Case 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?

case discussion

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.

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– Prof David Wilkinson

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20 comments on “Case discussion: How would you treat this patient? [5 September]

  1. 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.

  2. 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.

  3. 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.

  4. 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.

  5. 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!

  6. 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 .

  7. 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.

  8. 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.

  9. 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.

  10. 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/

  11. 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.

  12. 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 .