Case discussion: How would you treat this patient? [13 June]

This week’s case discussion, submitted by Dr Jagtaran Singh, features a 60-year-old male patient with a slow-growing lesion on his back.

What do you think? What would you do next?

case discussion


Here is the pathology result.

case discussion

– Prof David Wilkinson

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29 comments on “Case discussion: How would you treat this patient? [13 June]

  1. Appears like an irritated dermal nevus
    in view of ulceration with blood spots and a growing lesion in an adults (Chaos & clues: exceptions)
    Excision biopsy with 2mm margin is prudent.

  2. Incredible- the arborising blood vessels are easily visible to the naked eye dermatoscope not needed. On dermoscopy, a pink white lesion with crystalline structures, ulceration, arborising vessels, and scale so BCC for sure.
    So it’s a polypoid BCC that must be excised. Punch biopsy not really necessary except to establish the type of BCC which would dictate margins.
    That said likely a nodular BCC so simple ellipse with 2-3mm margins would do. I would be prepared to do this and advise the patient may need a further excision for margins if histology produced a surprise.

  3. Visible blood vessels and polypoid form have to think BCC –excise 4mm margin—have seen and excised similar polypoid shapes prurigo nodularis in patients with excess tattoos, but have not had vessels visible

  4. Nodular BCC. Excise.

    DSM shows a quite big tortuous and branching vessels with area of ulceration.

  5. I will cut it out as I am sure he does not want it and send for histology. Does not look malignant. But that is why we get histology


  7. An Ugly Duckling if ever there was one!

    Likely nodular BCC but possibly amelanotic MM

    Excise with 3 mm margins

  8. Cut it out as I am sure he does not want that lesion anyway. Send for histology Does not look malignant to me but that is why we have histology 🙂

  9. Nodular BCC, can be excised fully or deep shaved. Arborisation evident visibly without dermoscopy given the size

  10. Two options and might depend upon where on the back it is and after discussion with patient

    It has decent serpentine vessels and ulceration under derm SO
    1. Shave and send for histo – patient aware if BCC etc will need re-excision, depending upon how deep shave was etc
    2. Excise with 2-4mm margin with deep dermal closure to prevent opening etc later – location dependant

  11. Infiltrative subtype needs wider excision. Would reexcise with 5mm margin all around and down to superficial fascia instead of just fat.

  12. As deep margin is involved needs re-excision. I would discuss whether patient wants me to do it or refer to specialist

  13. Usually, as recommended in all the appropriate guidelines I like to have a “diagnosis” before I “treat”. Sometime, like in this one, I would get a diagnosis at the same time as treating – by excision. The trick in this situation is to make sure you take appropriate margins, both wide and deep, so that (as often as is possible) the patient only has one procedure