Case discussion: How would you treat this patient? [30 August]
In this week’s case discussion, submitted by Dr Anushka Seemungal, we consider the case of a 77-year-old, fair-skinned male patient who presents with a firm, pinkish, nodular lesion on the left shoulder with a pink, scaly plaque adjacent to it. Although the visible nodular portion is not large, palpation reveals firmness extending almost concentrically in the deep dermis.
- 77-year-old male
- Firm, pinkish, nodular lesion
What is your impression here, and what would you do next, based on the clinical and dermoscopy images?
Here is the pathology report and IHC findings. What would you do next?
We encourage you to participate in the case discussions and submit your own clinical images and questions, so we can all learn together.
3 comments on “Case discussion: How would you treat this patient? [30 August]”
? BCC nodular
excision biopsy with 2mm margin
Naked eye agree could be BCC but it looks about 10mm diameter on dermoscopy so I’d be thinking punch biopsy rather than excision biopsy initially. I’d also have concerns about the lesion at 9 o’clock to the large nodule and would biopsy that too. The surrounding firmness is a concern – could be something very nasty like Merkel cell so final excision could be very large. I guess we’ll see on Wednesday when the path report arrives!
Part 1 – The lesion is definitely suspicious given that it is firm. The surrounding dermal thickness is also suspicious. Dermascopically, the appearance is quite featureless. There are some possible atypical vessels and there is some patchy pigment which raise the question of an AHM but I would also consider a rare dermal cancer like a Merkel cell cancer or a dermatofibrosarcoma protuberans. Either way, definitely needs excision of the nodule and the dermal thickness for histological diagnosis. NB I haven’t looked at the path report yet!
Part 2 – Ok I’ve looked at the report now. I didn’t get the right diagnosis however the initial management was correct. I think given the report, I would now go back and excise with a wider margin, probably 5mm for safety.