Case discussion: How would you treat this patient? [1 April]

This week we have an engaging case from Dr David Stewart. There is no history, but that is often our reality.

What do you make of the clinical and dermoscopy pictures here? What approach do you take here? Biopsy? If so, how?

Case discussion      Case discussion

Update:

These are the results from the pathology report. What do you think now? How would you treat further?

Case discussion

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22 comments on “Case discussion: How would you treat this patient? [1 April]

  1. Poorly differentiated SCC vs granulomatous growth vs metastatic growth, and I guess an amelanotic melanoma is always in the mix.

    Not a lot of features on dermatoscopy.

    I think I would remove with a simple ellipse.

  2. Rounded nodular lesion lesion showing an ulcerated area with red blue structureless area with white lines and some sort of rainbow colour. I would like to know if any other places are affected including legs.
    DD could be KS, BCC, MCC. And ofcourse nodular melanoma is my preferential.

  3. Agree on Dx of poorly differentiated SCC ( “ white tumour”), amelanotic melanoma,and don’t forget Merkel.In any event,lesion needs to come out in its entirety.Decent ellipse with at least 3 mm margins should suffice.Growth history would have been helpful.

  4. I also think is an amelanotic melanoma. Appears to be large and nodular on clinical view. DD would be Merkel Cell Carcinoma

  5. it could be an Amelanotic melanoma Vs Poorly differentiated SCC Vs Merkel cell carcinoma Vs Dermatofibrosarcoma protruberans. Dermoscopic findings are quite non relevant here, Needs excision biopsy with 3mm margins done and send for urgent histopath

  6. Possible scc – small area of ulceration or bleed . Shave biopsy and plan excision margins pending biopsy report

  7. This is an asymmetrical nodular lesion with some residual peripheral pigmentation. It is difficult to say if it is an Atypical Amelanotic Nodular Melanoma, Pyogenic Granuloma or SCC. Looking at it I would do an excisional Elliptical Biopsy with good 2-4 mm margins. It needs complete excision so this biopsy would be best as one would only need to re-excise if it was a Melanoma depending on the Breslow score

  8. Asymmetrical Pattern Vascular Nodular Lesion should be excised anyway due to macroscopic pink and white pattern with Polymorphic Vessels and peripheral residual pigmentation. Differential Diagnosis is Amelanotic melanoma, Pyogenic Granuloma or Squamous Cell Carcinoma. Elliptical 3-5 mm margin excision so fully excised and only needs re-excision if it is a Melanoma depending on the Breslow score

  9. My second opinion after another look…..could this be trauma? the “lesion” is very symmetrical with a defined border and there appears to be some scabbing around the edges. Probably an off the track guess though

    1. Not entirely. I`ve cut out a similar looking nodule recently (ellipse w 2mm margins) on the lower leg of a lady because of presumed amelanotic melanoma, but the diagnosis was `dermal fibrosis and haemosiderin deposit, likely related to trauma’ .
      I found it difficult to accept and asked for additional staining which they did – no melanoma, just trauma related skin changes.
      (PS this lady has a mild mental disability so history was unreliable – she couldn`t remember trauma and the story was that of a nodule present since 2months)

  10. Excise with 2mm margins ?Poor diff SCC vs nodular melanoma vs weird-and-`wonderful` rare malignancies…

  11. Excise the whole lesion. Either melanoma scc or Merkel cell carcinoma. Could also be pyogenic granuloma.
    Dermascopic features are ulceration, distorted white circles, and white sclerosis.

  12. Thanks everyone for the comments. Just for everyone’s information, this was a 59 year old lady who had presented to one of my colleagues at the practice the week before with a new (2 weeks old) rapidly growing lesion on her arm arising within a pre-existing vascular birthmark. He thought it was infected and treated it with antibiotics and asked her to see me for follow up (I think this infection was what caused the scabbing round the edges Tracey) .
    Like most of you (except Souad – well picked!) I was concerned re an aggressive SCC/melanoma/nasty and felt it needed immediate biopsy. As she had only made a single appointment with me, I did an 8mm punch biopsy for speed, rather than an ellipse, but warned her that it would likely need a much wider excision afterwards. When she came back for removal of her sutures, the punch biopsy had healed beautifully and both she and I were very happy that no more needed to be done (here’s hoping the Prof agrees!)

  13. There was not sufficient history. U didn’t mention if this was long term skin lesion and if it was bleeding. Plus it’s an old forearm which would bring up the MM first thing in mind.

  14. get a second opinion from the pathologist, im not convinced its a haemangioma, has no features dermoscopically nor macroscopically

  15. what a great case – everyone (almost) agreed that this could well be a very nasty lesion! rapidly growing, pink lump – melanoma until proven otherwise. could be scc, could be Merkels. What would I have done – full excision biopsy. I am surprised at the pathology, and would be a little worried with a partial biopsy. if dave’s 8mm punch removed all the lesion (or almost all) then I would be happy with the diagnosis. I would definitely follow up in a month to be sure it has all gone!! thanks Dave

    1. Definitely all removed (but I’ll definitely follow up given the unexpected pathology result!) Thanks for the feedback 🙂

  16. Agree with Ashwin that it needs a second opinion from pathologist
    I would put Atypical Fibroxanthoma (AFX) high on the list and need specific staining panel along with HP
    Other Ddx to consider would be MM,SCC, Merkel cell ca, DFSP & histiocytoma