Case discussion: How would you treat this patient? [28 November]

In this week’s discussion, submitted by Dr Robert Teunisse, we look at the case of an 85-year-old male patient who is deaf, and his granddaughter communicated that this 25mm lesion on his right thigh has grown over three weeks.

What do you think, and what would you do?

case discussion

Update:

This lesion was excised as suspected exophytic squamous cell carcinoma with 5mm margin in ellipse. Here is the pathology result:

case discussion

case discussion

 

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21 comments on “Case discussion: How would you treat this patient? [28 November]

  1. Excisional biopsy. SCC, pyogenic granuloma less likely due to age , nodular melanoma would be in my differential .

  2. Rapidly growing fungating lesion. Excision biopsy. Further excision or specialist treatment may be required depending on the diagnosis. Differential Diagnosis 1. Poorly differenciated Squamous Cell Carcinoma. 2. Merkel Cell Carcinoma 3. AMelanotic Melanoma 4.Unlikely Pyogenic Granuloma

    1. Is the area with tumor had normal skin or unstable scars???…..I will go for incisional biopsy first….then I’ll leave the wound open….wound care, till the biopsy results to plan for wound closure

  3. Looks like a squamous cell carcinoma
    Punch biopsy first to get an idea of the actual histology
    Then excision with suitable margins based on histology

  4. Picture 3 more clearly delineates the carcinoma,irregular proliferating growth pattern probable SCC –needs excision, even if it was benign, to enable better care at age 85– 5mm margin

  5. Clinically most likely Squamous cell carcinoma confirmed by a punch biopsy followed by 2-3 mm ellipse excision.

  6. The history of this patient age 85 and the rapid growth within 3 weeks would make me think of nodular melanoma. Excise to rule out.

  7. Excision biopsy first to get diagnosis
    DDx.Pyogenic granuloma or more likely in combination with underlying SCC or BCC requiring wider excision.depending on histology.
    Merkles cell cancer- last I had of those in elderly was fast growing very fleshy and vascular, adherent to underlying tissues and very tender. That would need speciaist input and consideration for wider excision and radiotherapy.
    Melanoma always a possibility and concern but is it that fast-growing and produce the mushroom appearance? Usually more solid nodular appearance.
    I have seen a BCC in high morbidity dementia elderly look like this with pyogenic granuloma element making more mushroom like. Was on dorsum of foot and nursing home been dressing for weeks. I shaved off down to clean fascial surface to remove and get diagnosis. Fortunately adequate in that case otherwise would have required radiotherapy.

  8. The most likely diagnosis is a pyogenic granuloma. However, SCC is possible. I would shave (saucerize) the lesion and wait for the biopsy result before further excision.

  9. The diagnosis likely pyogenic granuloma. However scc is possible, I would save the lesion and wait for the biopsy result before further excision or specialist treatment. I have see a BCC in high morbidity dementia elderly look like this with pyogenic granuloma element making more mushroom like. I think operation.