J.M. 21 y/o female cc: scalp mass. History of Present Illness Slowly enlarging, firm, occasionaly tender mass on R parietoocipital area (3x3cm) Consult.

J.M.21 y/o femalecc: scalp mass

History of Present Illness

• Slowly enlarging, firm, occasionaly tender mass on R parietoocipital area (3x3cm)

• Consult– A: Hemangioma– P: Excision

14 years PTA

ADMISSION

2 mos PTA

• Recurrence of slowly enlarging mass (5x5cm)

• Consult at UST OPD– Scalp X Ray– Ultrasound of neck

PAST MEDICAL HISTORY

• (-) HPN• (-) DM• (-) HPV infection• (-) Asthma• (-) Allergies• (-) PTB

PERSONAL AND SOCIAL HISTORY

• Mixed diet • Nonsmoker• Not an alcoholic beverage drinker

FAMILY HISTORY

• (+) HPN – mother• (+) DM – grandfather• (-) Asthma• (-) CA

REVIEW OF SYSTEMS

• (-) weight loss, weakness, fatigue• (-) Headache, dizziness, blurring of vision• (-) hearing loss, aural discharge, tinnitus• (-) epistaxis, nasal discharge, sinusitis• (-) hoarseness, mouth sores, dysphagia• (-) dyspnea, cough

PHYSICAL EXAMINATION

• Conscious, coherent, ambulatory, not in distress• BP: 120/80 PR 80bpm RR 18cpm T 36.5°C Wt. 60 kg Ht. 162cm• Warm moist skin, no active dermatoses• Pink palpebral conjunctivae, anicteric sclerae• No naso-aural discharge, non-congested turbinates,

non-tender sinus, buccal mucosa, tonsils not enlarged, no bleeding gums

• Supple neck, (-) palpable cervical Lymph Nodes, no thyromegaly

• Symmetric on chest expansion, (-) retractions, lungs resonant, clear breath sounds

• Adynamic precordium, AB 5th LICS MCL, S1>S2 at the apex, S2>S1 at the base, no murmurs

• Flat abdomen, no organomegaly, (-) rebound tenderness, no masses

• (-) pallor, clubbing, petechiae, ecchymoses• Pulses ++ on all extremities

Admitting Impression

• Soft tissue tumor to consider recurrent hemangioma vs. granuloma

Merkel’s Cell Carcinoma

• Classified as a neuroendocrine malignancy of the skin.

• Cutaneous small cell undifferentiated carcinoma

• Incidence of 1200 per year in the US • Mortality rate of 33 %

National Cancer Institute. Fact Sheet MERKEL’S CARCINOMA. 2007Merkel Cell Carcinoma: More Deathsbut Still No Pathway to Blame Bianca Lemos and Paul Nghiem. Journal of Investigative Dermatology (2007)

Discussion

• Merkel’s cells located in the basal layer of the epidermis.

• Grossly, the primary tumor presents as a small, red, pink, or blue-violet, non-ulcerated, painless, intradermal nodular mass often located in sun-exposed areas of the skin such as the head and neck

Discussion

• Neuroendocrine markers– Neuron-specific enolase – Chromogranin– Synaptopysin

Merkel cell carcinoma, Virve Koljonen. World Journal of Surgical Oncology 2006

American Joint Committee on Cancer

• Stage I (primary lesion ≤ 2 cm)• Stage II (primary lesion > 2 cm). • Stage III (nodal involvement)• Stage IV disease (metastatic)

Prognosis

• Aggressive course with reported overall 5-year survival rates ranging from 30% to 64%.

• Survival after a diagnosis of MCC is highly dependent on the stage at presentation.

• 90 percent of recurrences occurring within three years of diagnosis

Merkel Cell Carcinoma: A Case Report and Literature Review. Oncology. Medical Journal of Islamic World Academy of Sciences 15:3, 91-94, 2005