Case discussion: How would you treat this patient? [8 March]

This week’s case discussion, submitted by Dr Alex Speight, features a 70-year-old male patient with multiple lesions found during a skin cancer check.

  • 70-year-old male
  • Multiple lesions

What is your evaluation, and how would you biopsy?

case discussion

Update

All lesions are reported as superficial multifocal or nodular BCC. What are the treatment options?

Click here to read the histopathology report.

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17 comments on “Case discussion: How would you treat this patient? [8 March]

  1. Looks like a heady mix of BCC, SCC, and Melanoma in-situ.

    All will need biopsy and follow up.

    Good luck!

  2. except lesion 9 and 10 others are non pigmented lesions. most of them has ulcer, white clues ( white scale , white lines and white structures areas. ) and polymorphous vessels (branched serpentine and other) lesion size vary from 5mm to 10mm , They are suggestive of SCC and DD include AK , BCC. and AMM
    Lesion 9 Chaos with reticular and structures , colour grey, brown border abruptness is not circumferential. clues . grey structures and eccentric structureless and areas of thick reticular . few visible dot vessels but not certain. Need to exclude melanoma \
    Lesion 10 chaos pattern structureless, colour red ,brown and grey . Border some areas of border abruptness. Clues grey structures , eccentric structureless, black dots polymorphous vessels, also areas of thick curved lines and white dots may suggest evolving melanoma from a Seb K.

    ideally excision biopsy but practically may not be able to biopsy all lesions at same time . i will biopsy 1, 5,7 as excision biopsy or large punch biopsy or deep shave biopsy. lesion 9 and 10 need excision biopsy .
    if histology is BCC in most of them then Gorlin Syndrome may be considered and can be referred to dermatologist ( depend criteria ) without biopsy of all lesions

  3. Obviously extensive sun exposure and damage over his life time. Most lesions either BCC /SCC.Lesion 9 clavicle MM and needs excision biopsy with wide margin .Other lesions excsion biopsies or punch biopsy with appropriate management depending on histopathology.

  4. number 10 is likely to be a melanoma and I would excise it
    number 9 =? dysplastic naevus- review in 2-3 months
    the rest are infiltrative BCC- may excise some and treat more superficial ones with Imiquimod

  5. BCC , Scc and melanoma. Excise clavicular lesion 1st with a 2 mm margin. Exc biopsy of the lesion on the neck next. The rest needs biopsy

  6. Looks like a mix of Bowen’s, superficial BCC and MMis. I would cryotherapy all the smaller Bowen’s and BCC and excisie the pigmented lesions with a 2mm margin.
    Lesion which don’t respond to cryo should biopsies and treated with topical treatment or excision

  7. lesion number leg 5, leg 10 and clavicle 9 appear concerning for me. seems like BCC and the clavicle one appears like a melanoma. needs a biopsy and histology

  8. Options:
    1. biopsy lesions. 3mm punch for all ?BCC except 9 and 10 which need an excision biopsy (can consider shave if flat and well defined)
    2. still excision biopsy 9 and 10. For the others use efudix for 4 weeks. Then biopsy lesions that remain.
    3. refer to derm for further management

  9. I`d schedule the nodular BCC lower leg for excision, together with the melanoma in situ. All the BCC`s on the torso I`d suggest C&C. The superficial BCC`s lower leg I`d treat with Imiquimod . Review the lot after maybe 6 months, and 6 monthly after that. Off label, but also the BCC lower leg could be attempted with Imiquimod – small nodular BCCs often seem to respond well …

  10. I think that in patients like this we need to be pragmatic. Here, I would recommend multiple punch biopsies – 4mm minimum for each of these, with a nice deep shave for the apparently pigmented lesion (it is small and pretty flat). All results show BCC – superficial or nodular. So, we have a range of options to consider including cryotherapy in small, superficial lesions, currette in nodular, and so on

    1. Why perform punch biopsy and not shave biopsy for these? They look like they would all be suitable lesions to shave for diagnosis?

  11. Thanks for your comments,
    This is the same patient as last week (MiS), all on the same skin check! Lesion number 8, MiS, isn’t in the photos this week but included on the histology report. The neck and clavicle lesions were seb Ks. I was interested to see what options people would choose for all the BCCs as many and mainly superficial. I wondered if people would go for imiquimod/cryo/c&c.

  12. He has chronically sun-damaged skin with multiple lesions all of which look suspicious. One looks like BCC, while others could be Bowens, AK, etc
    he will need a combination of Excision and Punch biopsy.