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

This week’s case discussion, submitted by Dr Terry Harvey, features an 80-year-old woman who presented for a routine skin check with no issues raised.

  • 80-year-old female patient
  • Routine skin check

What do you make of these two images, and what would you do next?

case discussion

Update

Here is the pathology report. What next?

case discussion

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

  1. 80 year old clinical BCC;
    dermoscospy demonstrate enfocused vessel branched vessels confirming the clinical

  2. Very likely a BCC
    Around 1/3 on face May have mixed histology, I believe
    Shave might not heal so well as multiple mapped punch biopsies – at least 3*3mm with suture for each
    Incisional biopsy might be more enlightening and go some way to debulking a malignancy

  3. dermoscopy looks pretty convincing for BCC but indistinct appearance on gross view and midline situation – ? morphoeic BCC.
    I’d punch biopsy and plan excision from there (might need plastics if morphoeic)

  4. Extensive sun damaged skin.?? Superficial spreading BCC . For punch biopsy and further management.

  5. I’m finding it hard to comment. What does it feel like? Firm, tender, scaled, raised ?
    An 80 year old with fair skin is most likely to have actinic keratoses. BCC, SBCC and SCC also common. If it looked suspicious I’d probably shave it off. Too small for multiple punch biopsies. This pt has multiple telangectasia which are common in aged skin.

  6. Prominent arborizing vessels with keratin .
    Differentail includes BCC,although sebacous hyperplasia cannot be entirely excluded as the lesion shows radial vessels converging towards the centre.

  7. BCC as its evident, its best to avoid unecessary biopsy and treat non invasively with Cryotherapy at 2 weekly interval with redermoscopy to assess changes, i have had excellent results with it

  8. Difficult to pin point an exact pathology without full history (eg, colour, texture, duration, associated conditions, etc). Telangectasia/ arborising v/s alone is insufficient to say BCC, as it is fairly common on thin/aged skin. It is understood, polarising dermatosopic picture with oil/gel use, resulting in artefacts circles. Given pale-whitish lesion clinically + yellowish-white stuff dermoscopically, I wondered some type of dermatologic disorders such as lichen sclerosus, morphea, scar (?from past cryotherapy), etc. If so, 3-4 mm punched biopsy from most whitish area should provided some clues or diagnosis.

    Ref:
    1/ Skin conditions (Lichen sclerosus). Check (RACGP), Unit 574 August 2020. https://www1.racgp.org.au/getmedia/44dd33b4-0117-437d-b1c6-4151c3e1826c/574-August-Skin-conditions_V10.pdf.aspx
    2/ https://pubmed.ncbi.nlm.nih.gov/33543162/

  9. Thanks, troubling case
    I am debating the aborising vessels : is this not just a background pattern, seen over her chin generally.
    Macro : flat patch / superficial
    I can see maybe a white line at 4o’clock but the rest is a scale/ hyperkeratosis. No polymorphic vessels in the lesion itself, unusual for SCC?
    Then to find this is infiltrative on path ?
    So its wide and deep excsion? Cant use Imiquimod if the pathology is correct

  10. Key points to make here are: 1) pink tumour, looks like BCC with arborising blood vessels, 2) MUST do punch biopsy to confirm diagnosis and determine subtype – essential to plan treatment, 3) aggressive tumour on pathology so needs nice wider and deep excision (5-6mm), Excision is easy – closing the hole is the tricky bit

  11. Bcc confirmed already, age, co-morbidities, probable life expectancy needs to be considered. I would discuss this with radio-therapist for local irradiation rx before any aggressive surgical approach.