Case discussion: How would you treat this patient? [27 April]

In this week’s case from Dr David Stewart, we have a 58 year-old renal transplant patient presenting with a growing lesion on the right cheek.

Please review images, and advise what, if anything, you would do next?

Case discussion      Case discussion

Update:

Here is the pathology report. Do you believe this? What would you do next?

Case discussion

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27 comments on “Case discussion: How would you treat this patient? [27 April]

  1. SCC until proven otherwise. Punch biopsy emcompassing half the lesion centrally and to depth of subcutis at least

  2. It can be anything! Growing and immunocompromised! Red flags so excision! I can see bleeding/erosion and its a nodular lesion. But I cant see white circles and ? Keratin. So could be a BCC???

  3. Thickened nodular lesion. Ulceration and keratinisation present. White structureless areas. Blood areas noted. Unable to see the type of blood vessels in this photo. Diagnosis SCC. Can be punch biopsied to confirm and will need full excision with 4mm margins.

  4. Scale, erosion, white circles, immunocompromised. no specific vessel pattern seen
    I think an invasive SCC and I would recommend an excision Bx in the circumstances. Especially as it is gowing quickly in an immunocompromised patient. Best to get rid of all of it in one procedure even though it is on the face.

  5. Scale, erosion, white circles, no specific vessel pattern .
    Growing and immunocompromised. I think SCC but nonetheless, highly likely malignant so in the context of the fast growing nature and immunosuppression, I think I do a straight excision Bx with 4mm margins.

  6. Likely SCC the scale may mean still well differentiated. Get as big and deep a biopsy as possible for diagnosis and to look for perineural spread

  7. Likely BCC – but could be SCC as well – Need a Bx either way and likely plan excision with histology.

  8. I have a patient who is immunosuppressed, following a kidney transplant 20 years ago. She was managed by RPH WA until 5 years ago when I became her main provider. In the early days I would remove 4-5 lesions per year, BCC’s mainly, from various sites until she started to take Nicotinamide 500mg BD this produced a decrease in the number of BCCs. It was not until she commenced on Neotigason 10mg daily, with the approval of her Renal physician, that we saw a dramatic reduction, 0ne lesion every few rears.
    I would say this is a BCC and in view of the history I would undertake a complete removal with a 1-2mm margin. Over the years I have had a good success rate and rarely need re-excision, an advantage to the patient in terms of time and cost.

  9. this is most likely a skin cancer either SCC or BCC in the context of the clinical history
    i would recommend bx and then remove by en bx

  10. dermoscopicaly only serum crusts on a raised nodular lesion suspected to be SCC well differentiated. I had a similar case i treated effectively with wide excision

  11. How does everyone feel about the pathology report? We all agree on the need to do a biopsy – do we believe the results???

    1. I would be more linear towards a SCC and may b the pathologist is not aware of the patient’s history also may have not done enough deep sections . This needs to be questioned in my opinion.

  12. This gives a better indication of the size of the lesion, and I have to admit I was a bit surprised when the pathology report came back as benign!
    I’d be keen to get people’s thoughts on what they would do next

  13. I have never seen pathology reporting of ‘moderately dysplastic and thick actinic keratosis’ before, usually path reports read hyperplastic actinic keratosis or well/mod/poorly diff SCC. Was this read by a general pathologist or a dermatopathologist? Renal transplant pts are immunosuppressed and some seem to grow SCCs frequently, especially those with a hx of extensive photo damage still living in a sunny clime.

    I would excise with appropriate margins empirically as an SCC.

    Nice clinical photos, can you get the histology photo from the pathologist? It would be interesting to see all three components of this lesion.

  14. Has to be an SCC on all counts albeit well demarcated.
    “SCC can kill”

    You could do a 6mm deep punch.
    But I would excise with say a 3mm margin.

  15. I think it’s worth excising the lesion regardless of the original biopsy report and you provide the full specimen for another assessment . I would speak to the pathologist and give the full history of the of the patient with the images and I am sure they will b linear towards a scc. Because it’s not easy to some times differentiate higher grade AK and SCC. In fact this patient would most likely be happy for the lesion to be gone anyways.

  16. I’m not convinced this is benign as the report has stated. Clinically and dermoscopically this is an SCC, especially in a type of patient you would expect to find SCCs! You could get a second opinion from another dermatopathologist, and emailing the pictures to him/her would be helpful. You could also do a 4-5mm punch biopsy down to fat and see what the report says then. At the end of the day, I would treat this as an SCC and excise it.

  17. The shave only represents part of the lesion. It is a keratinocytic lesion – it looks more like an SCC but since he is a renal transplant patient it is more likely to be a BCC – ?or maybe a basosquamous ca. Since the diagnosis is uncertain and this would affect the margin I would try to convince the patient to have another biopsy – large punch of 6 or 8 mm.

  18. It is certainly looks malignant and I would opt for definitive treatment with excision and 4mm margins. Sometimes, pathology could be wrong, but I would call pathology and ask another person to comment. The issue also could be punch or shave biopsy which is missing out on the parts of the lesion with definite malignant features? Complete excision would be better considering the Hx.

  19. So I asked the lab to review the histopathology and the reply was:

    It is floridly inflamed with irregular epidermal surface and dilated follicles filled with neutrophils.
    Not a tumour, but I suspect something to do with his immunosuppression. I can’t see fungi or viral inclusions.
    A micro swab might be of value.