A case posted to the IDS forum by Colic Sladjana

Age: 65 years, Sex: f, Location: paravertebral; lumbar region, left

Clinical history: appeared few years ago, enlarged slowly

Diagnosis: The lesion would be excised, but I m not sure for the margins? Is it BCC or MM?

Answers (comments)

Muir James: With those vessels and blue grey blotches I went BCC. Then I thought to myself, is that a negative network between 12 and 3 o'clock! Always nice to have a differential of 'malignant and needing excision' or 'malignant and needing excision!!

Baker Ron: Can't see how you can be sure of this one...go for a 4mm margin, which is usually enough to cure a BCC. Then if it is MM it will need a bigger 2nd cut anyway, bigness determined by the Breslow depth. It certainly won't be MIS, and you don't want a 10mm or bigger margin to start with if you don't need it, so 4mm makes sense and of course educating the patient of the possible need for a 2nd cut.

Fox Gary: Just to be ornery, I'm saying MEL. Could be either. I'd just tell pt narrow margin excisional biopsy, expect second procedure.

Szenczy Cornelia: I think pig BCC but cannot exclude MM so needs Bx / excision Bx / chrysalis / neg network/ telangactasia/ ulceration

Burns John: No sure signs of a melanocytic lesion for me. Go pigmented BCC. Thanks for the case and look forward to the pathology

Zalaudek Iris: triggy case - the gray globules make me however thinking more about BCC ...

Giuseppe Argenziano: to my eye, bcc

SALI Davide: Really unpleasant BCC wishing to be a melanoma. Thanks for the case and the path, when available.

Bartalini Paolo: I vote for: melanoma, excision, at least 5 mm margin. it's a very curveball!

Landi Christian: Boh? Clinically BCC.

Bartalini Paolo: Do you have the histology ? I'm very curious :) :)

Gourhant Jean-Yves: Never seen a Bcc with these reticular white lines. My guess is MM. Waiting for the path.

TZALOKOSTAS VASILIOS: BCC vs a MM ? BCC in my view.- Thank's for the case and waiting for the histo.-

Bergamo Antonella: Really is not easy! All togheter I think it's melanoma. Atipical vascular pattern... black glubules..

Colic Sladjana: Ca basocelullare /PH verified

PIGMENTED BCC

BCCs may occasionally be heavily pigmented due to the presence of melanin within aggregations of basaloid cells, thus clinically, and sometimes dermoscopically, resembling melanomas.

Clues for the diagnosis are the presence of focussed, branching, arborizing vessels, and the detection of loosely arranged blue-gray dots or globules, in the absence of any criteria for a melanocytic lesion. Ulceration may also be present.

In pigmented superficial BCC additional dermoscopic criteria are leaf-like areas (mostly peripheral brown gray streaks), spoke wheel areas and concentric structures.