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1. cutaneous lump

a bump, mess, swelling beneath skin. Either benign or malignant. Could be from various reason.

common causes : cyst, infection, tumour, lymph nodes.

2. Caucasian male

person who is white or pale skin, live in the European origin.

prone to get skin cancer, because of less melanin.

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1. 66 year old caucasian male

old age - low immunity

caucasian - relate to genetics

2. former gardener

lifestyle as a gardener

occupational hazard - involvement with skin cancer, ozone layer related.

exposure to UV light

UV related skin malignancy

exposed to parasites (insects, etc)

exposure to hazardous chemicals (eg rafflesia)

geographical disease

fungal infection - contaminated water, plant related fungal infection

bacterial infection - sawah padi ( watery environment, dangerous bacteria)

3. one year history of cutaneous Lump

long duration - chronic inflammation

no pain - benign tumour( no discomfort, only irritated growing)

human papilloma virus - warts

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1. rapidly growing  lump

Cause - growth hormone, during child too much growth hormone

Aggresive/malignant growth, suggests other malignancies

Genetic - inherit from parent

sign of cancer (lymphoma)

Abnormal mass of tissue in diff parts of organ

Benign (cyst, fibroma, fibroids) -> malignant (rapid growth,skin cancer)

2. size within three months, neglected for much longer

Lump reached the max size within 3 mnths (no medical attention sought)

Active growth or slow growth (quite diff to classify)

ignored for a long period

3. patient moved from the UK to Australia at the age of 20.

Aus has the highest rates of skin cancer

UV radiation exposure for longer period

Aus has environment quite hot (climate is warmer than UK)

Aus has higher UV radiation exposure

Consider he is Caucasian (low melanin)

4. received immunosuppressants to prevent corneal graft

Immunosuppressants contribute to skin cancer development

Non melanoma n squamous cell carcinoma has quite aggresive cancer manifestation

Our immune system looking for antigen/ cancer

Tumour immunosurveillance - Lump cells escape (rapid growth)

5. mother died of cancer  associated with a hereditary skin condition

family has associated w skin related problem

basal cell carcinoma (common) - painless, shiny, small BV running along

High risk of skin cancer

6. smoking about 20 cigarettes per day for the past 20

years

increase risk of skin cancer

Carcinogenic substance in cigarretes weakens immune system of thw body

Oppurtunity to get skin cancer

Premature skin aging

7. had no history of known medical illnesses, alcohol or drug  abuse.

not the factors contributing to diagnosis

Non-related to skin infection

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A 66-year-old Caucasian male, a former gardener, presented with  a 1-year history of a cutaneous lump on the back of his neck.

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1. at the back of neck

due to gardening, fungal easily enters

exposed more to the sun, compared to other parts of the body during gardening

sweating at the neck area - high sebaceous gland activity, that leads to sebaceous cyst

bite of parasites - insect exposure at the back of the neck, when insect attach, in invade the skin.

lymph nodes - swell, inflammation or malignancy,

enlargement of lymph nodes due to infection.

swelling - lymphocytes and macrophages accumulation at the sites.

size, texture is not described - for further determination of disease

trauma - experience trauma that lead to swelling

2. former gardener

attire during gardener - exposed clothes may lead to more risk

duration of his work during gardening

3. family history

skin cancer - ask if any family member has skin cancer

geographical disease he is exposed to

hereditary skin cancer - cancer associated skin condition

4. cutaneous lump

physical exam on lump - the size, texture, to know type of infection, to declare if its lump

acne or mole

ask is it painful, itchy, ulcerated

5. past medical history

allergies

cancer history - radiation exposed dues to chemotherapy, lead to formation of lump

past injury on the back of the neck

6. social history

lifestyle - alcohol drinking, smoking

travel history - may infected during his travels

sharing of clothes - scabies, infections, hygiene

drugs - pharmaceutical ( allergies to the drugs, due to previous diseases )or non pharmaceutical drugs

food intake - excessive fatty acid

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A full blood count and biochemistry were normal, and a total body computed tomography (CT) scan of including the patient’s neck  showed that the tumour had not infiltrated deep into the subjacent  tissues. No lymph node or distant metastases were noted.

