1300 856 695
+44 203 514 0688
1800 867 1390Case 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?
Update
Here is the pathology result.
– Prof David Wilkinson
We encourage you to participate in the case discussions and submit your own clinical images and questions, so we can all learn together.
1300 856 695
+44 203 514 0688
1800 867 1390
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.
BCC (Diff Dx : Melanoma) . Next step is to proceed with primary excision with minimum 5mm margins.
Full excision required 2mm margin ? Melanoma
Nodular BCC .
complete excision with 4 mm margins all side and send for Biopsy .
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.
I would do excision biopsy , features of BCC
Looks like nodular BCC. My approach will be excisional biopsy with 2-3 mm margins
I think it’s a BCC and could be shaved or excision biopsy performed.
Options:
Shave excision
*
Surgical
Since it’s on the back-I would probably SxEX
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
Excise with an adequate margin and send for histology
Shave biopsy and send for histopathology
Looks like Basal cell carcinoma
Nodular BCC. Excise.
DSM shows a quite big tortuous and branching vessels with area of ulceration.
excision,3 mm margin ,BCC
Can’t resist. Just between US its PINK, resembles a BCC but isn’t (anymore)
?nodular BCC
I would do a wide excision and send for histology
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
EROSION WITH ARBORIZNG BLOOD VESSELS WITH BLUE GRAY GLOBULES
BASAL VERSUS CARCINOMA
PUNCH BIOPSY
May be a BCC. Will in any case excise with 2mm margin and send for histology
? Nodular B.C.C – 4 mm margin excision
1.arborising vessels,
2.ulceration.
3.white crystalline structures
BCC
for excision
Arborizing vessels
Bcc??
Excision
An Ugly Duckling if ever there was one!
Likely nodular BCC but possibly amelanotic MM
Excise with 3 mm margins
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 🙂
Nodular BCC, can be excised fully or deep shaved. Arborisation evident visibly without dermoscopy given the size
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
Infiltrative subtype needs wider excision. Would reexcise with 5mm margin all around and down to superficial fascia instead of just fat.
As deep margin is involved needs re-excision. I would discuss whether patient wants me to do it or refer to specialist
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