Case discussion: How would you treat this patient? [5 October]

This week, we are sharing an interesting case provided by Prof. John Pyne:

  • 60 year-old female school teacher
  • No personal history of skin cancer
  • New papule on central forehead with 2-month history
  • Patient decided to have confocal imaging [live pathology] in preference to an excisional biopsy

Please review the dermoscopy images. What is your evaluation, and what would you do next (if anything)? Prof. John Pyne will share further details and guidance throughout the case discussion so please join in!

Case discussion

Case discussion    Case discussion


Here is the pathology result. What next?

  • Confocal Image 2- basaloid cells with mucous clefts- diagnosis nodular BCC
  • Confocal Image 3- mucous clefts- diagnosis nodular BCC
  • Histopathology confirms  nodular BCC

Case discussion

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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23 comments on “Case discussion: How would you treat this patient? [5 October]

    1. Hi Arif

      The patient has Fitzpatrick 1 to 2 skin and thus more llkely to have a hypomelanotic melanoma.


  1. Also if BCC is suspected, I will expect arborizing vessels,
    Crown vessels in sebaceous hyperplasia
    Comma vessels in dermal nexus
    Here I see dotted and hairpin like vessels and polymorphic vessels. Raising suspicion.

    1. Hi Cherian,

      Could be – but is not. PG often vascular, soft, bleed and ulcerated.

      The confocal is convincing for what it is.


  2. The lesion looks squeezed? If was should repeat dermoscopy as vascular pattern may show better. The peppering is grey and black. That and the polymorhous vessels would make me want to remove the lesion.

  3. with a 2 month history and on forehead /age of patient being 60/ on dermoscopy ans confocal imaging it appears to have pin point blood vessels and grey dots and my diagnosis would be nodular BCC and I would do excisional biopsy rather than biopsy or shave excision .

  4. Growing raised lesion on 60yo. Would be good to have some tactile and macroscopic views. Dermoscopy not classic of anything but possibly BCC or amelanotic melanoma. Basic dermpath knowledge but not confocal knowledge but appears to nests of cells which is likely nodular BCC. This is backed up by the filename sign 😉
    (Please note to author when you click on images you can see the file name and this can be a give away)

  5. With that history ; Raised red papular lesion with /aborising vessels?
    Dx ; Nodular BCC / Amelanotic melanoma
    P: for excision biopsy
    I don’t know about confocal imaging and would like to learn about it

  6. Well defined regular outline implies benign
    Chaotic internal appearance implies malignancy (and amelanotic melanoma is on the list)
    Recent changes, not identifiable as a benign lesion and the suspicion of malignancy: advise excision
    Will be interested to see what the confocal microscopy has added to patient’s management

  7. Grey dots and polymorphic blood vessels on an otherwise featureless background provides enough suspicion to consider amelanotic melanoma. Even with a regular border. I am unfamiliar with confocal imaging and so in the absence of further clues, would advise excision biopsy, as a shave may not provide adequate depth information in this raised lesion.

  8. New pink nodule – excision biopsy or punch biopsy in centre of lesion
    ? Amelanotic melanoma or nodular BCC
    not familiar with confocal imaging.

  9. The history is of concern; Well defined pink lesion with surrounding circle of structureless orange/pink; asymmetry, polymorphous vessels, subtle pigmentation in centre and at edge of the lesion, milky red areas; no scale or well focussed vessels; provisional diagnosis amelanotic melanoma; I really don’t know how to interpret confocal microscopy…..there are some bright white dots that aren’t meant to be there, but I don’t know what they are; the arrows are pointing at something filling a space! But I don’t know what this means.

  10. New lesion in a 60 yr old fair person on the head. The lesion is well circumcised .Not sure what confocal imaging is. However as it is new and o nthe face which is exposed to sunlight and can see sun damaged skin ,I would excise it .

  11. Try to correlate your knowledge of histology to the confocal images.

    Many of the comments have given the correct diagnosis.

  12. The histopathology confirmed a nodular subtype BCC. The confocal images show basaloid clusters of cells with clefting at the periphery and sharp defined margins.

    The tumour mass was excised with a microscopic margins of approx 2 mm in depth and at the peripheral margins. No recurrence found at a routine review 3 months after the excision.