The patient consented to an operation, following the induction of  general anaesthesia, the tumour was totally excised with a 2 to 3  cm clear margin around it. The tumour seemed to infiltrate the  subcutaneous tissue, and a 2 cm margins of subcutaneous tissue  were excised with the tumour. Following this wide tumoral  excision, the surrounding skin could not be approximated and was  left to heal slowly with reepithelialisation.

A histological examination of the surgical specimen revealed a  keratinising (well-differentiated) squamous cell carcinoma (SCC)  infiltrating into underlying subcutaneous tissue. Lymphovascular or perineural invasion was not a feature. Excision appeared complete in the sections examined.

After surgery, her condition significantly improved. The wound  was taken care of daily, and she was discharged home after two  weeks. The wound healed gradually within a couple of months.

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On physical examination, the patient’s vital signs were normal.

On the inspection, a protruding, ulcerated, mostly necrotic, foul-

smelling, cauliflower-like firm mass, 4 × 3 cm in size was observed

that had developed over a large erythematous skin area. Other

systems review revealed no abnormality.

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1. Immunosuppressants

-organ rejection

- medications that suppress immune sysmptoms (during transplant of tissue)

2. Corneal graft

- surgical procedure tht replace a damaged/diseased cornea w a healthy dorner cornea

replacing cornea w a healthy cornea

Graft - donor tissue used

Initiate a immune response - rapid cell in graft exposed to T lymphocytes (immune response doesnt recognjse th antigen on donor organ)

3. Keratoplasty

- procedure of transplanting healthy cornea

Replace of cornea

Replace or repair

risk n complication - graft rejection, infection, glaucoma, corneal graft failure

4. Hereditary skin condition

- passed down from older to younger gen

Genetic disease related to skin cond.

Affects hair,skin, nail

5. Rapidly growing

- significant increase in population size in short period time

Capable bcoz cell may get complete nutrient

Malignant tumour (rapid)

Possible malignancies - carcinoma, melanoma, cutaneous metastistis(cancer in various areas)

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On further questioning, it was revealed that the rapidly growing  lump had appeared and reached that size within three months;  however, evidently, it was neglected for much longer. The  patient moved from the UK to Australia at the age of 20. The  patient received immunosuppressants to prevent corneal graft  rejection after keratoplasty. His mother died of cancer  associated with a hereditary skin condition. He had been  smoking about 20 cigarettes per day for the past 20 years. He  had no history of known medical illnesses, alcohol or drug  abuse.

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1. Protruding - outward projection (clearly visible)

2. Ulcerated - having a sore / open wound

3. Foul-smelling - bad smell (rotting - necrotic)

4. Cauliflower-like firm mass - Large mass resembling cauliflower (collection of tissue)

5. Erythematous skin area - Red in colour (inflammation/UV radiation)

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A full blood count and biochemistry were normal, and a total body

computed tomography (CT) scan of including the patient’s neck

showed that the tumour had not infiltrated deep into the subjacent

tissues. No lymph node or distant metastases were noted.

The patient consented to an operation, following the induction of

general anaesthesia, the tumour was totally excised with a 2 to 3

cm clear margin around it. The tumour seemed to infiltrate the

subcutaneous tissue, and a 2 cm margins of subcutaneous tissue

were excised with the tumour. Following this wide tumoral

excision, the surrounding skin could not be approximated and was

left to heal slowly with reepithelialisation.

A histological examination of the surgical specimen revealed a

keratinising (well-differentiated) squamous cell carcinoma (SCC)

infiltrating into underlying subcutaneous tissue. Lymphovascular or

perineural invasion was not a feature. Excision appeared complete

in the sections examined.

After surgery, her condition significantly improved. The wound

was taken care of daily, and she was discharged home after two

weeks. The wound healed gradually within a couple of months.

