Case discussion: How would you treat this patient? [14 November]

This week’s case discussion, submitted by Dr Robert Teunisse, features a 48-year-old male patient with an elevated, firm and growing lesion on his right hand. There is a previous BCC excision adjacent to this lesion.

What do you think, and what would you do?

case discussion

Update:

Here is the pathology report. The patient was referred to a local melanoma surgeon who did a wide local excision and lymph nodes from elbow and axilla.

 

case discussion

 

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20 comments on “Case discussion: How would you treat this patient? [14 November]

  1. fULL H/O AND EXAMINATION AND FOR THOROUGHNESS INCLUDE IN EXAM FOR ANY PALPABLE LYMPHADENOPATHY IN TH EVENT THIS COULD POSSIBLY BE ANOTHER COINCIDENTAL SKIN CANCEROR EVEN A BENIGN LESION
    NEEDS PUNCH BIOPSY
    DD BCC SECONDARY TO PREVIOUS PROVEN ADJACENT BCC

  2. The overlying skin is intact .Dermoscopy shows peripheral pigmentation , could be Dermatofibroma . To be confirmed clinically through the pinch test .

    .

  3. Nodular lesion at the site of a previous proven BCC.

    It would be of interest to know the histology of the previous lesion that is was it an infiltrative or micronodular BCC, if the margins were insufficient then recurrence was likely, and indeed what were the margins of the original excision.

    The current lesion is white with pink periphery and maybe just a few abnormal vessels.

    It as least needs a punch biopsy to decide if dermatofibroma or BCC. He may wish if it is a DF to have it fully excised anyway.

  4. It’s a non-specific nodular lesion. unfortunately dermoscopy can’t help much with nodular lesions. could be SCC? BCC? hypertrophic scar? or even nodular non melanocytic melanoma.
    I would excise that lesion with 2-3 mm margin and send it off for pathology review.

  5. Clinically a nodular dermal/sub dermal lesion. A dermatofibroma does not keep growing.
    Dermatoscopically nothing to see, as this process is dermal/sub dermal.
    IMPRESSION= a clinically growing nodular lesion in a troublesome area, the dorsal hand, needs to be removed. There is a wide spectrum of possibilities like a neurofibroma, adnexal tumor and a cutaneous sarcoma. BCC spread would be unlikely unless a very aggressive sub type. (Histology of the BCC and margins would be helpful)
    PLAN = easy to remove with a simple elliptical excision. Further management will be based on histology.

  6. EFG, need excision with 2 mm margin, looks like dermatofibroma but could b amelanotic melanoma or nodular bcc in view of EFG