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

In this week’s case discussion, we revisit a very engaging case from Dr Kyung Lee (Bruce) featuring a 77-year-old female patient with a lesion on her lower left leg.

Please review the clinical and dermoscopy images. What is your evaluation, and what would you do next (if anything)?

Case discussion

Case discussion Case discussion

Update

The treating doctor applied liquid nitrogen, and the lesion now looks like this. What would you do next?

case discussion

– 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.

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

  1. A large 1.5cm elevated verrucous lesion. No given hx of sudden change, however there is a cribriform pattern with gyri and sulci and crypts with keratin/crust. However it has milky pink /blue globules with out of focus polymorphic BVs + Blue/black features.
    The diagnosis is an irritated Seborrhoeic Keratosis vs a Verrucous Melanoma vs a SCC, so a Melanoma or a SCC needs to be excluded. If it is a Squamous Cell Carcinoma, it is a keratotic raised lesion with some polymorphic BVs. no white circles or halos or radial hairpin BVs.
    PLAN = excision biopsy for histology.

  2. Appears to be seb ker if recent change could be SCC or BCC under it adjacent to it so punch biopsy or shave bx could be performed to avoid needing an unnecessary Halo graft

  3. Macroscopically it has the appearance of a SK ,however a Verrucous SCC would have to feature in the diagnosis,and the microscopic appearance of islets ,cribriform patterns and irregular pods of tissue favours this diagnosis .Surgical excision 2mm clearance possible Z plasty to close

    1. It appears to be an irritated Seb. Keratosis. Would do a short follow up after using topical steroids. If it becomes clearer that it is a SK, leave it, if there still are doubts, then shave biopsy.

  4. I am not very sure what is it. I can see some surface scales with division and some small purple lacunae like. I would think between irritated SK vs SCC. Either the way excise to rule out.

  5. blue grey ovoids nest
    browen globules and dotes asymmterical
    sws
    i think car wheel strucures

  6. It could be a simple Seborrhoeic Keratotic lesion, however there is not enough dermoscopic detail, so I would rather do a shave biopsy to exclude a possible atypical KA or other non-benign lesion and then treat it accordingly.

    I would also do an examination to check for any inguinal lymphadenopathy

  7. The macro exophytic nature suggests SCC, with peripheral vessels. DDx : Verucca or Seb K
    2 Punch biopsies from the edge . If SCC go to flap or halo graft

  8. likely to be seb k but might have SCC underneath. Given the location of the lesion and prolonged healing issue its best to refer to plastics for excision or else shave and do a halo graft

  9. I will bring the lesion to the pathologist for confirmation of the diagnosis and treat the wound . The remaining pigmented lesion will be follow up . i suspect a KA

  10. Looks to be healing nicely, could be fixed : but book an appt for 2-3 months and photodocument
    Low threshold to biopsy , and if returns : Donot retreat with N2

  11. Suspicious pigmentation not expect to find if Veruccous Seb k. Blue / white areas. Suspicious for melanoma. Hence excise lesion 2mm margins

  12. The Doctor looking after this patient obviously thought it was an irritated seb K, so the lesion was treated with cryosurgery . There is always a risk on the leg is cryosurgery depth is not managed , you will end up with a deep ulcer. I just looks like a post cryosurgery ulcer, so I will treat this with appropriate dressings and management for an ulcer, if it does not heal or if any red flags I would biopsy the lesion.

  13. Differential diagnosis would id be
    Hypertrophic Seb Keratosis
    Nodular BC
    SCC
    I would do a shave making sure to include the base of the lesion and send it for pathology