What is the recommended treatment approach for a 77-year-old male patient with a malignant skin lesion on the left side of the nose?

Treatment of Malignant Skin Lesion on the Left Side of the Nose

Surgical excision with appropriate margins based on the type and depth of the malignancy is the recommended treatment approach for this 77-year-old male patient with a malignant skin lesion on the left side of the nose. 1, 2

Initial Assessment and Diagnosis

• The patient has already had a biopsy confirming malignancy, which is the correct first step in management 1
• Further treatment decisions should be based on the specific type of malignancy (melanoma vs. non-melanoma skin cancer) and its characteristics 1, 2
• The location on the nose is significant as facial lesions may require special consideration for both oncological and cosmetic outcomes 2, 3

Treatment Approach Based on Type of Malignancy

If Melanoma:

• Surgical excision with margins determined by Breslow thickness is the standard treatment 1:

  • In situ melanoma: 5 mm margins 1
  • <1 mm thickness: 1 cm margins 1
  • 1.01-2 mm thickness: 1-2 cm margins 1
  • 2.1-4 mm thickness: 2-3 cm margins 1

  • 4 mm thickness: 3 cm margins 1

• For lentigo maligna melanoma (common on face/nose):

  • Complete excision with clear histological margins is essential 1, 2
  • Higher risk of recurrence due to "field effect" where atypical melanocytes extend laterally 1, 2

If Basal Cell Carcinoma:

• Surgical excision is the gold standard treatment 1
• For superficial basal cell carcinoma, alternatives include:
  • Imiquimod 5% cream applied 5 times per week for 6 weeks (for tumors ≤2 cm) 4
  • Fluorouracil 5% cream applied twice daily for 3-6 weeks (may require up to 10-12 weeks) 5

If Squamous Cell Carcinoma:

• Complete surgical excision with histological confirmation of clear margins is recommended 1
• Mohs micrographic surgery should be considered for high-risk lesions or those in cosmetically sensitive areas like the nose 1
• Alternative treatments for selected cases include:
  • Curettage and electrodesiccation (for small, well-differentiated tumors) 1
  • Radiotherapy (when surgery would result in significant functional or cosmetic impairment) 1

Special Considerations for Nasal Location

• The nose is a cosmetically and functionally important area, requiring careful planning of surgical approach 3
• Reconstruction options should be discussed with the patient prior to excision 3
• For extensive lesions, referral to a specialist skin cancer multidisciplinary team is recommended 1
• Patients with melanoma stage IB or higher should be referred to a Specialist Skin Cancer Multidisciplinary Team 1

Follow-up Recommendations

• For melanoma: follow-up frequency depends on stage, typically every 3-6 months for the first 3 years and every 6-12 months thereafter 1
• For non-melanoma skin cancers: follow-up for 5 years is recommended as 95% of local recurrences and metastases are detected within this timeframe 1
• Patient education on self-examination and sun protection is essential 1

Common Pitfalls to Avoid

• Inadequate surgical margins leading to recurrence, particularly for lentigo maligna on the face 1, 2
• Underestimating the extent of the lesion, especially for melanoma in situ on the face 2
• Delaying definitive treatment, as early intervention improves outcomes 6
• Neglecting to consider the cosmetic and functional impact of treatment on the nose 3

Given the patient's age and the location of the lesion, a careful balance between oncological safety and cosmetic/functional outcomes is essential. The urgent dermatology consultation is appropriate, as specialist evaluation will determine the optimal treatment approach based on the specific type and characteristics of the malignancy.