Case discussion: How would you treat this patient? [13 April]

This week, we present an interesting case from Dr Zaw Moe. Although we have no images today, this is still an important and instructive case. Please click on the below pathology result to read it.

  1. Can you comment on the choice of biopsy technique used?
  2. What would you do next?

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Case discussion

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12 comments on “Case discussion: How would you treat this patient? [13 April]

  1. I think he could have done a smaller punch biopsy like 3 or 4 mm punch mainly for diagnosis and once confirmed SCC, then a proper excision with 4-5 mm clearance can be performed for ultimate treatment.

  2. Ignoring the depth (first time I am confronted by this dilemma), the relatively small lesion has a clearance margin of 2mm. The recommended margin is 4-6mm and the lesion should thus be re excised. 2-3 mm margins around scar as guide and a bit deeper to ensure fully removed.
    GIven the small size of lesion I would probably also have done a primary excision rather then a punch biopsy first, especially if dermoscopy provides support that it is an SCC. (Saves the patient an extra step). I would like to think that I would have used bigger margins at the outset though.

  3. Principles I learnt at course:
    SCCs can kill
    This is an invasive SCC ie. special

    Punch biopsy with 6mm punch first.
    Once known from punch, wider excision 4-6mm margins with deep excision down to and including fat.
    If all excised with good margins including deep, seek a second opinion for any further action (none may be required).

  4. punch biopsy done on the lesion 6mm is appropriate to know the depth, now it should be excised with 5mm margins since the path has shown it to be poorly differentiated in nature. Will need to be done by plastics given the wrist location and the need for a graft

  5. I think an excision biopsy is an appropriate initial step if you are confident it is an SCC.
    I would consider the margin of excision to be inadequate on the deep margin and the risk is that with bread knife sampling of the sample for histopathology then invasion beyond the margin could easily be missed.
    The lateral clearance I would usually accept without aggressive features like perineurial invasion but given it is going to be excised more deeply then the lateral margin can be extended by another 2-3 mm each side of the wound.

  6. considering this is a non pigmented lesion if the diagnosis was in doubt, then a 4 mm punch was reasonable. It seems that an unnecessary big excisional biopsy has been performed. 4 mm punch would give the pathologist enough sample to comment on it (if taken properly).

    This needs further re-excision.

    but overall nothing has been missed.

  7. From the report:
    clinically the lesion was 6×6 mm in size. the doctor used 8 mm punch. that gives only 1 mm margin. technically as we need minimum 2 mm margins it was not the right choice. the doctor could have used small 3-4 mm punch to get the diagnosis and then do proper excision.

    the doctor used an 8 mm punch to do the excision. he/she went 2 mm deep in the skin before cutting it.
    issue 1) : did the doctor go deep enough into the fat later or was it cut in the dermis: I think it was not deep enough to go in the fat layer. I would have used good amount of local to raise a bleb and then do the biopsy.

    issues on report. The biopsy was 2 mm deep ( 8x8x2). however they have reported the the result as at least 2.7 mm deep. ( ambiguity here). was the tumour nodular?

    now I would do a wider excision with 3-4 m margin. ( we already have 2 mm peripheral clearance)

  8. This is a large diam punch biopsy. For a less aggressive lesion the biopsy may have been curative and no further surgery required. Since this is a moderately diff SCC further excision with 5 mm margin.