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1800 867 1390Case discussion: How would you treat this patient? [17 May]
This week, we present a case discussion from Dr Mazharul Islam featuring a 56-year-old lady who presented for a full-body skin check with no prior skin cancer history and otherwise healthy. The following flat, pink lesion was found on her upper right back.
- 56-year-old female
- Flat, pink lesion on back
What is your clinical impression based on the clinical and dermoscopic image? How would you manage this patient in your initial consult?
Update
Here is the pathology result. What would you do next?
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1300 856 695
+44 203 514 0688
1800 867 1390
I wish you could stretch out the lesion with your fingers before taking photo to help with more obvious abnormal features specially vessels structure. The lesion has no pigment network, is slightly raised on a sun damaged skin with some scar structures and abnormal vessels but not very specific of arborising vessels.
DDx: BCC, Amelanotic melanoma
Mx: excision biopsy with 2mm margin
Small area of linear vessels and white lines surrounded by brown pigment network, makes me concern about scc, However the location is not typical ( I would expect BCCs at this location more). I do consider the possibility of lentigo malignant due to structureless pigmentation, gray lines around 9:00 o’clock and lack of sharp border on right side.
Suspicious lesion;
?amelanoctyic melanoma
?SCC
The pink appearance could point towards scar – has this lesion previously been biopsied?
Extensive sun damage to skin with scarring and raised red irreg outline lesion wihich needs excison biopsy with adequate margin ? MM /SCC
? BCC ? Melanoma ? SCC
Excisional biopsy , 2 mm margins
Can do a punch biopsy to exclude in situ SCC vs Actinic keratosis. most likely appears to be AK
? Dermatofibroma or SCC.
Excision or punch biopsy
Looks like superficial BCC..plan for 4mm punch biopsy
Pink with white lines and ulcer. Bcc.
Excision Biopsy
DD Superficial BCC, SCC
shiny white sreaks
shiny whits areasa and globules
areas of dotted and linea blood vessels
suspecous for exision
amelanotic melanoma
morphea form bcc
New lesion on chronically sun-damaged skin.
White structureless areas.
Abnormal vessels, ? arborizing.
No network.
The differential is NMSC, Bowens disease, and amelanotic melanoma
Clinically: a small pink lesion with tiny central dent (ulceration).
Dermoscopically: Erythema (pink) lesion with white structure, which was surrounded by non specific solar lentigines. Vessels patterns look linear and dot, albeit hard to describe without zooming.
Impression: BCC, Scar or less likely MM (amelanotic). Wide-bore punch (to get whole pink structure) or 2mm margin excisional biopsy, and go from there.
I think this is a good case for “I don’t know what it is, but it is abnormal, so I need to do a biopsy”. I would do a shave here – small, flat, quick and easy