Case discussion: How would you treat this patient? [6 March]
In this week’s case discussion, submitted by Dr David Stewart, we look at the management of a tricky malignant lesion rather than its diagnosis.
An 86-year-old man was seen in 2018 with an ulcerated lesion on his nose. A biopsy confirmed nodular basal cell carcinoma. Dr Stewart referred the patient to a plastic surgeon, but the patient declined surgical treatment due to the cost.
How would you treat this lesion?
The patient was treated (reluctantly on Dr Stewart’s part) with malignant cryotherapy in 2018 and was advised to return if the BCC failed to clear. He next presented in 2022 post-pandemic claiming “the freezing didn’t work”, still adamant that he did not want surgery and just wanted to try freezing again. Dr Stewart persuaded him to try Aldara instead.
Update #2 (final update):
Photos show pre-treatment, reaction during treatment and results 1 week post-treatment. (Some pictures sent by patient so apologies for poor quality). 1 week post-treatment there was no sign of residual BCC with dermatoscope.
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18 comments on “Case discussion: How would you treat this patient? [6 March]”
Curretage and Electrodessication would be my first choice, As it seems deep I don’t think 5 Fu would be ideal ? , I’ve read that sonidegib a hedgehog drug can be used for more invasive BCC but I would try C & E first , and there is always A Go Fund Me page to raise money for surgery !
Biopsied in 2018 with refusal of treatment – he’ll have no nose left to do anything with!
I’d have referred him for radiotherapy
At this age, I’d agree with you and it would also deal with any nerve involvement.
That’s assuming he’s up for going to the hospital 5 days a week for 6 weeks…..
Curettage and Cryotherapy -possibly the best choice
Has colloidal gold still has a place in treatment of BCC?
Inject some local near the BCC.
Excise the small bcc with 2 mm margin
Suture with 4.0 or 5.0 x 2 0r 3 sutures.
Charge Medicare Item 31356 and get about $200.00
Send specimen to histopath
Remove sutures 10 days to 2 weeks later
Review histopath 1 week later – result – complete excision of nodular BCC
Tell patient that had complete excision and that he his cured.
Result : one grateful 86 year old gentleman with a cosmetically perfect nose for his age.
I do this on a daily basis using disposable instruments.
Of course I agree with you , but for a medicare rebate? NiTak
I would be more persuasive and tell him that surgery gives the best chance of cure of the cancer.
And then offer him a bilobed double transposition flap which would being about cure and an excellent cosmetic result.
cryotherapy 4 weekly until dissapeared is an option, or else radiotherapy
Better to refer to specialist for emphasis on need of surgical removal ( unless 5 year expectancy of life is quite low)
can’t you clearly see the patient refused surgery ? why you pushing that on him lol he aint doing that . when someone doesnt want something in australia you should never force it, i have 99% cure rates for BCC with cryo and even for some SCCs
I think more history is needed. Is it really the cost that is causing him not to have it excised? Or are there other factors? Because there’s plenty of GPs who will excise and skin graft this with very little to no gap.
There are plenty of GPs who will do this for little to no gap. Excision and skin graft +/- nerve blocks for anaesthetic will pay easily $600 and take less than an hour.
This is an ideal case for a curette with diathermy, to the base. Surgery excision would be the first choice, re the location, but a curette is a good option re his age and cost, with a good chance of a cure. My results from a curette and diathermy to the base (dangerous locations and nodular BCCs, rather than infiltrative, morpheic and sclerosing sub types excluded) have a greater than 95% chance of a cure. This nodular BCC is in a dangerous location, but considering the factors above a curette would be acceptable.
Curette is a good option for the elderly, with quick growing even some time large keratoacanthoma sub type of SCC.
I would suggest excision under local anaesthetic as a slow Mohs procedure and once it is all clear close with a skin graft. The local skin does not look healthy or good for a flap. Otherwise it needs a rebiopsy for the Radiation Oncologistc and referral for Radiotherapy
Cases like this often do extremely well with electron beam radiotherapy. The patient is over 80, so this could be an excellent choice for him, provided he’s willing to attend the radiotherapy unit every weekday for around 6 weeks.
Certainly, I think radiotherapy would be a much better option than “malignant cryotherapy” in terms of success rate and recurrence rate.
Some times it seems all too easy to be critical , yet sometimes the patient appears not to realise the significance if the issue , and what is required to correct it.
For myself there is no alternative other than the appropriate treatment, if the patient declines then one ought not apply therapies in which one has little confidence ( even if the patient insists) -because you will still be held responsible.
Cryotherapy is for cavemen , in 1922 anaesthetics were given with chloroform and “dry ice” was used .Today 100years later, no anaesthesia is applied with chloroform , so why are we still persisting with such old technology for skin lesions? Yes it may work but so does chloroform.
If the patient declines your advice , and that is all it can be, then they should be advised to seek another opinion.
As to “cost” and “affordability” in the words of Scheherazade ” that Sahib is another story”
The patient a biopsy confirm nodules basal cell carcinoma. The surgery give the best chance but the patient declined. So I have a lookup information Libayo(cemiplimab) is (PD-1) block antibodies, treatment of skin cancer (SCC. BCC) Treatment lung cancer (NSCLC ). Approved: Since 9/2018 ( FDA) USA. SCC. 9/2/2021 BCC. Since 28/6/2019 (EMA ) EUROPE BCC.
Only the pathologist can confirm cure, the dermatoscope while being helpful, cannot