Case discussion: How would you treat this patient? [25 July]

This week’s case discussion, submitted by Dr Terry Harvey, features a 65-year-old male who presented between regular skin checks with a new sore lump on his scalp.

What would you do next?

case discussion case discussion

Update #1

The biopsy showed invasive SCC. What would you do next?

Update #2

Here is the surgical outcome!

– Prof David Wilkinson

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

  1. Pink white lesion on a heavily sun-damaged scalp a few abnormal blood vessels ?BCC
    For excision depending on histology

  2. White lines with pin point vessels ; central core. : SCC likley
    Given he has needed a previous graft ? at 9o’clock ( macro) I think he will likely come to formal excision for a SCC
    I would favour an incisional biopsy rather than shave on the scalp.
    We could then go to definitive excision of a debulked lesion with 3 mm margin (hopefully flap not graft) or consider referral or radiotherapy if the patients preferrs.
    DDX lichenoid keratosis

  3. Thickened lesion , keratitis circles and keratin, few looped vessels. Radially.
    Mostly well differentiated SCC/KA.
    Biopsy then excision

  4. Rosettes at the periphery, ulcerated nodule with yellow amorphous structures, shiny white structures on polarized light, as well as dotted/glomerular vessels- SCC.

  5. Need to consider (well differentiated) SCC. Skin might be tight but I would try an excisional biopsy with at least 2mm margins (especially if <2cm defect), understanding that i may need to undermine below the galea. But this could be a benign lichenoid lesion.

  6. The clinical presentation is more concerning re tender keratotic nodule with a erythematous raised base . Dermoscopy a central slightly hemorrhagic keratin crust , some white lines . Some clusters of dotted BVs , one linear radial blood vessel, white structures. On top of actinic sun damaged skin.
    IMPRESSION = SCC/Bowens until proved otherwise , an irritated grade 3 actinic keratosis is less likely.
    PLAN = Because of the problematic surgical location and you want to be 100% correct. I would shave the top and at least a 4mm punch biopsy to the base. Further management depends on the histology.

  7. Tender, thickened lesion with ulcer. Dot and glomerular vessels. Otherwise structureless. Suspect invasive SCC. For punch biopsy and then if confirmed SCC for excision with 4mm margins. Closure with possible rotation flap if scalp fairly mobile, otherwise SSG.

  8. Ulcerated Nodule, Tender, vessels not clear may be polymorphic, white lines some perpendicular. Surrounding skin shows field cancerisation with Erythema, white circles and Rosettes. Differential Diagnosis is Amelanotic Melanoma or Squamous Cell Carcinoma ( unlikely Basal Cell Carcinoma or a Metastasic Nodule). Background Actinic Skin Damage. Excision with clear margins and await histopathology report before further management

  9. Scalp skin severe sun damage showing a raised skin lesion on the vertex. Physically it could be KA but can’t be sure as the photo is not good enough. Dermoscopy shows a rim of grayish with surrounding whitish fibrosis and with central few polymorphic/ coiled ?blood vessels. KA vs AK?

  10. This looks likely to be SCC or Keratoacanthoma.
    I would excise this in an ellipse, with at least a 4mm clearance.
    I would close the defect with chunky 3/0 nylon plain interrupted sutures and remove the stitches at one week.

  11. Most likely a Scc, differential diagnosis bcc
    dermoscopy :keratin plug in the center, linear vessels, sticky fiber sign
    Biopsy and histophatoly needed

  12. Symmetric nodular lesion. Not a lot of clues from dermoscopy. Suspicious for NMSC – SCC or BCC.
    Possibly locally invasive SCC. Amelanotic MM also possible. I would do excision biopsy aiming for clear margins

  13. New sore lump indicating rapid growth
    Ulcerated
    White signs
    Some grey brown pigment
    ? Pigmented SCC ??? Melanoma
    At least 10 mm diameter on scalp so excision biopsy is not exactly a quick office procedure
    So at least a 3 mm punch biopsy is ok to get a provisional histo result

  14. Extensively sun damaged skin. Supicous looking lesion. Not much give in the scalp skin.So referral to palstic surgeon for excision.

  15. This is a high risk SCC.
    PLAN = will need a full surgical excision with 6mm margin and down deep down to the galea on the scalp. Because of the location and the size of the excision he will need a skin graft. Mohs surgery will be the other option.
    The histology shows an Invasive SCC but it would be good to know the depth of invasion, and ? moderate or poorly differentiated SCC, because that would also determine management.

  16. Some interesting response to this week’s case. I think the best way to handle this is a punch biopsy. It is a pink lesion, and so a punch (3-4mm) is the advice in the national guidelines. I think it most unwise to move straight to excision biopsy – you don’t know what it is! Find out what it is first, with minimal trauma, then decide on treatment. For definitive excision, margins depends on details of pathology – degree of differentiation, thickness, location, presence of perineural invasion. Surgery is the only option here – radiotherapy would only be an option if the patient is not fit for surgery. Nice repair Terry!

    1. Pennington says, “White flaps turn pink and blue flaps turn black” On that basis, a good outcome is expected for this closure.

      With respect to flap design, I am interested in the choice to have the pivot point of the flap so close to a fixed structure (Previous SSG). In my experience this has led to flaps that have not performed to expectation. Wondering if others had had similar experience?

      1. Hi Scott – nice to meet in person on the weekend!

        I didn’t give it much thought at the time. Maybe I should have, or maybe it didn’t feel like there was much fixation when I played around with the area. But a great thought and something I’ll keep in mind – I’ve thought about that with keystones in the past.

        And yes… the white turned pink

          1. It looks like I can’t get the image attached – you’ll just have to take my word for it!