Case discussion: How would you treat this patient? [1 November]
This week’s case is from my respected colleague Dr Donal Kerrin at Birtinya Skin Cancer Centre on the Sunshine Coast, where I also practice.
An elderly male, regular patient presented for his routine skin check. Please review the images – what do you think and what would you do?
- Elderly male patient
- Lesion on right shoulder
– Prof David Wilkinson
Here is the pathology result. What next?
We encourage you to participate in the case discussions and submit your own clinical images and questions, so we can all learn together.
20 comments on “Case discussion: How would you treat this patient? [1 November]”
Keratinized lesion with white circles point to squamous cell carcinoma
Plan : Shave biopsy
Highly suspicious for amelanotic melanoma.
Features congruent with this are
1. Multiple types of vessels
2. White crystalline structures
3. Irregular pigmentary network at the lesion margins.
Recommended to excise the entire lesion with a cm margin & obtain pathologist opinion.
Lesion R shoulder. Pink lesion with arborising vessels
Bcc more likely .Melanoma in differential.
There another lesion L upper chest wall dermoscopic picture may elucidate whether biopsy is necessary
High risk for cancer based on nodular nature with ulceration. This alone warrants intervention.
Additional features are polarising white lines, polymorphous vessels (hairpin in 1 image, some helical and some branched in the other image). There appears to be a faint grey network in some of the lesion. There is also a white structureless area.
DDs- 1. AHM, 2. SCC
Management – Excisional biopsy with at least a 2mm margin accepting that further excision is likely to be required depending on the histological diagnosis
Seems to be two lesions?collision
White circles, other keratin clues and vessel arrangement suggest well differentiated SCC (bottom left image)
The upper right image shows polymorphic vessels, a pigment network, white lines and white circles – but chaotic
?well diff SCC collided with hypo/amelanotic melanoma
I would consider incisional biopsies of the lesions shown in the images and undertake any wider reexcision based on dermatopath report
Pink lesion with white areas with crystalline structures and white areas ulceration scale and some abnormal vessels
Suspicious lesion (BCC) requiring at least punch biopsy, and excision with margins if histology is reported as ‘benign’
Raised pink skin lesion with raised pearly edge all around showing short white lines and an ulcerated area with areas of surface keratin. I think it’s Basosquamous cancer.
Looks like a BCC
? Punch biopsy at least 4mm
whitich pinkish background with shiny white streaks with linear and hair pin blood vessels
?? bowens disease ?? amelanotic melanoma for punch biopsy
A big lesion with partly nodular component, pink color, linear and dots vessels, white structures, a few ulcers and in nodular part some keratinisation could be amelanotic melanoma or BCC
Certainly a highly suspicious lesion with remnant pigment network at periphery, polymorphous vessels, surface ulceration and some keratin scale. The lesion is suspicious for melanoma but Bcc is also possible on such sun damaged skin. I think I would do an excisional biopsy as it is most certainly a malignancy in my opinion so needs to be gone no matter what.
BCC, use cryotherapy at 2 weekly intervals can achieve excellent results. can punch to confirm it is so if not confident on dermoscopy that is
elderly male, type 2 sundamaged skin, presumably new plaque like lesion; dermoscopy shows a pink lesion with ulceration, white streaks and blotches, peripheral vessels, mainly linear/linear irregular, some looped vessels, no dot vessels, minimal scale; BCC, possibly infiltrating or sclerosing; I would excise with a 6mm margin, need to look for PNI on path report
This case has 2 dermoscopic pictures with slightly different v/s pattern. Clinically also 2 adjacent erythema over R upper back (torso).
1st Dermoscopy reveals coiled (glomerulus) v/s, keratin and small ulceration in the background of milky/pink erythema, which is suggestive of Bowen disease (IEC or SCC insitu).
2nd Dermoscopy shows radial distribution of hairpin and linear (elongated) v/s, peripheral white halo, keratin (hyperkeratosis) and ulceration in the background of milky/pink erythema, which is suggestive of SCC.
Overall, it is typical invasive SCC progressed from AK (Sol K) and IEC.
Initially biopsy should be performed to establish Dx. 3-4mm punch biopsy from those 2 erythema sites would confirm keratinocyte tumors or others, and go from there. MM would be very unusual from this given dermoscopic features but ….
Including these image on behalf of Dr Tim Aung:
– Abbie | HealthCert Education
it was looking like a basal cell carcinoma. thanks to the pathology that guides us better. I propose to do a large et deep excision and do a control of the sample. Treatment of other pathology found on the man is necessary too and the following schedule program has to be respected.
2 key points to make here I think: 1) in patients like this, with so much going on and so much obviously seb k that it is easy to switch off and assume everything is seb k…….it may not be! and 2) you must always biopsy (and a good sized piece) before treatment. It would be easy to dismiss this lesion, or assume it is “just” actinic keratosis etc
This case well reflects the literature that diagnosis of amelanotic/hypomelanotic melanoma is always challenging. They can mimic with wide range of deceptive appearances such as inflammatory dermatosis and common cutaneous neoplasms, and therefore, it is called sometimes a great masquerader.
Ref: doi: 10.1007/s40257-018-0373-6; PMID: 29141067