Case discussion: How would you treat this patient? [20 December]

In this week’s case discussion from my own practice, an elderly gentleman with long-standing chronic solar damage and multiple keratinocyte cancers presents for a skin check.

I found this on examination. It was firm and he was unaware of it.

  • Elderly male
  • Multiple keratinocyte cancers
  • Lesion found on examination

What would you do next, and what do you think it might be?

case discussion


I did an excision biopsy and the report was a benign cyst.

– Prof David Wilkinson

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24 comments on “Case discussion: How would you treat this patient? [20 December]

  1. Asymmetrical keratinized lesion with mild ulceration ,eccentric structureless area
    2 mm excision biopsy to rule out melanoma

  2. Pigmented Seborrhoeic Keratosis
    ? Melanoma
    The keratinised margins with central crater like ulcer ? BCC
    Take a Biopsy and follow the results

  3. pigmented AK- can do a punch to exclude well differentiated SCC, if positive aim cryotherapy on a fortnightly basis until better. i have achieved excellent results with cryo

  4. An 80 year old with lots of previous SCCs who gest an odd looking grey papule, all be it with a bit of scale but no hard signs of SCC/BCC, one would need to at least consider the possibility of Melanoma. Excisional Biopsy 2mm margins for me.

  5. pink and brown maks me frown!
    This lesion has many suspicious features.
    shiny white lines.
    Atypical pigmentation with peripheral globules
    erosion with crusts.
    Biopsy with 2 mm margin

  6. I see background sebaceous hyperplasia and I suspect the white area is a small seb cyst.
    However there is pink and grey and a vessel at 6 o’clock. There is scale and a dark centre. ? pigment ? sebum plug
    Excsisional biopsy 2-3 mm. is required

  7. Looks to me like a collision lesion between a keratinocyte cancer(upper left) and a seb k(lower right). I would excise both as one(with appropriate margins for BCC/SCC,but you could go down the biopsy followed by excision path as an alternative.Stay away from deep cryotherapy if you think there is ANY possibility of keratinocyte cancer,especially SCC.

  8. Firm pigmented lesion in severely damaged skin is a nodular melanoma until proven otherwise. Excision biopsy with 2 mm margin

  9. Thanks for your comments. I wasn’t at all sure what this was, when I examined this gentleman. I was thinking BCC, but I saw plenty of keratin, but was also wondering about “other more nasty” tumours. So, i did a biopsy – I used a large punch biopsy tool, to remove the whole lesion and closed the large hole with a single suture. Report was a nodular BCC with clear margins, and so no further treatment is needed. Thank you all for your cases and comments during the year – more to come in 2022, and I intend to share more cases from my own practice, and will expand the style beyond individual lesions

  10. We should assess the extension of the carcinoma in the body because we have many lesions. I think that we should let him ignore the diagnostic and tell them to his relatives then undergo symptomatic treatment when it will be necessary.

  11. It looks like a bcc although lumpy(could be the Seb K next to it), I would shave biopsy it only reason being if it was melanoma, I don’t want to inject the melanocytes