Case discussion: How would you treat this patient? [25 November]

This week we discuss an engaging case from Dr Mokesh Raj of a patient aged 40, no history or clinical picture.

What is your opinion on the dermoscopy image? Are there any features or criteria of note?

Would you biopsy this lesion from what you see here? Why? How?

Case discussion

Update:

These are the results from the pathology report. What would you do next?

Specimen.
SKIN LESION LEFT NECK

Gross Description.
Skin ellipse 15 x 8 x 4 mm with an eccentric brown plaque, 8 x 5 mm.  The
entire specimen has been processed.  Margins inked blue.  Transversely
sectioned.
A3 B2 NR 3L each

Microscopy.
Sections show a nodulocystic basal cell carcinoma that has extended to the
mid dermis.  There is mild fibrosis and mild chronic inflammatory
infiltrate around the tumour with mild solar degeneration of collagen in
the adjacent dermis.  The lines of excision are clear of the tumour.

NODULOCYSTIC BASAL CELL CARCINOMA, COMPLETELY EXCISED.

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? [25 November]

  1. W/out clinical photo and detailed Hx , difficult to pin point, However D/Dx-
    1/ MM (but age is 40). If so, likely to be nodular type d/t erosion and lack of network.
    2/ BCC (white structure + blue but no typical v/s pattern)
    3/ Naevus (blue)
    4/ maybe non-important traumatic and healing spot.
    2mm margin excisional biopsy would be favoured to r/o MM and go from there.

  2. Interesting lesion.
    .no melanocytic clues but have to include MM in DDx.
    . no vascular structures, but can’t exclude BCC
    .lichen planus could look like this dermoscopically.
    Excision Bx 2 mm margins

  3. Clinical history is very important here. It’s just guesswork without history, a clinical picture and a quality dermoscopic picture. I wish if the dermoscopy was more clear. However, DDS are;
    1 pigmented BCC
    2 MM
    3 traumatic lesion/scar
    4 IEC
    Treatment: excision with 2mm clinical margin

  4. Lesion is positive for blue/grey structures
    Lesion is positive for white lines and white structureless areas
    Cannot visualize any vessels or distribution of same
    DD: Melanoma, BCC
    Tx: Excision to r/u above or other malignancy

  5. Chaos of structure and pigment.
    White clods in the center and lines (streaks) peripherally.
    Pink background.
    Grey/blue clods and dots peripherally, some leaf-like structures.
    Red microerosions.
    Ds: pBSS.
    Tx: Excision with 2 mm margins.

  6. Great case here – good to see everyone thinking much the same way. I did not pick BCC high up the differential list, but like all of you, I would have done a 2mm excision biopsy

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