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

In this week’s case we look at a female patient who had seen her usual GP and had “a few sunspots” frozen off her back multiple times in the prior two years. She then presented to Dr Terry Harvey with persistent lesions.

How would you assess these images? What are you views on prior treatments? Would you biopsy these, and if so, how?

Update

Here are the results. What next? Any other commentary on this patient’s experiences?

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

  1. Any pink lesion you must stop and think! Plus age and past skon cancer history. See vessles in both lesions. ? White lines? Use of non polarised function of dermatoscope!
    I would do biopsy of both lesions

  2. Persistent lesions on back of female with sun damaged skin.
    Lesions have arborising vessels, are asymmetric and have featureless areas. ?BCC.
    I would plan excisional biopsies of each lesion.

  3. Pink lesions with arborising blood vessels on sun damaged skin makes the diagnosis of BCC high likely. For excision of both lesions.

  4. Using the “prediction without pigment” criteria both these lesions need Bx. Query mild ulceration, white lines and serpentine/arborising vessels make these very suspicious for BCC. If flat with no evidence of vertical growth I would consider deep shave Bx for histopathology

  5. History of sun exposure and an ulcerated skin lesion would prompt me to excise it. I can appreciate a pink skin lesion with some faint branching vessels and an ulceration with blood spot and some white lines. All are in alignment of BCC. Excise it.

  6. Recurrence of previous treated lesion would require either diagnosis or definitive excision. I would not re-treat these lesions by cryotherapy.
    Lesion marked blue : ?scc. I would remove with clear margins.
    Lesion marked red: biopsy. ?more advanced scc or bcc. Biopsy areas that seem to penetrate deepest.

  7. irregular non pigmented lesion with neo vascularisation.
    central regression
    My D/D will be
    amelanocytic melanoma
    non pigmented BCC
    solar keratosis

  8. Recurrent lesions of a patient with a (probable hx/o sun exposure) showing asymmetry in shape and colour, suspicious of SCC.

    Views on prior treatment:
    Cryotherapy MULTIPLE times isn’t acceptable. I would rather biopsy it in the second presentation.

    Will biopsy these today; punch biopsy

  9. Both lesions are asymmetrical, pink with white streaks and some evidence of ulceration. Both have arborizing vessels. Left lesion has ? small grey spots on far left and Right lesion also demonstrates some glomerular vessels especially along the lower right perimeter and possibly some dot vessels upper right. Excisional biopsy of both lesions for ?BCC and possible SCC or BCC on the right.

  10. I think a great case to demonstrate some key principles: 1) you can only ever TREAT a patient when you have a DIAGNOSIS. 2) Usually this means a tissue diagnosis to support your clinical impression. 3) Exceptions include TYPICAL solar keratosis, which is a legitimate clinical (naked eye) diagnosis). Then, ANY RECURRENT previously treated solar keratosis must have a punch biopsy before any further treatment.