Case discussion: How would you treat this patient? [7 December]

This week’s case discussion features a very interesting case from Dr Franco Rodriguez, whose patient presented with a rapidly growing ulcer on the scalp. The patient reported the lesion had been there for over 12 months, with noticeable growth over the past three months.

  • Male patient aged 60+
  • Rapidly growing scalp lesion

Please review the clinical image below. What is your differential diagnosis? What would you do next? If you are planning a biopsy, how would you biopsy this?

Update:

Here is the pathology result. What next?

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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16 comments on “Case discussion: How would you treat this patient? [7 December]

  1. Poor chap. Looks to be fungating. SCC or ?BCC or if growing rapidly as you say could be Merkel Cell but a bit on the young side. I’d do a couple of 4-5 mm punch biopsies LN exam and refer urgently. Ive seen a similar SCC which invaded through the mans skull.

  2. Rapidly growing and non-pigmented likely an aggressive SCC

    I would do several punch biopsies and for good measure a CT scan of the brain/skull.

    Ultimately will need referral to a specialist centre for management surgery +/- radiotherapy

    I had an elderly woman at our local nursing home who had an invasive SCC the treatment of which required removal of skull and radiotherapy. The brain was ultimately ‘on show’ and covered with a simple bandage until she died 12 months later of other causes.

  3. This appears to be an ulcerated SCC scalp
    needs wide excision and flap repair by Plastic surgeon followed by radiation

  4. D/D:
    1. Chronic Ulcer
    2. Marjolin’s Ulcer
    3. Invasive Squamous Cell Carcinoma
    I would do Excision Biopsy (Not the total excision, though).
    Punch biopsy is one of the option
    Referral to plastic surgeon/Skin Cancer specialist as this may require extensive investigation for local as well as systemic metastasis as well as an invasive surgical and adjuvent therapy.

  5. Rodent ulcer (aka large BCC), would do incisional biopsy incl. edge of lesion
    DDx amelanotic melanoma (but would have expected to have grown faster) or SCC
    Refer while waiting for Bx result

  6. In addition to BCC/SCC and the need for biopsy I would add
    Buruli Ulcer and
    Pyoderma gangrenosum as differentials.

  7. Scc
    needs wedge biopsy or punch biopsy
    radiotherapy followed by excision and flap

  8. consider malignancy – SCC, BCC, Merkels, dermal sarcoma; I would also speak with the microbiologist re atypical organisms and take the relevant samples for these; to biopsy I would take several punch biopsies, including from the centre and from the edge; an incisional biopsy would be ideal but I don’t think it would close; if he isn’t already on antibiotics, I would do the biopsies with antibiotic prophylaxis, such as cephalexin 2 g 1 hr pre-biopsy

  9. Hi, thanks for this case. It looks like the patient’s address and phone number are still on the pathology report. What has happened to him since?

    1. Hi Alex, thanks for your comment. I’m not sure if that information pertained to the patient, but I’ve cropped that out just in case! Unfortunately the doctor who sent us this case didn’t provide further details about the outcome, so I am not sure what happened to the patient since. Thank you – Abbie | HealthCert

  10. Clinially this is a very aggresive tumor and poorly differentiated probable SCC but could be Merkles carcinoma
    High risk spread locally to bone and metastatic disease to be considered. Biopsy deep to include active margin punch or wedge. Referral to specialist services as likely to need wide Mohs and graft and radiotherapy. Lymoh nodes in drainage area should be examined. Nasty.