Case discussion: How would you treat this patient? [8 April]

This week we have an interesting case from Dr Risto Cvetkovic. Have a look at the clinical and dermoscopy images.

What is your differential and what would you do next? What approach do you take here? Biopsy? If so, how?

Case discussion      Case discussion

Update 1:

Here is the result. How do you interpret this? What would you do next?

Case discussion

Update 2:

Dr Cvetkovic has asked for more detailed review, and below is the amended pathology report. How would you treat this lesion?

We encourage you to participate in the case discussions and submit your own clinical images and questions, so we can all learn together.

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11 comments on “Case discussion: How would you treat this patient? [8 April]

  1. Raised skin lesion on the nose root showing thick keratin with branching vessels at its base. It could be well diff scc or BSC. Take a punch biopsy to exclude it.

  2. It a nodular lesion with branching vessels pearly white. Keratotic plug, but I imagine ulcerative under this. It’s got to be a bcc.
    I would excise the whole lesion with clinical 3mm margin. I think a simple excision will work well from what I can see.

  3. Basoquamous carcinoma, a rare aggressive carcinoma with features of SCC and BCC. The central keratin is typical of SCC and the branched vessels are BCC. Wider Excision than for normal BCC is recommended.

  4. Its a Noduloulcerative BCC as the commonest D/D, alternatives can be Merkel cell CA, Keratoacanthoma. Needs an excisional biopsy done. Arborisation with Keratinous plug and some serum crusts.

  5. Re. biopsy report (punched). How do you interpret this? What would you do next?

    Given atypical squamoproliferative lesion (hyperplastic and dysplastic suspicious for invasion), certainly it is more than a simple benign. Thus it would be wise to proceed with WLE (3mm) with +/= flap or referral to a specialist.

    My pre-biopsy impression was KA, nBCC, nodular SCC (although never encounter such lesion), or MCC. Basosquamous cell carcinoma is widely used in Europe. Nice case!

  6. Yes the clinical and dermatoscopy would fit with the scc. However it’s with keratin which imply a well differentiation lesion. Why it’s stated invasive. What feature would Imply so from the dermatosxopy image.

  7. as long as the margins are out with 4mm is all thats needed now, this patients needs a Mohs micrographic techniquie on that area by plastics

  8. Just for everyone’s interest, this was an 88 year old lady who presented with a new rapidly growing lesion. I did a shave biopsy (not a punch biopsy, despite the pathology report) as I had the same concerns about the lesion as everyone here ( I was thinking possible basosquamous lesion due to is unusual appearance).
    Once the final report was back I suggested excision with a plastic surgeon but the lady was very keen to avoid this (she’s not in great health) so I reluctantly tried cryotherapy (30s FTC x 2).
    I saw her today (3 weeks posy cryo) and the area has responded pretty well. She is aware of the risk of recurrence/spread/etc but she is very happy with how it has gone so far. Thanks everyone for the feedback

    1. Just in case it’s confusing people, I was the one who sent the case in, not Dr Cvetkovic 🙂
      The photo above is the post cryotherapy appearance of the lesion in the case.