Case Presentation:

82 year old diabetic male presents on emergency admission to the office with complaint of new onset lesion to his anterior leg.  Patient is non-compliant with his "hands" and has eroded the dorsal surface of the lesion by scratching.

He has related that the lesion "sprung" up approximately 1 week ago. 

Medical History

Significant for NIDDM, HTN.  Medications include Metformin and Lisinopril, No allergies. 

Patient is an avid golfer, and plays approximately 3x/week in South Florida.

No other medical history or treatment history is pertinent.

Patient incidentally, has an appointment with his dermatologist 2 hours after this emergency visit at your office.

How would you manage this case?

Considering this history,and the clinical image, i would definitely be concerned and would advise an excisional biopsy to completely remove the lesion, being mindful to evaluate for any tracking or extension into the deeper tissues.  Initially, i would start with a  3-1 ellipse of skin to allow for wound closure.  If the margins come back malignant, you can always go back in and take more.  It is important to tag the specimen to be able to maintain the orientation, should you need to return and take wider margins.

Great case--thanks for sharing with the community!  I look forward to hearing how it turns out!!

Ryan,

Good plan.  However, in today's day and age of defensive medicine, the prudent treatment is to plan for incisional punch biopsy or even a shave biopsy in-office.  Send the specimen to Dermatopathology of choice, then plan for excision of lesion exactly as you have outlined.

Remember, its easier to plan surgery when you know WHAT you are dealing with.

Eric,
Why are you so adamant about your choice? I would have thought that the "fly in the ointment" would be the fact that the patient was headed to the dermatologist in 2 hours and she/he would have preferred a virgin specimen from which to make a diagnosis.

I would have no doubt that the dermatologist would take the entire lesion through a shave biopsy for diagnosis and worry about a cosmetic closure later, if at all, in this patient.

I look forward to hearing your reasoning. 

I am with Ryan. I would just do an excisional biopsy, close the wound primarily, then send the specimen to the pathology, while tagging the orientation. 

If the patient wants the 2nd opinion from his dermatologist, I think that is perfectly fine. They would probably choose the same treatment anyways, I would think. 

Just my 2 cents... 

I'd have to weigh in on the side of Kazu and Ryan.  I'd excise the lesion also (assuming the patient wants me to do it and not the dermatologist).  I'd probably still have the patient see the dermatologist (CYA in this litigious country) anyway.  The incisional biopsy, though, is reasonable too.  You haven't burned any bridges with this.  I would disagree with the shave biopsy.  The pathologists I trained with talked me away from shave biopsies for pigmented lesions, because you can't determine depth of invasion.  Dr Bakotic would disagree with this, I believe, as he's lectured before on the ease of shave biopsies, leading to more biopsies, leading to more pathological diagnoses.  I would also culture it.  "Biopsy your cultures and culture your biopsies."

I reread my submission later and imagined my colleagues probably thought I was being a real wimp, not wanting to clash with the big scary M.D. dermatologist. I wanted to tell you what my mindset was.

While at the University of Texas Health Science Center at San Antonio I had a case of a probable malignant melanoma of the distal hallux. I would have bet my house on this one. The chair of my dept. was an ortho. oncology surgeon. I did a proximal hallux amp., asking for additional information that he would need for cellular ID and staging. The resident and I thought we had the bases covered.

Although he did not go ballistic, he was not happy with us. He gave me a mini-lecture on the importance of going into a case like this with staging in mind, how he would have done this case in a definitive manner. I was looking for an interesting case for my resident.

This did not alter the treatment for the patient in the end. He did not take her care on to an amputation or nodal dissection immediately. There were more diagnostic tests certainly. I was in academic hot water for a while.

In private practice though, this might open up an opportunity to work with the dermatologist OR it might raise even more turf battles, since dermatology is one of our sub-specialties?????

Yes we can certainly propagate this case for the patient by performing incisional or excisional biopsies and obtain tissue diagnosis but if there are any clinical signs of malignancy, I usually send this to a surgical oncologist.  If he thought this was malignant we would proceed to the OR together.  He would perform the excision and sent for frozen section, achieve definitive margins and I would perform soft tissue reconstruction for closure.  He would do the necessary follow up for further oncologic networking (chemotherapy, radiation etc. literature at most of us don't keep up with on a daily basis)  This relationship has worked well for us for many years. I am not an oncologist and do not excise potentially malignant lesions every day.  Pathologists get upset when they get a specimen that is a malignancy and they find out your protocol for wide versus radical excision is not to immediately follow because you already closed the patient and sent them home.  From a medicolegal aspect, if you wish to perform this type of work be very familiar with parameters for marginal, wide and radical excisions. Remember they are not the same for every lesion and treatment / surveillance for the patient usually does not end with taking of the suspicious lesion.  Wide excisions for a high grade lesion in the forefoot is not 2 cm excision but potentially a foot amputation.  

Sorry I have been out of touch lately, I am recovering from back surgery....

Kathleen,

I guess becuase of where I practice (Florida) I tend to lean to the aggressive nature to fully resect en bloc the lesion after obtaining an incisional biopsy.  

I see plenty of patients daily that have been to the "Mohs Dermatologist" and have been referred for "non-healing wound" after they have been chopped up.

I prefer for my patients to undergo the en bloc resection by me, a surgeon, rather than an internist who "dabbles in skin surgery".
 

Dr. Bakotic advocates for shave biopsies for subtle lesions, not those that are highly suspicious for malignancy. It isimportant not to misquote him. He clearly advocates for punch or incisional for a case like this, which is hardly subtle and has a good chance of being problematic.

Bryan C. Markinson, DPM