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1800 867 1390Case discussion: How would you treat this patient? [11 October]
This week’s case discussion, submitted by Prof David Wilkinson, features an elderly male patient in his mid-70s who has multiple co-morbidities and a proven nodular BCC on his left mid shin. He has quite good skin but questionable blood supply and no distal pulses.
This 1.5cm lesion is noted. How would you manage this man? What options do you face and what are the pros and cons?
- Mid-70s male patient
- 1.5cm lesion
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1300 856 695
+44 203 514 0688
1800 867 1390
Below the knee, on the shin (even worse), over 70, comorbidities, and peripheral vascular disease likely.
So a healing disaster-in-waiting.
But the cancer must be cured nonetheless.
One could shave excise or remove with simple ellipse and then hope for the best expecting prolonged healing times and infection.
An alternative to improve prospects would be to obtain a vascular opinion first and correct any deficiency, and then proceed, the case being a BCC is not time sensitive.
Risk of infection, slow healing, dehiscence, especially near tibial region. Can consider field therapy if appropriate, otherwise halo graft will be perfect.
Have a conservative approach here, use cryotherapy at 2 weekly cycles to treat it, defer surgery. will heal well if cryoed properly. i have done so with good results using dermoscopy to confirm clearance
? nodular melanoma – needs excision for biopsy, but with vascular compromise, I would refer to a specialist
The peripheral vascular disease needs to be fully documented. Questions about intermittent claudication and any other kind of vascular history/diabtes Et cetera suggesting significant peripheral vascular disease, maybe popliteal artery obstruction and diminished run-off –that that should be first attended to with a referral to a vascular surgeon. Ankle /brachialDoppler should be included obviously as part of that assessment. Severe peripheral vascular disease,can not only predispose to infection but I have reviewed one case,progressing to gangrene and amputation. Excision of that lesion with all of those above provisos could be done under local anaesthetic with a simple Z-plasty, again with encouragement after the initial 48 hours for movement from the patient to encourage blood flow to the wound.
Venous Stasis Dermatitis. Consider elastic stockings and review after 4 wks. Consider excisional biopsy only if persists.
consider punch Bx to see if risk of wider excision is worthwhile
With the history stated it will imply delayed healing and risk of gangrene. Vascular opinion is needed for further approach.
EXCISION WITH SKIN GRAFTING
Is this lesion the BCC or a new lesion? Looks like a bruise secondary to trauma with possible mild infection. In which case antibiotics and elevation to start. Consider a foreign body. If the whole lesion is a cancer it needs excising. I tend to cut an ellipse, create Burrows triangles and pull them together. Antibiotics and a stocking can help. But if the blood supply is poor, he may be better in hospital. If it is only a small BCC, then a punch excision and secondary intention healing may work.
For a nodular BCC in that position , I would excised with 2-3 mm margins and close with either a HALO graft or I prefer a keystone flap repair
Needs biopsy with a risk of delayed healing. Specialist referral will be beneficial.
Biopsy proven modular BCC with severe peripheral vascular disease can be referred/ treated with radiotherapy effectively .
This looks like a traumatic injury with some skin damage. Obviously a history will assist in likey diagnosis
I should have read the question.
The lesion looks like alot of surrounding inflammation and some clot or necrosis center of lesion. Many of my patients have reduced vascular supply. With good tissue handling skills it is possible to get this lesion excised and healed primarily.with a ellipse. A skin graft is also a good option if your tissue handling skills are not 100% BUT definetely NOT a HALO graft.
There is NEVER a place for HALO grafts in skin cancer managment.
The borders of this 1.5cm BCC appear rather poorly defined so I would suggest 4mm margins and avoid skimping on this as you want to get it right the first time. So defect size approx 2.3 cm. If surgery is attempted I would prefer an ellipse as this generally heals with the lowest complication rate, a lazy S pattern would be a suitable option. This likely can be closed primarily with some undermining, but how tense/mobile the skin is can be difficult to appreciate on a picture.
Off course there will be a need for rather detailed consenting regarding the increased risk for complications as infection and non healing/ulcer etc. , and possible also for reflecting on the severity of the comorbidities and the the expected lifespan of the patient.
Is the surgery necessary at all (relatively short lifespan expected)? If yes, does the patient have a reliable caregiver that can look after them post-op, so they can rest and elevate the leg during the initial week, and longer if needed. I usually suggest to bring a family member and suggest they make arrangements for a `stay-over`. If no appropriate home support is available it may be be better done in hospital.
Long public waiting times however may result in a bigger lesion that may no longer be able to be closed with a simple ellipse – hence a higher complication rate. And they may just do it in day surgery and sent the patient home – lack of funding …
Same issue if deciding to postpone the surgery due to expected short lifespan – as some patients surprise you in that regards by beating the odds.
If smoking, I would decline to do it untill they stop smoking (at least till the wound is healed) – may need nicotine replacement scripts.
I`d prescribe a profylactic dose of Cephalexin 2G 1hr before surgery, and apply chloramphenicol on the wound despite the lack of evidence.
Some do arm/leg BP studies to further assess vascular supply and surgical risk – seems a good idea here.
So many factors to take into account to reduce risk …
Thanks everyone, for a wide range of really useful and interesting comments. Like all of you, my view was 1) the cancer needs to be treated – that is the easy bit! 2) the challenge is closing the hole, the healing. So, what I did (today) was to very gently currette the obvious tumour – that was easy enough, as it fell away nicely – and very gently extended the gentle currette into the edge of normal skin. I then did PDT with ALA. I will see him again in a week, and will post photos. He will almost certainly need a second round of PDT (without currette) 2 weeks later. Again, I will share this journey with you. PDT works well for nodular BCC when it is small and thin – which this one is, after my gentle currette today. Of course, all this was discussed at length with the patient.
Very interesting approach! Thanks for sharing …
Would there be any (surgical) alternatives to this option, btw?
Shin is always a difficult area to close. I would check the laxity of the shin first, most of the time if the skin moves well , likely able to close. In upper part of the shin lesion, a longitudinal ellipse is better to close, and the lower part lesion, transverse ellipse works better. Need adequate undermining and sometimes deep dermal suture also helps. I would try this lesion to be excised by longitudinal ellipse. Thank you
Can consider radiotherapy but side effects of radiotherapy
, immiquimod but might not be fully effective and can cause side effects as well. Might recur
Surgical excision with appropriate margin , with possibly halo grafting. But poor blood supply and wound may not heal