Clinical Case 007

An elderly lady presents to the clinic with a large lesion on the right shoulder.

...images here

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Q1. Describe the clinical & imaging findings.

There is a large fleshy 25cm+ exophytic lesion arising from the right supraclavicular fossa. There is evidence of a biopsy. The surrounding skin shows dilated superficial veins. The imaging shows that the lesion is only superficially infiltrative, although the fat in the SCF looks to be stranded.

Q2. What differential diagnoses are applicable in this instance?

The principle diagnoses to be verbalised and considered are:

1. basal cell carcinoma
2. squamous cell carcinoma
3. malignant melanoma

Q3. a) read the histopathology report.

CLINICAL NOTES: Large fungating skin tumour at base of neck
MACROSCOPIC: NOT LABELLED AS TO SITE AND NATURE, consists of skin 20 x 10 mm to a depth of 8 mm. There is a cut across the surface. There is no obvious skin on the surface can be seen.
MICROSCOPIC: Sections of skin show widely infiltrating basal cell carcinoma. No perineural invasion is seen in these sections. Excision is incomplete.
SUMMARY: Skin from neck - BASAL CELL CARCINOMA. EXCISION INCOMPLETE.

Q3. b) describe the typical features that would have been seen.

Histopathology should indicate that the basal cell carcinoma is a malignant epithelial tumor, with compact areas, well delineated and invading the dermis, usually with no connection with the epidermis. There are small, monomorphous dark cells with a palisading margin at the periphery (they are more spindle-shaped and irregular in the middle). Tumor clusters may be separated by a reduced stroma with inflammatory infiltrate.

[4 underlined statements to be included in the answer.]

Q4. what would be your intent of treatment?

Q5. list the therapy options to achieve this intent

Q5. list the advantages and disadvantages of these therapy options

Q6. select the therapy modality you think is most appropriate, and its chances of success.

Q7. assume that the patient is not an operable candidate and that radiotherapy will be used as the only therapy, describe your treatment approach in detail, including a prescription.

Q8. describe in detail for the patient the expected outcomes of radiotherapy including timings and severity.