Case discussion: How would you treat this patient? [16 May]

This week’s case discussion, submitted by Dr David Stewart, features a 49-year-old female patient who came in for a routine skin check. She is unaware of the lesion below her bra strap.

How do you evaluate this, and what would you do next?

case discussion

Update

Here is the pathology result. What are the treatment options for BCC of this type and location?

case discussion

– Prof David Wilkinson

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25 comments on “Case discussion: How would you treat this patient? [16 May]

  1. Lesion arising from solar lentigo has polymorphic blood vessels, white structures and some pigmented globules. DDx: melanoma vs SCC. Excisional biopsy with 2-4 mm margins required

  2. Chaotic lesion. Coiled and serpentine vessels. White lines.

    Management – excisional biopsy with 2mm margins ?malignant melanoma

  3. The lesion as an ugly duckling and is asymmetrical.
    Can’t name it outright however it is suspicious mainly because of the abnormal vasculature – arborising and serpentine (polymorphic) blood vessels. Also crystalline white structures.
    Would lean towards BCC but in any event at minimum a punch biopsy and then excision depending on the result.

  4. Polymorphic vessels ( dotted and linear irregular) and shiny white polarized white lines.
    There is some pigment there
    Hypomelanotic mm> PBCC

  5. Not a great photo, can’t zoom to dermoscopic magnification, but think that this lesions shows both:

    Benign features:
    – Keratin horn cysts of a Seb Keratosis dermoscopically
    – macro suggests a benign pigmented naevus

    Worrying features:
    – Asymmetry of colours (2or3) structure
    – Loss of pigment network
    – depigmentation (=regression?) white structures

    Management Plan: Excision Bx with 2mm lat margin & cuff of fat

    1. If you zoom using the Zoom feature in your browser you can have a proper look. Usually in the settings option in the top right hand corner 😉

  6. light brown to yellowish structure less areas containing asymmetrical globules and areas of erythema, need to follow after 3 monthes

  7. Suspicious lesion. Pigmented globules with white structure and blood vessel.
    ?BCC? Bowen’s? Melanoma

    Management- Ecxision biopsy with 2mm margin.

  8. Hmm, a little trickier but there is definite pigment as well as white areas, vessels, very irregular. Excision biopsy – could consider a simple excision biopsy with explanation to the patient that further surgery may be necessary

  9. She was unaware of the lesion but we do not know when she had her last general skin examination. The lesion is macroscopically a pigmented macula and the dermoscopy presents an image more than 6 mm wide that is irregular in color and asymmetrical with vascular structures. The 3-point checklist score is 2 . I propose a deep and wide excision of the 4mm margin of the lesion and take the sample to the pathologist with all the available information. The dermoscopic image pleads for a BCC.

  10. While a higher resolution may be more definitive, there are a few aspects, as others have mentioned, which indicate possibly a melanoma or MIS. The asymmmetry,small clods and variation in pigmentation, arborization of vessels. Because these are not uniform throughout the lesion, a punch biopsy may not get a good enough ‘representative’ sample. Would therefore favour an excision biopsy with a 2 mm margin.

  11. Excison biopsy 2mm margins. Features: Illdefined margins, irregualr border, peripheral dots, pink & brown makes you frown colour, white lines, coiled blood vessel, non-pigmented patches. ‘Malignant Melanoma’

  12. Shave would have been appropriated to establish diagnosis on this collision lesion. concern is if multinodular BCC as on backs they just seem to be so widespread and often recur and with incomplete margins. Will do wide excision as nit sure as to the exact histo

  13. Once again, with hindsight – but I did decide without looking at report!!!

    Does it blush with alco swab (I do love that little ‘test”)?
    Poor border and little deposits of pigment and vessels again and some ?depigmentation, white lines

    Shave or C&C