case from Peter. Can happen! as a benign lesion of Syringoma- small papules of skin color around eyes. They generally erupt as multiple over forehead and around eyes, upper chest, .. with F > M. This case was a solitary but might has some in the past.

  10. You need to carefully interpret the diagnosis of lesions reported as syringomas that look unusual .
    Microcystic Adenexal Carcinoma may be reported as Syringoma if only superficial biopsy is done
    Tumour cells in MAC go deeper down and therefore requires deep incisional biopsy for histopathologist to interpret it correctly
    MAC is a locally malignant tumour but can spread along the nerves

  11. I am also adding additional just for educative and informative purpose. Had a similar case with similar location 3 yrs ago- a solitary pearly nodular, turned out nBCC at 3mm punched biopsy. Thanks Peter and David for bringing a motivational and challenging case. Thanks for Kiran for further stimulation. Truly we learned several possibilities as D/Dx, and I wondered that’s why David was asking us D/Dx rather than a single Dx. Thanks David. A solitary lesion with rapidly growing in Hx was more than benign ??? thoughts!!!

    1. Now we’ve all seen it and that’s the great thing about this forum.
      When I shaved this, it left a ring of dermal bleeding, with a firm center,like cartilage. The lesion had healed well at review. He’s away working for a month. The plan is to review then and excise the remnants.
      It’s a treacherous area for excisions. With the risk of causing a medial web.
      Anyone got opinions about the bests approach? If it were malignant I would graft it.

      1. Hi Peter
        MAC is an infiltrative sclerosing sweat duct carcinoma and its tissue invasion frequently extends far beyond the clinical margins. It can also extend deep into fat and even bone. In addition perineural involvement is common.
        Although it does not metastasise, significant morbidity can occur as a result of deep local tissue invasion and therefore complete removal of the tumour is the treatment of choice.
        MMS is the preferred choice but if you are practising in an area where there is no local MMS surgeon then do Slow MMS.