Case discussion: How would you treat this patient? [15 August]

A 69-year-old gentleman presented to Dr Phoebe Chisnall with a ‘hard knobbly thing that has gradually eaten away the right ear lobe’ over the preceding two years.

What is your preliminary diagnosis on review of the macroscopic and dermoscopic images and how will you manage this patient?

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Update 1 of 2

A biopsy confirmed infiltrative BCC and the tumour was subsequently excised using a staged procedure, leaving the defect open pending histological confirmation of complete excision. The initial histology report is below. A second excision was required to achieve complete tumour clearance.

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The case was referred internally within the practice to Dr Helena Rosengren for closure. See below photo of the ultimate defect.

How would you opt to close the defect? He has a normal looking left ear lobe on the left side.

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Final update 2 of 2

To achieve the semblance of an earlobe, the defect was closed with two large banner flaps, one taken from the mastoid process and the other from the lateral jaw area. It is important to face one banner flap superiorly and the other inferiorly for easier closure of the secondary defects.

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– Prof David Wilkinson

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19 comments on “Case discussion: How would you treat this patient? [15 August]

  1. Looks like a ‘rodent ulcer’
    BCC with aborising and/or serpentine blood vessels

    For removal with a modified wedge excision

  2. Clinically a large 2-3cm erythematous raised lesion with a central ulcer, distorting the R ear lobe. This has grown over 2 yrs. Dermoscopic image, shows a haemorrhagic ulcer with polymorphic blood vessels.
    IMPRESSION=likely to be a BCC , but a more invasive SCC can look like this, but would have likely caused more damage over 2 years. A amelanotic melanoma is less likely but needs to be excluded.
    PLAN = A biopsy first because this lesion is in a high risk area(area H), if it is an infiltrating, morphoeic or micronodular BCC , Mohs surgery would be the best option. Also with managing a complex large area, we need to be sure of the histology first.

  3. Right Lower Ear Lobe. Appears to be a Nodular Pink Lesion with Central Keratin. Dermatoscopy shows some white circles and looped vessels, polymorphic vessels. Impression most likely a Squamous Cell Carcinoma. Plan excision with 4 mm margins. Closure is reconstruction of the lower ear and ear lobe with Pre- auricular Banner Transpisition Flap. I have done this repair for many such lesions including an Invasive Melanoma of the lower libe of the ear with good results.

  4. Distorted right ear lobe.
    Dermatoscope shows an ulcerated area with some branching as well as coiled vessels.

    DD: rodent ulcer/ morphic BCC vs SCC

    Excise for histology

  5. CREAMY BACKGROUND WITH MULTIPLE CHAOTIC BLOOD VESSELS HAIR PIN SEPENTIN GLOMERULAR EXCISION OF TOTAL LOB

  6. Ddx:
    1. BCC (most likely)
    2. AMM
    3. SCC
    Mx:
    Wedge ex with simple closure
    After histo dx and margins, then re ex(including cartilage), reconstruct or refer

  7. SCC or BCC ?
    pink lesion slow growing
    glomerular and arborising vessels and ulceration
    I would do a punch biopsy to diagnose the lesion then consider if I can define edges and is it connected to deep structures.
    excision looks like would remove the entire ear lobe so consider if can close the wound with remaining skin or graft or refer for reconstruction of ear lobe?

  8. Filarial worm infection
    Dermascope pictures shows tiny thread like structures.
    Can give Ivermectin or Diethylcarbamazine which can kill microfilaria or Albendazole

  9. Before any closure of the defect, there needs to be a clear deep margin. I am not a plastic surgeon so unsure in this situation if a flap, or graft would be better.

  10. A really great case to share and discuss this week, showing just what can be done, safely and very effectively in a primary care setting. A couple of key points I would make in support of the case. First, always do a biopsy before any complex procedure especially in a sensitive area. Why? Too often a BCC that looks nodular has an infiltrative component. And, as such, needs a more extensive excision with wide margins. Second, when doing a staged excision be confident in taking decent margins and don’t ever feel rushed in the whole process.

  11. I would refahion the facial area to close with modified ellipse then do full thickness skin graft to produce an ear lobe ? Using the skin from previous procedure.