Case discussion: How would you treat this patient? [21 June]

This week’s case discussion, submitted by Dr Randa Al-Hajali, features a 62-year-old male who presented with a lesion on his left thigh. The patient stated the spot started like an insect bite, but recently became more lumpy. There is no clinical picture but the lesion appeared red and firm; part of it looked like a scar.

  • 62-year old patient
  • Red, firm and lumpy lesion

What do you make of the dermoscopy? What would you do next?

case discussion

Update

Here is the pathology report. What would you do next?

case discussion

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15 comments on “Case discussion: How would you treat this patient? [21 June]

  1. From the dermoscopy this could be anything really but given it is an EFG lesion (elevated firm and growing) it needs to be removed. Excision biopsy with 2mm margins seems a reasonable place to start to me. I look forward to the histology report 🙂

  2. ” One picture thousand words ”
    I have only one, please provide photo without marker so we can see
    Thank you

  3. Elevated and growing ;although not classic appearance for BCC ?SCC may still be either or Merkel Cell tumour —excise 2mm margin

  4. dermoscopy too unclear to comment on, buy by the clinical description possibly could be a dermatofibroma

  5. Lesion is irregular, structureless pink background with white streaks and some white structures which look like rosettes (insufficient image definition to say). There are some arborising blood vessels to be found notwithstanding image issues.
    GIven that it is also enlarging and ‘firm’ I think that malignancy is likely possibly BCC but SCC is possible. A punch biopsy at minimum should be done while being skeptical of a benign histology result.
    If the patient is happy with complete excision with 2mm margins without first doing a punch biopsy, I would excise.

  6. There isn’t much in the history to spot the diagnosis. Given the fact the age of the patient and it’s lumpy. I would like to rule out any malignancy for sure. Based on the photo which is a bit unclear I would think of SCC as I can see white keratinised thing, if was fast growth I would think of MCC, she stated it’s like insect bit lesion at start this would go with DF. So awaiting ur histology report impatiently.

  7. Elevated,Firm and Growing(EFG acronym) means mandatory excision of the whole lesion to obtain dermatopathology.
    My best guess,based mainly on the history as I can’t tell much from the dermatoscope image presented,is a moderate to poorly differentiated SCC.
    These can be invasive and aggressive,so excision biopsy is reasonably urgent given the story.

  8. The lesion is larger than the marked area
    It has Whit structureless areas and white linear and curvilinear lines. Dotted blood vessels in the R. side of the lesion and a brownish blotch at 12 O’clock. there are brownish areas around the lesion and a small ulcer nearer to 5 O’Clock.
    I suspect this may be amelanocytic melanoma or SCC.
    It is unlikely to be BCC or MCC as i do not see linear vessels
    I would excised it with 2 mm m. Looking forward for the histology report.

  9. Desmoplastic melanoma is the toughest diagnosis I think – looks like a “scar”, and as Dave says – “could be anything”. So, as we all know, just because it could be benign (or indeed is likely to be) doesn’t mean it actually is – and so it needs a biopsy with this history. Great case

    1. This pt had it excused and PETScan showed metastasis. He recently came with a new nodule in his
      L upper arm which Dermoscopically looked similar to the previous nodule, had excision all bx.