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1800 867 1390Case discussion: How would you treat this patient? [5 September]
In this week’s case discussion from Dr Terry Harvey, we look at a 70-year-old patient who recently had a halo split thickness skin graft on the left anterior leg to remove an infiltrative BCC. Histology margins were clear on that excision. He presented 8 weeks later as a new nodule had started growing out of the site of the skin cancer removal.
What do you think, and what would you do next?
Update:
This was diagnosed as invasive SCC occurring in a graft scar and excised with a keystone flap repair. Margins were clear on that excision too. These final images are six months post-operatively.
– Prof David Wilkinson
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1300 856 695
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1800 867 1390
Appearances are of a recurrent BCC, the original lesion was infiltrative. The alternative is that a new BCC has grown out of the halo graft skin.
Punch biopsy and review.
re excise with full thickness graft and wider margins
It’s quite common to have lepidic growth especially if this was a previously inadequately treated lesion, with skip lesions.
Sometimes these nodules are haemorrhage in a new scar or foreign body reaction to sutures.
K would punch it for a histological diagnosis and go from there.
Whether this is a Basal Cell Carcinoma or a Squamous Cell Carcinoma it is difficult to say from limited dermatoscopic vessel visibility. It i not a good idea to do a Halo Graft here as the sorrounding skin is sun damaged and there is a high risk of new malignancies arising. This is most likely a separate NMSC arising from sundamaged skin in the halo graft or a recurrence as Infiltrative Basal cell Carcinomas need wide margins to ensure clearance. There are 2 options.
1. Punch Biopsy to check diagnosis as to whether this is a BCC or SCC amenable to Radiotherapy
2. Complete excision with a dressing and delayed Slow Mohs result with a few to performing a remote site eg Anterior thigh Split Skin Graft once complete excision is confirmed.
The lesion with asymmetrical shape and colour, hypertrophic skin, hyperkeratosis, scarring looks like SCC and that needs to have biopsy in view to get confirmation then complete excision.
Shave biopsy
If BCC excised with wide margins at least 3-5 mm, and STSG, going to do a graft anyway may as well take enough
Halo: probably harvested BCC from the adjacent skin??? Field effect!
The significant sun damage to the skin does raise the possibility of an BCC/SCC in the split skin graft. Therefore would excise marked lesion with mimimum 2mm margin and close with an Zplasty or H plasty/advancement flap– with 2 punch biopsies of previous distal flap .
Appears to be trauma induced well differentiated SCC lower leg- can do a punch to confirm
This may be a KA growing on the traumatized skin. Or possibly a granuloma.
I would re-scollop it with a new halo graft and send for histo.
Hyperkeratotic surface that fits SCC vs BCC. Needs excision biopsy to find out.
DARK BLUE CENTRAL BLOOD SINUSOIDS, RAINBOW COLOR
?? KAPOCI SARCOMA
Well : its only 8 weeks post op on a lower leg. If it is a BCC thats only local. I cant see much lost waiting 3-4 weeks , Initial biopsy in healing wounds are less accurate ( often reactive . Consider serial photography and making sure patient is not lost to follow up. Flaps are good, but second attempts are high risk.
Wait a few weeks , biopsy then if needed and reconsider. It depends on the patient : how much you trust them and how much they trust you.
SCC-Iwould do a wide excision biopsy to be on the safer side.
SCC
I would do a punch biopsy first because the history says it’s only few weeks post op.
If it’s SCC then I will refer to a plastic surgeon. Too much headaches dealing with below knee large lesion in a 70 year old patient.
If I have to deal with it myself I’ll do a split graft or secondary intention.
Agree that surrounding sun damaged skin is a relative contra-indication for Halo graft.
Given initial histology – infiltrative would favor recurrence of same, but appearance also consistent with SCC.
I would biopsy first – large punch or deep shave.
Alternative to FSG for this site is use of parallel incisions to reduce tension on main lesion.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5889464/
I would do a punch biopsy to rule out new/regrowth of BCC or SCC.
Clinically, 8 weeks post-split skin graft, for a completely excised infiltrative BCC, a new raised keratotic lesion. The image with the dermatoscope, shows a central hemorrhagic keratin crust, on a slightly indurated nodule with some white structures esp. white circles. No obvious BCC features = likely a SCC for actinic sun damage on the split skin graft.
IMPRESSION = a SCC until proved otherwise, the size makes an elliptical excision possible, with, if possible, a 3-4 mm margin, otherwise a 2mm margin.
PLAN= Elliptical excision, rather than mucking around with a punch biopsy.
Thanks , elegant solution.
Hi !!
I think that the initial lesion did not correspond to a basal cell, review the histopathological slide again and remove this with elliptical exicion 0.5 from all edges thinking in Agressive SCC or Keratoacanthoma. Wait the results and decide .
Interesting case – and lovely end result!