Case discussion: How would you treat this patient? [29 June]

This week’s case discussion from Dr David Stewart features:

  • 58 year-old male patient
  • Lesion on forearm

Please review images and advise your differential diagnosis, and what would you do next?

Case discussion

Case discussion      Case discussion

Update:

Here is the result. How to treat?

Case discussion

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20 comments on “Case discussion: How would you treat this patient? [29 June]

  1. Looks like a nodular BCC based on the dermoscopic appearance of vessels but if sudden and rapid increase in size, keratacanthoma cannot be ruled out
    Some structurless area may raise a suspicion of amelanotic melanoma but unlikely or rare
    Management will be excision biopsy with at least 3mm margin

  2. – large (ca 15mm) nodular lesion with some scaling mainly at the periphery on an arm without much sun damage
    – would have liked some more history but even without that: chaos, multiple colours, incl 2-3mm deeper bluish area at 10 o’clock, marked branched blood vessels
    – macroscopically looks as if it might have bled (1- and 5-7 o’clock), sticky fibre sign w/ dermoscopy (12 o’clock towards centre)
    – whitish discolouration of surrounding skin could indicate previous treatment with liquid nitrogen
    – definitely malignant appearance
    – ?amelanotic melanoma, SCC
    —-> excise

  3. Lesion looks raised ,multiple vessels on microscopy,centre looks necrotic.DD iagnosis BCC,SCC,Amelanotic melanoma,Keratoacanthoma.
    I Would excise with 0.5cm margin,and keep close follow up on scar .Also check surrounding areas with dermatoscope for other lesions.

  4. Hi it is large over 1 cm isze with rolled edges and telangectasia on a fair skin. It has central scabbing. Hall marks of BCC . Needs excision due to size.

  5. With limited history provided, other than SCC/BCC/ even melanoma, I will prefer to do excisional biopsy and ask for testing the other possibilities like deep fungal infection or atypical mycobacterial infection

  6. Differential diagnosis : Nodular BCC, SCC/Keratoacanthoma. Plan : Excision biopsy with 2-3mm margins as the first step.

  7. Macroscopically looks like a rodent ulcer.
    Microscopically peripheral curvilinear blood vessels , as well as a single blue/black ovoid .Central distortion with scarring .
    Nodular BCC . Will need excision with a 3 mm border

  8. Large pink nodule on type 2 skin; poorly defined lesion, polymorphous vessels, some well focused, some out of focus; white lines on polarised dermoscopy, blue clod 10 o/clock, no network; not sure what this is; ?poorly differentiated SCC, ?BCC, ?met; for excisional biopsy with 4mm margin, may need to go back and take wider margin depending on pathology

  9. Noduloulcerative Infiltrating BCC with serpiginous vessels on a raised lesion with pink structureless

  10. clinical: elevated, indurated amelanotic nodule with rolled in edges typical of BCC or KA
    dermoscopy: hint of grey, white clues, arborizing vessels, clues of keratin in yellow and stuck on cotton ends,
    DDx: BCC, KA, amelanotic melanoma
    Rx: excision biopsy 4mm margins to sub cutis

  11. This nodular erythema with central dent and keratin coupled with branched v/s, white stuff and blue ovoid (9′ o clock) on dermoscopy is consistent with nBCC. Some of features (11′ o clock) might be collision with SCC/KA (called-Basosquamous) but less likely.

    I wondered by standard, why not! biopsy should be done first to establish diagnosis and infiltration, before straight onto wider margin excision. Let’s listen from Prof David Wilkinson!

  12. Thanks Everyone. The clinical and dermoscopy “screams out” BCC. This is a very typical lesion – and the blood vessels are the key. The so-called ‘arborising’ (=tree-like) pattern is almost 100% diagnostic. The best next step is to do 1 or 2 nice, large punch biopsy/s. At last 4mm, even 5mm. Why? To confirm the diagnosis. For example it could be a ‘base-squamous” tumour. You need a precise diagnosis before excision, so that you can choose the appropriate excision margin. It is a nodular BCC and so an excision margin with 3-4mm will be adequate.

  13. Relatively big and thick BCC. Borders are relatively well defined. Marking out the lesion with dermatoscope + wide excision with 4 mm margins and down to the underlying fascia I would hope would result in clear margins. If the lesion feels `stuck to the deeper tissue and doesn`t `lift` during LA one could consider a staged excision. Closure with an ellipse may be challenging – ? Lazy S. diagonally across. May be `closeable`, but this will likely result in a `dip`. The surrounding skin doesn`t look great either, not ideal for a flap. A skin graft with donor site from the dorsal upper arm may be preferable.