Collision or all one lesion?

A case posted to the IDS forum by Baker Ron

age: 86 years, sex: m, location: head and neck

Clinical history:

Patient with no prior skin cancers, aware of brownish area R tip of nose 9-12 months, lateral aspect has bled recently. I have sent him to a plastic surgeon, advising he needs to biopsy both the lateral aspect of this lesion which has bled and which looks like a BCC to me, and the medial browner area which looks like one of the 3 amigos (LM, PAK, solar k). In the clinical shot you can see a smaller circle, and a tiny scab within it, which I advised the surgeon is hiding a separate tiny focus of BCC. There was also a neck lesion, not presented. Patient tells me he is having 3 biopsies tomorrow, 2 on the nose and 1 on the neck. So I should have some histology in 4-5 days, time to present him.

Diagnosis: suggesting BCC and collision?

Question: I don’t think this will all be BCC, what do you think?

cotm.1406.a cotm.1406.b cotm.1406.c

Comments:

Fox Gary: Rosettes and AK in addition?

Baker Ron: I’m not seeing rosettes, Gary (I’m not very good at rosettes) but I’m favouring PAK (exclude LM) for the eastern area and BCC for the western area that I’ve circled roughly in the picture:

Pyne John: There are rosettes in photo 3. The clinical photo demonstrates this pigmented area is a loner. This increases the suspicion for LM. This could be a collision between pigmented AK and LM. Anyhow……… a definite Amigo situation.

Baker Ron: Got the pathology today, but I will hold onto it for awhile on the theory this might be interesting enough to attract a few more comments.

Baker Ron: PS I am seeing rosettes now, actually quite a few, about 10 best seen in picture 3 as you say John. Guess I haven’t really focussed on them much, I don’t relate to them as having any accurate diagnostic usefulness.

Bartalini Paolo: I’m fascinated by the idea of the collision. I would vote as JP.

TZALOKOSTAS VASILIOS: I agree witn Paolo and JP.- Thank’s for the case.-

Landi Christian: BCC and lentigo?

Baker Ron: Guess that is everyone. With my telling the surgeon there were 2 separate BCCs and the pigmented area in between that was either PAK or LM, he did a series of 4 small punch biopsies:

  • Right lateral nose: sclerosing BCC being invaded by LM
  • Right medial nose: LM
  • Left medial nose (really more centrally): LM
  • Left lateral nose: nodular BCC being invaded by LM

The d-path commented: “This is a remarkable case. There is extensive lentigo maligna which invades 2 separate basal cell carcinomas (parts 1 and 4). Conceptually, though there are melanoma cells within the dermal basal cell carcinoma there is no direct invasion of the dermis by melanoma and therefore I believe that all these biopsies should be staged as in situ melanoma.”

There was no suggestion of actinic keratosis in any of the biopsies, which strengthens my view that rosettes are not helpful in pointing to a diagnosis….though maybe I will get used to looking for them now just for fun. Having been told they are there (thanks Gary and John), I count 10 of them here along the sclerosing BCC’s eastern margin and within the LM.

Others have reported rosettes in BCCs and LM, so I do not think they point to PAK with any sort of reliability at all.

Bartalini Paolo: GREAT CASE! Ron, now I am forced to raise 🙂 🙂 🙂

Pyne John: LM and sclerosing BCC – 2 mongrels having a kiss in a familiar part of the park!