Case discussion: How would you treat this patient? [15 June]

We present an interesting case this week from Dr Tim Aung, featuring:

  • 65 year-old male patient
  • Pink, nodular lesion right shoulder for 6m
  • Slowly growing

What is your assessment? What would you do next?

Case discussion      Case discussion

Update:

Here is the result. What next?

Case discussion

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27 comments on “Case discussion: How would you treat this patient? [15 June]

  1. Cutaneous horn which can be associated with an SCC ; and has that appearance in 2nd photo–excision biopsy with 10mm margin as in head and neck region

  2. nodular keratinised lesion with radiating telangiectasia and scarring on dermatoscopy.
    DIagnosis: SCC or KA
    Management:
    shave biopsy to confirm diagnosis and if confirmed then excision with 4mm margins.

  3. Mostly agree with previous comment, most likely Keratoacanthoma, (some potential to become a SCC)
    Full excision not my first choice, CryoRx with several freeze-thaw cycles if small (5-6mm or less) is usually adequate with reviews to see of any recurrance.)
    Deep aggressive currettage may be adequate, and provides histology as well
    If excised without prior histology, a narrow margin is adequate,and can be re-excised with larger margins if histology says it is a SCC.

  4. not well defined, not fast growing, looks indurated on macro; I don’t think it’s a KA. White structureless areas, scale, polymorphous vessels; can’t call it benign, suspect mod well differentiated SCC, excise with 4-6mm margin.

  5. not well defined, not fast growing, appears indurated edge on macro, prob not KA; white structureless areas, scale, polymorphous vessels; suspect SCC, excise with 4-6mm margin

  6. lots of keratin and chaos . cancerous process. SCC very likely . I would excise with 5mm margins.

  7. grade 3 Actinic keratosis, can trial cryotherapy 2 weekly cycles until dissapeared. Even if this is a Well differentiated SCC it will still respond to the cryo

  8. Clinically it’s a nodular SCC ,I would Do an oriented excision of the lesion with 2mm margin in case it’s an atypical amelanotic melanoma —which is common around shoulder area

  9. nodular keratinized lesion, surrounded by an erythematous rim; scaling present; blood spot present; 1 cm diameter, increasing in size; radial looped vessels

    Dx keratocanthoma vs SCC;
    DDx BCC, amelanoctic melanoma
    Plan: it is difficult to distinguish KA from SCC, therefore I would remove this lesion (excision with adequate margins [3-5 mm]). Partial shave biopsy usually inadequately distinguishes between keratoacanthoma and invasive SCC.

  10. With slowly growing type ,

    Nodular Melanoma is unlikely along with clinical features.

    DDx – Keratoacanthoma , SCC
    So I prefer partial biopsy first after explaining the patient first then , if positive for NMSC , will do full excision

  11. DDx , as per clinical features and examination ,
    For non-pigmented nodular lesion
    – 1. Keratoacanthoma
    2. SCC
    3. nodular BCC ( least likely )

    All go to NMSC DDx.
    Hence

    I prefer partial biopsy to complete excision first .
    Therefore, along with patient’s preference , will do Partial biopsy (prefer 8 mm punch biopsy ) then if positive for NMSC , will do full excision

  12. Horn on white lesion with polymorphous peripheral vessels. Excision with 4-6mm margin for SCC / KA.

  13. Appears to be a SCC. Excision biopsy with 4mm margin would be my first approach. However, as the skin on shoulder is generally tight, I would probably do a shave biopsy for diagnosis and then consider excision.

  14. The appropriate approach here is a nice, large punch biopsy (4-5mm) right into the heart of the pink part of the lesion. It “looks like an SCC” and the punch will confirm this. Then, full excision once you know depth, differentiation and presence / absence of nerve involvement. As this is well-differentiated, 4mm will do the trick.

  15. As Prof Wilkinson suggested, The ideal biopsy site is not onto the keratosis/scab/scales. Underneath of keratosis may be a hollow or cavity with poor tissue amount. It is highly recommended to confirm the diagnosis first before considering wider margin excision (2 – 5 mm ). Punched biopsy is generally favourable for Keratinocyte tumour/ NMSC.

    1. Further info for this nodular: To be able to differentiate from BCC, the latter is characterised by random arborising (serpentine) v/s. Radial distribution of hairpin (loop) v/s is commonly seen in SCC or KA.