Case discussion: How would you treat this patient? [6 June]

In this week’s case discussion, submitted by Dr David Stewart, we look at a 58-year-old male patient with a lesion on his foot that was thought to be from rubbing of his shoes. It has been present for three months.

What do you think, and what would you do?

case discussion

Update

Here is the pathology result. What next?

case discussion

– Prof David Wilkinson

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25 comments on “Case discussion: How would you treat this patient? [6 June]

  1. Gray color/dots …white crystalline strictures …….pigmented nevi on periphery……erosion……definitely needs biopsy to rule out melanoma or SCC

  2. Looks like a dermatofibroma, but some atypical features – would do a punch biopsy 3mm to exclude a BCC

  3. Not very clear to comment on though. I can see some subtle branching / polymorphic vessels ? And two ulceration areas. The brownish periphery I don’t know how to comment – is it pigment ?? Anyway would excise to rule out BCC vs AMM.

  4. Peripheral pigmented areas at 12, 3, and 7 o’clock which look like atypical networks with large central white area which could do for regression.

    Would consider the lesion as suspicious. Given the poor healing area I would to two punch biopsies. SCC even BCC a possibility.
    If the results were negative for skin cancer I would then consider excision biopsy with 2mm margins.

  5. The way the light catches the surrounding skin on the macro picture makes me think there is some tethering going on suggesting something with high cell turnover. I also think the distribution of pigment across the surface of the dorsum is not randomly distributed and may be related to this lesion.
    I don’t find the dermoscopy that helpful here, could be anything. I’m inclined to do a good sized punch right in the middle.

  6. Painless and Non healing for 3 months. Suspicious. Will biopsy and check it out. Not sure of dermatoscope features.

  7. An ulcer that persists for 3 months, needs a biopsy clinically. Dermoscopy there is not much to show apart from an ulcer and crystalline white line. Some dotted BVs .The white circles on red could be just actinic sun damage.
    IMPRESSION a Basal Cell Carcinoma vs ongoing Trauma vs Bowens ( not many features)
    PLAN a biopsy first , then management will be dependent on the histology.

  8. Looking again at the Clinical and Dermoscopic images, the BCC reported with the histology is likely superficial BCC rather than deeper or more aggressive. The size and location is problematic.
    PLAN I would follow up after the curette, to allow time for healing. I am not sure whether the base had diathermy treatment. Cryosurgery or imiquimod ( though could be problematic in that area ) could be used to deal with any residual BCC.

  9. It is necessary to remove the lesion as far as possible ( more than $mm margin ) and to take a sample from the bones and surrounding tissue to assess the extension of the lesion and bring all to the pathologist.

  10. Appears like a morpehaform BCC, an aggressive subtype, a WLE with 5mm margin can be done and close with a rotation flap.

  11. BCC subtype, depth and any infiltration not established as curettage only not formally biopsied. It is unknown if the cancer is cured or not.
    I would do a couple of punch biopies of the area to try and determine this including to determine if there is undeed residual tumour. Any further action other than continued observation would be dictated I think by the histology.

  12. I believe it is a SCC that needs to have an excision biopsy with 2-3mm marginal clearance, viewing for wider excision if required.