Case discussion: How would you treat this patient? [2 August]

This week’s case discussion, submitted by Dr David Stewart, features an 87-year-old man with a lesion on his chest. He had been advised by a dermatologist 9 months prior to have it removed but due to COVID restrictions was scared to go and have it done. The lesion had grown significantly since the dermatologist saw it.

  • 87-year-old male patient
  • Lesion on chest
  • Significant growth during COVID

What do you make of the clinical and dermoscopic images? What would you do next?

case discussion

Update

Here is the pathology result. What next?

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24 comments on “Case discussion: How would you treat this patient? [2 August]

  1. EFG + Red
    Will need excision as elevated, firm and growing + red.
    Likely a nodular BCC as arborising vessels and blue grey structures.
    Cannot rule out a melanoma collision lesion on the right of the photo (left of the lesion) so wide excision with 10cm margins would be sensible to consider.

  2. Sinister looking skin growth showing various structure and pattern. I can appreciate red mass with branching vessels, white lines, blue clods/ dots, blue tinge and some ulceration. I would excise to rule out nodular BCC vs MCC vs Nodular melanoma as well.

  3. The lesion appears to be of nodular pink lesion. There are arborising vessels as well, suggestive of nodular BCC.
    I would excise the lesion as BCC is highly likely.

  4. – Clinical image suggests ulcerated nodular erythema lesion.
    – Dermoscopically, arborizing v/s in the erythema with few keratin is strongly suggestive of nodular ulcerative BCC. Either 4mm punched or shaved biopsy first to establish a diagnosis, and go from there for WLE or necessary action.
    – Given fast growing, secondary metastasis and KA are also impossible to exclude here without biopsy. MCC is rare in this location.

  5. Probable BCC with colour, nodularity and vessels. Excise 2cm margin under local anaesthetic with possible Z Plasty.

  6. Part ulcerating nodular lesion > 3 cm central chest
    Macro and dermatoscope views cannot rule out Melanoma, likely nodular BCC
    I would excise with 5mm margins and if possible delay closure until path report available.
    IF BCC and adequate margins I don’t think this would need a flap, plenty of open space

  7. Blue white veil, polymorphic vessels, assymmetrical lesion with ulceration
    ddx Amelanotic Melanoma vs BCC
    No punch bx here / we want the whole lesion Excisional biopsy 2mm margin, maybe little flap to close without wasting real estate but keep it simple as we will prob. need to go back with this one if not referring on

  8. It is a suspicious lesion Score 3 . Lesion seem to be extended . According to his 87 years .I think it is late to do any excision or invasive treatment . Side effects of medicines are more harmful for him. i will propose him to see nutritionist for food supplement while waiting the will of God .

  9. Clinical picture is pink raised lesion, border well defined, 30 mm size with area of ulceration .
    Dermoscopic picture shows prominent arborizing vessels, blue clods , white lines , area of ulceration
    Clinical diagnosis BCC ,
    Differential diagnosis : (and all much less likely), SCC , Merkel Cell, anything pink.
    Management , Biopsy with minimum 3mm punch in center of lesion and await histology
    Histology confirms clinical diagnosis, nodular BCC , no risk factors
    Treat with Surgical excision, 2-3 mm margin , Likely able to close with ellipse in older man on chest, loose skin.
    According to training tips from Health Cert training experts: a few comments:
    “Never” shave a raised lesion
    “Always” biopsy first for histology , clarity and direction before excising with large margins.
    a Nodular BCC is a nodular BCC, and management is the same regardless of age of patient or site on body,
    your formal excision pathology result will confirm Nodular BCC. Best management would have been for the first person to see this to perform biopsy to avoid unnecessary delays in removal.
    There is no scientific evidence that nutritional or dietary supplement can alter the course of an existing BCC.

  10. Clinically a BCC and dermoscopy confirms this. So, for me, I would do a large (4-5mm) punch biopsy to confirm. Nodular BCC confirmed on pathology leads to an excision of 3-4mm and I would expect an easy close here with a large-ish ellipse. So sad to see delays in clinical presentation through the COVID epidemic – plenty of evidence now in the literature of large numbers of deaths (non-COVID) due to lockdowns….

  11. Thats a big shave with a big raw wound to complicate assessment of margins . I think I would have preferred to chance by arm and do a large ellipse with 4mm margins in the first instance. It would probably close with a couple of pulley sutures. One could use the the tips of the specimen as FTSG if a get out of jail card is needed. Prophylactic antibiotics would be indicated because of ulceration.
    10 days later the ulcerating tumour would be gone and the wound healed. In the event that it is anything other than a BCC we could worry about a wider margin is appropriate

  12. Thanks everyone for the comments. As a follow up before the Prof leaves his comments, I did a shave biopsy in this case more to remove the weeping bleeding ulcerated portion of the tumour while I arranged to get the patient back to remove the lesion. I would agree that shave biopsy is not the way to biopsy raised lesions in general. Given the size of the lesion, I thought it was too big for an ellipse so did a Mercedes style closure which healed well (and the patient was very happy with the permanent Mercedes badge over his heart!)

  13. It has >2cm in chest so it’s high risk bcc. Standard excision with complete evaluation of margins or Mohs is indicated.