Case discussion: How would you treat this patient? [25 January]

This week’s case discussion from Dr Terry Harvey features a male patient in his 50s with no specific concerns, presenting for a skin check.

  • Male aged 50+
  • No specific concerns

Please review the clinical and dermoscopy images. What is your differential diagnosis and how would you proceed?

case discussion

Update:

Here is the result. What are your treatment options and preferences for BCC and particularly nodular BCC?

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24 comments on “Case discussion: How would you treat this patient? [25 January]

  1. Most likely a BCC. Arborising vessles and top of the lesion u can see few clods so may be a superficial BCC that part of the lesion

  2. Looks like a bcc. Clods and aroborising vessels. Slightly amorphic area at 7oclock is only thing that points towards melanoma for me. I’d prob punch biopsy but if concerned about melanoma but could be morphoic BCC. pragmatic approach and excise with 3mm margin. That way if bcc then good margin.

  3. Sun damaged skin. Suspicious lesion upper 1/2 of photo with irregular pigmentation and white patches.??For punch biopsy .

  4. Yes I agree with most that it is likely a pigmented BCC. One of the colleagues does mention the features at 7 O clock which could also be regression and hence together with the peripheral pigment clods and dots at the 12 and 1 o’clock margins we need to rule out lentigo maligna melanoma.

  5. This is a BCC with classic aborizing vessels, clods and translucency. What will be interesting will be the subtype and the margins as there appears to be a superficial component at the 5 o’clock position. The clods indicate dermal invasion and this part of the lesion may be infiltrating. This will need excision with minimal 3mm margins. Will be a difficult closure given the location and may well need a flap/halo graft of can’t bring edges together when planning the excision.

  6. Yes, there are asymmetries, seemingly clods. But is it a melanocytic lesion?- which is less likely unless most of the lesion is regressed!! There are obviously arborising blood vessels. Pigmented BCC is most likely diagnosis. It is safe to take 3mm excision bx, and will wait for pathology reports on Wednesday!! A challenging case!! Thank you.

  7. Chaos, brown/grey peripheral clods. Arborising vessels. Looks like pigmented BCC to me. Excise with 3mm margin. Differential Melanoma.

  8. erythematous macule, brown dots/clots, arborising vessels; suspicious for BCC, would do diagnostic PBx first

  9. The dermoscopy image here is very diagnostic
    It is showing arborizing vessels, grey/blue globule, brown structures and white strands
    This is BCCs
    although we can shave the lesion to confirm the diagnosis, I would prefer to excise this lesion as BCC with direct closure.

  10. This is, without doubt, on the dermoscopy, a BCC: arborising blood vessels and ovoid nests. If you have the dermoscopy skills to make this diagnosis, then excision with 3mm margins is the way to go. But, let’s be clear – you need to be sure that this is a nodular BCC (this appearance is typical) – to do that. Otherwise, do a punch biopsy first. What I would do here – even with my dermoscopy experience – is a punch biopsy at the time of consultation (in order to confirm the clinical diagnosis with a tissue diagnosis) and also book the patient for an excision on the next available appointment. That way, I have followed the national guidelines, have a confirmed diagnosis before the treatment itself, and I can bill the correct item on the day of the excision