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1. Skin Cancer - hereditary from parents

2. Neglected the problem for longer period - cancer has manifested/developed/metastasizes

3. Radiation towards other parts of body (not specifically on the back of neck)

4. Characteristics of lump associated from other disease

5. Migration to Aus - UV radiation

6. Early UV damage can sustain in the body for longer

7. Smoking -> premature skin aging + caucasian = skin cancer, DNA damage (nicotine is carcinogenic)

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1. Skin cancer has developed over large erythematous skin area

2. Enlarged mass- serious, possibilities of radiation

3. No past injury

4. Malignant tumor - determination of treatment (excision//radiotherapy)

Dx

biopsy >>> to ensure malignancy, histological type

Full blood count >>> for skin infection, identify stage of cancer, detect metastasis in organs

Allergic test

CT Scan, MRI >>> detect metastasis (organs), evaluate local invasion into deeper tissue (muscle, bone)

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Describe the nomenclature of benign and malignant neoplasia based on origin.

2. Describe the characteristics of benign and malignant neoplasms, including degree

of differentiation, growth rate, local invasion, and metastasis. Correlate with the

case.

3. Discuss the epidemiology of common cancers in Malaysia, including incidence and

discuss the risk factors.

4. Describe genetic predisposition to cancer.

5. Describe acquired preneoplastic disorders and conditions.

6. Describe the basis of carcinogenesis, and the ability to invade and metastasize.

7. Describe chemical and radiation carcinogenesis.

8. Describe host defense against tumors, including tumor antigens, antitumor effector

mechanisms, immune surveillance, and escape.

9. Outline the general clinical presentation of cancer.

10.Outline the investigation of cancer including tumor markers.

11. Outline management of cancer

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1. Smoking Hx - could contribute to recurrence

2. Less UV exposure - former gardener

3. Advise the patient

negative effects of smoking / awareness

usage sunscreen / sun block

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1. Full blood count and biochemistry were normal

skin condition - doesn't effect the systemic parts

early stage of development

2. Total body CT scan of including the patient’s neck: tumor had not infiltrated deep into the subjacent tissues

early stage of development

no widespread of tumor

3. No lymph node or distant metastases were noted

early stage of development

no widespread of tumor

lymph node involvement - vital for staging cancer

4. tumour was totally excised with a 2 to 3 cm clear margin around it

no cancer cells were found at the site

completely excised - reduced risk of recurrance

no additional surgery is needed

5. the surrounding skin was left to heal slowly with reepithelialisation

positive indicator of recovery

monitor any signs of infection

6. Keratinising (well-differentiated) squamous cell carcinoma (SCC)

grows into keratin containing mass

well-differentiated - tumor cells looks similar to normal skin cell

poorly differentiated - anaplasia

7. Lymphovascular or perineural invasion was not a feature

early stage of development

no lymph node involvement

well-differentiated

8. Excision appeared complete in the sections examined

entire tumor is successfully removed

no cancer cells detected

reduce the recurrence of cancer

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1. Distant metastases - spread to other body parts

2. Computed tomography (CT) scan - medical imaging method which takes picture using xray

3. Subadjacent tissue - located underneath another tissue

4. General anasthaesia - state where patient is unconscious, doesn't feel any pain

5. Reepithelialisation - process of wound healing by replacing damaged epithelium

6. Histological Examination - study of the microscopic structure of tissue (biopsy specimen // surgical sample)

7. Lymphovascular / Perineural Invasion - presence of malignant cell in vascular //lymph vessels

8. Excision - surgical removal of tissue, growth, organ, bone

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1. Vital signs: normal

doesn't effect other systems

normal temp - no fever

2. Protruding, Ulcerated, mostly necrotic, foul-smelling

dead cells

related to malignant tumor

3. cauliflower-like firm mass, 4 × 3 cm in size was observed

no abcess (not infection)

firmness >>> malignancy

irregular >>> advanced squamous cell carcinoma (SCC)

4x3cm >>> bigger in size

4. large erythematous skin area

Redness of skin (basal/squamous cell carcinoma)

Increased blood flow (infection) >>> vasodilation/development of BV

Possibilities of blister

Large >>> spreading mass, invasion into deeper skin layer

5. No systemic abnormality

no infection

symptoms indicate malignancy